Roland Jaussaud

Pre-exposure rabies vaccination: strategies and cost-minimization study.

An alternative strategy for pre-exposure rabies vaccination to the institutional recommendations of the World Health Organization and the Centers for Disease Control and Prevention is proposed based on recent long-term follow-up of post-vaccinal seroconversion rates. The alternative strategy uses the same primary series (i.e. vaccination in the deltoid area on D0, D7, and D28), but is completed by a scheduled booster vaccination at D365. The frequency of recommended subsequent booster injections depends on the serological test results obtained by a RFFIT on D379 and 3 years later. The objective of this study was to compare the efficiency of the two pre-exposure strategies. A cost-minimization analysis was carried out to compare the two rabies pre-exposure vaccination and serological test strategies based on the data from two published studies on the long-term evolution of the immunity achieved using the different recommendations. For a theoretically equivalent immunogenicity, the cost of the alternative strategy ranged from 1.7 to 5.2 times lower than that of the institutional recommendations. A sensitivity analysis confirmed the robustness of the results. The alternative strategy should be validated externally under field conditions. This approach would compare its real efficiency to the institutional recommendations.

Tuberculose lors d'un traitement par agents inhibiteurs du TNF alpha

Key points The clinical forms of tuberculosis that occur during anti-TNFα treatment are frequently extrapulmonary or even disseminated and life-threatening. The paradoxical reactions that can occur under appropriate treatment after stopping TNFα inhibitors raise the question of an immune restoration phenomenon. Adverse drug reaction reporting and epidemiologic studies, despite their methodological limitations, appear to show an excess risk of tuberculosis. Experimental studies reinforce these data. The French drug agency (Afssaps) has issued guidelines for the prevention and management of tuberculosis occurring under anti-TNFα treatment. Analogous guidelines in Spain led to a reduction in the incidence of these cases.The clinical forms of tuberculosis that occur during anti-TNFalpha treatment are frequently extrapulmonary or even disseminated and life-threatening. The paradoxical reactions that can occur under appropriate treatment after stopping TNFalpha inhibitors raise the question of an immune restoration phenomenon. Adverse drug reaction reporting and epidemiologic studies, despite their methodological limitations, appear to show an excess risk of tuberculosis. Experimental studies reinforce these data. The French drug agency (Afssaps) has issued guidelines for the prevention and management of tuberculosis occurring under anti-TNFalpha treatment. Analogous guidelines in Spain led to a reduction in the incidence of these cases.

Métastases mixtes cutanéo-osseuses révélatrices d’un carcinome hépatocellulaire

Resume Un homme de 55 ans etait hospitalise pour une tumefaction frontale gauche. Elle mesurait 6 centimetres de diametre. Elle etait indolore et battante a la palpation, avec un revetement cutane normal. Cette lesion etait apparue depuis 15 jours. La radiographie de crâne et la tomodensitometrie cerebrale montraient une lyse osseuse avec extension endocrânienne, evocatrice de metastase sous cutanee. Les autres explorations (tomodensitometrie thoraco-abdominale et fibroscopie bronchique) ne mettaient en evidence qu’un foie heterogene, et des localisations secondaires sur les surrenales. Les marqueurs tumoraux (ACE, αFP, CA19-9) etaient normaux. C’est la ponction biopsie de la tumefaction qui confirmait le diagnostic de carcinome hepatocellulaire.

Étude comparative des primo-infections à Epstein-Barr virus et à cytomégalovirus chez 52 patients immunocompétents

OBJECTIVE The objective of this study was to compare epidemiological, clinical, and biological data of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) primary infections in immunocompetent adults, admitted in the infectious disease department of the Reims Teaching Hospital between 2000 and 2005. PATIENTS AND METHODS Inclusion criteria were the presence of anti-VCA IgM antibodies or the presence of CMV specific IgM antibodies and the absence of any other positive serology. Differences in reported percentage were compared with a Khi(2) test or Fischers exact test, when appropriate. Continuous variables were compared with the Mann-Whitney Test. RESULTS There were no significant changes over the years in the numbers of EBV (n=32) and CMV (n=20) primary infections. The patients mean age was 22.7 years (14-48 years) in EBV primary infections and 38.6 years (13-66 years) in CMV primary infections (P<0.01). The clinical variables significantly associated with primary EBV infection were sore throat and cervical lymphadenopathy (P<0.01). Arthromyalgia and respiratory manifestations were less frequent in EBV primary infection (P<0.01). The biological variables significantly associated with EBV primary infection were a marked alanine aminotransferase elevation and a marked lymphocytosis with atypical lymphocytes (P<0.001). Thrombopenia was less frequently associated with EBV primary infection (P<0.001). CONCLUSION Clinical and biological presentations of EBV and CMV primary infections were similar. The simultaneous serologic diagnosis of these two infections remains necessary to provide a specific diagnosis, for the most efficient patient care.

Existe-t-il une place pour les AINS/corticoïdes dans la prise en charge de l'érysipèle ?

Resume La place des anti-inflammatoires au cours du traitement des erysipeles, conjointement a une anti-biotherapie adaptee, reste largement controversee dans la litterature. Leur utilisation, par analogie avec les pratiques d’autres specialites, pourrait venir de la capacite de ces molecules a diminuer les phenomenes inflammatoires locaux, a soulager plus rapidement les patients et a prevenir d’eventuelles sequelles liees au processus inflammatoire. De nombreuses observations publiees dans la litterature font etat de complications infectieuses graves, surtout a type de fasciites necrosantes, survenues lors de l’utilisation de telles molecules et plus particulierement des anti-inflammatoires non steroidiens (AINS) au cours de ces situations. Aucune etude controlee (AINS versus placebo) verifiant l’efficacite et l’innocuite de ces traitements n’est actuellement disponible. Une seule etude comparative impliquant la prednisolone fait etat d’un gain modeste d’une journee, dans le groupe recevant de la prednisolone, en termes de mediane de guerison, de diminution de la duree de sejour hospitalier et de diminution de la duree de traitement antibiotique par voie veineuse. Si les donnees actuellement disponibles ne permettent pas d’etablir de facon certaine une relation de cause a effet entre les complications infectieuses severes a type de fasciites necrosantes et l’utilisation des AINS, la prudence est de rigueur et les AINS restent contre-indiques au cours du traitement des erysipeles, en l’absence de preuve objective de leur efficacite.

Thyroidite suppuree. A propos d'une observation

Resume Les auteurs rapportent une observation de thyroidite suppuree a Pneumocoques. A cette occasion, ils passent en revue les problemes etiologiques, diagnostiques, evolutifs et therapeutiques poses par ces affections.