Isabelle Pelloux

Human Tularemia in France, 2006–2010

BACKGROUND Tularemia is an endemic but rare disease in France. We describe the epidemiologic, clinical, diagnostic, treatment, and prognostic aspects of the disease in 101 consecutive patients investigated during a 5-year period (2006-2010). METHODS All tularemia cases confirmed at the French Reference Center for Tularemia (FRCT) were included. Data were collected both at the Institut de Veille Sanitaire (mandatory notification) and FRCT. Diagnostic methods included serological tests (microagglutination and indirect immunofluorescence assay), Francisella tularensis cultures, real-time polymerase chain reaction (RT-PCR) tests, and molecular identification of the F. tularensis subspecies involved. RESULTS The patient cohort consisted of 55 men and 46 women (sex ratio, 1.2; average age, 51.7 years), including 93 sporadic cases that occurred throughout France. Contaminations occurred predominantly through contact with or ingestion of lagomorphs (31.7%), tick bites (10.9%), or contaminated environments (7.9%). The glandular and ulceroglandular forms predominated (57.5% of cases), but 18.8% of patients experienced a systemic disease and 29.7% were hospitalized. Specific diagnosis was mainly based on serology, but 38.6% of patients had positive RT-PCR tests and 20.8% had a positive culture. F. tularensis subspecies holarctica was identified in 25 patients. All patients except 1 recovered from infection, but 38.6% experienced relapses despite appropriate antibiotic therapy. CONCLUSIONS The epidemiological and clinical aspects of tularemia in France are varied, suggesting different modes of contamination. The high rates of systemic diseases and hospitalization indicate that the more serious cases are more likely to be diagnosed and notified. RT-PCR tests may help to improve diagnosis and reporting of the disease.

African Tick Bite Fever in Elderly Patients: 8 Cases in French Tourists Returning from South Africa

BACKGROUND African tick-bite fever, a tickborne disease caused by Rickettsia africae, is endemic in rural areas of sub-Saharan Africa and in the French West Indies. Most cases reported in the literature occurred in middle-aged, otherwise-healthy persons and corresponded to benign diseases. The course of African tick bite fever in elderly people is less well documented. METHODS The medical records of 8 elderly patients infected with R. africae during a trip to South Africa in 2005 are presented to summarize the epidemiologic, clinical, microbiological, treatment, and disease course characteristics. RESULTS Eight patients, aged 63-75 years, developed African tick bite fever symptoms after a trip to South Africa. R. africae was grown from cutaneous eschar biopsy specimens obtained from 4 patients, confirming African tick bite fever. We observed unusual findings in this elderly population. Rash was frequent (present in 87.5% of patients), vesicular (in 100% of patients with rash), and often associated with an enanthema (in 50% of patients with rash). Severe clinical manifestations occurred: lymphangitis and myocarditis in 1 patient and suspected brain involvement in 2 patients. We observed severe and long-lasting general symptoms, including fever (in 75% of patients), chills (87.5%), asthenia (50%), anorexia (50%), and weight loss (12.5%). With doxycycline therapy, the outcome was favorable in all cases, but complete recovery was slow. CONCLUSION Ecotourism to sub-Saharan Africa is expanding, and people of advanced age, often with underlying chronic diseases, account for an increasing proportion of travelers. African tick bite fever appears to be more symptomatic in this population. Recommendations advising personal prophylactic measures to prevent tick bites in travelers to regions of endemicity may be particularly important for elderly individuals.

Real-Time PCR for Diagnosis of Oculoglandular Tularemia

To the Editor: Oculoglandular tularemia accounts for 3%–5% of all diagnosed tularemia cases (1). We report the diagnosis of this disease in 2 patients in France by real-time PCR. Patient A, a 43-year-old woman, was referred in October 2006 to the infectious disease department of Auch Hospital (Auch, France). She had a fever (39°C) and severe conjunctivitis of the right eye that had evolved over 2 weeks despite administration of amoxicillin/clavulanate. The patient lived in a rural area endemic for tularemia and had regular contact with dogs and ring doves. She remembered harvesting mushrooms in a nearby forest a few days before onset of clinical symptoms. Physical examination showed a hyperemic and painful right conjunctiva, enlarged (0.5–1.5 cm in diameter) and tender preauricular and submandibular lymph nodes, and cellulitis of the right hemiface. Her condition rapidly improved after she received doxycycline and gentamicin. Patient B, a 42-year-old woman, was referred in October 2008 to the infectious disease department of Dijon University Hospital (Dijon, France) for intermittent fever (38.5°C) and swollen left-sided pretragal and cervical lymph nodes, which had evolved for 3 weeks despite administration of amoxicillin, followed by pristinamycin and prednisone, and ciprofloxacin for 7 days. The patient remembered being scratched on the left hand by her dog several weeks earlier; the scratch healed spontaneously. She had recently walked in a nearby forest that was endemic for tularemia. Physical examination showed enlarged (2–3 cm in diameter), tender lymph nodes and bilateral conjunctivitis. Her condition improved after doxycycline therapy, but the pretragal lymph nodes were removed surgically in late November 2008 because of suppuration and necrosis. Ofloxacin was administered until January 2009 because of persistence of inflammation in cervical lymph nodes and suppuration with skin fistulization in the pretragal region. Diagnostic investigations (Table) conducted at Grenoble University Hospital included serologic tests (microagglutination and indirect immunofluorescent antibody assay by using locally prepared Francisella tularensis subsp. holarctica antigen), culture, and 2 real-time PCRs. These PCRs were specific for insertion sequence ISFtu2 or the Tul4 protein–encoding gene of Francisella sp. and used previously described primers, probes, an amplification protocol (2), and a LightCycler 2.0 apparatus (Roche, Meylan, France). We tested 5 μL of DNA extracted from clinical samples by using the QIAamp DNA Mini kit (QIAGEN, Hilden, Germany). Three negative controls (DNA-free water) and 1 positive control (DNA extracted from the F. tularensis subsp. holarctica LVS strain) were used for each PCR. Table Characteristics of the 2 patients in the study and test results for tularemia, France* Seroconversion was found between acute-phase and convalescent-phase serum samples from both patients. A conjunctival cotton swab sample from patient A and pretragal lymph node suppuration and biopsy samples from patient B were positive for F. tularensis by both real-time PCRs. A Francisella sp. strain was isolated from the conjunctival discharge from patient A at Auch Hospital and Grenoble Hospital laboratories. Cultures were grown in a BioSafety Level 3 laboratory at Grenoble University Hospital because results of both PCRs were positive. Cultures of specimens from patient B were negative. Both patients were infected with an F. tularensis subsp. holarctica strain. Infection was identified by PCR amplification and sequencing of the 16S rRNA gene (fD1 and rP2 primers) and the intergenic spacer region (FTitsFw 5′-ACCACGGAGTGATTCATGACTG-3′ and FTitsRv 5′-TCTCAATTGATTTCTCTTCCTAAGG-3′ primers) from the strain isolated from patient A and directly from the lymph node biopsy specimen from patient B. Conjunctival inoculation of F. tularensis usually occurs by contact when a contaminated finger comes into contact with the eyes, e.g., after handling of an infected animal or tick (3,4), but the source of infection often remains undetermined, as for our 2 patients. Symptoms are not specific and correspond to Parinaud oculoglandular syndrome (1). Reported complications include keratitis, occasional corneal perforation, and lymph node suppuration; tonsillitis, cellulitis in nearby skin tissue, retinitis, erythema nodosum, and progression to systemic disease occur less frequently (3–7). A specific microbiologic diagnosis is needed for appropriate treatment because many microorganisms can cause Parinaud oculoglandular syndrome and clinical symptoms are not specific (1,8). Fluoroquinolones are now considered first-line treatment for tularemia; β-lactam antimicrobial agents are not effective (9). Oculoglandular tularemia is a painful disease with a short incubation period (3–5 days), and results of serologic tests of acute-phase samples are often negative (1,9). Isolation of F. tularensis is difficult and hazardous to laboratory personnel (1,9). PCR-based techniques may enable a more rapid diagnosis (1,9,10). Heating clinical samples before testing prevents laboratory-acquired infections. We report the use of real-time PCR for detection of F. tularensis from a conjunctival swab specimen. Many clinical laboratories are now equipped with this technology. Transport conditions of clinical samples (4°C, no transport medium, 24–48 h) are not restrictive. When compared with PCR, real-time PCR does not require post-PCR processing, enabling a faster turn-around time. Oculoglandular tularemia is a rare but underestimated disease. Real-time PCR detection of F. tularensis DNA from conjunctival swab suspensions now provides a rapid, noninvasive, sensitive, and specific diagnosis of oculoglandular tularemia. This assay enables early establishment of specific antimicrobial drug therapy and poses no risk of infection for laboratory staff.

Treatment of Tularemia in Pregnant Woman, France

A pregnant woman who had oropharyngeal tularemia underwent treatment with azithromycin and lymph node resection and recovered without obstetrical complication or infection in the child. Azithromycin represents a first-line treatment option for tularemia during pregnancy in regions where the infecting strains of Francisella tularensis have no natural resistance to macrolides.

An original case of Francisella tularensis subsp. holarctica bacteremia after a near-drowning accident

Abstract We report the first case of Francisella tularensis subsp. holarctica bacteremia after water contamination in France. A 75-year-old man developed septic pneumonic tularemia after a near-drowning accident. We highlight the need for a longer incubation time for isolation of F. tularensis from blood cultures.

Two cases of type A infant botulism in Grenoble, France: no honey for infants

We report two severe cases of infant botulism diagnosed at Grenoble University Hospital, France, respectively in 2006 and 2009. Both cases were characterized by a delay in diagnosis, severe neurological manifestations and extended period of hospitalization in intensive care unit, but a complete recovery. Infant botulism is a rare but life-threatening disease. It primarily affects infants, and the main risk factor is honey ingestion. Diagnosis should be systematically evoked by pediatricians in infants suffering from constipation, fatigue, muscle weakness, difficult feeding and altered cry, but before the onset of generalized flaccid paralysis, so as to administer specific treatment (BabyBIG®, a human derived botulinum antitoxin) at an early stage of the disease when it is most effective. In conclusion, parents should be aware of the role of honey as a source of spores of Clostridium botulinum and therefore infant botulism in the first year of life.

Borrelia crocidurae meningoencephalitis, West Africa.

Borrelia crocidurae–associated relapsing fever is endemic to West Africa and is considered benign. We report 4 patients with B. crocidurae–associated neurologic symptoms; 2 of their cases had been misdiagnosed. Frequency and severity of this disease could be underestimated; molecular methods and serodiagnostic tests for Lyme disease might be helpful in its detection.

Francisella tularensis et la tularémie

Resume Francisella tularensis est une bacterie a Gram negatif, intracellulaire facultative, de reservoir animal etendu, responsable de la tularemie. Ce pathogene hautement infectieux chez l’Homme, est considere comme agent potentiel de bioterrorisme (classe A du CDC). Les infections humaines sont dues a F. tularensis subsp. tularensis (souches de type A, les plus virulentes) en Amerique du Nord et a F. tularensis subsp. holarctica dans tout l’hemisphere Nord. Les infections humaines surviennent au contact d’animaux infectes (lievres), par l’intermediaire d’arthropodes (tiques, moustiques en Scandinavie) ou a partir d’un environnement hydrique ou tellurique contamine. Les manifestations cliniques varient principalement en fonction de la porte d’entree des bacteries et correspondent habituellement aux formes ulcero-ganglionnaires et ganglionnaires (voie cutanee), oculo-ganglionnaires (voie oculaire), oro-pharyngees (voie orale), pulmonaires (voie aerienne ou hematogene) et typhoidiques (variable). Le diagnostic de certitude repose sur l’isolement de F. tularensis a partir de prelevements cliniques, mais cette bacterie fastidieuse est rarement obtenue en culture. La serologie permet le plus souvent de confirmer le diagnostic. L’amplification genique par PCR permet de detecter l’ADN bacterien en phase precoce ou plus tardive de la maladie et apporte une identification de certitude de l’espece F. tularensis et de la sous-espece en cause. Le traitement repose sur les fluoroquinolones et les tetracyclines, les aminosides (streptomycine et gentamicine) etant reserves aux formes graves. La tularemie entraine rarement le deces des patients, mais demeure une maladie frequemment invalidante en particulier du fait de l’abcedation des ganglions infectes. Aucun vaccin contre la tularemie n’est disponible actuellement.