Jennifer P. Stahl

Acute varicella zoster encephalitis without evidence of primary vasculopathy in a case-series of 20 patients

Varicella zoster virus (VZV) is a leading cause of acute viral encephalitis but little is known about its clinical, biological and imaging features. Furthermore, the most favourable treatment regimen has not been determined. We studied a prospective cohort of 20 HIV-negative patients presenting with acute VZV encephalitis caused by primary infection or reactivation. VZV was identified in 16 of 20 cases by PCR detection of the DNA in the cerebrospinal fluid. The four remaining cases occurred during or soon after a VZV rash. The median age of the 17 adults was 76 (19-86) years; the three other patients were children (0.5-5 years). Three patients were immunocompromised. Nine adult patients presented with a rash. Eighteen patients presented with fever and an acute encephalitic syndrome: diffuse brain dysfunction, focal neurological signs, seizures and cranial nerve palsies. Three patients presented with either ventricular or subdural haemorrhage, one with myelitis, and one with asymptomatic stenosis of the middle cerebral artery. The imaging was either normal or revealed non-specific abnormalities such as cortical atrophy but no evidence of stroke. All patients were given acyclovir at various dosages and durations but the case fatality rate remained high (15%) and sequelae were frequently observed either at discharge or at follow-up 3 years later.

Herpes simplex encephalitis and management of acyclovir in encephalitis patients in France.

This study reports on the clinical profiles of herpes simplex encephalitis (HSE) case-patients and the management of acyclovir prescriptions. We designed a study on the causes of encephalitis in France in 2007. Case-patients fulfilling the inclusion criteria were enrolled in all the hospitals that volunteered to participate. Fifty-five of 253 enrolled case-patients were diagnosed with HSE. Three (5%) HSE patients died and 48 (89%) were discharged with persistent neurological symptoms. All HSE patients were prescribed acyclovir, 10 of whom had a 2-week course; 42 a 3-week course; two received incomplete courses; and one received two courses of 21 days each due to relapse. The acyclovir dosage was reported for 45 adult HSE patients, 25 (53%) of whom received 10 mg/kg t.i.d. and 22 (47%) received 15 mg/kg t.i.d. The mortality rate was low despite 49% of patients being admitted to intensive-care units. A high dose of acyclovir was not associated with a better outcome in HSE patients. Most patients had persisting symptoms on discharge suggesting neuropsychological rehabilitation is an important issue for survivors.

Prospective assessment of fluoroquinolone use in a teaching hospital.

The aim of this study was to review the use of fluoroquinolone (FQ) drugs in a teaching hospital and to bring to light the factors associated with FQ misuse. A prospective observational study of FQ prescriptions was conducted in a 2,200-bed teaching hospital. Every hospitalized patient receiving a FQ drug during the 3-week survey period was included. A questionnaire was filled out using medical records and face-to-face interviews with FQ prescribers. An infectious diseases specialist reviewed the questionnaires and analyzed FQ therapy according to local guidelines for FQ prescription. Among the group of 174 patients included, FQ therapy was inappropriate in 88 cases (50.6%; 95% CI 43–58) for the following reasons: inappropriate clinical setting, 43; non-first-line recommendation, 24; inappropriate choice of FQ agent, 9; and inappropriate combination of FQs, 12. FQ prescriptions did not comply with prescription rules in 45 cases (25.9%; 95% CI 20–33). Appropriateness and compliance overlapped for 17 of these 45 patients who received an inappropriate FQ course that did not comply with prescription rules. Finally, FQ therapy was misused for 116 of the 174 patients (66.6%; 95% CI 59–74). Characteristics linked with FQ misuse were hospitalization in surgical wards (p = 0.03), intravenous therapy (p < 0.01), and presumptive therapy (p = 0.05). The FQ misuse rate progressively decreased during the survey period (p = 0.04). FQ misuse was a common phenomenon in the teaching hospital studied. The significant improvement in FQ prescribing practices observed during the study period demonstrates that frequent review of antibiotic use with prescribers is warranted.

Epidemiology of infectious encephalitis causes in 2016

We performed a literature search in the Medline database, using the PubMed website. The incidence of presumably infectious encephalitis is estimated at 1.5-7 cases/100,000 inhabitants/year, excluding epidemics. Infectious encephalitis and immune-mediated encephalitis share similar clinical signs and symptoms. The latter accounts for a significant proportion of presumably infectious encephalitis cases without any established etiological diagnosis; as shown from a prospective cohort study where 21% of cases were due to an immune cause. Several infectious agents are frequently reported in all studies: Herpes simplex virus (HSV) is the most frequent pathogen in 65% of studies, followed by Varicella-zoster virus (VZV) in several studies. Enteroviruses are also reported; being the most frequent viruses in two studies, and the 2nd or 3rd viruses in five other studies. There are important regional differences, especially in case of vector-borne transmission: Asia and the Japanese encephalitis virus, Eastern and Northern Europe/Eastern Russia and the tick-borne encephalitis virus, Northern America and Flavivirus or Alphavirus. Bacteria can also be incriminated: Mycobacterium tuberculosis and Listeria monocytogenes are the most frequent, after HSV and VZV, in a French prospective study. The epidemiology of encephalitis is constantly evolving. Epidemiological data may indicate the emergence and/or dissemination of new causative agents. The dissemination and emergence of causative agents are fostered by environmental, social, and economical changes, but prevention programs (vaccination, vector controls) help reduce the incidence of other infectious diseases and associated encephalitis (e.g., measles).

Guidelines on the management of infectious encephalitis in adults

Recommandations de prise en charge des encéphalites infectieuses de l’adulte J.P. Stahl a,∗,1, P. Azouvi b, F. Bruneel c, T. De Broucker d, X. Duval e, B. Fantin f, N. Girard g, J.L. Herrmann h, J. Honnorat i, M. Lecuit j,k, A. Mailles l,1, L. Martinez-Almoyna m, P. Morand n, L. Piroth o, P. Tattevin p,1, The reviewing group2 a Infectiologie, université et CHU Grenoble Alpes, 38700 La Tronche, France b Réhabilitation neurologique, centre hospitalier de Garches, 92380 Garches, France c Service de réanimation, centre hospitalier de Versailles, 78150 Le Chesnay, France d Neurologie, centre hospitalier de Saint-Denis, 93200 Saint-Denis, France e Thérapeutique, CHU Bichat, 75018 Paris, France f IAME, UMR 1137, Inserm, médecine interne, hôpital Beaujon, université Paris Diderot, Sorbonne Paris Cité, AP–HP, 75013 Paris, France g Neuroradiologie, hôpital La Timone, 13385 Marseille, France h Microbiologie, hôpital Raymond-Poincaré, 92380 Garches, France i Neurologie, hôpital neurologique, CHU de Lyon, 69002 Lyon, France j Unité de biologie des infections, institut Pasteur, CNR et CCOMS Listeria, Inserm U1117, 75015 Paris, France k Department of infectious diseases and tropical medicine, institut imagine, Paris Descartes university, Sorbonne Paris Cité, Necker-Enfants–Malades university hospital, Assistance publique–Hôpitaux de Paris, 75015 Paris, France l Direction des maladies infectieuses, santé publique, 94415 Saint-Maurice, France m Neurologie, hôpital Nord, 13015 Marseille, France n Virologie, université et CHU Grenoble Alpes, 38700 La Tronche, France o Infectiologie, CHU de Dijon, 21000 Dijon, France p Infectiologie, CHU de Rennes, 35000 Rennes, France

Encephalitis due to Mycobacterium tuberculosis in France.

PURPOSE Two hundred and fifty-three patients were included in a study on the etiology of encephalitis, carried out in France in 2007. Tuberculosis was the second most frequently identified cause, after HSV and with the same number of cases as VZV. The authors report the specific features of patients presenting with tuberculosis encephalitis (TE). METHODS TE patients were defined as patients presenting with encephalitis, with positive culture or PCR for Mycobacterium tuberculosis, or the association of clinical, biological, imaging, and epidemiological evidence (possible cases). Clinical, microbiological, and brain imaging data was analyzed and compared to that of other included patients. RESULTS Twenty cases of TE were identified. The M/F sex-ratio was 1.5, the mean age 53 years. Four (20%) patients had a history of tuberculosis before the encephalitis. The median delay between the onset of general and neurological symptoms was significantly longer for tuberculosis cases than for others (10 days vs. 2; P<10(-10)). The median CSF protein level was significantly higher for tuberculosis cases (2.1 g/L vs. 0.8 g/L, P=0.002). CT scan and MRI were normal on admission for eight patients out of 17. Fourteen isolated strains of M. tuberculosis were susceptible to first-line anti-tuberculosis drugs and one was rifampicin-resistant. Six (33%) patients died during hospitalization and two were lost to follow-up. Ten out of 12 (78.6%) had persisting neurological symptoms on discharge. DISCUSSION Despite non-multiresistant MT strains, the case fatality rate among TE patients was high in our series. Early brain imaging is poor contributive for the diagnosis of TE.

La perception de l'hygiène domestique par les Françaises

Objective – Home hygiene is very important in order to prevent transmission of community-acquired infections. We had for aim to determine the habits and knowledge of French women on this issue. Methods – A phone-call survey (CSA-TMO group) was performed, from November 22 to 28, 2000, among 500 women, 18 years of age or more. The women were selected according to usual poll techniques (quotas according to age, social condition, housing, region), and their answers overweighed for mothers with infants. Results – Spontaneously, the word “hygiene” called to mind cleanness (46%), house keeping (20%), but food hygiene or body hygiene was mentioned by only 3% of women. The three most spontaneously mentioned places at home, as requiring strict hygiene, were the kitchen (83%), bathroom (78%), and restroom (67%). The refrigerator was spontaneously mentioned by only 4% of surveyed women, but was rated as 9–10, on the risk scale, by 82% of the same women. The three factors perceived by over 30% of women as facilitating bacterial growth were humidity, lack of hygiene, and dust. The bad conservation of food was mentioned by only 8% of women, at the same rank as the presence of pets. The words Listeria (or listeriosis), Salmonella (or salmonellosis), Staphylococcus were in the mind of only 22%, 18%, and 13% of women. Comments – Home hygiene is more and more frequently mentioned in medias, during epidemics. But the general populations knowledge is still low and requires information and education.

Isolation ofFrancisella tularensis from lymph node aspirate inoculated into a non-radiometric blood culture system

Francisella tularensis is the causative agent of tularemia (1). This zoonosis is infrequent in France (2) but has recently reappeared in the region of Is~re. The diagnosis of human tularemia is commonly established by serologic tests because Francisella tularensis is a fastidious aerobic microorganism (1, 3) and cultures are usually negative (84% serological diagnosis vs. 10% bacterial culture) (4). In the present case Francisella tularensis was isolated from the lymph node aspirate of an infected patient, using the Bactec standard aerobic NR6A bottle (Becton Dickinson, France) as broth culture.

CD-ROM continuous medical education model for the management of urinary tract infections in family practice

OBJECTIVES This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations. METHODS We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included. RESULTS All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P=0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required. CONCLUSION FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.

COL1-02 Détection moléculaire des herpes simplex 1 et 2 et interprétation diagnostique dans l’étude encéphalite, France 2007

Introduction et objectifs L’impact de la detection moleculaire (PCR) dans le liquide cephalorachidien des HSV1/2 sur la prescription d’Aciclovir (ACV) a ete analyse chez les patients de l’enquete encephalite. Materiels et methodes Tous les dossiers ont ete analyses selon le moment de la PCR par rapport au debut des signes neurologiques, la mise sous traitement ACV et sa duree, l’impact d’un diagnostic etiologique autre qu’HSV sur le traitement ACV. Resultats Tous les patients (253) ont eu une PCR HSV, et 55 (22 %) avaient une encephalite herpetique. 173/198 (87,5 %) patients « PCR negative » ont recu d’emblee de l’ACV. Parmi eux, 20 (11,6 %) avaient une infection VZV justifiant le traitement. Les 153 patients restants « PCR negative » mis sous ACV ont ete analyses. Le delai entre les premiers signes neurologiques et la PCR etait de 0 a 13 j (mediane 1 j), la duree du traitement ACV allait de 1 a 25 j (mediane 7 j). Quand un diagnostic etiologique autre que HSV ou VZV a ete fait, la duree du traitement ACV observee a ete coherente avec les delais d’obtention du diagnostic alternatif (arret de l’ACV apres obtention du resultat alternatif). Pour 31 patients, la PCR a ete faite > 3 j (un resultat negatif permettait d’exclure une etiologie herpetique). Pour 118 patients, la PCR a ete faite Conclusion La detection genomique doit etre realisee apres 3 j d’evolution neurologique et dans ces conditions, en cas de resultat negatif, l’utilite du traitement ACV est a reevaluer.