Christophe Rapp

Pathological rupture of the spleen in malaria: Analysis of 55 cases (1958–2008)

BACKGROUND Splenic rupture during acute malaria is rare but underreported. Because splenic rupture occurs mostly in non-immune adults, ongoing malaria elimination efforts may paradoxically increase the proportion of Plasmodium-infected patients suffering from this life-threatening complication. The pathogenesis and optimal patient management are still debated. METHOD We collected and analysed reports of pathological rupture of the spleen associated with malaria published over the last 50 years in five languages. RESULTS Fifty-five cases were reported, due to Plasmodium falciparum (n=26), Plasmodium vivax (n=23), Plasmodium ovale (n=2), Plasmodium malariae (n=2), or P. vivax-falciparum (n=2), and occurred in travellers (n=24), locals (n=21), expatriates (n=6) or migrants (n=4). Median age was 31.5 years and sex ratio M/F 3.2. Splenic rupture was complete with hemoperitoneum (n=50), or partial (n=5). Death occurred in 12 patients (22%), 8 of whom from early irreversible collapse (n=7) or unexpected death (n=1). Death rate was higher among travellers than in other patients (9/24, 38%, versus 3/31, 10%, p=0.01). Clinical features of P. falciparum- or P. vivax-associated splenic rupture were strikingly similar. Treatment included in-hospital medical observation without surgery (conservative management, n=14), immediate splenectomy (n=29), delayed splenectomy (n=4), or none (patients dying at admission, n=8). The type of treatment, conservative or not, had no influence on prognosis. The median duration of malaria symptoms before diagnosis was longer in our review (5-6 days) than in previous reports on imported malaria (3-4 days), suggesting that early diagnosis and therapy of malaria may reduce the incidence of splenic rupture. CONCLUSIONS Abdominal pain, collapse, or fainting is warning symptoms. Fourteen published observations support conservative management in carefully selected patients. Spleen preservation likely reduces the risk of future severe malaria attacks in patients with potential further exposition to Plasmodium sp., and also that of overwhelming sepsis in all.

Adverse events following pandemic influenza vaccine Pandemrix® reported in the French military forces--2009-2010.

BACKGROUND In the face of the A(H1N1) 2009 influenza pandemic, in October 2009 the French military health service (SSA) initiated a large vaccination campaign with Pandemrix(®) vaccine in the military forces. The aim of this study was to describe vaccine adverse events (VAE) reported during this campaign. METHODS VAE and the number of people vaccinated were surveyed by the SSA Epidemiological network across all military forces during the campaign, from October 2009 to April 2010. For each case, a notification form was completed, providing patient and clinical information. Three types of VAE were considered: non-serious, serious and unexpected. RESULTS There were 315.4 reported VAE per 100,000 vaccinations. Vaccination and VAE incidence rate peaks coincided with influenza epidemic peak in early December. The number of injected doses was 49,138, corresponding to a 14.5% vaccination coverage among military personnel, and 155 VAE were reported, including 5 serious VAE (1 Guillain-Barre syndrome, 2 malaises and 1 convulsive episode). Most VAE were non-serious (97.1%). Among these, 6 cases of local, rapidly regressive paresthesia were observed. DISCUSSION The military VAE surveillance system constitutes the only observatory on benign VAE in France. The reporting rate was much higher after the pandemic vaccine than after the seasonal vaccine, which may be a reflection of stimulated reporting. This report provides a useful description of VAE among military personnel during a mass emergency vaccination program, showing that the tolerance of the pandemic vaccine appeared acceptable.

Molecular Characterization of blaNDM-1 in a Sequence Type 235 Pseudomonas aeruginosa Isolate from France

ABSTRACT An NDM-1 carbapenemase-producing Pseudomonas aeruginosa isolate was recovered from a patient hospitalized in France after a previous hospitalization in Serbia. Genetic studies revealed that the blaNDM-1 gene was surrounded by insertion sequence ISAba125 and a truncated bleomycin resistance gene. This blaNDM-1 region was a part of the variable region of a new complex class 1 integron bearing IS common region 1 (ISCR1). The presence of ISPa7 upstream of this integron suggests insertion in a chromosomally located Tn402-like structure.

Delayed-Onset Hemolytic Anemia in Patients with Travel-Associated Severe Malaria Treated with Artesunate, France, 2011–2013

Hemolysis occurred in a low proportion of patients and did not increase transfusion requirements.

Doxycycline failure in lymphogranuloma venereum

Lymphogranuloma venereum (LGV) cases are currently re-emerging in the homosexual community, particularly in HIV-seropositive patients. The standard treatment for this infection, which is caused by Chlamydia trachomatis L1, L2 and L3 serotypes, is a 3-week doxycycline regimen. The case is reported of a male patient presenting with LGV, who was rapidly cured with moxifloxacin treatment after failure of extended treatment with cyclines. This fluoroquinolone is known to be highly active in vitro on the LGV pathogenic agent. Thus it may be a useful alternative when doxycycline treatment results in failure.

Prevention of combat-related infections: antimicrobial therapy in battlefield and barrier measures in French military medical treatment facilities.

Infection is a major complication associated with combat-related injuries. Beside immobilization, wound irrigation, surgical debridement and delayed coverage, post-injury antimicrobials contribute to reduce combat-related infections, particularly those caused by bacteria of the early contamination flora. In modern warfare, bacteria involved in combat-related infections are mainly Gram-negative bacteria belonging to the late contamination flora. These bacteria are frequently resistant or multiresistant to antibiotics and spread through the deployed chain of care. This article exposes the principles of war wounds antimicrobial prophylaxis recommended in the French Armed Forces and highlights the need for high compliance to hygiene standard precautions, adapted contact precautions and judicious use of antibiotics in French deployed military medical treatment facilities (MTF).

The challenge of diagnosing Plasmodium ovale malaria in travellers: report of six clustered cases in french soldiers returning from West Africa

BackgroundPlasmodium ovale is responsible for 5% of imported malaria in French travellers. The clinical and biological features of six clustered cases of P. ovale malaria in an army unit of 62 French soldiers returning from the Ivory Coast are reported.Case reportAll patients were symptomatic and developed symptoms on average 50 days after their return and 20 days after the end of chemoprophylaxis (doxycycline). Clinical features included fever (6/6), mostly tertian (4/6), aches (6/6), nausea (3/6), abdominal pain (2/6), diarrhoea (2/6), or cough (2/6). Thrombocytopaenia was lower than 100,000/mm3 in half the cases only, and the haemoglobin count was normal for all patients. The diagnosis was made after at least three thick and thin blood smear searches. Parasitaemia was always lower than 0.5%. All rapid diagnostic tests were negative for HRP2 and pLDH antigens.DiscussionPlasmodium ovale malaria is currently a problem to diagnose in travellers, notably in French soldiers returning from the Ivory Coast. Early attempts at diagnosis are difficult due to the lack of specific clinical features, the rarity of biological changes and the poor sensitivity of diagnostic tools to detect low parasitaemia. Thus, the diagnosis is commonly delayed or missed. Physicians should be aware of this diagnostic challenge to avoid relapses and provide prompt and adequate treatment with chloroquine and radical cure with primaquine.

Malaria control strategies in French armed forces.

Each year, 40,000 French soldiers deploy or travel through malaria-endemic areas. Despite the effective control measures that were successively implemented, malaria remains a public health concern in French armed forces with several important outbreaks and one lethal case every two years. This article describes the malaria control strategy in French armed forces which is based on three combined strategies: i) Anopheles vector control to prevent infection with the implementation of personal protection against vectors (PPAV) adapted to the field living conditions of the troops. ii) Chemoprophylaxis (CP) to prevent the disease based on prescription of effective and well tolerated doxycycline. iii) Management of cases through early diagnosis and appropriate treatment to prevent death. In isolated conditions in endemic areas, rapid diagnosis tests (RDT) are used as first-line tests by military doctors. Treatment of uncomplicated Plasmodium falciparum (P. falciparum) malaria is based either on the piperaquine tetraphosphate-dihydroartemisinin association since 2013, or on the atovaquone-proguanil association. First-line treatment of severe P. falciparum malaria is based on IV artesunate. These measures are associated with constant education of the military, epidemiological surveillance of malaria cases and monitoring of parasite chemosensitivity.

Travel-Related Cerebro-Meningeal Infections: The 8-Year Experience of a French Infectious Diseases Unit

BACKGROUND The etiological spectrum of cerebro-meningeal infections (CMI) in travelers has never been specifically analyzed. OBJECTIVES To assess the etiologies of CMI in hospitalized travelers and to propose a diagnostic approach to travel-related CMI. METHODS During an 8-year period, we retrospectively collected data on all travelers hospitalized in our department for a CMI occurring during travel or in the month after their return. RESULTS Fifty-six patients (35 men and 21 women; mean age 29 years (16-83); 44.6% tourists, 26.8% military, 16% immigrants, 12.5% expatriates) were included. The main destinations were Africa (57.2%), Europe (19.5%), and Asia (12.5%). The median duration of travel was 24 days (5-550). Symptoms occurred during travel in 20 patients (11 of which required a medical evacuation). In the remaining 36 patients, the median duration between return and clinical onset was 10 days. The median time from clinical onset to hospitalization was 4 days (0.5-96). Twenty-four patients presented with a meningeal syndrome and 20 others with encephalitic features. The remaining 12 patients had an incomplete clinical presentation (headaches or fever). The etiology was confirmed in 42 cases (75%) of which tropical diseases (n = 14) were less common than cosmopolitan ones (n = 28). Sub-Saharan Plasmodium falciparum malaria (n = 12) was the leading tropical infection, whereas viral infections (enterovirus, herpesviridae, HIV) were the main cosmopolitan etiologies. Only four bacterial infections were reported (Neisseria meningitidis, Mycoplasma pneumoniae, Brucella melitensis, Salmonella typhi). Sixteen patients were admitted to intensive care for a median time of 9.5 days (1-63). The average duration of hospitalization was 14 days (3-63). One death by herpes simplex virus 1 encephalitis was recorded. Four patients (7%) had neurological sequelae. CONCLUSIONS Among the diversified etiological spectrum of CMI, cosmopolitan infections are widely predominant, particularly viral infections, followed by tropical causes, of which malaria is the leading disease in returnees from endemic areas. The diagnostic approach should be driven by history and physical examination. Key investigations include: blood smear, cerebrospinal fluid polymerase chain reaction and culture as well as neuroimaging. Management should focus on curable causes.

Acute Meningitis Owing to Phlebotomus Fever Toscana Virus Imported to France

Acute lymphocytic meningitis, seen in France in summer, is often due to enteroviruses. Arboviruses as West Nile and tick-borne encephalitis do exist in Europe, but other viruses are rarely considered in patients unless they have had recent tropical travel. Toscana virus infection, which is endemic, especially in Italy,1-3 has been documented in some European travelers returning from Italy,4-6 but surprisingly was not documented in France until recently.7 We report a case of meningitis caused by Toscana virus imported to France.