Risk factors for emergency surgery for diverticulitis: A retrospective multicentric French study at 41 hospitals

BACKGROUND

The observed increase in the incidence of complicated diverticulitis may lead to the performance of more emergency surgeries. This study aimed to assess the rate and risk factors of emergency surgery for sigmoid diverticulitis.

METHOD

The primary outcomes were the rate of emergency surgery for sigmoid diverticulitis and its associated risk factors. The urgent or elective nature of the surgical intervention was provided by the surgeon and in accordance with the indication for surgical treatment. A mixed logistic regression with a random intercept after multiple imputations by the chained equation was performed to consider the influence of missing data on the results.

RESULTS

Between 2010 and 2021, 6,867 patients underwent surgery for sigmoid diverticulitis in the participating centers, of which one-third (n = 2317) were emergency cases. In multivariate regression analysis with multiple imputation by chained equation, increasing age, body mass index <18.5 kg/m2, neurologic and pulmonary comorbidities, use of anticoagulant drugs, immunocompromised status, and first attack of sigmoid diverticulitis were independent risk factors for emergency surgery. The likelihood of emergency surgery was significantly more frequent after national guidelines, which were implemented in 2017, only in patients with a history of sigmoid diverticulitis attacks.

CONCLUSION

The present study highlights a high rate (33%) of emergency surgery for sigmoid diverticulitis in France, which was significantly associated with patient features and the first attack of diverticulitis.

Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study

BACKGROUND

In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level.

METHODS

All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD.

RESULTS

In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma.

CONCLUSIONS

This series provides a real-life picture of elective sigmoidectomy for SDD at a national level.

TRIAL REGISTRATION

Comité National Information et Liberté (CNIL) (n°920361).

Impact of the first wave of COVID-19 epidemy on the surgical management of sigmoid diverticular disease in France: National French retrospective study

OBJECTIVE

To analyze the surgical management of sigmoid diverticular disease (SDD) before, during, and after the first containment rules (CR) for the first wave of COVID-19.

METHODS

From the French Surgical Association multicenter series, this study included all patients operated on between January 2018 and September 2021. Three groups were compared: A (before CR period: 01/01/18-03/16/20), B (CR period: 03/17/20-05/03/20), and C (post CR period: 05/04/20-09/30/21).

RESULTS

A total of 1965 patients (A n = 1517, B n = 52, C n = 396) were included. The A group had significantly more previous SDD compared to the two other groups (p = 0.007), especially complicated (p = 0.0004). The rate of peritonitis was significantly higher in the B (46.1%) and C (38.4%) groups compared to the A group (31.7%) (p = 0.034 and p = 0.014). As regards surgical treatment, Hartmann's procedure was more often performed in the B group (44.2%, vs A 25.5% and C 26.8%, p = 0.01). Mortality at 90 days was significantly higher in the B group (9.6%, vs A 4% and C 6.3%, p = 0.034). This difference was also significant between the A and B groups (p = 0.048), as well as between the A and C groups (p = 0.05). There was no significant difference between the three groups in terms of postoperative morbidity.

CONCLUSION

This study shows that the management of SDD was impacted by COVID-19 at CR, but also after and until September 2021, both on the initial clinical presentation and on postoperative mortality.

[Cushing's syndrome with inhaled corticosteroid: Drug interactions to avoid]

Cushing's syndrome is an iatrogenic event occurring during co-administration of inhaled corticosteroids and potent inhibitors of P450 cytochromes. We report the clinical case of a 29-year-old woman with a past history of asthma treated with inhaled fluticasone propionate (FP), chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis (ABPA) treated with itraconazole (ITZ), and Mycobacterium xenopi infection treated with moxifloxacin (MXF), ethambutol (EMB) and clarithromycin (CLR). Four months after initiation of antibiotic and antifungal medication, the patient contracted Cushing's syndrome. Its etiology consisted in interaction between FP, ITZ and CLR, which led to pronouncedly increased corticosteroid concentrations in circulating plasma cells. Following on the one hand cessation of FP and ITZ and on the other hand hydrocortisone supplementation, evolution was favorable. Several cases of iatrogenic Cushing's syndrome induced by co-administration of FP and potent CYP3A4 inhibitors have been reported in the literature. If possible, FP should be avoided in patients being treated with CYP3A4 inhibitors. Due to its differing physicochemical properties, beclometasone may be considered as the safest therapeutic alternative.

[Spontaneous pneumomediastinum]

INTRODUCTION

Pneumomediastinum, which can be spontaneous or secondary, is defined by the presence of free air in the mediastinum as shown on a chest X-ray and/or chest CT, with or without subcutaneous emphysema. Secondary pneumomediastinum develops in various contexts (thoracic traumatism, perforation of central airway or digestive tract, pneumothorax, barotraumatism complicating mechanical ventilation…). Spontaneous pneumomediastinum , which will be the focus of this review, develops without any of the above-mentioned conditions.

STATE OF ART

Spontaneous pneumomediastinum is a rare entity which usually occurs in young people either without medical history or with an history of asthma. A trigger event is detected in 40% to 60% of cases. Positive diagnosis is made on chest radiographt but thoracic CT is more sensitive. Distinction between spontaneous pneumomediastinum and secondary pneumomediastinum is in general easy but may sometimes be more difficult, particularly in case of oesophageal perforation. The evolution of spontaneous pneumomediastinum is most often benign but, rare complications may occur. Management is most often conservative.

PERSPECTIVES

There is no consensual management of spontaneous pneumediastinum because of the lack of randomized prospective studies. This may be explained by the rarity of the disease. The actual trend is to offer to the patients a conservative treatment, which could be ambulatory in some cases.

CONCLUSIONS

Spontaneous pneumomediastinum is a rare entity developing mainly in young subjects. The evolution is in general benign, justifying a conservative approach.

Safety of laparoscopic fundoplication in children under 5 kg: a comparative study

BACKGROUND

Laparoscopic fundoplication in children under 5 kg is still debated. Our objective was to evaluate the safety and efficacy of laparoscopic fundoplication (LF) in children under 5 kg.

METHODS

We reviewed the cases of 96 children treated by laparoscopic fundoplication between 2005 and 2014. Thirty-five patients had a weight of 5 kg or less at the time of LF (Low Weight Group) and 61 patients had a weight between 5.1 and 10 kg (High Weight Group). The pre-operative, peri-operative, post-operative data regarding surgery and anesthesia were compared between groups.

RESULTS

Mean weight was 3.9 ± 0.8 kg in the LWG and 7.8 ± 1.5 kg in the HWG. Children in the LWG were more prone to pre-operative respiratory management (40% mechanical ventilation and 42.9% oxygen therapy). The operating times (82 ± 28 min for LWG and 85 ± 31 min for HWG) and respiratory parameters during the procedure (PCO₂) were comparable between groups. Post-operative complications were 1 gastric perforation with peritonitis and 1 small bowel obstruction in the LWG, 2 cases of gastric perforation with peritonitis in the HWG. Mean follow-up was 67 ± 44 months. Significant recurrence of GERD requiring a redo fundoplication was noted in 3 patients in the LWG and 1 patient in the HWG.

CONCLUSION

Laparoscopic fundoplication is a safe procedure in infants ≤ 5 kg without increase of post-operative complications, recurrence, or mean operative time.

[Allergic bronchopulmonary aspergillosis: Evaluation of a maintenance therapy with nebulized Ambisome®]

BACKGROUND

Allergic bronchopulmonary aspergillosis (ABPA) affects 3-13% of patients with asthma. Its natural history includes possibly life-threatening exacerbations and evolution towards fixed obstructive ventilatory disorders or even irreversible lung fibrosis lesions. ABPA prognosis is directly associated with exacerbation control and the main objective of the treatment is to decrease their frequency and duration. Recommendations regarding dosage and duration of treatment are not very precise. The currently used combination of itraconazole and corticosteroid therapy has many limitations. The interests of a therapeutic strategy using nebulized liposomal amphotericin B (LAmB) are to heighten antifungal lung tissue concentration, to circumvent drug interactions and decrease the potential toxicity of systemic antifungal treatments. Finally, this association leads to improved eradication of Aspergillus, thereby limiting the risk of side effects and the emergence of treatment-resistant Aspergillus strains.

METHODS

This is a phase II, multicentre, randomized, single blind, controlled therapeutic study, with the objective of comparing the potential benefit on exacerbation control of a maintenance therapy by LAmB nebulization. The main objective of the study is to compare the incidence of severe clinical exacerbations in ABPA treatment, between a maintenance treatment strategy with nebulized LAmB and a conventional strategy without antifungal maintenance therapy.

EXPECTED RESULTS

The results will guide practitioners in the management of ABPA treatments and help to define the place of aerosols of LAmB on "evidence base medicine" criteria.

An estimation of burden of serious fungal infections in France

OBJECTIVE OF THE STUDY

An estimation of burden of serious fungal diseases in France is essential data to inform public health priorities on the importance of resources and research needed on these infections. In France, precise data are available for invasive fungal diseases but estimates for several other diseases such as chronic and immunoallergic diseases are by contrast less known.

MATERIALS AND METHODS

A systematic literature search was conducted using the Web of Science Platform. Published epidemiology papers reporting fungal infection rates from France were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in those populations to estimate national incidence or prevalence, depending on the condition.

RESULTS

The model predicts high prevalences of severe asthma with fungal sensitization episodes (189 cases/100,000 adults per year), of allergic bronchopulmonary aspergillosis (145/100,000) and of chronic pulmonary aspergillosis (5.24/100,000). Besides, estimated incidence for invasive aspergillosis is 1.8/100,000 annually based on classical high risk factors. Estimates for invasive mucormycosis, pneumocystosis and cryptococcosis are 0.12/100,000, 1/100,000 and 0.2/100,000, respectively. Regarding invasive candidiasis, more than 10,000 cases per year are estimated, and a much higher number of recurrent vaginal candidiasis is probable but must be confirmed. Finally, this survey was an opportunity to report a first picture of the frequency of tinea capitis in France.

CONCLUSION

Using local and literature data of the incidence or prevalence of fungal infections, approximately 1,000,000 (1.47%) people in France are estimated to suffer from serious fungal infections each year.

Dielectric relaxation properties of carboxylic acid-terminated n-alkyl monolayers tethered to Si(1 1 1): dynamics of dipoles and gauche defects

Molecular-level insights into the organization and dynamics of n-alkyl monolayers covalently bonded to Si(1 1 1) were gained from admittance measurements of dipolar relaxation in rectifying Hg|| HOOC-C10H(25-n) Si junctions performed as a function of applied voltage and temperature. A collective behavior of dipole dynamics is inferred from the non-Debye asymmetric relaxation peak shape and strong coupling of the dipole relaxation path with some bending vibrations of the n-alkyl OML (multi-excitation entropy model). A variety of relaxation mechanisms is observed in the frequency range (0.1 Hz-10 MHz) with different dependence of relaxation frequency and dipolar strength on measurement temperature and applied voltage. Their microscopic origin is discussed by comparing the activation energy of relaxation frequency with previous molecular mechanics calculations of saddle point energy barriers for structural defects such as gauche conformations or chain kinks in n-alkanes assemblies. Gauche conformations organized in pairs (kinks) have vanishing relaxation strength below an order-disorder transition temperature T(D) =  175 K and their probability strongly increases with applied reverse voltage, above T(D). The presence of hydrogen bonds between terminal carboxylic acid functionalities is inferred from a comparison with a similar junction bearing a low density of carboxylic acid end groups. This temperature-dependent hydrogen-bond network provides some additional stiffness against external electrostatic stress, as deduced from the rather weak sensitivity of relaxation frequencies to applied bias voltage.

Bronchiolitis obliterans syndrome after allogeneic hematopoietic SCT: phenotypes and prognosis

Bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic SCT (HSCT) is recognized as a new-onset obstructive lung defect (OLD) in pulmonary function testing and is related to pulmonary chronic GVHD. Little is known about the different phenotypes of patients with BOS and their outcomes. We reviewed the data of all allogeneic HSCT recipients referred to our pulmonary department for a non-infectious bronchial disease between 1999 and 2010. We identified 103 patients (BOS (n=77), asthma (n=11) and chronic bronchitis (n=15)). In patients with BOS, we identified two functional phenotypes: a typical OLD, that is, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio <0.7 (n=53), and an atypical OLD with a concomitant decrease in the FEV1 <80% and FVC <80% predicted with a normal total lung capacity (n=24). The typical OLD was characterized by more severe FEV1 and fewer centrilobular nodules on the computed tomography scan. The FEV1 was not significantly affected during the follow-up, regardless of the phenotype. In addition to acute and extensive chronic GVHD, only the occurrence of BOS soon after transplantation and the intentional treatment of BOS with steroids were associated with a poor survival. The determination of patient subgroups should be explored to improve the management of this condition.

[Bacterial pneumonia in HIV-infected patients (excluding mycobacterial infection)]

Respiratory infections are the most common complications in HIV patients, regardless of the degree of immunosuppression. Even though antiretroviral therapy has a protective effect on the risk of bacterial pneumonia, this still remains high (including those with CD(4)>500/mm(3)). The most frequently isolated bacteria are Streptococcus pneumoniae and Haemophilus influenzae. The clinical and radiological presentations of lower respiratory tract infections in HIV patients are quite variable. The clinical presentation is more severe and the radiological presentation is more atypical if the immunosuppression is severe. The first-line antibiotic therapy is an injectable third-generation cephalosporin (ceftriaxone or cefotaxime) or co-amoxiclav. Pneumococcal vaccination (as well as influenza vaccine) is recommended. Although rare, Nocardia spp. and Rhodococcus equi seem more common among AIDS patients.

Voriconazole for chronic pulmonary aspergillosis: a prospective multicenter trial

Early evidence suggests the efficacy of voriconazole for chronic pulmonary aspergillosis (CPA). We conducted a prospective, open, multicenter trial to evaluate the efficacy and safety of voriconazole for proven CPA in minimally or non-immunocompromised patients. Patients had CPA confirmed by chest computed tomography (CT) and/or endoscopy, positive Aspergillus culture from a respiratory sample, and positive serologic test for Aspergillus precipitins. Patients received voriconazole (200 mg twice daily) for a period of 6-12 months and were followed for 6 months after the end of therapy (EOT). The primary endpoint was global success at 6 months, defined as complete or partial (≥50 % improvement) radiological response and mycological eradication. Forty-one patients with confirmed CPA were enrolled. All patients had A. fumigatus as the etiologic agent. By EOT, five patients had died from comorbidities and seven had discontinued voriconazole due to toxicity. The global success rate at 6 months was 13/41 (32 %): 10/19 (53 %) for chronic necrotizing aspergillosis and 3/22 (14 %) for chronic cavitary aspergillosis (p = 0.01). The respective success rates at EOT were 58 and 32 %. Clinical symptoms and quality of life also improved during treatment. Voriconazole is effective for CPA, with acceptable toxicity. The response rate is higher and obtained more rapidly in necrotizing than cavitary forms.

Lung infections: the radiologist's perspective

Imaging plays a key role in lung infections. A CT scan must be carried out when there is a strong clinical suspicion of pneumonia that is accompanied by normal, ambiguous, or nonspecific radiography, a scenario that occurs most commonly in immunocompromised patients. CT allows clinicians to detect associated abnormalities or an underlying condition and it can guide bronchoalveolar lavage or a percutaneous or transbronchial lung biopsy. An organism can vary in how it is expressed depending on the extent to which the patient is immunocompromised. This is seen in tuberculosis in patients with AIDS. The infective agents vary with the type of immune deficiency and some infections can quickly become life-threatening. Clinicians should be aware of the complex radiological spectrum of pulmonary aspergillosis, given that this diagnosis must be considered in specific settings.

Benefit of CT scanning for assessing pulmonary disease in the immunodepressed patient

INTRODUCTION

Management of pulmonary disease in immunodepressed patients requires a clear diagnostic and therapeutic strategy and multidisciplinary cooperation.

DISCUSSION

The diagnostic approach should take into account the type of immunodepression, the clinical picture, the radiological signs and symptoms, and the microbiological, cytological and even histological examination of the pulmonary or extrapulmonary specimens. The high-resolution CT scan plays a central role and makes it possible to prioritize the diagnostic possibilities.

CONCLUSION

The analysis of the literature shows three important points: the chest X-ray has low diagnostic value; the CT scan of the chest can reveal lesions that cannot be detected on a standard chest X-ray; the CT scan is helpful for early detection and monitoring of invasive pulmonary aspergillosis.

Bias Stress Induced Instabilities in Amorphous Silicon Nitride / Crystalline Silicon and Amorphous Silicon Nitride / Amorphous Silicon Structures

The effects of positive and negative bias stress on hydrogenated amorphous silicon nitride / crystalline silicon and hydrogenated amorphous silicon nitride / hydrogenated amorphous silicon (a-Si:H) structures are investigated as a function of stress time, stress temperature and stress bias. It is shown that in both structures bias stress induces a parallel shift of the C-V (capacitance-voltage) characteristics. For a given stress bias the direction of the C-V shift depends on the sign of the applied stress voltage, while the magnitude of the C-V shift depends on stress time and temperature. In addition, it is shown that positive bias stress slightly increases the number of localized states in the a-Si:H mobility gap, but negative bias stress does not. These results lead us to conclude that the C-V shift is not induced by dangling bond defects in a-Si:H but rather by carrier trapping in the insulator.

[Diagnosis and epidemiological surveillance of influenza and respiratory syncytial virus infections: interest of multiplex PCR]

Objectif

Le diagnostic étiologique des infections respiratoires nécessite d'être réalisé rapidement pour une prise en charge efficace des patients. Nous avons évalué une PCR multiplex pour le diagnostic et l'épidémiosurveillance des infections grippales et à virus respiratoire syncytial (VRS).

Patients et méthodes

Notre étude a porté sur 278 patients (âge moyen : 37,2 ± 22,9 ans) présentant un syndrome grippal ou pseudogrippal, consultant des médecins vigies du GROG Poitou-Charentes ou hospitalisés au CHU de Poitiers. Une PCR multiplex détectant les virus grippaux A(H3), A(H1), B et les VRS A et B, a été réalisée en parallèle à un examen direct par immunofluorescence et une culture cellulaire.

Résultats

Nous avons mis en évidence une infection virale chez 139 (50,0 %) patients : 99 cas de grippe A(H3), deux cas de grippe A(H1), 28 cas de grippe B et 11 cas d'infection à VRS. Le rendement diagnostique chez les patients du GROG (52,3 %) était significativement plus élevé que celui observé chez les hospitalisés (34,5 %) (p = 0,04). Nous avons obtenu une concordance technique de 61 %. La PCR multiplex a permis un gain de positivité de 22,3 % par rapport aux techniques traditionnelles. Tous les prélèvements positifs par les techniques traditionnelles l'ont été également en PCR multiplex. Nous avons observé une parfaite corrélation entre les types et les sous-types viraux déterminés par PCR et par culture cellulaire.

Conclusion

La PCR multiplex est une technique sensible permettant un diagnostic efficace et rapide des infections respiratoires dues aux virus grippaux et au VRS.

Mycoplasma hominis osteitis in an immunocompetent man

Mycoplasma hominis has been associated with pelvic inflammatory illness, postpartum and neonatal infections and respiratory tract diseases. It is rarely isolated from patients with other infections. Reported here is a case of tibial osteitis that occurred in a 16-year-old immunocompetent man. Clinical and laboratory findings improved under treatment with clindamycin and fluoroquinolones.

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.

Vertebral osteomyelitis due to Fusobacterium species: report of three cases and review of the literature

We describe three cases of Fusobacterium spp. diskitis and review with attention to risk factors, clinical features, diagnosis, treatment and outcome. In most of the reported cases, a ear-nose-throat infection was found. Clinical manifestations were similar to those of classic bacterial vertebral osteomyelitis. Clindamycin is the most appropriate antibiotic. The outcome seems to be very good without relapse with appropriate treatment compared to pyogenic vertebral osteomyelitis.

Botulism in Patients Who Inhale Cocaine: The First Cases in France

We describe 2 cases of mild botulism in patients who inhaled cocaine. Botulism, though rare, is increasing in incidence among illicit drug users. To our knowledge, these are the first cases of botulism in illicit drug users in France. Clinicians should be aware of this phenomenon; botulism should be considered in illicit drug users with neurological symptoms.

[Co-infection with Mycobacterium tuberculosis and Pneumocystis jiroveci in a patient without HIV infection]

INTRODUCTION

Co-infection with Pneumocystis jiroveci and Mycobacterium tuberculosis is rarely reported in patients without HIV infection.

CASE REPORT

We report the case of a 30 year old woman admitted to hospital for respiratory distress associated with a diffuse infiltrative pneumopathy. Corticosteroid therapy had been started two months earlier for suspected pulmonary sarcoidosis. Fibreoptic bronchoscopy and broncho-alveolar lavage produced evidence of Mycobacterium tuberculosis and cysts of Pneumocystis jiroveci. HIV serology was negative. Clinical progress was satisfactory following anti-tuberculous and anti-fungal therapy.

CONCLUSION

Pneumocystis pneumonia is rare in subjects without HIV infection and is most often associated with a pathology or treatment leading to depression of cellular immunity. Corticosteroid treatment, even of short duration, presents the greatest risk. Systematic antibiotic prophylaxis should be considered in relation to the immune status of the patient. Co-infection with the tubercle bacillus as reported here is exceptionally rare.

Concomitant disseminated herpes simplex virus type 2 infection and varicella zoster virus primoinfection in a pregnant woman

We report the first case of a HSV and VZV coinfection during pregnancy. VZV infection was diagnosed by a seroconversion and PCR. HSV 2 infection was diagnosed by cell culture. The mother and the newborn received no treatment and did not develop any complication. This case report highlights the need for increased surveillance of pregnant women with herpes virus infections.

Analysis of nutritional parameters in idiopathic scoliosis patients after major spinal surgery

OBJECTIVE

The aim of the study is to investigate the evolution of nutritional parameters after major spinal surgery in patients with idiopathic scoliosis.

METHODS

This retrospective study included 31 patients with a mean age of 18 y, diagnosed with idiopathic scoliosis. The following variables were analyzed: demographic, surgical (type, number of fused segments, duration, and blood loss), nutritional assessment (proteins, albumin, prealbumin, transferrin, lymphocytes, and body mass index), and duration of hospitalization at different time points. Statistical analyses were performed with the SPSS 6.1 software.

RESULTS

Before surgery, nutritional status was normal in all patients. At 24-48 h after surgery, statistically significant decrease with respect to preoperative values was recorded for all the parameters studied: proteins (P < 0.001), albumin (P < 0.001), prealbumin (P < 0.01), transferrin (P < 0.001), and lymphocytes (P < 0.001).

CONCLUSION

Our results showed a significant postoperative decrease in the nutritional parameters analyzed in a previously well-nourished population considered to be at low risk for nutritional depletion.

[Anesthesia for scoliosis surgery: preoperative assessment and risk screening of patients undergoing surgery to correct spinal deformity]

Spinal column deformity is associated with potentially serious alterations of respiratory and cardiac function. Such alterations, in association with the underlying disease that caused the deformity--such as neuromuscular disease--are risk factors that affect the prognosis for scoliosis patients undergoing anesthesia and surgery. It is important for the anesthesiologist to carry out a detailed preoperative assessment to identify patients at risk with the aim of decreasing morbidity and mortality related to surgical correction of deformities. Of paramount importance is awareness of the risk of injury to the spinal cord that will affect function. Other issues are how to manage the patient in anomalous positions, the risk associated with hypothermia secondary to exposure of a large surgical field for a long period, and bleeding, which can sometimes exceed the patient's total volume. In the case of scoliosis surgery, all those situations may converge, obliging us to provide careful intraoperative monitoring, particularly of spinal function; to choose the appropriate anesthetic technique; and to maintain vigilance during the early postoperative period to foresee possible complications. Because scoliosis surgery is multidisciplinary, several teams must work together to assure success.

[Imported malaria: prevention should strengthened]

INTRODUCTION

The risk of acquiring malaria infection can largely be prevented by the regular use of chemoprophylactic drugs combined with protective measures against mosquito bites. In a retrospective study we had for aim to evaluate the compliance to malaria chemoprophylaxis in patients presenting with malaria infection.

METHODS

We analyzed the compliance to the recommended malaria chemoprophylaxis of French travelers hospitalized in a department of infectious diseases because of malaria infection, between January 1999 and December 2003.

RESULTS

Eighty-five patients, with a mean age of 34.1 years (16-65) were treated for malaria infection. Seventy-seven were due to Plasmodium falciparum. The outcome was favorable for all patients, despite four severe accesses. Forty-six patients (54%) did not take any chemoprophylaxis (CP), 19 (22%) had an inadequate CP for the risk, 13 (15%) badly complied with intermittent intake of CP and seven (8%) complied well with the recommended malaria CP. Among the 85 patients, 27 (32%) had come to the travelers' consultation and been given recommendations and a recommended malaria CP prescription before traveling.

CONCLUSION

These results confirm that the majority of imported malaria cases is a consequence of bad compliance to CP. Understanding user profiles and factors predicting non-compliance may help us to improve pretravel counseling, thereby reducing the risk for travelers to acquire malaria infection.

Maternal Herpes simplex virus type 2 encephalitis following Cesarean section

Herpes simplex virus type 2 (HSV-2) encephalitis is rare especially during pregnancy. In immunocompetent patients, HSV-2 meningitis (contrary to HSV-1 meningitis) is usually mild, without encephalitis. We report a rare case of maternal HSV-2 encephalitis following Cesarean section. The woman had no symptomatic genital lesion, and the infant was not infected. The route of meningeal infection (neuronal or hematogenous) is discussed.

Pneumocystis carinii pneumonia in patients with hematologic malignancies: a descriptive study

Objectives. A retrospective multicentric study was conducted over a five-year period to evaluate the clinical and laboratory characteristics and outcome of patients with proven Pneumocystis carinii pneumonia (PCP) complicating hematologic malignancies.Results. The study included 60 HIV-negative patients with 18 non-Hodgkin's malignant lymphoma (30%), 13 chronic lymphocytic leukaemia (21.7%), 10 acute leukemia (16.6%), 5 multiple myeloma (8.3%), 4 Waldenström's diseases (6.6%), 4 chronic myeloid leukemia (6.6%), 3 myelodysplasia (5%), 2 Hodgkin's diseases (3.3%) and 1 thrombopenia. Bronchoalveolar lavage was diagnostic in all patients. Forty-nine patients received cytotoxic drugs (81.7%), 25 (41.7%) a long-term corticotherapy and 15 (25%) underwent bone marrow transplantation. Twenty-seven patients (45%) required admission in the intensive care unit, 35 (58.3%) received an adjunctive corticotherapy and 18 mechanical ventilation (30%). Twenty patients (33.3%) died of PCP. A previous long-term corticotherapy (p=0.04), high respiratory (p=0.05) and pulse rates (p=0.02), elevated C reactive protein (p=0.01) and mechanical ventilation (OR=13.37; IC: 1.9-50) were associated with a poor prognosis. Adjunctive corticotherapy did not modify the prognosis.Conclusions. These results suggest that PCP can occur during the course of various hematologic malignancies, not only lymphoproliferative disorders. Prognosis remains poor. The diagnosis should be advocated more frequently and earlier to improve the prognosis.

Pneumocystisjiroveciidihydropteroate synthase genotypes in French patients with pneumocystosis: a 1998–2001 prospective study

Dihydropteroate synthase gene (DHPS) mutations at codons 55 and 57 have been associated with sulfa/sulfone resistance in Pneumocystis jirovecii strains from patients who previously received prophylaxis. To evaluate the prevalence of these mutations, a portion of P. jirovecii DHPS gene was analysed using PCR combined with restriction fragment length polymorphism (RFLP) analysis in 92 bronchoalveolar fluid samples collected between January 1998 and September 2001 from French patients with pulmonary pneumocystosis (PCP). Seventy-six samples contained the wild-type DHPS genotype (82.6%) and 16 contained a mutant genotype (17.4%). Twelve out of the 16 isolates with a mutant DHPS genotype corresponded to patients who had never received sulfa or sulfone prophylaxis, suggesting that DHPS mutants may be acquired de novo. There was no significant difference in favourable or adverse outcome in PCP caused by the wild or mutant DHPS genotypes (P = 0.34).

[Radial artery aneurysm: an unusual complication of radial artery catheterization]

Percutaneous arterial cannulation is systematically used in cardiac surgery and reanimation for hemodynamic monitoring. It was frequently used in coronarography. Risk factors for occurrence of radial aneurysm after catheterization may include advanced age, longer duration of catheterization, hospitalization duration, and general infection with Staphylococcus aureus. We report an uncommon case of radial artery aneurysm, after cardiac surgery. We operated the patient with a good result.

Analysis of underlying diseases and prognosis factors associated with Pneumocystis carinii pneumonia in immunocompromised HIV-negative patients

The aim of this retrospective study was to determine the underlying diseases associated with Pneumocystis carinii pneumonia (PCP) in immunocompromised HIV-negative patients and to identify prognosis factors in this population. One hundred three cases of PCP were diagnosed over a 5-year period. Diagnosis was established on the basis of clinical features and by detection of Pneumocystis carinii cysts in bronchoalveolar lavage fluid. Underlying diseases comprised hematologic malignancies (n=60; 58%), inflammatory diseases (n=27; 26%), and solid tumors (n=18; 17.5%); 9 (8%) patients were solid organ transplant recipients. Seventy-one (69%) patients received cytotoxic drugs, 57 (55%) were treated with long-term corticotherapy, and 15 (14.7%) underwent bone marrow transplantation. Fifty-eight (56%) patients were admitted to the intensive care unit, and 52 (41%) required mechanical ventilation. Thirty-nine (38%) patients died of PCP; data from these patients were compared with those from surviving patients. The following factors were associated with a poor prognosis: high respiratory rate (P=0.005), high pulse rate (P=0.0003), elevated C-reactive protein (P=0.01), elevated serum lactate dehydrogenase level (P=0.02), and mechanical ventilation (OR, 14.4; 95%CI, 5-50). The results suggest that PCP can occur during the course of many immunosuppressive diseases, particularly various hematologic malignancies. The diagnosis of PCP should be considered more frequently and advocated earlier in immunocompromised HIV-negative patients, since prompt diagnosis may improve the prognosis of these patients.

Prevalence of asymptomatic cardiac valve anomalies in idiopathic scoliosis

The prevalence of asymptomatic cardiac valve anomalies was determined in 82 patients (69 females and 13 males) diagnosed as having idiopathic scoliosis and scheduled for corrective surgery (mean age at surgery 16.3 years). The preoperative study in each patient included echocardiography and ultrasound Doppler. Twenty-three valvular anomalies were found in 20 patients (24.4%). The most frequent was mitral valve prolapse. The occurrence of valvular anomalies did not correlate with sex, curve magnitude, or age at diagnosis. Eighteen patients presented a total of 20 comorbid conditions: positive family history of scoliosis (five cases), isthmic spondylolisthesis (five cases), nervous anorexia (two cases), hereditary exostosis, cystic fibrosis, ureteral stenosis, mammary hypoplasia, slipped capital femoral epiphysis, psoriasis, celiac disease, and lactose intolerance. A significant relationship was found between valvular anomalies and comorbidity. Valvular anomalies were detected in 11 out of 64 patients (17.2%) with no comorbidity and in nine out of 18 patients (50%) with a comorbid condition (Chi-square 8.2, p = 0.004). In this latter group of patients, routine echocardiographic study seems advisable in the preoperative evaluation.

Rapid diagnosis of alcoholic ketoacidosis by proton NMR

In alcoholic patients, metabolic acidosis can be related to lactate acidosis associated with sepsis or thiamine deficiency, ketoacidosis, methanol or ethylene glycol poisoning. High resolution proton nuclear magnetic resonance (NMR) can be used to detect abnormal organic acid metabolites in urine or serum from patients with various metabolic disorders. In the present case, a 26-year-old patient was admitted for a coma associated with severe metabolic acidosis. Alcoholic ketoacidosis (AKA) was identified by urine proton NMR. Her metabolic disorders rapidly improved. Persisting associated neurological alteration was related to extrapontine myelinolysis as shown by imaging cerebral NMR.