Pregnancy outcomes in women with imported malaria in mainland France: A retrospective study from 2004 to 2014

OBJECTIVES

There is little data on pregnant women with imported malaria in high-income countries, especially regarding offspring outcomes. We wanted to determine pregnancy outcomes of imported malaria in pregnant women in mainland France.

PATIENTS AND METHODS

We conducted a retrospective, descriptive study of outcomes in pregnant women hospitalized with malaria from 2004 to 2014 in two regions of mainland France. An adverse outcome was defined as a miscarriage, stillbirth, preterm birth (<35 weeks of gestation), low birth weight (LBW) defined as less than 2,500 g, or congenital malaria.

RESULTS

Of 60 pregnancies, 5 were excluded because of elective abortions; 55 were investigated, of which 11 were primigravidae and 44 multigravidae. Pregnancies were singleton (n=51) or twin (n=4). Mean age was 30.4 years (range:19-45 y). Among the 55 cases, 9 ended in a miscarriage (8 singletons and 1 twin pregnancy) and 1 had a stillbirth at 21 weeks of gestation, all immediately after the malarial episode. 45 gave birth (29 vaginal deliveries and 16 caesarean sections) to 48 (42 singletons and 6 twins) newborns. Amongst these, 30 were healthy full-term newborns, 10 had LBW, and 8 were preterm. Overall, 26 of 55 (47.3%) pregnancies, and 29 of 59 (49.2%) offsprings had adverse outcomes. Compared to singleton pregnancies, twin pregnancies were associated with adverse outcomes (p=0.0438).

CONCLUSIONS

Imported malaria has a severe impact on pregnancy outcomes. Prevention and management of imported malaria in pregnancy should be optimized.

How do we fight COVID-19? Military medical actions in the war against the COVID-19 pandemic in France

'We are at war', French President Emmanuel Macron said in an address to the nation on 16 March 2020. As part of this national effort, the French Military Medical Service (FMMS) is committed to the fight against COVID-19. This original report aimed to describe and detail actions that the FMMS has carried out in the nationwide fight against the COVID-19 pandemic in France, as well as overseas. Experts in the field reported major actions conducted by the FMMS during the COVID-19 pandemic in France. In just few weeks, the FMMS developed ad hoc medical capabilities to support national health authorities. It additionally developed adaptive, collective en route care via aeromedical and naval units and deployed a military intensive care field hospital. A COVID-19 crisis cell coordinated the French Armed Forces health management. The French Military Centre for Epidemiology and Public Health provided all information needed to guide the decision-making process. Medical centres of the French Armed Forces organised the primary care for military patients, with the widespread use of telemedicine. The Paris Fire Brigade and the Marseille Navy Fire Battalion emergency departments ensured prehospital management of patients with COVID-19. The eight French military training hospitals cooperated with civilian regional health agencies. The French military medical supply chain supported all military medical treatment facilities in France as well as overseas, coping with a growing shortage of medical equipment. The French Armed Forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the review of the scientific literature on COVID-19 daily and provided expert recommendations on biosafety. Finally, even students of the French military medical academy volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the FMMS engaged multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. The collaboration between military and civilian healthcare systems reinforced the shared objective to achieve the goal of 'saving the greatest number'.

Community-acquired pneumonia in the emergency department: an algorithm to facilitate diagnosis and guide chest CT scan indication

OBJECTIVE

The aim was to create and validate a community-acquired pneumonia (CAP) diagnostic algorithm to facilitate diagnosis and guide chest computed tomography (CT) scan indication in patients with CAP suspicion in Emergency Departments (ED).

METHODS

We performed an analysis of CAP suspected patients enrolled in the ESCAPED study who had undergone chest CT scan and detection of respiratory pathogens through nasopharyngeal PCRs. An adjudication committee assigned the final CAP probability (reference standard). Variables associated with confirmed CAP were used to create weighted CAP diagnostic scores. We estimated the score values for which CT scans helped correctly identify CAP, therefore creating a CAP diagnosis algorithm. Algorithms were externally validated in an independent cohort of 200 patients consecutively admitted in a Swiss hospital for CAP suspicion.

RESULTS

Among the 319 patients included, 51% (163/319) were classified as confirmed CAP and 49% (156/319) as excluded CAP. Cough (weight = 1), chest pain (1), fever (1), positive PCR (except for rhinovirus) (1), C-reactive protein ≥50 mg/L (2) and chest X-ray parenchymal infiltrate (2) were associated with CAP. Patients with a score below 3 had a low probability of CAP (17%, 14/84), whereas those above 5 had a high probability (88%, 51/58). The algorithm (score calculation + CT scan in patients with score between 3 and 5) showed sensitivity 73% (95% CI 66-80), specificity 89% (95% CI 83-94), positive predictive value (PPV) 88% (95% CI 81-93), negative predictive value (NPV) 76% (95% CI 69-82) and area under the curve (AUC) 0.81 (95% CI 0.77-0.85). The algorithm displayed similar performance in the validation cohort (sensitivity 88% (95% CI 81-92), specificity 72% (95% CI 60-81), PPV 86% (95% CI 79-91), NPV 75% (95% CI 63-84) and AUC 0.80 (95% CI 0.73-0.87).

CONCLUSION

Our CAP diagnostic algorithm may help reduce CAP misdiagnosis and optimize the use of chest CT scan.

Hypereosinophilia and epigastralgia after visiting Tunisia: a rare differential diagnosis of helminthiases

Causes of hypereosinophilia among travelers returning from North Africa are dominated by helminth infections, especially when associated with gastrointestinal signs. Non-infectious causes must nonetheless be investigated after negative microbiological assessment and failure of a broad empiric antiparasite treatment. We report the case of a young man with epigastralgia and major weight loss since a stay in Tunisia. Empiric treatment with albendazole was not successful. Eosinophilic gastroenteritis was diagnosed and resolved under corticosteroid treatment.

Microbiology of French military casualties repatriated from overseas for an open traumatic injury

BACKGROUND

This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB).

METHODS

Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR.

RESULTS

A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles.

CONCLUSIONS

Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.

Severe infectious mononucleosis in immunocompetent adults

OBJECTIVES

To determine the risk factors for severe infectious mononucleosis (IM) occurrence in immunocompetent adults.

METHODS

We performed a multicenter, retrospective case series including immunocompetent adults presenting with confirmed IM between 2001 and 2011. Severe presentations were compared with uncomplicated presentations using Stata^® 9 software. The significance level was set at 5%.

RESULTS

In univariate analysis, age over 30 years (n=13 or 41.9% vs. n=5 or 12.8%; P=0.006), prior use of non-steroidal anti-inflammatory drugs (NSAIDs) (n=7 or 87.5% vs. n=1 or 12.5%; P=0.009), and smoking (n=13 or 68.4% vs. n=6 or 31.6%; P=0.013) were associated with severe IM onset. In multivariate analysis, only age over 30 years (OR=3.55; P=0.05) and prior use of NSAIDs (OR=15; P=0.05) remained associated with severe IM onset, without reaching significance level (P=0.05).

CONCLUSION

Our study confirmed that age over 30 years is a risk factor for severe IM onset. Prior use of NSAIDs also seems to be correlated with severe presentations. This new data needs to be confirmed in a prospective study.

[Disseminated nocardiosis caused by Nocardia nova with brain abscesses and osteomyelitis in an immunocompetent patient]

INTRODUCTION

Nocardia is an opportunist bacteria involved in patients with cellular immunodepression or chronic lung disease. The most frequent portals of entry are the respiratory tract by inhalation or direct inoculation through a cutaneous effraction. Nocardiosis may be localised or disseminated.

CASE REPORT

We report a rare case of disseminated nocardiosis to Nocardia nova with pulmonary, cutaneous, cerebral attacks and femoral osteomyelitis. The diagnosis was confirmed by prolonged cultures of the bronchoalveolar fluid and the pus extracted from a cutaneous lesion. The outcome was favorable under adapted and prolonged antibiotherapy with imipenem and amikacine and then cotrimoxazole.

CONCLUSION

This observation is original because it involves a immunocompetent patient with an association of two exceptional locations for N. nova: brain abscesses and femoral osteomyelitis. Screening for cerebral involvement should be systematic, even in the lack of neurological signs. An adapted and prolonged antibiotherapy must be conducted.

[Acute pericarditis and tamponade: An unusual revelation of a visceral tuberculosis]

Tuberculosis is a common pulmonary disease, which is still endemic in disadvantaged communities. Pericarditis is a rare but very lethal visceral localization. The authors report the case of a 58-year-old man, without neither medical history nor social risk, who presented a cardiac tamponade as the first and atypic manifestation of a visceral tuberculosis.

[A French soldier returns from the Central Africa Republic with hepatitis A: Vaccination failure is possible!]

In stays in tropical countries, the French military, and travelers in general, are exposed to diseases transmitted by the fecal-oral route, some of which are vaccine-preventable. Here we report a 42-yer-old soldier with hepatitis A, which first appeared on his return from a military operation in the Central African Republic. Despite its excellent immunogenicity and a duration of seroprotection extending beyond 20 years in the vast majority of cases, the hepatitis A vaccine can fail. This reminds us of the importance of combining vaccine and non-vaccine prevention in tropical countries, especially in precarious living conditions.

COL02-02: Intérêt de la recherche de virus respiratoires par PCR multiplex dans les pneumopathies communautaires de l’adulte vu aux urgences – protocole PACSCAN

Introduction – objectifs

Le diagnostic des pneumopathies communautaires (PAC) de l’adulte vu aux urgences repose essentiellement sur la clinique et la radiologie. Le rôle exact des agents viraux dans ces pneumopathies est mal connu.

Objectifs

–

Identifier les virus circulants chez les patients (pts) suspects de PAC vus aux urgences

–

étudier la corrélation entre la présence de ces agents infectieux et le diagnostic clinique de PAC ;

Matériels et méthodes

Un prélèvement nasal et pharyngé a été réalisé chez des pts adultes inclus dans le protocole PACSCAN (impact du scanner dans le diagnostic de PAC) pour suspicion de PAC dans quatre services d’urgences de CHU parisiens. Une PCR multiplex détectant 15 virus (Grippe A/B, H1N1, VRS A, B, Parinfluenzae (1 à 4), Adénovirus, 3 Coronavirus, Metapneumovirus, Rhinovirus), et 4 bactéries (Mycoplsma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, Bordetella pertussis), a été réalisée en aveugle sur chaque prélèvement. Le diagnostic clinique de PAC a été validé par un comité d’experts indépendants.

Résultats

Parmi les 254 pts prélevés en novembre 2011-décembre 2012, 78 (31 %) pts avaient une PCR positive, avec un seul (75,96 %) ou plusieurs (3, 4 %) agent infectieux (bactéries ou virus). Les virus les plus fréquemment identifiés étaient les virus de la grippe (35 %) et les Rhinovirus (26 %).

Les prélèvements de routine détectaient une bactérie chez 31/190 (16 %) pts. 18/78 (23 %) pts avec PCR positive avaient un score FINE IV ou V plus faible que chez les pts PCR négatives (39 %) (p = 0.001). Contrairement aux virus Influenza, la proportion de Rhinovirus, était plus faible chez les pts ayant un diagnostic de PAC que chez ceux dont la PAC était exclue (p < 0.01).

Conclusion

L’implication des virus respiratoires dans les PAC n’est pas négligeable, Une analyse conjuguée clinique, radiologique et virologique peut permettre

Aortic thrombus and multiple embolisms during a Mycoplasma pneumoniae infection

We report the case of a patient who presented with a thrombus of the aortic arch complicated with splenic, renal and peroneal artery embolisms, associated with transient lupus anticoagulant, during a Mycoplasma pneumoniae infection. The outcome was good under antibiotic and anticoagulant treatment. We also review the medical literature on M. pneumoniae-related thromboses.

Recurrent pyelonephritis due to NDM-1 metallo-beta-lactamase producing Pseudomonas aeruginosa in a patient returning from Serbia, France, 2012

We describe the first isolation in France of a New-Delhi metallo-beta-lactamase-1 (NDM-1) producing Pseudomonas aeruginosa. In March 2012, a patient with history of prior hospitalisation in Serbia was diagnosed in France with acute pyelonephritis due to NDM-1 producing P. aeruginosa. Clinical and microbiological cure was obtained under appropriate antibiotic treatment. Two months later, she presented with a recurrence due to the same bacteria, with a favourable evolution. During both hospitalisations, contact isolation precautions were implemented and no cross-transmission was observed.

Recurrent pyelonephritis due to NDM-1 metallo-beta-lactamase producing Pseudomonas aeruginosa in a patient returning from Serbia, France, 2012

We describe the first isolation in France of a New-Delhi metallo-beta-lactamase-1 (NDM-1) producing Pseudomonas aeruginosa. In March 2012, a patient with history of prior hospitalisation in Serbia was diagnosed in France with acute pyelonephritis due to NDM-1 producing P. aeruginosa. Clinical and microbiological cure was obtained under appropriate antibiotic treatment. Two months later, she presented with a recurrence due to the same bacteria, with a favourable evolution. During both hospitalisations, contact isolation precautions were implemented and no cross-transmission was observed.

[Mycoplasma pneumoniae: a cause of febrile hemolytic anemia in travelers]

Mycoplasma pneumoniae can cause varied hematologic manifestations that are frequently associated with lower respiratory tract infections. Acute febrile hemolysis without respiratory symptoms is quite rare. We describe the case of a 25-year-old man, admitted for acute fever with hemolysis, after returning from Djibouti. M. pneumoniae infection was proved by serological testing. A favorable outcome followed macrolide treatment.