Delphine Lebrun

Poor knowledge among French travellers of the risk of acquiring multidrug-resistant bacteria during travel

Since it is not routine practice in France to raise public awareness about the risk of acquiring multidrug-resistant Enterobacteriaceae (MRE) during international travel, we aimed to determine, among French travellers attending a consultation for travel medicine, their level of knowledge about the risk of acquiring MRE. Among 191 adults enrolled in the study, only 10% of travellers were aware of the risk of becoming a carrier of MRE during travel, and 87% did not understand the difference between being colonized with MRE, and having a clinical infection with MRE. Consultations for travel medicine could be an opportunity to deliver specific information about the risks of acquiring MRE. Antibiotic resistance among Gram-negative bacteria is an emerging problem worldwide, mainly with the diffusion of extended spectrum beta-lactamase, plasmid-encoded cephalosporinases and carbapenemases-producing Enterobacteriaceae. These strains often show multi-resistance and are now diffusing worldwide in the community setting, outside of the hospital. Travel in areas endemic for multidrug-resistant Enterobacteriaceae (MRE) has been identified as a risk factor for the acquisition of MRE.1–5 Faecal colonization with MRE is very frequent among travellers to tropical regions, with a risk ranging from 20 to 70%, especially among those visiting the South Asian continent.2,3,5 Moreover, antibiotic use could favour proliferation of MRE by disrupting the intestinal microbiota balance, and the use of antibiotics for travel diarrhoea was associated with a 4-fold increase in the risk of acquiring MRE, whereas travel diarrhoea itself was only associated with a 2-fold increase in risk.2,3,6 Taken together, these elements suggest that informing the public about the risk of acquiring MRE during international travel could represent a preventive measure against the spread of MRE in France. The French public has been made aware of multidrug-resistant (MDR) bacteria through a media campaign conducted …

Validation of the Fautrel classification criteria for adult-onset Still’s disease

OBJECTIVES To validate the Fautrel classification criteria for adult-onset Stills disease (AOSD) and to compare the discriminative performance to that of the Yamaguchi criteria. METHODS We retrospectively reviewed the medical charts of 426 patients who had serum ferritin level and percentage glycosylated ferritin assayed at the biochemistry laboratory of Bichat Hospital. Medical data were extracted by use of a standardized form. All clinical, biological, and imaging features were collected, as well, evidence favoring an alternative diagnosis, specifically symptoms suggestive of other immune-mediated inflammatory diseases (IMID) or active infections. Patients were classified as AOSD patients or controls according to a predefined procedure, including consultation with a multidisciplinary expert group. Algorithms corresponding to the Fautrel and Yamaguchi classification criteria were applied for each patient. RESULTS In all, 54 AOSD and 278 control patients were included. For the Fautrel criteria, the sensitivity was 87.0%, specificity 97.8%, and positive and negative predictive values 88.7% and 97.5%, respectively. For the standard Yamaguchi set-without strict application of exclusion criteria-the sensitivity was 96.3%, specificity 98.9%, and positive and negative predictive values 94.5% and 99.3%, respectively. If we applied a stricter definition of exclusion criteria, the sensitivity of the Yamaguchi set decreased to 31.5%. As wall, 37 AOSD diagnoses were missed. CONCLUSION This study validates the Fautrel classification criteria with a cohort independent of that used for the original publication. This criteria set demonstrates good sensitivity and specificity, overcomes exclusion criteria, and includes glycosylated ferritin level. It also confirms the high discriminative power of the Yamaguchi criteria, albeit substantially affected by how exclusion criteria are interpreted.

Macroscopic amoxicillin crystalluria.

A 62-year-old woman was referred to our hospital in September, 2013, with fever, arthralgia, and dyspnoea lasting for 6 days. Her medical history was uneventful apart from hypertension and active tobacco use. Her glomerular fi ltration rate at admission was 82 mL/min per 1·73 m2 (normal range ≥90 mL/min per 1·73 m2). Blood cultures on admission grew Strepto coccus agalactiae and acute aortic infective endocarditis was rapidly diagnosed with transoesophageal echocardiography. She was immediately started on highdose intravenous amoxicillin (200 mg/kg per day) with intravenous gentamicin (240 mg once-daily). After 4 days, we noticed cloudy urine, with a thin granular appearance (fi gure). Her urine pH was 5·5. Direct examination of the urine showed amoxicillin crystalluria with large, typically aggregated needle-shaped crystals (fi gure) that were birefringent under polarised light microscopy. Her clinical condition worsened with oliguria, acute renal failure, and pulmonary oedema within 24 h. An aortic ring abscess was evident on a second echocardiography. After emergency valve replacement surgery and renal replacement therapy, she recovered well and was discharged home in October, 2013, without further renal replacement therapy, and with improving renal function. Her last glomerular fi ltration rate was 45 mL/min per 1·73 m2 in March, 2014. At last follow-up, in September, 2014, the patient was asymptomatic. Amoxicillin is known to cause urine crystallisation, although its incidence is unknown. Amoxicillin crystalluria usually occurs with high-dose amoxicillin therapy, in urines that have a low pH and are highdensity (mainly due to insuffi cient fl uid intakes). Amoxicillin crystalluria can be microscopic or macroscopic. The typical microscopic appearance described here is usually suffi cient for diagnosis in a compatible context but the amoxicillin composition of these crystals can be confi rmed by infrared spectroscopy if needed. Amoxicillin crystalluria can be asymptomatic or can be responsible for haematuria or acute renal failure attributable to intratubular precipitation or urinary tract obstruction. In our patient, acute renal failure was multifactorial, but we speculate that amoxicillin crystalluria could have played a part. Physicians should be aware of such a complication of amoxicillin because high intravenous doses are frequently prescribed worldwide and because urine alkalinisation and increased fl uid intake might prevent crystalluria.

Epidemiology of autoimmune and inflammatory diseases in a French nationwide HIV cohort

Background: HIV infection and inflammatory and autoimmune diseases (IADs) are both related to immune dysfunction. Epidemiological data on IAD in patients living with HIV (PLHIV) are scarce. The aim of this study was thus to estimate the prevalence of 26 IAD among PLHIV followed in a large French multicenter cohort in the combination antiretroviral therapy (cART) era (from January 2000 to July 2013), and to describe their occurrence according to cART onset, the immuno-virological status of patients and hepatitis C virus (HCV) and/or hepatitis B virus coinfection. Method and results: During the study period, 33 403 PLHIV were included in the Dat’AIDS cohort; 1381 patients with an IAD were identified. The most prevalent IADs were psoriasis, sarcoidosis, rheumatoid arthritis, ankylosing spondyloarthritis, Graves disease, autoimmune hemolytic anemia, immune thrombocytopenia and chronic inflammatory bowel disease. In contrast, the prevalence of systemic lupus erythematosus and multiple sclerosis were low. Most patients (59%) developed IAD after HIV infection with a mean delay of 10.6 ± 6.4 years. Compared with the entire cohort, HCV coinfection was significantly more frequent in patients with psoriasis, Graves disease and immune thrombocytopenia, and chronic hepatitis B in patients was more frequent in those with immune thrombocytopenia and autoimmune hemolytic anemia. Among patients developing IAD after the diagnosis of HIV infection, 572 (70%) were on antiretroviral therapy and 419 of them (73%) had undetectable HIV viral load. Conclusion: Our study showed that some IAD are not rare among PLHIV and occur mostly in patients with immuno-virological control under cART. The higher frequency of HCV or hepatitis B virus coinfection for some IAD is also confirmed.

High prevalence of measles seronegativity in adults with HIV infection born in the era of measles vaccination in Northern France.

We investigated measles humoral immunity levels in a cohort of HIV-infected adult patients in France and attempted to identify risk factors for antimeasles antibodies seronegativity. Being born after 1983 [odds ratio (OR) 4.40; 95% confidence interval (95% CI) 1.26–14.09; P = 0.0013] and a nadir CD4+ cell count below 100 cells/&mgr;l (OR 4.79; 95% CI 1.61–14.82; P = 0.0048) were the two factors independently associated with measles seronegativity. Systematic measles antibody screening should be performed in HIV-infected individuals born in the era of measles vaccination (after 1983 in France).

Severe post-artesunate delayed onset anaemia responding to corticotherapy: a case report

Delayed onset haemolysis occurring post-artesunate and post-artemisinin combination therapy is secondary to delayed clearance of infected erythrocytes spared by pitting during treatment. We report a case of severe post-treatment delayed haemolytic anaemia with a positive direct antiglobulin test and a positive response to corticosteroid therapy, suggesting an associated immune mechanism.

Bioclinical Test to Predict Nephropathia Epidemica Severity at Hospital Admission

This test identifies patients at low, intermediate, and high risk for severe disease.

Early neuropsychological adverse events after switching from PI/r to dolutegravir could be related to hyperthyroidism in patients under levothyroxine

We report two patients who had taken levothyroxine at the same dose for several years and who had stable thyroid stimulating hormone (TSH) levels, and who developed clinical and biological hyperthyroidism following switch from ritonavir-boosted protease inhibitors (PIs) to dolutegravir-based HAART. Levothyroxine is metabolized by deiodination and glucuronidation and the induction of glucuronidation by ritonavir leads to an increased elimination of levothyroxine and a necessity of higher daily doses. Patients who switch from ritonavir-boosted PIs to antiretroviral drugs-based HAART with minimal drug-interaction such as dolutegravir, may require an adjustment in their dose of levothyroxine in order to prevent hyperthyroidism due to impaired elimination of levothyroxine without ritonavir.