A description of a hepatitis A outbreak in men who have sex with men and public health measures implemented in Seine-Maritime department, Normandy, France, 2017

BACKGROUND

In 2016-2017, a European-wide circulation of genotype IA hepatitis A virus was responsible for hepatitis A outbreaks in men who have sex with men (MSM). This study aimed to describe the outbreak investigation in Seine-Maritime department (France) and the control measures implemented accordingly.

METHODS

Outbreak description used data from mandatory reporting and enhanced surveillance of male cases. Confirmed case was genotype IA isolated, possible cases had no reported genotype information. Targeted control measures included communication on sexual practices at risk of hepatitis A transmission and two vaccination campaigns in April 2017 and January 2018. Characteristics of cases and vaccinees were described. We reported the best communication channel for relaying outbreak information and control measures based on the monitoring of social network activities and feedback from vaccinees.

RESULTS

During the outbreak period (December 2016 to December 2017), a total of 48 confirmed outbreak cases and 30 possible outbreak cases were notified. Among them, 69 were male (88%). Two epidemic waves were observed. Cases encountered their partners through gay-dating apps (54%) and in one specific sauna (62%). In response to the outbreak, two vaccination campaigns were deployed. A total of 156 MSM were vaccinated, of whom 56 in a truck parked beside the sauna. Most of the vaccinees had been informed about the campaign through dating apps (44%). Community-based organizations involved in sexual health promotion and other gay social media were very proactive in sharing information about the outbreak and promoting the vaccination campaign through their social media account and also on site (gay venues). Vaccinees reported the same sexual practices at risk of hepatitis A transmission as cases.

CONCLUSIONS

In response to this massive hepatitis A outbreak that affected mostly MSM in Seine-Maritime department, vaccination campaign remained the cornerstone of prevention. Prevention officers from the community-based organization played a key role in vaccination promotion. Gay-dating apps and outdoor sessions of vaccination allowed to effectively reach MSM. Cost-effectiveness studies might analyze the interest of a continuous sexual health promotion including vaccination against hepatitis A in MSM through dating apps and social networks.

Benefits of a Pre-Treatment Comprehensive Geriatric Assessment in a Rare Case of Gemella Haemolysans Endocarditis in an 86-Year-Old Patient and a Review of the Literature

Infective endocarditis is a serious condition, which is associated with high mortality in elderly patients. Gemella haemolysans (GH) is a microorganism from the Streptococcus family, rarely involved in infective endocarditis. Here, we present a case of Gemella haemolysans endocarditis in an 86-year-old patient, successfully treated by antibiotics and surgery following a pre-treatment comprehensive geriatric assessment (CGA). This case is discussed in the context of a review of all published cases of Gemella haemolysans endocarditis. We illustrate the benefit of a systematic pre-treatment comprehensive geriatric assessment in elderly patients with infective endocarditis.

Antineutrophil Cytoplasmic Antibodies Associated With Infective Endocarditis

To determine the prevalence of antineutrophil cytoplasmic antibodies (ANCA) in patients with infective endocarditis (IE) in internal medicine; and to compare clinical and biochemical features and outcome between patients exhibiting IE with and without ANCA.Fifty consecutive patients with IE underwent ANCA testing. The medical records of these patients were reviewed.Of the 50 patients with IE, 12 exhibited ANCA (24%). ANCA-positive patients with IE exhibited: longer duration between the onset of first symptoms and IE diagnosis (P = 0.02); and more frequently: weight loss (P = 0.017) and renal impairment (P = 0.08), lower levels of C-reactive protein (P = 0.0009) and serum albumin (P = 0.0032), involvement of both aortic and mitral valves (P = 0.009), and longer hospital stay (P = 0.016). Under multivariate analysis, significant factors for ANCA-associated IE were: longer hospital stay (P = 0.004), lower level of serum albumin (P = 0.02), and multiple valve involvement (P = 0.04). Mortality rate was 25% in ANCA patients; death was because of IE complications in all these patients.Our study identifies a high prevalence of ANCA in unselected patients with IE in internal medicine (24%). Our findings further underscore that ANCA may be associated with a subacute form of IE leading to multiple valve involvement and more frequent renal impairment. Because death was due to IE complications in all patients, our data suggest that aggressive therapy may be required to improve such patients' outcome.

[Lightning strike and lesions outside the brain: Clinical cases and a review of the literature]

INTRODUCTION

Every year, 240,000 people are struck by lightning worldwide, causing injuries leading to significant handicaps. Most of the symptoms involve brain lesions; neuromuscular sequelae and myelopathy are less common.

OBSERVATIONS

We describe five cases of patients struck by lightning with various clinical presentations. The first patient presented painful paresthesias in both upper limbs that disappeared 18 months later; the injury was a plexopathy. The second patient developed proximal weakness in the upper-left limb due to a myopathy. Two patients presented with various motor weaknesses in the lower limbs due to motor neuron disease and myelopathy. The last patient had a transient tetraplegy, which resolved in 5minutes; the diagnosis was keraunoparalysis.

DISCUSSION

Lightning injuries can have many consequences depending on the different mechanisms involved. The clinical presentation is often due to a very focal lesion without any secondary extension. Motor neuron disease probably results from post-traumatic myelopathy. We discuss the ALS-electrocution association, frequently described in the literature.

CONCLUSION

Various peripheral nerve and spinal cord lesions can be seen in lightning strike victims involving myelopathy, motor neuron, muscle and plexus. Clinical syndromes are often atypical but outcome is often favorable.

[Primary urethral carcinoma. Epidemiology, diagnosis and pathology. Guidelines from the French Urological Association Cancer committee]

Primary urethral carcinomas are unusual. The most frequent histology is the epidermoid carcinoma in both sex, followed by the urothelial carcinoma in men and adenocarcinoma in women. The diagnosis is often late. It is based on a clinical examination under anesthesia and biopsies. MRI is the best imaging modality for the local stadification.

In Vivo Retroviral Mediated Gene Transfer into Bladder Urothelium Results in Preferential Transduction of Tumoral Cells

OBJECTIVES

Superficial bladder tumours are at high risk for recurrence, relapse after resection, escape to intravesical immunotherapy and they may become invasive. New therapeutics are therefore needed to achieve cure. Thus, gene therapy is an attractive new treatment modality for malignant bladder tumours. The purpose of this study was to evaluate the feasibility and the efficiency of retroviral mediated reporter gene transfer into malignant urothelial cells both in vitro and in vivo.

METHODS

We evaluated the feasibility of the transfection of bladder tumour with direct intravesical instillation of a defective retrovirus. The vector was derived from LXSN. The efficiency of transduction with the Moloney Leukaemia Murine virus-based vector, amphotrophic retroviral vector, was monitored through the expression of two marker genes (nls-LacZ and NeoR). The canine animal was chosen since it can present with spontaneous bladder carcinomas mimicking human pathology. Primary cultures of two normal canine bladder urothelium and two canine primary bladder tumours were first studied. We then investigated in vivo, in two normal and two spontaneous tumour bearing dogs, the transduction of urothelial cells following direct intravesical instillation of 2.10(4) to 3.10(6) of the retroviral vector.

RESULTS

Transduced cells were evidenced in all primary cultures of canine normal urothelium and transitional cell carcinoma. Bladder biopsies from sound dogs instilled with the viral solution showed long lasting transduction up to 60 days long. Bladder cryosections from tumour-bearing dogs displayed transduction of superficial layers of urothelial cancer cells without passing through lamina propria. In vivo transduction was evidenced in 1 to 15% (mean 5%) of the cells in the tumours and preferentially addressed malignant cells. Normal epithelium either originating from sound or tumour-bearing animals was not transduced.

CONCLUSION

These results demonstrate for the first time the feasibility of in vivo retroviral transduction of bladder cancer using a clinically relevant procedure.

[Protocol for the pathologic examination of cystectomy and cystoprostatectomy specimens. Proposal for a standardized form]

We present practice guidelines for the examination of bladder specimens removed for bladder cancer and propose an example of standardized form for their reporting. This approach takes place in looking for better quality and facilitates use of the morphologic data.

[Recommendations for reforming prostatic specimens. Les Membres du Sous-Comité Prostate du Comité de Cancerologie de l'Association Française d'Urologie]

The purpose of these recommendations proposed by the members of the <<comités de Cancérologie de l'Association Française d'Urologie>>, is to provide an informative report for the clinician and the pathologist, in the management of patients with prostate cancer. These recommendations are common to the ADSAP and UICC recommendations on prostate cancer. Standardized forms are recommended to be included in every report.

Variability of immunohistochemical reactivity on stored paraffin slides

AIMS

To investigate the effects of slide storage on immunohistochemical staining, since recent reports have indicated that storage of unstained paraffin slides for up to 12 weeks may lead to false negative immunostaining of tumour markers.

METHODS

11 antibodies (anti-cytokeratin, epithelial membrane antigen (EMA), vimentin, smooth muscle actin, PS100, chromogranin, CD45, CD20, CD3, CD30, and oestrogen receptor (OR) were tested on unstained paraffin slides of breast carcinomas, lymphomas, and neuroendocrine tumours that had been stored for three to 10 years. All the paraffin blocks were recut less than one week before immunostaining. Immunostainings of years old slides were compared with those of recent slides in at least five cases for each antibody. For three antibodies (antichromogranin, anti-CD3, and anti-OR) we also tested one year old and three months old slides.

RESULTS

Intensity of staining on years old slides was strikingly reduced for chromogranin and CD3 in several cases and was slightly stronger for vimentin. In some cases a significant decrease of OR positivity was observed after three months storage, and a complete loss of OR immunostaining after 12 months. No significant difference was noted with the other antibodies.

CONCLUSIONS

Immunohistochemical detection of some antigens located either in the nucleus, in the cytoplasm, or on the cytoplasmic membrane could be impaired by storage of paraffin slides as short a time as three months. One should be cautious of doing retrospective immunohistochemical studies on stored unstained slides.

[Can the prostatic capsule be preserved during cystectomy for bladder tumors: a study of urethral and prostatic involvement in the cystectomy specimens]

OBJECTIVES

To evaluate the frequency of urethral and prostatic lesions on cystectomy specimens for bladder tumour.

MATERIAL AND METHODS

This retrospective histological study was based on 260 specimens: radical cystectomies performed in 7 operative sites. The prostate and urethra were analysed in 3 planes (upper, middle and lower thirds). The apex was studied separately. Urethral invasion was identified by continuity of the tumour or by the presence of vesical CIS.

RESULTS

Urethral involvement is frequent (30.6% cases) essentially due to contiguous invasion (43/80). CIS is the second pathological association (44 urethral CIS/75 bladder CIS). Prostatic adenocarcinoma was present in 17.8% of cases with a Gleason score > 6 for 30% of lesions.

CONCLUSION

The high frequency of urethral and prostatic involvement does not justify preservation of the prostate during cystectomy. A serial prospective study should define the precise criteria able to minimize the risk of conservative surgery.

[A case of primary signet ring cell adenocarcinoma of the bladder]

A case of primary signet ring cell carcinoma of the urinary bladder. This case of adenocarcinoma of the bladder including immunohistochemical study and autopsy demonstrates the diagnostic problems and the bad prognosis of these rare tumors.

Renal chromophobe cell carcinoma and oncocytoma. A comparative morphologic, histochemical, and immunohistochemical study of 124 cases

BACKGROUND

Renal oncocytoma has several features that overlap with other renal neoplasms, including the eosinophilic subtype of chromophobe cell carcinoma. In fact, strict criteria for renal oncocytoma have not been well defined and remain a matter of controversy. Ultrastructural studies or sophisticated methods such as flow cytometry and cytogenetic techniques can be of great use in distinguishing the two tumors, but are difficult to propose as routine methods because of their limited availability.

OBJECTIVE

To further characterize the histologic criteria of these tumors, we undertook a retrospective study to define the utility of routinely available histochemical and immunohistochemical techniques.

DESIGN AND SETTING

Twenty-one cases of chromophobe cell carcinoma, eosinophilic subtype, and 103 cases of oncocytoma were tested with histochemical (Perls, periodic acid-Schiff, and Hale's colloidal iron) and immunohistochemical (peanut agglutinin antigen and UEA-1 for lectins; cytokeratin KL1, epithelial membrane antigen, vimentin, S100 protein, and lysozyme) staining.

RESULTS

The antibodies tested and the histochemical staining using Hale's colloidal iron allowed eosinophilic chromophobe cell carcinoma to be distinguished by its characteristic reaction pattern. Seventy-six percent of the chromophobe cell carcinomas showed a microvacuolated pattern, and 89% of the renal oncocytomas showed an apical positivity with Hale's colloidal iron staining (P < .01). Peripheral cell accentuation reactivity for cytokeratin KL1 was observed in 66% of the chromophobe cell carcinoma cases, and apical cytoplasmic positivity was observed in 37% of the renal oncocytoma cases (P = .01). Significant patterns were observed with anti-epithelial membrane antigen and anti-peanut agglutinin antigen antibodies (P = .05 and P = .01, respectively). Positive reactions for vimentin, S100 protein, lysozyme, and UEA-1 were not significant characteristics.

CONCLUSION

Our study demonstrated that a precise morphologic description associated with simple histochemical and immunohistochemical techniques provides sufficient criteria for a high level of discrimination between the eosinophilic subtype of chromophobe cell carcinoma and renal oncocytoma.

[The role of endoscopy in the diagnosis and treatment of keratinizing and desquamating malpighian metaplasia of the kidney pelvis]

Keratinized squamous cell metaplasia of the renal pelvis (KSMRP) is a rare lesion, difficult to differentiate from urothelial tumour on the basis of the usual morphological examinations. It is therefore usually diagnosed retrospectively, on histological examination of a nephroureterectomy specimen. However, as its benign nature justifies conservative treatment, preoperative recognition of this lesion is essential. Upper urinary tract endoscopy, which allows diagnosis and treatment of this disease, is therefore very important in this context. Endoscopy is indicated when KSMRP is suspected clinically in a doubtful case of urothelial tumour of the upper urinary tract, in a context of passage of soft stones or a history of renal stones or upper urinary tract infection. Ureteroscopy constitutes the first step to confirm the diagnosis. It must be completed by a percutaneous procedure to eradicate any residual lesion, which could be responsible for recurrence. We report a case of KSMRP in a solitary kidney treated by retrograde and percutaneous endoscopic surgery.

[Total extended ++urethrectomy and transureteral continent cystostomy in the treatment of urethral melanoma in women. Report of a case]

Malignant melanoma of the urethra is one of the rare urethral tumours which can be controlled by total urethrectomy with preservation of the bladder. The authors report the first case of melanoma of the urethra treated by total urethrectomy and continent transureteric urinary diversion according to Mitrofanoff's principle.

[Carcinoma of Bellini's tubules]

Carcinoma of the papillary ducts of Bellini is a rare form of renal cancer. Patients are usually asymptomatic middle-aged men who frequently have metastatic disease at the time of diagnosis. The diagnosis is based on histological examination of the nephrectomy specimen with a precise immunohistochemical examination. Radical nephrectomy is the first-line treatment and adjuvant chemotherapy, recommended by certain authors, does not appear to improve the usually poor prognosis of these tumours.

Exploration and endoscopic treatment of unilateral primary haematuria: is non-specific diffuse pyelitis a real entity?

Chronic unilateral primary haematuria is rare and raises difficult problems of diagnosis and treatment as most of the knowledge in this field has been based on a very limited number of patients. This clinical entity needs critical reevaluation as recent progress in endourological investigations has revealed that lesions other than the classical submucosal haemangioma are just as frequently responsible for unilateral primary haematuria. These endoscopic lesions have generally been poorly defined up to now and our data based on a retrospective review of 8 patients emphasises the persistent gaps in our understanding of the pathophysiology of this disease. Among the lesions responsible for unilateral primary haematuria, diffuse petachiae of the renal pelvis and cavities represent the most frequent endoscopic lesion described in our experience (50% of cases). Histologically, these diffuse lesions correspond to non-specific pyelitis, consisting of simple oedema of the lamina propria. In addition to its diagnostic role, endoscopy can also be used to effectively treat the lesions responsible for unilateral primary haematuria, using either electrocoagulation or nitrate cautery, provided a retrograde approach can be completed by a percutaneous approach, with an overall success rate of 75% of cases with a mean follow-up of 16 months.

Intestinal microsporidiosis in human immunodeficiency virus-infected patients with chronic unexplained diarrhea: prevalence and clinical and biologic features

Eighteen patients infected with human immunodeficiency virus and with chronic unexplained diarrhea were prospectively studied to investigate the prevalence and clinical and biologic features of intestinal microsporidiosis. All patients underwent extensive evaluation for bacterial, viral, and parasitic pathogens. Enterocytozoon bieneusi was found in 9 patients (50%; 95% confidence interval, 27-73) in stools and duodenal and jejunal biopsies. In 8 patients, it was the sole pathogen found. Other pathogens were also isolated from the intestinal tracts of 4 patients, but diarrhea remained unexplained in 6. Patients with intestinal microsporidiosis had significantly lower mean Karnofsky scores (69.4 vs. 85.5, P = .009), CD4 cell counts (18.6 vs. 209.8/microL, P = .02), and D-xylose absorption tests (0.13 vs. 0.36 g/L, P < .001) than did patients without intestinal microsporidiosis. Intestinal microsporidiosis appears to be a frequent cause of unexplained chronic diarrhea in patients with AIDS and is associated with diminished D-xylose absorption.

Double ureter and congenital diverticulum of the ureter

The ureteral duplication is a relatively common malformation and usually has no pathologic consequences. On the contrary, congenital diverticula of the ureter are rare and often give rise to urinary complications. A double malformation combining left ureteral duplication and a congenital diverticulum of the right ureter is reported and discussed. This rare case illustrates one and the same malformational process arrested at different stages of development.

Multiple endocrine neoplasia (MEN) type II b: report of a case observed at autopsy with immunohistochemical study of mucosal neuromas

A case of multiple endocrine neoplasia (MEN) II b syndrome was studied in a 28-year-old Colombian woman. The patient presented initially with medullary carcinoma of the thyroid (MTC), an unusual habitus, numerous mucosal neuromas, and intestinal ganglioneuromatosis. Recurrent medullary carcinoma in the mediastinum produced compression. The tumor mass could not be removed surgically, and the patient died of post-operative complications. At autopsy metastatic MTC was present in the liver, lymph nodes, and lungs. In addition, multiple mucosal neuromas were present in the mouth, nasopharynx, larynx, digestive tract, peri-adrenal fat, and hepatic portal spaces. There was no evidence of pheochromocytoma. Immunofluorescence study of mucosal neuromas showed hyperplasia and hypertrophy of nerves, without evidence of tumor. Kindred screening was negative.