Candida endocarditis: role of new antifungal agents

Despite the relative high frequency of Candida bloodstream infection, Candida endocarditis is a rare entity. We report seven cases, which occurred during a period of 1 year in western France. Six cases were because of Candida albicans , and one pacemaker endocarditis was because of Candida parapsilosis . All patients were men and presented risk factors for candidaemia. Of the six patients with valvular involvement, five received caspofungin and two had surgical valve replacement. Three patients treated with caspofungin antifungal therapy without valve replacement were cured from endocarditis. Antifungal and surgical strategies are discussed, in particular, the possible role of new antifungal therapies and long-term suppression therapy without surgery. One patient died in the acute phase of endocarditis, three patients died of causes unrelated to infective endocarditis and three patients had a favourable outcome.     

Un érysipèle révélant une infection à Dermatobia hominis

Myiases are parasitic infections by larvae of flies. The development of intercontinental travels increases the incidence of tropical myiasis in travellers. We report the case of a patient, having recently stayed in Peru, presenting with an inflammatory plate of the right shoulder, covered with small papules with a hole inside. The initial aspect seemed like an erysipelas. Considering the resistance to the antibiotic treatment, the diagnosis of myiase was suspected. The local application of petroleum jelly allowed the exit of nine larvae of Dermatobia hominis and a fast good outcome. In human beings, the number of larvae usually infecting the same individual varies from one to four. This observation is original because of the number of implied larvae, which explains the intensity and the extent of the local inflammatory signs, which first looked like erysipelas. This diagnosis must be suspected in cases of erysipelas resistant to antibiotics in patients back from an endemic area.     

Anticardiolipin antibody levels predict flares and relapses in patients with giant-cell (temporal) arteritis. A longitudinal study of 58 biopsy-proven cases

OBJECTIVE: To evaluate the usefulness of anticardiolipin antibodies (aCL) in identifying flares and relapses in giant-cell arteritis. METHODS: We studied 58 consecutive patients with biopsy-proven temporal giant-cell arteritis. C-reactive protein and aCL serum levels were measured simultaneously at the time of diagnosis and at each out-patient visit until recovery. All observed episodes of a rise in C-reactive protein attributable to a precise cause, for which the simultaneous measurement of aCL was available, were analysed. RESULTS: The mean duration of clinical observation and serum aCL assessment was 34+/-18 and 24+/-11 months, respectively. Anticardiolipin antibody positivity (IgG or total antibodies > or =20 U) before treatment was found before treatment in 27 cases (46.6%) (mean 45.6+/-26 U/l, range 20-110 U). Levels of aCL decreased below 10 U with appropriate treatment in all patients except one, after a variable delay. No rise in aCL levels was recorded subsequently in any patient whose disease was controlled permanently. A significant rise in aCL was recorded in 20 of 27 (74%) of the flares or relapses of giant-cell arteritis, including seven of 12 flares in seven patients whose initial aCL level was <20 U vs none of the 28 inflammatory episodes unrelated to giant-cell arteritis (P<0.0000001). IgM aCL, infrequently found at diagnosis, was not associated with signs of disease activity. CONCLUSION: Serum aCL levels are useful in the detection of flares and relapses in giant-cell arteritis, with fairly good sensitivity (74%) and a specificity of 100%, and can be of value in distinguishing subclinical flares from infection.     

Optimal duration of antibiotic therapy in vertebral osteomyelitis

OBJECTIVES: To compare the risk of relapse of vertebral osteomyelitis (VO), according to the duration of antibiotic therapy (< or =6 weeks versus >6 weeks). METHODS: We performed a 10-year retrospective study to assess the risk of VO relapse and to verify that this risk was not enhanced in patients who received 6 weeks of antibiotic therapy (Group 1) as compared with those who received a longer treatment (Group 2). VO was diagnosed based on clinical manifestations, magnetic resonance imaging and/or computed tomography findings, and isolation of a pyogenic organism in blood cultures and/or a discovertebral biopsy. Relapse was diagnosed based on isolation of the same organism in blood cultures and/or a discovertebral biopsy. Outcome was evaluated 6 months post-treatment and in December 2004. RESULTS: Group 1 included 36 patients (mean age, 58 +/- 15 years) and Group 2 included 84 patients (mean age, 67 +/- 15 years) (P = 0.003). Clinical data and microorganisms were comparable in the 2 groups. In the first 6 months, 6 (5%) patients died (Group 1, n = 2; Group 2, n = 4), and 5 (4%) in Group 2 relapsed, 2 with recurrent VO and 3 with recurrent bacteremia. In 2004, 91 patients were evaluated (mean follow-up, 40.6 +/- 31 months): 77 (85%) were cured, 13 (14%) died (Group 1, n = 3; Group 2, n = 10), 1 had VO due to a different microorganism (Group 2), and no long-term relapses occurred. CONCLUSION: Our results suggest that antibiotic therapy of VO could be safely shortened to 6 weeks without enhancing the risk of relapse.     

Legionnaire's pneumonia: Is there really an interstitial disease?

OBJECTIVE: Legionella pneumonia is usually classified as "atypical pneumonia", which suggests a predominance of interstitial patterns in chest X-rays. Based on a selection of recent clinical cases and a brief review of the literature, the aim of the study is to clarify, how far the actual radiological findings would be consistent with these expectations. PATIENTS AND METHODS: A retrospective analysis of 18 epidemic personal cases and a review of the literature data were performed to describe the chest X-ray findings of Legionella pneumophila (LP) community acquired pneumonia. X-ray review was performed simultaneously and in consensus by two radiologists (J.P.T., E.C.) and a physician (C.G.). RESULTS: From our series, 17 patients had an abnormal chest X-ray on admission. Among these pathological X-ray cases, infiltrates were more often confluent (n=16), or patchy (n=7), rather than interstitial (n=1). Fifteen patients had infiltrates involving the lower lung fields. Bilateral distribution of abnormalities and pleural effusion were each observed in three cases. Radiological findings deteriorated between the second and seventh days following admission, particularly in the form of patchy infiltrates with pleural effusion. The review of the literature is consistent with these findings, by reporting prevalent confluent or patchy infiltrates. CONCLUSIONS: These findings are consistent with the physiopathological particularity of this affection and incite us to avoid the classification "atypical pneumonia" in radiologic terminology. This term is more appropriate for clinical and microbiological use.     

Tuberculosis treatment duration in France: From guidelines to daily practice

BACKGROUND: Guidelines for tuberculosis (TB) recommend 6 months of treatment except for meningeal TB, where a 9- to 12-month course may be preferred. METHODS: In order to assess whether practices in France are in agreement with those guidelines, we performed an anonymous audit of the policy of French physicians, focusing on TB treatment duration and corticosteroid use according to the TB presentation. RESULTS: Sixty-six completed forms were analyzed. Reported treatment duration was usually 6 months for pulmonary TB (91% of physicians) and miliary TB (45%), 9 months for pulmonary TB in HIV-infected patients (42%) and for TB lymphadenitis (57%), and 12 months for TB meningitis (79%) and osteo-articular TB (65%). Corticosteroid use was systematic for meningitis (80%) and pericarditis (65%). CONCLUSION: This study reveals discrepancies between guidelines and daily practice for TB treatment duration in France: We observed a very high reported rate of unnecessary, prolonged treatment for most extrapulmonary TB.