Pneumocystis exhalation by infants developing Pneumocystis primary infection: putative infectious sources in hospitals and the community

Pneumocystis jirovecii DNA was detected using a polymerase chain reaction assay in air samples collected using an air-liquid impaction device at 1 m distance from three out of 14 infants who had developed Pneumocystis primary infection. P. jirovecii genotype identification was successful in one out of three pairs of air samples. Matching of P. jirovecii genotypes between the nasopharyngeal and air samples suggested that P. jirovecii was effectively exhaled by the infected infant. These original results represent a proof of concept of the role of infants with primary pneumocystis infection as infectious sources of P. jirovecii in hospitals and in the community.

Investigation of nosocomial pneumocystis infections: usefulness of longitudinal screening of epidemic and post-epidemic pneumocystis genotypes

BACKGROUND

Twenty-five patients, of whom 22 were renal transplant recipients, developed Pneumocystis jirovecii infections at the nephrology department of Reims University Hospital (France) from September 2008 to October 2009, whereas only four sporadic cases had been diagnosed in this department over the 14 previous years.

AIM

This outbreak was investigated by analysing patient encounters and P. jirovecii types.

METHODS

A transmission map was drawn up. P. jirovecii typing at DHPS, ITS and mtLSU rRNA sequences was performed in the patients of the cluster (18 patients with Pneumocystis pneumonia (PCP) and seven colonized patients), 10 unlinked control patients (six PCP patients and four colonized patients), as well as 23 other patients diagnosed with P. jirovecii (nine PCP patients and 14 colonized patients) in the same department over a three-year post-epidemic period.

FINDINGS

Eleven encounters between patients harbouring the same types were observed. Three PCP patients and one colonized patient were considered as possible index cases. The most frequent types in the cluster group and the control group were identical. However, their frequency was significantly higher in the first than in the second group (P < 0.01). Identical types were also identified in the post-epidemic group, suggesting a second outbreak due to the same strain, contemporary to a disruption in prevention measures.

CONCLUSIONS

These results provide additional data on the role of both PCP and colonized patients as infectious sources. Longitudinal screening of P. jirovecii types in infected patients, including colonized patients, is required in the investigation of the fungus's circulation within hospitals.

Importance of tissue sampling, laboratory methods, and patient characteristics for detection of Pneumocystis in autopsied lungs of non-immunosuppressed individuals

To understand the epidemiological significance of Pneumocystis detection in a lung tissue sample of non-immunosuppressed individuals, we examined sampling procedures, laboratory methodology, and patient characteristics of autopsy series reported in the literature. Number of tissue specimens, DNA-extraction procedures, age and underlying diagnosis highly influence yield and are critical to understand yield differences of Pneumocystis among reports of pulmonary colonization in immunocompetent individuals.

Pneumocystis jirovecii genotypes and granulomatous pneumocystosis

This study describes the initial data concerning molecular typing of Pneumocystis jirovecii in a patient having developed granulomatous Pneumocystis pneumonia (PCP). Three types, B(1)a(3), B(1)a(4), B(1)b(2), were identified. All three had been described in reports concerning patients with common diffuse alveolar PCP. The present data show that identical microorganisms can be involved in both granulomatous PCP and diffuse alveolar PCP and that the pathogenesis of the granulomatous response to P. jirovecii may more likely be related to host factors.

[Granulomatous pneumocystis pneumonia]

INTRODUCTION

Granulomatous pneumocystis pneumonia (PCP) is a rarity whose presentation may be misleading.

CASE REPORT

We report the case of a patient suffering from chronic lymphatic leukaemia presenting with acute respiratory insufficiency, with a fatal outcome, due to granulomatous PCP. Broncho-alveolar lavage (BAL) remained negative and the diagnosis could only be made later by open lung biopsy.

CONCLUSION

Although infrequent, granulomatous PCP should be recognised because in this situation the standard investigation (BAL) may be negative. New, more sensitive, methods of investigation such as the polymerase chain reaction (PCR) may permit earlier diagnosis.

Development of an RT-PCR on the heat shock protein 70 gene for viability detection of Pneumocystis carinii f. sp. hominis in patients with pneumocystosis and in air sample

To test the viability of Pneumocystis carinii f. sp. hominis, an RT-PCR assay that employs specific primers from the Heat Shock Protein 70 gene was developed. Using this method, the viability of P.c. hominis in bronchoalveolar lavage fluids from patients developing PCP and in the environment of PCP patients was established.

[Difficulties in diagnosis of human dirofilariasis outside known enzootic areas]

INTRODUCTION

Human non-visceral dirofilariasis, a mosquito-borne disease of carnivores (dogs), is chiefly due to Dirofilaria repens in France and is well known in the Mediterranean basin. This zoonosis can be misdiagnosed in northern areas of France. We present and discuss two human cases diagnosed in Abbeville and Amiens (Picardy) by histological examination.

EXEGESIS

The former case appeared as an axillary tumefaction occurring in a 41-year-old women 6 months after holidays in Montauban (southwestern France), the other as an intraorbital 'tumor' in a 53-year-old man who travelled for professional purposes in Central Europe and North America. Morphological, clinical, and epidemiological data of these human infections are discussed and the diagnostic features in tissue sections for species identification are reviewed.

CONCLUSION

Increasing travel customs during the last decades favour the emergence of zoonotic parasites unusually in human hosts. Outside known enzootic areas, diagnosis is often delayed until pathological examination. In France, the incidence of human dirofilariasis has steadily increased and must be considered in the workup of cutaneous or intraorbital nodules.

Molecular characterization of Cryptosporidium isolates obtained from humans in France

Cryptosporidium parvum is usually considered the agent of human cryptosporidiosis. However, only in the last few years, molecular biology-based methods have allowed the identification of Cryptosporidium species and genotypes, and only a few data are available from France. In the present work, we collected samples of whole feces from 57 patients from France (11 immunocompetent patients, 35 human immunodeficiency virus [HIV]-infected patients, 11 immunocompromised but non-HIV-infected patients) in whom Cryptosporidium oocysts were recognized by clinical laboratories. A fragment of the Cryptosporidium 18S rRNA gene encompassing the hypervariable region was amplified by PCR and sequenced. The results revealed that the majority of the patients were infected with cattle (29 of 57) or human (18 of 57) genotypes of Cryptosporidium parvum. However, a number of immunocompromised patients were infected with C. meleagridis (3 of 57), C. felis (6 of 57), or a new genotype of C. muris (1 of 57). This is the first report of the last three species of Cryptosporidium in humans in France. These results indicate that immunocompromised individuals are susceptible to a wide range of Cryptosporidium species and genotypes.

Metronidazole and albendazole susceptibility of 11 clinical isolates of Giardia duodenalis from France

The metronidazole and albendazole susceptibility of 11 clinical isolates of Giardia duodenalis from France was determined using a neonatal mouse model and compared with the outcome in patients after standard metronidazole therapy (0.75 g/day for 5 days). All isolates found to be clinically resistant to metronidazole (4/11) exhibited an ID50 > 120 mg/kg in the mouse model. This therefore appears to be a suitable animal model in which to explore drug failures in human giardiasis.

[Hemodialysis and strongyloidiasis: a presumed cause of eosinophilia able to mask the other]

The authors report a case of recurrent strongyloidiasis in a former French soldier of the Indochina colonial war (1946-54). Strongyloidiasis was associated with inaugural renal failure (acute steroid-resistant interstitial-type), requiring permanent hemodialysis. Despite antiparasitic treatment, relapse with digestive and pulmonary symptoms occurred 10 years later, following chronic eosinophilia. This observation emphasises that in dialysed subjects, eosinophilia should always stimulate a search for parasitic etiologies before incriminating dialysis-material allergy. Strongyloidiasis is a self-perpetuating helminthiasis whose distribution area is far greater than the intertropical zone. It can be completely asymptomatic, appear as late digestive complications and be responsible for bacteraemic peaks with septic visceral localizations. It causes a chronic oscillating eosinophilia. Diagnosis is usually performed by iterative stool examinations by Baermann technique in order to detect Strongyloides stercoralis rhabditoid larvae. In dialysed patients with unexplained eosinophilia awaiting renal transplant, the options of systematic thiabendazole (50 mg/kg) or ivermectine (0.2 mg/kg) single-dose to overcame the risk of disseminated strongyloidiasis induced by immunosuppressive post-transplantation therapy could be debated.

[Malaria chemoprophylaxis: tolerance and compliance with mefloquine and proguanil/chloroquine combination in French tourists]

To determine if mild adverse events attributed to mefloquine (MQ) and chloroquine + proguanil (CQ-PRO) were experienced with the same frequency, we carried out a study in two groups of French native adult short-term visitors to Africa originating from Amiens. CQ (100 mg daily) + PRO (200 mg daily) prophylaxis was prescribed for all patients travelling to Senegal and those for Kenya when MQ was contraindicated, including all the patients with an history of any neuropsychiatric events, even mild (group 1). MQ (250 mg weekly) was prescribed for the others subjects (group 2). The self-reported questionnaire has been sent by mail to 534 travellers between one to three months after the end of their travels for obtaining information about travel conditions and health problems, mainly those attributed to anti-malarial drugs taken for chemoprophylaxis. We have received 377 available responses (71%): 183 in group 1 and 194 in group 2. There are no significant differences for age, sex, exposition and measures of protection against mosquito bites, concomitant drug use, mean duration of chemoprophylaxis. The compliance during the travel is excellent in each group. CP was interrupted prematurely (< 15 days after returning) in 13.8% of the case with MQ against 4.2% only with CQ-PRO (OR = 3.7; CI 95% = 1.5-9.1). The rates of overall side effects attributed to malaria chemoprophylaxis are respectively: 15.8% for MQ against 12.4% for CQ-PRO (difference not significant). However non-serious neuropsychiatric adverse events (dizziness, headache, mood change and sleep disturbance) are more frequent with MQ: 11.5% against 2.1% with CQ-PRO (OR = 6.2; CI 95% = 2.2-17.2). Although all side effects were transient and judged to be mild to moderate by the subjects themselves, these results back up the fact that mefloquine should be used with caution.

Compliance with and tolerance of mefloquine and chloroquine + proguanil malaria chemoprophylaxis in French short-term travellers to sub-Saharan Africa

To compare the compliance with and tolerance of mefloquine (MQ) and chloroquine + proguanil (CQ-PRO) chemoprophylaxis, we conducted a study using a self-reported questionnaire in 2 groups of native French adult visitors to Senegal or Kenya. CQ (100 mg daily) + PRO (200 mg daily) prophylaxis was prescribed for all patients travelling to Senegal and for those going to Kenya when MQ was contraindicated; MQ (250 mg weekly) was prescribed for the other subjects. There were no significant differences in age, sex, exposition and measures of protection against mosquito bites, concomitant drug use or mean duration of chemoprophylaxis between the 2 groups, and compliance during travel was excellent in both. Chemoprophylaxis was more frequently interrupted prematurely in the MQ group. The rates of overall side-effects attributed to malaria chemoprophylaxis were 16% for MQ against 12% CQ-PRO (not significant). However, nonserious neuropsychiatric adverse events are more frequent with MQ: 11.5% compared to 2% with CQ-PRO. MQ should be used with caution.

[Entomophthoramycosis: a case report of a Congolese child with rapid regression using ketoconazole]

We report the second Congolese case of subcutaneous entomophthoramycasis, a rare tropical disease expressed as cellulitis. Despite characteristic clinical features, the diagnosis for this twelve-year old child was confirmed four years after the beginning of the disease. Dramatic clinical improvement was observed within the first month of treatment with ketoconazole.