[Atypical alveolar echinococcosis with systemic involvement in a patient treated with dupilumab]

INTRODUCTION

Alveolar echinococcosis is an endemic parasitic disease prevalent in certain cold regions of the Northern Hemisphere, including Eastern France, Switzerland, Germany, Canada, and the United States. Widely underdiagnosed, it is associated with infection by Echinococcus multilocularis, a small tapeworm belonging to the cestode class, capable of causing multi-systemic involvement, particularly in elderly or immunocompromised patients.

CASE REPORT

We present the case of an 82-year-old patient, immunocompromised due to prolonged corticosteroid therapy and treatment with dupilumab. She was referred to our department for a diagnostic assessment of atypical hepatic and pulmonary lesions, initially suspected of tuberculosis or an IgG4-related disease. The hypothesis of alveolar echinococcosis caused by E. multilocularis was eventually considered based on a set of arguments, further confirmed by molecular diagnosis. We discuss the role of dupilumab in the systemic evolution and atypical presentation of the disease, through the induction of a specific immunosuppression.

CONCLUSION

Alveolar echinococcosis should be systematically considered in case of systemic disease with prominent hepatic and pulmonary involvement, especially in immunocompromised patients.

[Management of HPV-induced cervical lesions in immunosuppressed patients - Review of the literature]

INTRODUCTION

Current French recommendations for the management of cervical lesions related to human papilloma virus (HPV) infection are limited to general population. Patients who are immunocompromised appear to be at increased risk of induced HPV lesions. The objective of this review is to summarize the various existing data about risk of induced HPV lesions in immunocompromised patients to specify the management.

METHODS

The Medline database was searched through the Pubmed portal, as well as the recommendations of various international learned societies.

RESULTS

Situations with an increased risk are regardless of treatment: Human Immunodeficiency Virus (HIV) infection, transplants, lupus. Patients with chronic inflammatory bowel disease (IBD) and rheumatoid arthritis are at increased risk only when immunosuppressive therapy is required. Screening for dysplasic intraepithelial lesions in HIV+ patients should be more sustained than in the general population. Due to lack of data, recommendations for other conditions have been extrapolated from the management of HIV+ patients. HPV vaccination is effective in these populations, particularly at times when the immune system is the most effective.

DISCUSSION

Identified immunocompromised populations are at higher risk of induced HPV lesions due to an incomplete immune response and should be screened on a sustained basis. In addition, HPV vaccination should be encouraged.

[Cytomegalovirus infection in systemic lupus erythematosus patients. A series of 12 case reports and literature review]

INTRODUCTION

Patients with systemic lupus erythematosus (SLE) are at risk of cytomegalovirus (CMV) infection, due to the disease itself or to drug-induced immunosuppression. Also, active CMV infection may trigger or worsen SLE flare-up.

METHODS

In this retrospective single-centre cohort study, we reported all adult inpatients with a diagnosis of SLE, presenting with active and confirmed CMV infection. The goal was to describe their characteristics and outcomes (evolution of CMV infection, secondary infections and SLE flare-up), and to review the existing literature.

RESULTS

We identified 400 patients with confirmed SLE, including 12 who presented with active CMV infection. Severe CMV manifestations were present in 7 patients treated with immunosuppressive regimen out of 10, and in one patient out of two without immunosuppressive therapy. Six patients developed other infections, and 3 showed characterised SLE flare-up over the 3-month follow-up. All patients were alive at end of follow-up.

DISCUSSION

Among patients with SLE, CMV infection affected more frequently those treated with immunosuppressive drugs, but treatment-free patients were sometimes severely affected. CMV infection was associated with an increased incidence of SLE flare-up and infectious complications. Our results suggest that early anti-viral chemotherapy may be beneficial in these patients.

[Gastrointestinal symptoms revealing COVID-19 in Malian breast cancer patient undergoing chemotherapy]

Les auteurs rapportent le cas d’une patiente malienne suivie pour cancer du sein métastatique au niveau osseux sous chimiothérapie chez qui le diagnostic de la COVID-19 a été posé 9 jours après le début des troubles digestifs avec survenue du décès de la patiente avant toute prise en charge de cette virose. Face au mauvais pronostic des patients atteints de cancer et de COVID-19, les auteurs insistent auprès des cliniciens sur la nécessité d’une attention particulière devant de telles associations morbides afin de trouver l’équilibre thérapeutique entre ces deux pathologies.

[The place of bronchoalveolar lavage in the diagnosis of pneumonia in the immunocompromised patient]

INTRODUCTION

Bronchoalveolar lavage (BAL) was previously considered as the standard diagnostic procedure to investigate pneumonia occurring in immunocompromised patients, and it is probably still widely used. However, the development of new microbiological diagnostic tools, applicable to samples obtained non-invasively, leads to questioning of the predominant place of BAL in this situation.

BACKGROUND

The available studies agree on the acceptable tolerance of BAL performed in immunocompromised patients. Although imperfect, the diagnostic yield of BAL in immunocompromised patients is well established, but it may vary between studies depending on the underlying disease. However, it must also be compared to the yield of non-invasive microbiological tools, now widely available and effective. The position of BAL remains important both for the diagnosis of fungal infections (invasive aspergillosis, pneumocystis pneumonia) and non-infectious lung diseases both of which occur frequently in immunocompromised patients.

CONCLUSION

The place of BAL in the diagnostic work-up of pneumonia occurring in immunocompromised patients must be considered in the framework of a structured consideration, taking into account the diagnostic performance of non invasive microbiological tests and the broad spectrum of lung diseases occurring in this context.

[Functional immunoassays in the setting of infectious risk and immunosuppressive therapy of non-HIV immunocompromised patients]

The holistic approach of the human immune system is based on the study of its components collectively driving a functional response to an immunogenic stimulus. To appreciate a specific immune dysfunction, a condition is mimicked ex vivo and the immune response induced is assessed. The application field of such assays are broad and expanding, from the diagnosis of primary and secondary immunodeficiencies, immunotherapy for cancer to the management of patients at-risk for infections and vaccination. These assays are immune monitoring tools that may contribute to a personalised and precision medicine. The purpose of this review is to describe immune functional assays available in the setting of non-HIV acquired immune deficiency. First, we will address the use of theses assays in the diagnosis of opportunistic infections such as viral reactivation. Secondly, we will report the usefulness of these assays to assess vaccine efficacy and to manage immunosuppressive therapies.

[Eruptive disseminated superficial porokeratosis associated with acute hepatitis E]

BACKGROUND

Porokeratosis (PK) is a rare form of dermatosis characterized by a keratinization disorder of unknown etiology. Herein we describe the first case associated with hepatitis E virus infection.

PATIENTS AND METHODS

A 69-year-old patient with colorectal cancer treated with radiation and chemotherapy followed by surgery in April 2017 presented two months later with jaundice associated with annular keratotic lesions of the skin with a raised border. Blood tests revealed elevated liver enzymes and hyperbilirubinemia. Viral hepatitis E was diagnosed based on serology and viral PCR after other aetiologies such as obstruction, auto-immune disease and other viruses (HAV, HBV, HCV, HSV, HIV, EBV and CMV) had been ruled out. A skin biopsy showed a cornoid lamella. Disseminated superficial porokeratosis associated with hepatitis E infection was then diagnosed.

DISCUSSION

The mechanism of PK is unknown and probably involves a combination of different factors. PK has been described in patients with treatment-induced immunosuppression, solid cancer or AIDS, sometimes promoted by HCV viral infection, but never with concomitant HEV infection. A combination of immunosuppression induced by radio-chemotherapy and HEV infection could have prompted the development of PK in our patient.

CONCLUSION

We report the first case of eruptive disseminated superficial porokeratosis associated with hepatitis E infection. The exact role of hepatitis E infection in the development of PK is still unclear.

[Influenzae and pneumococcal vaccination rate in an internal medicine ward]

INTRODUCTION

Vaccination against influenza virus and Streptococcus pneumoniae is a global health priority and authorities, on the basis of recent publications, have recently updated French recommendations. The aim of this study was to describe the influenzae and pneumococcal vaccination's rate in an internal medicine ward.

MATERIAL AND METHODS

All patients consecutively hospitalized during a 10 week-period in an internal medicine ward were included. The reasons for non-vaccination and the impact of an educational program for corrective measures were reported.

RESULTS

Overall, 198 consecutive patients were included; 93 (47%) were immunocompromised; 142 (71.2%) had an indication for pneumococcal vaccination and 171 (86.4%) for influenza vaccination but only 16.2% and 55% of them were vaccinated against these microorganisms, respectively. Prior pneumococcal vaccination was more frequently observed in immunocompromised patients than in non-immunocompromised patients (21.1 versus 6.4%; P=0.029), but no significant difference was observed for influenza vaccine. Corrective measures were initiated in 46 patients (39%), non-immunized against S. pneumoniae.

CONCLUSION

These results underline the very low prevalence of pneumococcal vaccination rate in at-risk hospitalized patients, as compared with influenza, despite recent recommendations.

[French recommendations on control measures to reduce the infectious risk in immunocompromised patients]

The increase use of immunosuppressive treatments in patients with solid cancer and/or inflammatory diseases requires revisiting our practices for the prevention of infectious risk in the care setting. A review of the literature by a multidisciplinary working group at the beginning of 2014 wished to answer the following 4 questions to improve healthcare immunocompromised patients: (I) How can we define immunocompromised patients with high, intermediate and low infectious risk, (II) which air treatment should be recommended for this specific population? (III) What additional precautions should be recommended for immunocompromised patients at risk for infection? (IV) Which global environmental control should be recommended? Based on data from the literature and using the GRADE method, we propose 15 recommendations that could help to reduce the risk of infection in these exposed populations.

Bordetella bronchiseptica infection

OBJECTIVE

To collect data of all patients admitted to hospital with a positive test to Bordetella bronchiseptica between 2001 and 2015.

METHODS

We performed a retrospective monocentric study of all hospitalized patients over the past 15 years with a positive test to B. bronchiseptica.

RESULTS

Nine patients were included between 2001 and 2015; two presented with infectious relapses, i.e. a total of 14 positive test samples were observed. Age, induced immunodeficiency, and preexisting respiratory illnesses are risk factors. All patients showed symptoms at sample collection and the infection was exclusively respiratory. The diagnosis was obtained through a cytobacteriological test of sputum, bronchial aspiration, or bronchial fibroscopy with a bronchoalveolar lavage. The drug susceptibility test revealed a natural resistance to cephalosporins including ceftazidime, monobactam, and fosfomycin. There were cases of resistance to penicillin A and to the trimethoprim/sulfamethoxazole association. The classically used antibiotic treatment for community-acquired pneumonia is based on probability and may thus fail. Four patients died. The duration and nature of the antibiotics to use have not been codified.

CONCLUSION

B. bronchiseptica infection mainly affects the elderly. All patients should be treated, regardless of the importance of the inoculum, and all infected animals should be treated.

[Molecular epidemiology and kinetics of early Escherichia coli urinary tract infections in kidney transplant recipients]

BACKGROUND

Escherichia coli strains causing Urinary Tract Infections (UTI) have a fecal origin.

METHODS

A fecal sample was collected before Kidney Transplantation (KT) and concomitantly with urine at each of the 15 E. coli UTIs which occurred in 11 KT recipients. Unique E. coli strains were identified among 25 isolates per feces and 5 isolates per urinary sample by random amplification of polymorphic DNA. Phylogenetic group (which is correlated to virulence in the E. coli species) was determined for each E. coli strain by a PCR based method.

RESULTS

Forty-three unique fecal strains and 14 unique urinary strains were identified among 650 fecal isolates and 75 urinary isolates. Urinary strains frequently (55% of the cases) belonged to a phylogroup usually not linked to virulence. They were detected in the feces collected concomitantly in 60% of the cases. Urinary strains belonging to a phylogroup usually linked to virulence were more frequently dominant in the feces (100%) than urinary strains belonging to a non-pathogenic phylogroup (42%; P<0.05). Vesical catheter was a facilitating factor only for urinary strains belonging to non-pathogenic phylogroups. Thirty-three percent of the fecal strains were persisting in two consecutive fecal samples and 62% were detected for the first time at the UTI. Numerous pathway lead to UTIs: from a unique, virulent and persisting strain to a non-virulent recently acquired strain facilitated by a vesical catheter.

CONCLUSION

Our work shows the diversity of host-microbial interactions which precede extra-intestinal virulence.

[Nocardiosis: A retrospective case series of 19 patients]

INTRODUCTION

Nocardiosis are uncommon. The diagnosis may be difficult, with significant morbidity and mortality, often occurring on frail patients. Few data are available in France.

METHODS

A retrospective single center study was conducted from 2002 to 2014 and included all patients with at least one positive microbiological sample for Nocardia with a follow-up in our hospital.

RESULTS

Nineteen patients, including 15 men, were included with a mean age of 58 years (25-85). Seventeen had a risk factor (lung diseases [13], corticosteroids [12], solid neoplasia [2], HIV infection [2], diabetes mellitus [3], kidney transplant [2], lymphopenia [1]). Infections' locations were: pulmonary (12), brain (3), skin (2), lymph node (1) and corneal (1). The slow growth leads to a median of 35 days for a positive result (3-95). Nine species were identified. Fifteen patients (79%) received one or more lines of antibiotics including: cotrimoxazole (9), amoxicillin (7) cefotaxime/ceftriaxone (7) imipenem (3), or amikacin (3). The average duration of antibiotic therapy was 207 days. Four patients did not receive antibiotics due to a late result or a bacterial co-infection masking nocardiosis. Five patients died (26%) including 2 with cerebral nocardiosis. Six patients were cured, 4 suffered a relapse, 4 had an unknown evolution, and 1 was still treated.

CONCLUSION

Our study shows that nocardiosis is a disease difficult to treat. A better understanding of this type of infection is necessary.

[Pneumocystis pneumonia in HIV-negative adults]

In HIV-negative adults, Pneumocystis jirovecii pneumonia can be observed when immunodeficiency is present, especially in case of drug-induced immune suppression (steroids, chemotherapy, transplantation). Clinical, radiological, and biological presentations are different in HIV-positive and HIV-negative individuals with different immunodeficiency profiles. In HIV-negative patients, dyspnea occurs more quickly (median duration of 5 days to get a diagnosis), diagnosis is more difficult because of less Pneumocystis in bronchoalveolar lavage, and mortality is higher than in HIV-positive individuals. Lung CT-scan typically shows diffuse ground glass opacities, but peri-bronchovascular condensations or ground glass opacities clearly limited by interlobular septa can also be observed. Lymphopenia is common but CD4+ T-cells count is rarely performed. HIV-negative patients with Pneumocystis pneumonia are co-infected with bacteria, viruses or fungi in about 30% cases. Bronchoalveolar lavage is often more neutrophilic than in HIV-positive individuals. PCR and β-D-glucan have good sensitivity but poor specificity to diagnose Pneumocystis pneumonia. Trimethoprim-sulfamethoxazole remains the first choice of treatment. Duration is 14 days in HIV-negative patients whereas it is typically of 21 days in HIV-positive individuals. Adjunctive corticosteroids are of beneficial effect in HIV-positive adult patients with substantial hypoxaemia but are not recommended in HIV-negative patients, as they could be deleterious in some individuals.

[Disseminated cryptococcosis in an immunocompetent patient]

Disseminated cryptococcosis is a serious opportunistic fungal infection caused by a yeast-encapsulated fungus of the genus Cryptococcus neoformans. It occurs most often in patients with a significant deficit of cellular immunity and preferentially affects the central nervous system. The skin and the lungs are the most commonly affected sites outside the neuro-subarachnoid location. We report the case of a patient apparently immunocompetent who had a disseminated cryptococcosis. The disease started with the multiple purplish skin lesions, large umbilicated on the face, groin, forearm and leg with progressively increasing volume. This symptomatology had evolved in the context of weight loss and poor general condition. The diagnosis was established by the presence of cryptococcal at the skin biopsy and cerebrospinal fluid. Research of immunosuppression common pathologies were negative. Treatment was initiated based on amphotericin B for 40 days. The patient's condition deteriorates onset of paraplegia and swallowing disorders causing death in an array of cachexia. This observation points out that disseminated cryptococcosis can occur in an immunocompetent patient. The skin lesions may be the first sign of the disease.

[Cryptococcal infection and sarcoidosis: a coincidence?]

INTRODUCTION

We report a case of cryptococcal infection that underwent in a patient with a medical history of asymptomatic sarcoidosis. This finding seems to be not incidental.

CASE REPORT

A 35-years-old female was referred to hospital for a community-acquired pneumonia with pleural involvement. A physical examination showed a pleural syndrome. Chest imaging showed a parenchymal involvement with pleural effusion and numerous mediastinal nodes. Fiberoptic bronchoscopy revealed an obstruction of the right apical bronchus of the lower lobe. Biopsies and bronchoalveolar lavage confirmed a cryptococcal infection. The disease was considered as disseminated with a urinary and neurologic involvement. The outcome was fair under prolonged antifungal therapy.

CONCLUSIONS

Cryptococcal infection is generally associated with immunosuppression. We suggest that sarcoidosis, although non symptomatic, may be a condition that promote the onset of cryptococcal infection. Even rare, cryptococcal infection is the most frequent opportunistic infection recorded with sarcoidosis patients. Histologic similarities between sarcoidosis and cryptococcal infection and the role of the macrophages which phagocyte the Cryptococcus neoformans are one of the hypothesis to assess these pathologic findings. A register is warranted to recover all opportunistic infection related to sarcoidosis in order to better understand the pathogeny.

Update on pulmonary Pneumocystis jirovecii infection in non-HIV patients

Pneumocystis jirovecii is the only fungus of its kind to be pathogenic in humans. It is primarily responsible for pneumonia (PJP). The key to understanding immune defences has focused on T-cells, mainly because of the HIV infection epidemic. Patients presenting with PJP all have a CD4 count below 200/mm(3). The introduction of systematic primary prophylaxis and the use of new anti-retroviral drugs have significantly reduced the incidence of this disease in the HIV-infected population, mainly in developed countries. The increasingly frequent use of corticosteroids, chemotherapy, and other immunosuppressive drugs has led to an outbreak of PJP in patients not infected by HIV. These patients presenting with PJP have more rapid and severe symptoms, sometimes atypical, leading to delay the initiation of a specific anti-infective therapy, sometimes a cause of death. However, the contribution of new diagnostic tools and a better understanding of patients at risk should improve their survival.

Scedosporium prolificans fungaemia in a patient with acute lymphoblastic leukaemia

Aggressive chemotherapy and immunosuppressive treatment may prolong patients' life, but influence the risk of severe, life-threatening infections. Here, we report the case of a 21-year-old caucasian female who developed a disseminated infection of Scedosporium prolificans after allogenic stem cell transplantation performed for treatment of relapsed acute lymphoblastic leukaemia. The pathogen was isolated from the blood and identified on the basis of its macroscopic and microscopic morphological features. The empirical treatment with amphotericin B provided no improvement. However, introduction of intravenous voriconazole resulted in amelioration of fever. Unfortunately, the patient died due to progression of underlying disease and multiorgan failure. However, this case report indicates a possible relevance of voriconazole-based treatment regimens in invasive S. prolificans infections.