Systematic PCR Detection in Culture-negative Osteoarticular Infections

Background

Identification of microorganisms is crucial for the successful treatment of osteoarticular infections. Molecular methods are more sensitive than culture-dependent methods but may suffer from lack of specificity.

Methods

We studied a large series of 3840 bone and joint culture-negative samples collected from 2308 patients hospitalized in Marseille University Hospitals from November 2007 to October 2009. The samples were systematically cultured for 15 days, and conventional broad-range polymerase chain reaction (PCR) (16S rDNA and 18S rDNA) as well as real-time PCR assays targeting human Bglobin, Staphylococcus aureus, and Kingella kingae were realized on one culture-negative specimen.

Results

Specimens from 741 patients (32.1%) tested positive by culture, including 38 in which bacteria grew only after 6 days of incubation. PCR was positive in 141 (9%) culture-negative specimens. Microorganisms identified by PCR were classified into 2 groups: fastidious bacteria (n = 35), mostly anaerobes in adult patients, and K. kingae in children; and nonfastidious bacteria (n = 106), mostly S. aureus (32.7%). A discrepancy between a positive PCR result for S. aureus and a negative culture were explained by previous antibiotherapy in 31.4% of cases. Our study highlights the usefulness of systematic 16S rDNA gene PCR for the diagnosis of bone and joint infections in culture-negative patients, thus enabling the administration of specific antibiotic treatments.

Conclusions

We recommend the use of conventional broad-range PCR for culture-negative bone and joint specimens, as well as S. aureus-specific PCR for adults and K. kingae-specific PCR for children. 18S rDNA PCR should be reserved only for specific cases.     

Two cases of zoonotic cryptosporidiosis in Spain by the unusual species Cryptosporidium ubiquitum and Cryptosporidium felis

Introduction

Two cases of infection by zoonotic transmission of unusual species of Cryptosporidium were detected in 2010–2011 in Spain (León and Zaragoza).

Materials and methods

Cryptosporidium spp. was detected by microscopic examination of modified Ziehl–Neelsen stained fecal smears. PCR-RFLP of the SSUrDNA gene and sequencing of the amplified fragment confirmed the species.

Results

C. ubiquitum and C. felis were identified in samples from an immunocompetent child and from a HIV-positive adult, respectively.

Conclusions

This is the first report of human infection by C. ubiquitum (cervine) and autochthonous C. felis, identified in Spain.     

Méningite à éosinophiles

Introduction

Diagnosis of Angiostrongylus cantonensis meningitis is not always obvious, even in endemic areas.

Case report

We report a 51-year-old Polynesian man, farmer without past medical history, who was admitted for mild fever, headache, neurological subjective symptoms, and severe muscle pain impeding walking. The diagnosis of A. cantonensis meningitis, guided by hypereosinophilia was confirmed by lumbar puncture and positive specific serology. Lumbar puncture and administration of corticosteroids rapidly reduced headache whereas paraesthesias declined more progressively.

Conclusion

Diagnosis of A. cantonensis meningitis should be considered in patients living or returning from endemic areas with headache associated with subjective neurological symptoms and hypereosinophilia.     

Association between Chlamydophila pneumoniae infection and risk of coronary heart disease for Japanese: The JPHC study

Background

Chlamydophila pneumoniae infection is considered a risk factor for atherosclerosis and coronary heart disease in western countries. However, evidence of it being a risk for Japanese is very limited because of a lower risk of coronary heart disease than for western people. The aim of this study was to examine further the association between C. pneumoniae infection and risk of coronary heart disease in Japanese.

Methods

We conducted a nested case–control study of 49,011 Japanese men and women who participated in The Japan Public Health Center (JPHC) study. By the end of 2004, 196 cases of coronary heart disease and 155 cases of myocardial infarction had been documented among the participants. Two controls were selected for each case. For these subjects, we examined the association between serum anti C. pneumoniae IgA and IgG on the one hand and risk of coronary heart disease on the other.

Results

Concentration of C. pneumoniae IgA antibody was positively associated with risk of coronary heart disease and more specifically myocardial infarction. Subjects with the highest quartile of IgA antibody showed 2.29 (95%CI, 1.21–4.33) times higher risk of coronary heart disease and 2.58 (95%CI, 1.29–5.19) times higher risk of myocardial infarction than those with lowest quartile. However, no such association was detected for IgG antibody.

Conclusion

C. pneumoniae infection was found to be positively associated with risk of coronary heart disease.     

Campylobacter Jejuni and Cytopenias

Background

Leukopenia and thrombocytopenia in a febrile patient are not uncommon and may be a diagnostic clue in patients without an alternative explanation for cytopenias. This has not been reported in Campylobacter jejuni infections.

Methods

A healthy patient with fever, rigors, and an acute diarrheal illness was noted to have a white blood cell count of 2.65 × 10⁹/L and platelet level of 125 × 10⁹/L. Retrospective chart review of all adult C. jejuni stool-positive cases admitted over 1 year revealed leukopenia in 6 of 20 (30%), thrombocytopenia in 5 of 20 (25%), and both in 1 of 20 (5%).

Results

Cytopenias were mild, transient, and not associated with prolonged hospital stay or complications.

Conclusions

Acute C. jejuni infections should be added to the differential diagnosis of acute febrile illnesses that may be associated with leukopenia or thrombocytopenia. Cytopenias can be an important diagnostic clue in febrile illnesses, and their differential is presented.     

Caractéristiques clinicobiologiques des méningites à Enterovirus de l’adulte : étude de 59 cas

Purpose

To describe the epidemiological and clinical features of enteroviral meningitis as well as the biological profile of the cerebrospinal fluid (CSF).

Methods

A retrospective study conducted in a single centre between 2004 and 2008. All aseptic meningitis due to Enterovirus were included.

Results

Fifty-nine patients were included. The triad including fever, headache and neck stiffness was reported in 62% of patients. Twelve patients (20%) had a neutrophilic leukocytosis and 23 (39%) an elevated CRP level. Twenty-eight patients (47%) had a prominent neutrophilic reaction in the CSF and nine (15.2%) had a low glucose concentration. A presumptive anti-bacterial treatment was initiated in 47 patients (80%) for an average of 3.2 days.

Conclusion

Due to the lack of specificity of clinical features and biological manifestations of Enterovirus meningitis, the widespread use of real-time Enterovirus PCR is a priority for reducing the number of unnecessary anti-bacterial treatment. Guidelines based on clinical and biological features may be associated to help physicians in the differential diagnosis between bacterial and viral meningitides.     

Utilité diagnostique de l’hypo-uricémie dans l’hyponatrémie par sécrétion inadéquate d’hormone antidiurétique

Purpose

Hypo-uricemia is still considered as a hallmark of the syndrome of inappropriate secretion of antidiuretic hormone.

Methods

We analyzed prospectively 98 hospitalized patients with hyponatremia (≤135 mmol/L), excluding those receiving diuretic treatment. Gold standard for the syndrome of inappropriate secretion of antidiuretic hormone combined plasma hypoosmolality, inappropriately concentrated urine, and normal volemia.

Results

A final diagnosis of inappropriate secretion of antidiuretic hormone was obtained in 55 patients. They were significantly hypo-uricemic (188 μmol/L [153–245], median [interquartile range]) versus 241 μmol/L, [179–333]; p < 0,02) but hypo-uricemia (≤240 μmol/L) performed poorly as a diagnostic test: 71 % sensitivity, 53 % specificity. Positive and negative likelihood ratios were 1,67 and 0,49, respectively.

Conclusions

The syndrome of inappropriate secretion of antidiuretic hormone is associated with a lower plasma uric acid concentration, but in routine clinical practice, contrary to what has been previously published, this difference is insufficient for hypouricemia to discriminate reliably between the syndrome of inappropriate secretion of antidiuretic hormone and other causes of hyponatremia.     

Fièvre prolongée intermittente survenant à l’effort

Introduction

Fever of unknown origin is a common reason for care in internal medicine. The wide variety of possible etiologies makes it difficult to standardize the diagnostic work-up that has to be primarily guided by the interview and physical examination.

Case report

We report a case of prolonged fever having as main characteristics to be intermittent and triggered by efforts. The diagnosis of cerebrospinal fluid shunt infection with Propionibacterium acnes was finally made. In reaching this conclusion, many tests were needed, including renal explorations with biopsy showing an aspect of shunt nephritis.

Conclusion

Prolonged fever of unknown origin in a patient having prosthetic material should raise the suspicion of prosthesis infection (especially if the fever is associated with efforts).     

Registro Español de Hemodinámica y Cardiología Intervencionista. XXII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2012)

Introduction and objectives

The Working Group on Cardiac Catheterization and Interventional Cardiology presents the yearly report on the data collected for the Spanish registry.

Methods

Institutions provided their data voluntarily (online) and the information was analyzed by the Working Group's Steering Committee.

Results

Data were provided by 109 hospitals (71 public and 38 private) that mainly treat adults. There were 136 912 diagnostic procedures, 120 441 of which were coronary angiograms, slightly fewer than the year before, with a rate of 2979 diagnostic studies per million population. Percutaneous coronary interventions increased slightly to 65 909 procedures, for a rate of 1434 interventions per million population. Of the 99 110 stents implanted, 62% were drug-eluting stents. In all, 17 125 coronary interventions were carried out during the acute phase of myocardial infarction, 10.5% more than in 2011, representing 25.9% of the total number of coronary interventions. The most frequently performed intervention for adult congenital heart disease was atrial septal defect closure (292 procedures). The use of percutaneous mitral valvuloplasty continued to decline (258 procedures) and percutaneous aortic valve implantations increased by only 10% in 2012.

Conclusions

In 2012, the only increase in hemodynamic activity occurred in the field of ST-elevation myocardial infarction, and the increasing trend had slowed for percutaneous aortic valve implantation and other procedures affecting structure.Full English text available from:www.revespcardiol.org/en     

Micro-angiopathie thrombotique avec anticorps anti-ADAMTS 13 révélant une fièvre Q aiguë

Introduction

Q fever can commonly mimic systemic diseases, leading to several immunological manifestations. Thrombotic micro-angiopathies manifest as a spectrum of related disorders in the form of thrombocytopenic purpura and hemolytic uremic syndrome.

Case report

We report a 77-year-old woman, who presented an acquired thrombotic microangiopathy with renal expression associated with the presence of anti-ADAMTS 13 antibodies, which occurred during an acute infection by Coxiella burnetii (acute Q fever).

Conclusion

Auto-immune disorders are well-known in chronic or acute Q fever but to our knowledge, this is the first reported observation of thrombotic microangiopathy with anti-ADAMTS 13 antibodies.     

Manifestations vasculaires des infections à Campylobacter fetus subsp. fetus : à propos de deux cas

Introduction

Campylobacter fetus is a rare Gram-negative bacteria affecting especially elderly and immunocompromised patients, and that is responsible of vascular and cutaneous involvement.

Observations

We report two cases of C. fetus infection in two diabetic male patients, aged 75 and 85 years. The first patient was admitted for chronic fever. First-line examinations were inconclusive. Combined positron emission tomography and computed imaging tomography (PET-CT) diagnosed an infection of a previously operated popliteal aneurysm. The patient underwent surgery, and per-operative samples were positive for C. fetus. The second patient was admitted for a leg cellulitis. Blood cultures were positive for C. fetus. PET-CT found a septic superficial thrombophlebitis. The outcome was favorable for both patients with prolonged antibiotic therapy.

Conclusion

Vascular involvement should be suspected in the presence of C. fetus infections. PET-CT may be useful, as other imaging modalities are not always contributive.     

Low antibodies titer and serological cross-reaction between <Emphasis Type="Italic">Coxiella burnetii</Emphasis> and <Emphasis Type="Italic">Legionella pneumophila</Emphasis> challenge the diagnosis of mediastinitis,an emerging Q fever clinical entity

Background

Coxiella burnetii is an intracellular and fastidious bacterium responsible of acute and persistent Q fever infection. Endocarditis and vascular infections are the most common serious complications of acute Q fever.

Case report

We report the case of a 63-year-old man that presented a mediastinitis associated with a prosthetic vascular infection. Serological cross-reaction was observed between Coxiella burnetii, the agent of Q fever, and Legionella pneumophila with higher antibodies titer for L. pneumophila (IgG = 1:512) than for C. burnetii (phase I IgG = 1:400). We performed western blot with cross-adsorption that supports the diagnosis of C. burnetii infection. Two weeks later, a positive qPCR and culture for C. burnetii on swab taken from the mediastinal cutaneous fistula confirmed the definitive microbiological diagnosis of Q fever mediastinitis.

Conclusion

Cross-reactivity between C. burnetii and Legionella spp. has long been known and should be considered in patients with persistent infections. It is important to establish the definite diagnosis because the antibiotic treatment regimens and duration are significantly different. To the best of our knowledge, we reported here the first case of mediastinitis associated to C. burnetii and we diagnosed this persistent infection despite low anti-C. burnetii phase I IgG levels.

     

Arthrites réactionnelles secondaires à la BCG-thérapie. Deux observations et revue de la littérature

Introduction

Intravesical bacillus Calmette-Guérin (BCG) therapy-associated articular complications are uncommon, occurring in only 0.5 to 1% of the patients.

Observations

We report two patients who were given intravesical BCG therapy for superficial bladder cancer. Both patients developed polyarthritis and fever related to intravesical BCG instillation. The outcome of articular manifestations was favorable after administration of nonsteroidal anti-inflammatory therapy.

Conclusion

Intravesical BCG therapy-associated articular complications should not be overlooked, as they may result in high morbidity. Nevertheless, the diagnosis of intravesical BCG therapy-related reactive arthritis should be discussed after excluding infectious arthritis due to Mycobacterium bovis. Therefore, joint fluid microbiological tests (cultures, PCR) are required in the patients receiving intravesical BCG who develop arthritis.     

Évaluation départementale des délais de reperfusion des syndromes coronariens aigus avec élévation du segment ST en fonction de la filière de recours aux soins

Introduction

Acute coronary syndrome with ST segment elevation (STEMI) remains a major cause of morbidity and mortality in France, directly correlated with the time management of the patient to achieve reperfusion of the artery as early as possible. But the delay of reperfusion is related to the course that will take the patient to the revascularization.

Methods

To make an observation of departmental practices, we conducted a retrospective monocentric study on the STEMI supported on 4 years in the Departmental Hospital of La Roche-sur-Yon by comparing the time of reperfusion in two groups: patients who used the recommended chain = diRect chain (Call the emergency number–specialist mobile emergency unit–Cardiac intensive care unit or cardiac catheterization laboratory), and patients who used another chain = Long chain.

Results

On 838 patients with STEMI, 356 (42.5%) used the Direct chain. The average time of reperfusion in the Direct chain group is 4.26 hours (±3.12), 6.17 hours (±4.82) in the Long chain group. There is a significant difference between the two groups of 1.9 hours (P < 0.001). Of 186 patients who consulted a general practitioner, 40.3% of patients were not supported by the mobile emergency unit.

Conclusion

These results should lead to improved practices, to carry on continuing medical education with all actors in the chain and patient information to shorten up the time of reperfusion.     

Prise de poids,démence et syndrome cérébelleux sensible à la doxycycline : un probable nouveau cas lié à T. whipplei

Introduction

Whipple's disease is a rare infectious disease due to Tropheryma whipplei, a bacterium rarely causing severe localized neurological infection (only 25 cases reported in the literature), which are more often diagnosed by a positive T. whipplei PCR performed on cerebrospinal fluid.

Case report

We report the third case of progressive dementia associated with obesity and ataxia in a 52-year-old man. Classic laboratory results performed to identify the etiology of the clinical features were non-contributive: only a saliva T. whipplei PCR was strongly positive and the Western blot serology has detected an asymptomatic carriage profile. The ¹⁸FDG-PET highlighted a frontal area hypometabolism. An antibiotic treatment by doxycycline allowed a partial regression of the neurological manifestations, a weight loss and a significant improvement of the ¹⁸FDG frontal hypometabolism.

Conclusion

Progressive dementia associated with ataxia and obesity is a new clinical syndrome caused by T. whipplei. Antibiotic test by doxycycline can help to the diagnosis and ¹⁸-FDG could facilitate the follow-up.     

Algorithm proposal based on the C. Diff Quik Chek Complete ICT device for detecting Clostridium difficile infection

Objective

To assess a new immunochromatography (ICT) test that detects glutamate dehydrogenase (GDH) antigen and Clostridium difficile toxin A/B simultaneously, and to propose an algorithm for the diagnosis of C. difficile infection (CDI) based on this test.

Methods

We analysed 970 stool samples. Discrepant results between GDH and toxin A/B were resolved using toxigenic culture as the reference.

Results

This test enabled us to obtain a conclusive result in <30 min in 93.8% of the samples. Among the discrepant results (GDH (+)/Toxin A/B (−)), 41.7% (25/60) were found to be toxigenic C. difficile by toxigenic culture.

Conclusion

This test has a high sensitivity and specificity for the diagnosis of CDI.     

Low prevalence of H. pylori infection in patients with gastroparesis

Background

The histopathology of the gastric mucosa in patients with gastroparesis, a condition characterized by gastric retention without obstruction, has not been described.

Aim

To test the hypothesis that reactive gastropathy is more common in patients with gastroparesis than in subjects with normal gastric motility.

Methods

We compared the prevalence of reactive gastropathy, Helicobacter pylori infection, chronic gastritis, and intestinal metaplasia in patients with and without a clinical diagnosis of gastroparesis extracted from a national database of subjects with gastric biopsies (1/2008–6/2012).

Results

There were 3040 patients with gastroparesis (median age 58 years, 67.3% women) and 575,895 controls (median age 57 years, 62.0% women) with no evidence of gastroparesis. Reactive gastropathy was marginally more prevalent in patients with gastroparesis (18.9%) than in controls (17.0%). In contrast, H. pylori gastritis was present in 10.8% of controls, but only in 5.9% patients with gastroparesis (OR 0.52; 95% CI 0.45–0.61). Intestinal metaplasia was also less common in patients with gastroparesis (2.8% versus 3.9%; OR 0.82; 95% CI 0.58–0.89).

Conclusions

The low prevalence of H. pylori infection in gastroparesis could be explained by higher rates of previous eradication, conditions unfavourable to the survival of H. pylori, or a protective effect of mucosal inflammation against the development of motility disorders.