Philippe Ovetchkine

Rhinoscleroma: A French National Retrospective Study of Epidemiological and Clinical Features

BACKGROUND Rhinoscleroma (RS) is a rare, chronic, granulomatous disease of the upper respiratory tract that is associated with infection with Klebsiella rhinoscleromatis. RS is more common in certain geographic regions than in others, but other risk factors and the pathogenesis of RS remain unclear. METHODS We sent a standardized questionnaire to all pathologists and otolaryngology specialists in French University Hospitals and asked whether they had seen patients with RS in the previous 16 years (1990-2005). We then retrospectively reviewed the files of all patients identified. RESULTS We collected 11 cases of RS, with a median patient age at diagnosis of 35.7 years (range, 5-72 years). The 3 patients with a familial history of RS presented with early-onset forms of RS; 1 had an uncommon aggressive presentation of the disease with ischemic stroke. Two unrelated consanguineous families were identified, 1 of which included 2 affected siblings. Two patients with sporadic disease were positive for HIV infection. All patients were living in France, but most were immigrants from areas where RS is endemic (North Africa, 3 of the 11 patients; West Africa, 4 patients; and Turkey, 1 patient). The probable duration of exposure to K. rhinoscleromatis in endemic areas varied widely: 0-28 years. Clinical features and outcome also varied considerably among cases. Biopsies had been performed for all patients and revealed granulomas containing Mikulicz cells. Cultures of biopsy tissue were positive for K. rhinoscleromatis in 5 of the 11 cases. Prolonged antibiotic treatment was administered to all patients, as follows: ciprofloxacin (7 patients), third-generation cephalosporins (2), tetracycline (2), and clofazimine (2). Eight of the 11 patients did not experience relapse during extended periods of follow-up (1.3-12 years). Relapses in 3 patients were confirmed by a second biopsy. CONCLUSIONS The occurrence of early-onset RS in multiplex and/or consanguineous families suggests that genetic control of the host response to K. rhinoscleromatis may be involved in the pathogenesis of RS in endemic areas.

Tuberculosis in adolescents: A French retrospective study of 52 cases.

Background: The only available data about tuberculosis (TB) among adolescents date back to the 1980s, although the incidence of tuberculosis has been increasing in this age group. Methods: Medical records were reviewed for all adolescents aged 12 to 18 years hospitalized with the diagnosis of TB in Avicenne/Jean Verdier Teaching hospital (Seine-Saint-Denis, suburb of Paris) between September 2000 and December 2004. Results: Of the 52 patients identified, 52% were female. Median age at diagnosis was 15 years (range, 12–18 years). The proportion of adolescents known to be born abroad was 90%. Diagnoses resulted from the examination of a sick child in 79% of cases, a case contact investigation of an adult suspected of having TB in 19% and routine tuberculin skin test in 2%. Twenty-seven of 52 patients (52%) had isolated pulmonary disease. Sixteen patients (31%) had pulmonary and extrapulmonary TB and 8 cases (17%) had exclusively extrapulmonary disease. The site of extrapulmonary TB included pleural (n = 8), meningitis (n = 4), lymph node (n = 4), peritoneal (n = 5), osteoarticular (n = 3) and genitourinary (n = 1). TB was confirmed by the isolation of Mycobacterium tuberculosis from sputum (n = 21), gastric aspirate (n = 8), bone (n = 1) or cerebrospinal fluid (n = 2). No case had a relapse or recurrence of disease in median 3.2 years of follow up. Conclusions: Our results indicate that demographic and clinical characteristics of adolescents with TB differed from adults and children. A specific approach to the prevention and treatment of TB in adolescents is absolutely necessary.

Bordetella holmesii Bacteremia in Asplenic Children: Report of Four Cases Initially Misidentified as Acinetobacter lwoffii

ABSTRACT Bordetella holmesii is a fastidious Gram-negative rod that was initially identified in 1995. It causes bacteremia, predominantly among patients with anatomical or functional asplenia. We report four cases of B. holmesii bacteremia in asplenic children occurring within the last 4 years. In all cases, B. holmesii was misidentified by an automated system as Acinetobacter lwoffii.

Varicella-Zoster Virus Disease Is More Frequent after Cord Blood Than after Bone Marrow Transplantation

Immune reconstitution may differ following cord blood transplantation (CBT) and bone marrow transplantation (BMT), and this may lead to a difference in varicella zoster virus (VZV) disease rates. One hundred fourteen VZV seropositive children received a CBT (37 patients), or a T-replete BMT (77 patients) at our institution. Patients did not received specific VZV disease prophylaxis. VZV disease was diagnosed by immunofluorescence or culture in 41 (36%) patients. In multivariate analysis, VZV disease was more frequent in older children (relative risk [RR] 1.11 per year; 95% confidence interval [CI], 1.04-1.18; P = .002), and after CBT (RR 2.27; 95% CI, 1.18-4.34; P = .013). The cumulative incidence of VZV disease at 3 years posttransplant was 46% following CBT. VZV disease incidence was 71% in CBT patients over 10 years old at transplant. Visceral dissemination occurred in 7 patients (6 CBT and 1 BMT) (P = .005). VZV disease is thus more frequent and more severe after CBT than after BMT.

An 8-y-old boy with acute stroke and radiological signs of cerebral vasculitis after recent Mycoplasma pneumoniae infection.

A young boy was admitted to hospital for acute stroke. Cerebral angiography showed a pattern suggestive of vasculitis and a recent Mycoplasma pneumoniae infection was detected. The absence of microorganisms in cerebrospinal fluid, the pattern of vasculitis and previous reports supporting a post-infectious immunological mechanism for certain complications of M. pneumoniae infection suggest this mechanism as the cause of the stroke.

Therapeutic drug monitoring for triazoles: A needs assessment review and recommendations from a Canadian perspective

Therapeutic drug monitoring (TDM) is necessary for certain drugs to ensure that the levels are sufficient to be effective, but not so high as to cause adverse effects. This review summarizes the literature regarding TDM for newer-generation extended-spectrum triazoles, including when TDM may be necessary for each drug and why, and laboratory techniques used for the measurement of levels of these drugs. The document includes recommendations for the use of TDM for each triazole that is discussed.

Evaluation of streptococcal clinical scores, rapid antigen detection tests and cultures for childhood pharyngitis

Three strategies for the diagnosis of group A streptococcal pharyngitis in children have been compared. The predictive negative value of rapid antigen detection tests forgoes the need for confirmative bacteriological culture. Group A streptococcal (GAS) pharyngitis is one of the most frequent bacterial infections in childhood; however, acute rheumatic fever (ARF) is now, in most developed countries, a very rare disease [1]. The dilemma is to maintain the previous outcomes (prevention of ARF and the other benefits of antibiotic treatments) and reduce antibiotic consumption. The aim of this study was to compare three strategies: the use of streptococcal clinical scores (SCS), rapid antigen detection tests (RAT) alone or follow-up with culture on all RATnegative patients. The study population consisted of children presenting with signs and symptoms of pharyngitis at 20 private paediatric practices and three hospital paediatric emergency units. For each patient, the physician completed a brief assessment form including the scores devised by McIsaac et al. [5] and Wald et al. [6]. A throat swab was obtained using a double collection device (Culturette Marion II with transport medium). Swab 1 was used for the RAT; if negative, then swab 2 was submitted for conventional culture within 48 h. All patients with positive RAT or positive GAS culture were considered as infected (GAS+) and all patients with negative RAT and negative culture were assumed to be not infected (GAS-). Between January 1998 and January 1999, 604 of 684 patients (median age 5.5±2.9 years) were assessed. A total of 268 patients (44%) had a positive RAT and 7 out of 336 patients (2%) with a negative RAT had a positive GAS culture. The GAS+ patients were more likely to present with sore throat, palatal petechiae, skin rash, and cervical lymphadenopathy. In contrast, the GASpatients presented more frequently with rhinorrhoea and cough. Distribution of scores and conditional frequency of GAS pharyngitis according to each score are presented in Table 1. In our study, with the currently available test kits, the incidence of RAT-negative patients with a positive back-up culture was very low (2%) but comparable with recent studies [4]. The use of a simple SCS without microbiological confirmation has recently been recommended as an acceptable alternative; however, this strategy is not supported by the findings in children [5,6]. If RATs are performed only for patients with high scores, most patients will have a positive test and only a few will require a confirmatory culture. On the other hand, patients with low scores could have only conventional throat culture. This strategy could reduce the cost of correctly identifying children with GAS pharyngitis [6]. RATs provide results faster than culture and falsepositive results are minimal, leading to rapid identification and treatment, minimising over-prescription of antimicrobials [3]. Neither conventional throat culture nor RATs differentiate accurately infected persons from asymptomatic Presented in part at the 21st European Society for Paediatric Infectious Diseases, Sicily, April 2003.

CLINICAL AND MICROBIOLOGIC CHARACTERISTICS OF GROUP A STREPTOCOCCAL NECROTIZING FASCIITIS IN CHILDREN

An increase in the incidence of Group A streptococcal necrotizing fasciitis has recently been observed in Montréal, Canada. Clinical features of children hospitalized for invasive Group A streptococcal infections and various virulence factor genes of the bacteria were concomitantly analyzed. It was determined that varicella and presence of speC gene in group A streptococcal strains were associated with necrotizing fasciitis.

Evaluation of a school-based program for diagnosis and treatment of latent tuberculosis infection in immigrant children

OBJECTIVE To evaluate a 10-year school-based latent tuberculosis infection (LTBI) screening program, targeting immigrant children in Montreal, Canada, and to identify predictive factors for refusal and, poor adherence to treatment. METHODS Immigrant children were screened for LTBI with Tuberculin Skin Test (TST). Isoniazid was, given when LTBI was diagnosed. Predictors of LTBI, of refusal of follow-up and treatment and of poor, adherence to isoniazid were analyzed. RESULTS Four thousand three hundred and seventy-five children were offered screening, 82.3% consented to TST and 22.8% were positive. An, older age at migration (odds ratio (OR)=1 [95% CI: 1.0-1.01]), as well as migration from a none, established market economy country (OR varying from 2.41 to 4.23) were significantly associated with, positive TST. Among positive children, further evaluation was refused in 5.7%, mainly in migrants from, Eastern Europe (OR=4.05 [95% CI: 2.14-7.69]). Refusal of treatment (11.2%) was more frequent in, Eastern European when compared to South-eastern Asian (OR=6.91 [95% CI: 1.56-30.75]), in, blended families (OR=3.25 [95% CI: 1.25-8.46]) and when the first visit to hospital was delayed (OR=1.01 [95% CI: 1.0-1.02]). Adequate completion of treatment was noted in 61.3%. Age>16 years (OR=1.82 [95% CI: 1.82-2.99]), a delay between TST and first visit>15 days (OR=1.6 [95% CI: 1.12-2.28]), as well as the presence of relative>18 years in the household (OR=1.56 [95% CI: 1.0-2.43]), were associated with poor adherence to treatment. CONCLUSION Sociocultural and behavioural factors are involved in acceptance of LTBI treatment in, immigrant children. Adherence to treatment is challenging and requires comperhension of sociocultural beliefs and accessibility to TB clinic.

Systemic capillary leak syndrome presenting as recurrent shock.

Objective: To report a case of systemic capillary leak syndrome (SCLS) in a child. Design: Case report. Setting: Pediatric intensive care unit. Patient: A 6-yr-old girl was admitted twice to the pediatric intensive care unit, at a 10-month interval, in severe shock with important edema. Results: The patient presented with acute symptoms of abdominal pain, vomiting, and syncope in the hour preceding the shock. During both episodes necessary management included aggressive intravenous fluid rehydration, mechanical ventilation, and use of inotropes/vasopressors. Suspicion of a lower limb fasciitis necessitated surgical exploration, but pathology reports were negative on both occasions revealing only subcutaneous tissue edema. The patient recovered within 24 hrs on both episodes. Investigation ruled out cardiogenic shock and septic shock due to bacterial etiology. On the first episode, a nasopharyngeal aspirate was positive for influenza A (H3N2) by both viral immunofluorescence and culture. The presumed diagnosis was toxic shock syndrome associated with influenza virus. On the second episode, all bacterial and virology cultures remained negative. Hypovolemic shock was suspected, but there was no history of dehydration, bleeding, or gastrointestinal losses (persistent vomiting or diarrhea). Noninfectious causes of hypovolemic shock with edema were ruled out, leading us to believe that she suffered from SCLS. Conclusions: Although well described in the adult literature, there have been few reports of SCLS in pediatric patients. SCLS should be considered in the differential diagnosis of recurrent hypovolemic shock without identifiable cause. The only therapeutic intervention is to obtain vascular access when initial manifestations occur and give aggressive fluid reanimation.