Hossein Mehdaoui

Zika virus detection in urine from patients with Guillain-Barré syndrome on Martinique, January 2016.

We report two cases of Guillain-Barré syndrome who had concomitant Zika virus viruria. This viruria persisted for longer than 15 days after symptom onset. The cases occurred on Martinique in January 2016, at the beginning of the Zika virus outbreak. Awareness of this possible neurological complication of ZikV infection is needed.

Treatment of Optic Neuritis by Plasma Exchange (Add-On) in Neuromyelitis Optica

OBJECTIVEnTo assess the contribution of plasma exchange (PE) in association (add-on) with pulsed intravenous corticosteroids in acute optic neuritis of neuromyelitis optica (NMO) and limited forms of NMO.nnnMETHODSnThirty-six patients with optic neuritis were treated from January 1, 1995, through December 31, 2010, with pulsed intravenous corticosteroids and 16 with pulsed intravenous corticosteroids plus PE. The ophthalmologic examination was performed at least 6 months after optic neuritis treatment. Visual acuity and visual field assessed with the Snellen scale and the logarithmic scale of the Early Treatment Diabetic Retinopathy Study were measured using standard automated perimetry and frequency doubling technology perimetry. Retinal peripapillary fiber thickness was measured using optical coherence tomography.nnnRESULTSnFinal visual acuity was 20/400 in the corticosteroid group and 20/50 in the PE group (P=.04). The gain in visual acuity was 20/200 in the corticosteroid group and 20/30 in the PE group (P=.01). A poor final visual acuity outcome (≤20/200) was found in 19 of 36 patients (53%) in the corticosteroid group and 2 of 16 patients (13%) in the PE group (P=.008). Mean (SD) thickness of peripapillary retinal nervous fibers was 63.1 (20.4) μm in the corticosteroid group and 70.3 (20.3) μm in the PE group (P=.16). The mean (SD) thickness in the temporal quadrant was 38.5 (14.1) μm in the corticosteroid group and 44.5 (12.7) μm in the PE group (P=.02). In multivariate analysis, PE treatment was the only independent factor associated with a visual acuity greater than 20/200.nnnCONCLUSIONnIn optic neuritis associated with NMO, sequential treatment with pulsed intravenous corticosteroids and PE is more effective than standard monotherapy with corticosteroids on visual acuity outcome.

Prospective observational study of low thresholds for platelet transfusion in adult dengue patients

BACKGROUND: The practice of platelet (PLT) transfusions has been adopted into the standard clinical practice in many dengue‐endemic countries. Because many patients were found to have received unnecessary PLT transfusions, the development of guidelines for the management of dengue patients with thrombocytopenia has become a necessity.

Bothrops lanceolatus Bites: Guidelines for Severity Assessment and Emergent Management

Approximately 20-30 declared snakebite cases occurin Martinique each year. Bothrops lanceolatus, a member of the Crotalidae family, is considered to be the only involved snake. B. lanceolatus, commonly named “Fer-de-Lance”, is endemic and only found on this Caribbean island. Envenomation local features include the presence of fang marks, swelling, pain, bleeding from punctures, and ecchymosis. Severe envenomation is associated with multiple systemic thromboses appearing within 48 h of the bite and resulting in cerebral, myocardial or pulmonary infarctions. Diagnosis requires first of all identification of the snake. Coagulation tests are helpful to identify thrombocytopenia or disseminated intravascular coagulation. A clinical score based on 4 grades is helpful to assess envonimation severity. A specific monovalent equine anti-venom (Bothrofav®, Sanofi-Pasteur, France) to neutralize B. lanceolatus venom is available. Its early administration within 6h from the biting in case of progressive local injures, general signs or coagulation disturbances is effective to prevent severe thrombosis and coagulopathy. Its tolerance is considered to be good. Despite an increasing incidence of bites, no deaths have been recently attributed to B. lanceolatus in Martinique, probably due to the currently recommended strategy of early antivenom administration when required.

Star fruit poisoning is potentially life-threatening in patients with moderate chronic renal failure

PurposeStar fruit intoxications have been reported mainly in uremic patients, leading to various degrees of neurological symptoms and potentially fatal outcomes. Nephrotoxicity has been reported in few patients with normal renal function or moderate chronic renal impairment (CRI). The present report describes clinical course, management, and outcome of six patients with moderate CRI admitted to ICU for severe star fruit intoxication.MethodsOver a 1-year period we observed six cases of star fruit intoxication. All but two patients were prospectively monitored. For each case we collected clinical characteristics, management, and outcome.ResultsOn admission, all patients presented acute renal failure with underlying moderate CRI and required intubation for coma. The most common symptoms were hiccups, mental confusion, seizures, and coma. Status epilepticus was authenticated in three patients. Management consisted of several methods of renal replacement therapy (RRT) and supportive measures. Four patients survived without sequelae and two patients died.ConclusionsSevere star fruit intoxication can occur in patients with moderate CRI with a potentially fatal outcome. Prompt continuous RRT should be instituted.

Factors Associated with Severe Leptospirosis, Martinique, 2010–2013

To identify factors associated with disease severity, we examined 102 patients with quantitative PCR–confirmed leptospirosis in Martinique during 2010–2013. Associated factors were hypotension, chest auscultation abnormalities, icterus, oligo/anuria, thrombocytopenia, prothrombin time <68%, high levels of leptospiremia, and infection with L. interrogans serovar Icterohaemorrhagiae/Copenhageni.

Envenomation by the invasive Pterois volitans species (lionfish) in the French West Indies - a two-year prospective study in Martinique.

Abstract Context: The invasion of the lionfish (Pterois volitans) in the French West Indies represents one of the most important marine invasions by alien species in history. Since its first recognition in Martinique in February 2011, the lionfish presence has strongly progressed, resulting in increasing envenomation cases. Our objective was to report features of lionfish envenomation and outcome. Methods: A prospective study conducted at the Martinique University Hospital by the emergency departments, general practitioners, and the pre-hospital emergency ambulance service included all the patients referred from November 2011 to February 2014 for one or several stings by lionfish, as strongly suggested by the fish description and the association with marked local pain and edema. Recommended management included immersion of the affected body part in hot water at 35–40u2009°C for 60u2009min, analgesics, tetanus toxoid, and antibiotics. Results: 117 patients [98M/19F; age: 42u2009±u200914 years [meanu2009±u2009SD]; with significant past morbidities (16%)] were included. Envenomation resulted in marked pain and local edema (100%), paresthesia (90%), abdominal cramps (62%), extensive edema (53%), tachycardia (34%), skin rash (32%), gastrointestinal disorders (28%), fainting (27%), transient weakness (24%), hypertension (21%), hypotension (18%), hyperthermia (9%), bradycardia (3%), hypophosphatemia (12%), elevated aspartate aminotransferase (AST) (10%), and thrombocytopenia (3%). The sting was complicated by local infection (18%) including skin abscess (5%), cellulitis (3%), skin necrosis (3%), and septic arthritis (2%). 26 patients (22%) were hospitalized requiring surgery (8%). Lionfish stings were single (81%) or multiple (19%). Localization was preferentially at one upper (67%) or lower limb (32%). All patients actually improved. Based on multivariate analyses, pain durationu2009>u200924u2009h was significantly associated with skin eruption (pu2009=u20090.001) and muscle cramps (pu2009=u20090.0002). Local infectious complications occurred more frequently in patients presenting multiple stings (pu2009=u20090.008). Immersion in hot water (44%, performed less than 3u2009h after the sting in 36% of the cases) significantly reduced pain duration (pu2009=u20090.02) and local infection (pu2009=u20090.02). Conclusion: Lionfish represents a major health threat in Martinique with increasing envenomation and significant morbidities. Outcome is favorable if promptly managed, with possible reduction in pain duration and local infections with the rapid immersion of the stung body part in hot water. Our data encourage the authorities to develop investigations on the exact extent of the lionfish invasion and set up a regional taskforce to inform the ecosystem users and register all lionfish-attributed incidents.

Preclinical evaluation of the neutralizing ability of a monospecific antivenom for the treatment of envenomings by Bothrops lanceolatus in Martinique

ABSTRACT Bothrops lanceolatus is an endemic viperid species in the Lesser Caribbean island of Martinique. Envenomings by this species are characterized by local and systemic effects, among which the development of thrombosis in various organs is the most severe complication. An experimental toxicological characterization of this venom was performed using in vivo mouse tests and various in vitro assays. The venom induced lethal, local and systemic hemorrhagic, edema‐forming, myotoxic, thrombocytopenic, proteinase and phospholipase A2 activities. The preclinical efficacy of a batch of monospecific Bothrofav® antivenom currently in use in Martinique was assessed. The antivenom was highly effective in the neutralization of all activities tested, in agreement with its described clinical efficacy. This batch of antivenom showed a higher preclinical efficacy as compared to a previous batch used in the past. HIGHLIGHTSThe toxicological profile of the venom of Bothrops lanceolatus from Martinique was studied.Venom induced lethal, hemorrhagic, myotoxic, edema‐forming, and thrombocytopenic effects.The monospecific antivenom Bothrofav® was effective in the neutralization of these effects.This batch of antivenom showed a higher potency than another batch previously used.

Severe snakebite envenomation in French Guiana: When antivenom is not available

&NA; In French Guiana, Bothrops atrox, Bothrops brazili, Bothrops bilineatus, Lachesis muta and Micrurus sp are responsible for most cases of snakebite envenomation. The clinical features in patients suffering from envenomations by viperid snakes involve local tissue damage and systemic manifestations, such as hemorrhage, coagulopathies and hemodynamic instability. We report a severe case of envenomation in a patient bitten by a large unidentified pit viper in French Guiana. Due to lack of antivenom, the patient only received symptomatic management. Severe manifestations of local and systemic envenomation developed, and the patient needed multiple debridement procedures and ultimately required a transfemoral amputation. In addition, Aeromonas hydrophila was cultivated from the affected tissue, suggesting that infection contributed to necrotizing fasciitis. This case highlights the clinical features of a severe viperid snakebite envenomation, and illustrates the urgent need to ensure accessibility of effective and safe polyvalent viperid antivenom in French Guiana. HighlightsSnake envenomation is an underestimated public health issue in Central and South America, with estimated 70,000 cases yearly.In French Guiana, snake bite is an understudied public health problem.In the Amazonian region, severe snakebites are caused by B.atrox, B.brasili, B.bilineatus, L.muta and Micrurus spp.Our patient presented extensive muscular and cutaneous necrosis with multiorgan failure. He did not received antivenom.According to our case and to a recent death from snakebite, antivenom therapy is currently used in French Guiana.

Oral Microbiota of the Snake Bothrops lanceolatus in Martinique

In Martinique, Bothrops lanceolatus snakebite, although relatively uncommon (~30 cases/year), may result in serious complications such as systemic thrombosis and local infections. Infections have been hypothesized to be related to bacteria present in the snake’s oral cavity. In this investigation, we isolated, identified, and studied the susceptibility to beta-lactams of bacteria sampled from the oral cavity of twenty-six B. lanceolatus specimens collected from various areas in Martinique. Microbiota from B. lanceolatus oral cavity was polymicrobial. Isolated bacteria belonged to fifteen different taxa; the most frequent being Aeromonas hydrophyla (present in 50% of the samples), Morganella morganii, Klebsiella pneumoniae, Bacillus spp., and Enterococcus spp. Analysis of antibiotic susceptibility revealed that 66.7% of the isolated bacteria were resistant to amoxicillin/clavulanate. In contrast, the majority of isolated bacteria were susceptible to the third-generation cephalosporins (i.e., 73.3% with cefotaxime and 80.0% with ceftazidime). Microbiota from B. lanceolatus oral cavity is polymicrobial with bacteria mostly susceptible to third-generation cephalosporins but rarely to amoxicillin/clavulanate. In conclusion, our findings clearly support that first-line antibiotic therapy in the B. lanceolatus-bitten patients, when there is evidence of infection, should include a third-generation cephalosporin rather than amoxicillin/clavulanate.