Camille Aubry

Demographics, health and travel characteristics of international travellers at a pre-travel clinic in Marseille, France

With the aim to identify at-risk individuals among a cohort of international travellers, 3442 individuals who sought advice at Marseille travel health centre in 2009 were prospectively included. Demographics, travel characteristics, chronic medical conditions, vaccinations and antimalarial chemoprophylaxis were documented. Chronic medical conditions were reported by 11% of individuals, including hypertension (39%), asthma (20%), thyroid disease (15%) and depression (13%). 4% reported taking a daily medication, and psychotropic and cardiovascular medications were the most commonly used. Older travellers (≥60 years) accounted for 10% of the travellers and the prevalence of chronic medical conditions was 27% in this group. Individuals aged 15 years or less accounted for 13% of the travellers. Age, last minute travel (17%) and neurological and psychiatric diseases were the most frequent factors that influenced Yellow fever vaccination and malaria chemoprophylaxis, with more than one tenth of the travellers reporting at least one risk factor for which adjusted advice may be necessary. Migrants visiting their relatives in their origin country accounted for 14% of travellers and 73% of this group travelled with their family including young children. We demonstrate that a significant proportion of travellers are at-risk (43%) because of their travel conditions (VFR), their age, or their health status, and should be targeted for risk reduction strategies.

Brill-Zinsser disease in Moroccan man, France, 2011.

To the Editor: Epidemic typhus is caused by Rickettsia prowazekii and transmitted by human body lice. For centuries, it has been associated with overcrowding, cold weather, and poor hygiene. Brill-Zinsser disease is a recurrent form of epidemic typhus that is unrelated to louse infestation and develops sporadically years after the primary illness. Clinical features are similar to, but milder than, those of epidemic typhus (1). We report a case of Brill-Zinsser disease in a patient who was born in Morocco and had no history of epidemic typhus. A 69-year-old man living in France sought care from his general practitioner on March 7, 2011, after 2 days of high-grade fever (40°C) associated with headache, myalgia, fatigue, and mild cough. Amoxicillin was prescribed for a putative diagnosis of acute respiratory infection. He was admitted to hospital on March 9 for persistent fever. Physical examination results were unremarkable. Blood test results were as follows: C-reactive protein 111 mg/L (reference 0–8 mg/L); procalcitonin 0.49 ng/mL (reference 0.1–0.4 ng/mL), lymphocyte count 0.7 × 103 cells/μL (reference 1–4 × 103 cells/μL), platelet count 92 × 103 cells/μL (reference 150–450 × 103 cells/μL), and lactate dehydrogenase 376 U/L (reference 94–246 U/L). Chest radiograph results were normal. Results of 5 blood cultures and a urine culture were negative. Stupor developed on March 11. Cerebrospinal fluid test results were normal. Because the patient lived near a goat farm, Q fever and tularemia were considered plausible hypotheses, and oral doxycycline was introduced on March 13. The patient became afebrile on March 15, and he was discharged from the hospital and remained well. On the basis of serologic results, the following diagnoses could be ruled out: viral infections (HIV, cytomegalovirus, Epstein-Barr virus); tularemia; Q fever; leptospirosis; salmonellosis; and Legionella, Mycoplasma, and Chlamydia spp. infections. Acute-phase and convalescent-phase serum samples were positive for typhus-group rickettsiae by the microimmunofluorescence assay at the World Health Organization Collaborative Center for Rickettsioses and Other Arthropod-Borne Bacterial Diseases (Marseille, France). A microimmunofluorescence assay showed titers of 100 for IgM and 6,400 for IgG. Western blot analyses and cross-adsorption studies strongly suggested R. prowazekii as the cause of the man’s illness. Quantitative PCR result on DNA extracted from the acute-phase serum was negative (2). The patient had been raised in Morocco. At 19 years of age, he emigrated to France, where he lived in a urban area. He subsequently traveled every 3 years to Morocco for 1-month summer holidays, always in urban areas. He had most recently traveled to Morocco in 2008. He denied any history of hospitalization for a severe febrile illness and any exposure to louse bites. In the weeks before disease onset, he had not taken any new drug. He had no immunoglobulin deficiency. On the basis of serologic analysis with Western blot, we confirmed R. prowazekii infection in a patient with no recent travel and no contact with lice or flying squirrels. R. prowazekii infection may occur rarely in France; it was found in Marseille in 2002 in an asymptomatic homeless person (3). In contrast, the patient in our report was living in a hygienic environment, and an autochthonous infection is therefore highly unlikely. Epidemic typhus was endemic to North Africa until the 1970s (4). Subsequently, this region was thought to be free from epidemic typhus, but 2 cases have been reported since 1999 in Algeria, where 1 case of Brill-Zinsser disease was observed in a man who had had epidemic typhus in 1960 during the Algerian civil war (5–7). Few published data exist about the seroprevalence of R. prowazekii infections in North Africa (4). In Tunisia, no epidemic typhus was found in 2005 among 47 febrile patients (8). However, a seroepidemiologic survey performed in blood donors and hospitalized patients in the Aures, Algeria, found a prevalence of 2% (4). This finding suggests that R. prowazekii infection might have occurred in this population more often than suspected. No recent published data are available from Morocco. Since 1970, reports of only 8 cases of Brill-Zinsser disease have been published (9,10). In all cases, known risk factors were present (overcrowding, poor hygiene, or contact with flying squirrels). Brill and Zinsser described that stress or waning immunity could reactivate R. prowazekii infection (2). Corticosteroids can trigger recurrence of R. prowazekii in mice (2), but no such observations were made in humans. In the case presented here, we found no stress factor, no immunosuppression, and no medical history of epidemic typhus. Brill-Zinsser disease can develop >40 years after acute infection. The mechanism of R. prowazekii latency has not been established. A recently explored reservoir for silent forms of R. prowazekii infection is adipose tissue because it contains endothelial cells, which are the target cells for R. prowazekii infection, and because of its wide distribution throughout the body (2). Brill-Zinsser disease should be considered as a possible diagnosis for acute fever in any patient who has lived in an area where epidemic typhus is endemic.

Bacterial agents in 248 ticks removed from people from 2002 to 2013

A retrospective study was conducted to analyze the tick species removed from people and to detect tick-infecting bacteria in the specimens collected over the past 10 years at the reference center for rickettsioses, Marseille, France. A total of 248 ticks were removed from 200 people, including Dermacentor (73), Rhipicephalus (67), Ixodes (60), Amblyomma (8), Argas (3), Hyalomma (1), and Haemaphysalis (1) species. Bacterial DNA was detected in 101 ticks: Rickettsia slovaca (34%) and Rickettsia raoultii (23%) were detected in Dermacentor ticks; Rickettsia conorii (16%) and Rickettsia massiliae (18%) were found in Rhipicephalus ticks; and Anaplasma phagocytophylum (5%), Borrelia spp. (8%) and Rickettsia spp. (2%) were detected in Ixodes ticks. Among the bitten people for which clinical data and laboratory samples were available, tick borne diseases were confirmed in 11 symptomatic individuals.

From Expert Protocols to Standardized Management of Infectious Diseases

We report here 4 examples of management of infectious diseases (IDs) at the University Hospital Institute Méditerranée Infection in Marseille, France, to illustrate the value of expert protocols feeding standardized management of IDs. First, we describe our experience on Q fever and Tropheryma whipplei infection management based on in vitro data and clinical outcome. Second, we describe our management-based approach for the treatment of infective endocarditis, leading to a strong reduction of mortality rate. Third, we report our use of fecal microbiota transplantation to face severe Clostridium difficile infections and to perform decolonization of patients colonized by emerging highly resistant bacteria. Finally, we present the standardized management of the main acute infections in patients admitted in the emergency department, promoting antibiotics by oral route, checking compliance with the protocol, and avoiding the unnecessary use of intravenous and urinary tract catheters. Overall, the standardization of the management is the keystone to reduce both mortality and morbidity related to IDs.

Escherichia coli spontaneous community-acquired meningitis in adults: A case report and literature review

Gram-negative bacillary meningitis occurring post-trauma and following neurosurgical procedures has been described widely. However, reports of spontaneous cases are sparse, particularly community-acquired cases. Spontaneous community-acquired Escherichia coli meningitis is a rare (although increasingly seen) and specific entity that is poorly reported in the literature. A review of the literature identified only 43 cases of community-acquired E. coli meningitis reported between 1946 and 2016. This article describes two new cases of spontaneous community-acquired E. coli meningitis encountered in Marseille, France, and presents the results of a literature review on spontaneous community-acquired E. coli meningitis.

Case report: Ribavirin and vitamin A in a severe case of measles

Rationale: Despite a vaccine being widely available, measles continues to occur frequently, with sometimes lethal consequences. Patients concerns: The mortality rate reaches 35% and measles represents 44% of the 1.4 million deaths which are due to preventable diseases. Severe forms of measles are reported, mainly in young, unvaccinated adults, and in specific populations. The risk factors for severe measles include no or incomplete vaccination and vitamin A deficiency. Apart from secondary measles-related infections, severe measles is mainly represented by neurological, respiratory, and digestive symptoms. Diagnoses: Strengthening the hypothesis that there is a link between vitamin A deficiency and severe measles in this paper we report the case of a 25-year-old unvaccinated man hospitalized for severe and complicated measles. Outcomes: The evolution was good after administration of intramuscular vitamin A as well as intravenous ribavirin. Lessons: Measles remains a fatal and serious disease. The early use of ribavirin and vitamin A shows significant improvements regarding morbimortality and should be systematic in severe cases.

Thigh abscess and necrotizing fasciitis following an inside-out transobturator tape intervention: a case report

BackgroundTension-free vaginal transobturator tapes are used worldwide in the treatment of urinary incontinence in women. Very few severe complications have been described following this procedure, with no standard treatment yet established.Case presentationWe present the case of a 36-year-old French white woman with no remarkable medical history, presenting with an abscess and necrotizing fasciitis 48 hours after an inside-out tension-free transobturator procedure. Samples were collected by guided puncture from the abscess, retrieving Staphylococcus aureus and Citrobacter koseri.ConclusionsSevere complications following this procedure are rare, although it can have the potential for significant morbidity and even mortality, which is worth highlighting. We recommend early surgical treatment in combination with broad-spectrum antibiotics and coverage for Staphylococcus aureus, which may be a causative agent.