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Objectives The aim was to assess the incidence of sink contamination by multidrug-resistant (MDR) Pseudomonas aeruginosa and Enterobacteriaceae, risk factors for sink contamination and splashing, and their association with clinical infections in the intensive care setting. Methods A prospective French multicentre study (1 January to 30 May 2020) including in each intensive care unit (ICU) a point-prevalence study of sink contamination, a questionnaire of risk factors for sink contamination (sink use, disinfection procedure) and splashing (visible plashes, distance and barrier between sink and bed), and a 3-month prospective infection survey. Results Seventy-three ICUs participated in the study. In total, 50.9% (606/1191) of the sinks were contaminated by MDR bacteria: 41.0% (110/268) of the sinks used only for handwashing, 55.3% (510/923) of those used for waste disposal, 23.0% (62/269) of sinks daily bleached, 59.1% (126/213) of those daily exposed to quaternary ammonium compounds (QACs) and 62.0% (285/460) of those untreated; 459 sinks (38.5%) showed visible splashes and 30.5% (363/1191) were close to the bed ( Discussion Our data showed frequent and multifactorial infectious risks associated with contaminated sinks in ICUs.

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We report three cases of pruritic dermatitis with erythematous maculopapules, having a similar clinical presentation, in summer, and caused by two different arthropods. In wandering diagnosis since sometimes several months, patients have made entomologic investigations in their home. Two of three samples, have shown an infestation by Anobium punctatum, the common furniture beetle, a xylophagous beetle (usually harmless for human). It may be parasited by Pyemotes ventricosus, a mite known since the 19th century to cause this type of hurt. The third sample contained Cimex lectularius or bedbug, haematophagous insect, classically looked for in endemic zone.

Summary Mucormycosis infections are rare in France, and are caused by fungi of the class Zygomycetes, order Mucorales. The prognosis of these emergent pathologies remains severe. We report a case of a 44-year-old man, who has been admitted to the Emergency Care Unit, for a fly-away acute sinusitis resistant to antibiotic treatment. Biological parameters revealed a diabetic ketoacidosis. On day 2 after admission, ocular dysfunctions happened. An ethmoido-oculo-cerebral lesion was revealed by a cerebral MRI, suggesting a mucormycosis infection. Isolation of Rhizopus orizae was performed by a surgical histologic biopsy. Mucormycosis agents of are ubiquitary. Rhino-cerebral lesions are the most common clinical manifestations. Diabetic ketoacidosis and hematologic malignancies are respectively the two higher risk factors of mucormycosis development. This angioinvasive fungal infection induces more than a 50 % rate mortality despite the first surgical-line therapy. To conclude, a global therapeutic care and a complete knowledge of this varied clinical fungi infection must be controlled. The actual incidence of diabetes is increased, thus a mucormycosis infection must be evoked in non-responsive head and neck infections.

Myelodysplastic syndrome with erythroid hypoplasia or erythroblastopenia has not yet been clearly defined, and in most patients it is mistaken for acquired pure red cell aplasia. Including one additional patient reported in this article, a literature review revealed only 50 cases over the last 20 years. These patients were predominantly elderly males, all required regular packed red cell transfusions, and they had a poor prognosis, mainly because of acute transformation. The mechanisms of erythroid aplasia remain unclear. However, recent data suggest the association of an intrinsic stem cell defect with immunological implication.

Four cases of Streptococcus pyogenes infection due to an emm-type 11 strain, including one with a fatal outcome, occurred within a seven-member family. All strains shared biotype 5, pyrogenic exotoxin genes speB and speC, and resistance to kanamycin, tetracycline, macrolides and lincosamides. The identity of SmaI pulsed-field gel electrophoresis patterns confirmed their clonal origin. This highlights the ability of S. pyogenes to spread rapidly among family members. This first report of a family outbreak due to emm11 S. pyogenes reinforces the importance of surveillance of close family contacts of individuals with invasive streptococcal disease, and provides further support for antibiotic prophylaxis among the elderly.

We present a 73-year-old woman presented to our hospital with a 2 years history of eyes itching. The ophthalmological testing was normal. Physical examination revealed blepharitis and lesions acnea-like on mouth, nose and chest. Biological testing revealed no abnormalities. Histologic study and direct immunofluorescence on a cutaneous biopsy were no contributive. The research of an allergic origine was practised by cutaneous and serological tests and negative. An examination of eyelashes was performed and yielded Demodex. Demodex folliculorum is a mite that is the most common permanent ectoparasite of humans, which is thought to be linked to blepharitis and allergic blepharoconjunctivis with rosacea, although much controversy persists. Recent studies demonstrate a high frequence of chronic blepharitis when Demodex are abundant. Several molecules can be used to treat this infestation. Parasiticide as oral ivermectine may be useful when the infestation is important.

Resume Les manifestations cliniques et biologiques des leptospiroses meningees sont trompeuses. Nous presentons le cas d’un homme de 62 ans, sans facteurs de risque, souffrant de cephalees febriles avec liquide cephalorachidien pseudotumoral, par leptospirose meningee pure. Nous discutons a ce propos des moyens diagnostiques disponibles et de leur interet pratique.

Resume Les infections a pneumocoque representent aujourd'hui un probleme de sante publique. Le pneumocoque est une cause majeure des infections communautaires invasives et non invasives du nourrisson et de l'enfant. Les infections invasives, notamment les meningites, restent graves, avec un taux de mortalite superieur a 8 % et un risque eleve de sequelles. Chez le petit enfant, leur expression clinique peut etre atypique. Le diagnostic biologique beneficie d'avancees techniques comme la detection rapide d'un antigene par immunochromatographie sur membrane, encore a evaluer chez l'enfant. L'augmentation de la frequence des souches de pneumocoque de sensibilite diminuee a la penicilline impose d'adapter la therapeutique a la pathologie et a l'epidemiologie. La frequence, la gravite et la resistance des infections a pneumocoque justifient la vaccination par le vaccin conjugue Prevenar® ou le vaccin Pneumo 23® selon l'âge de l'enfant. Une surveillance locale, nationale et internationale permet en outre d'emettre des recommandations en matiere de traitement probabiliste et de vaccination.

Resumen Las infecciones neumococicas constituyen hoy en dia un problema de salud publica. El neumococo es una causa grave de infecciones invasivas y no invasivas de lactantes y ninos en ambientes comunitarios. Las infecciones invasivas, en especial las meningitis, siguen siendo graves, con una tasa de mortalidad superior al 8% y gran riesgo de secuelas. En los ninos pequenos, su expresion clinica puede ser atipica. El diagnostico de laboratorio ha beneficiado de los avances tecnicos, como la deteccion rapida de un antigeno mediante inmunocromatografia sobre membrana, tecnica aun no evaluada en los ninos. El aumento de la frecuencia de cepas de neumococos con sensibilidad reducida a la penicilina exige que se adapte el tratamiento a la enfermedad y a la epidemiologia. La frecuencia, la gravedad y la resistencia de las infecciones por neumococos justifican la vacunacion mediante distintas vacunas segun la edad del nino. Por otra parte, el control local, nacional e internacional permite establecer recomendaciones respecto al tratamiento empirico y a la vacunacion.

To the Editor: Mycobacterium riyadhense is a newly described mycobacterial species that is potentially pathogenic for humans. Extrapulmonary infection with this nontuberculous mycobacterium (NTM) has been reported (1).We report 2 cases of pulmonary infection with this NTM. The first case of infection was in a 39-year-old woman who was admitted to Toulon Military Hospital, Toulon, France, in December 2005 with suspected pulmonary tuberculosis. For 1 month, the patient had a persistent cough, fever, asthenia, and weight loss. Findings on chest radiographs were suggestive of tuberculosis, with cavitation in the right upper lobe, and the tuberculin skin test reaction was positive. Sputum specimens collected on 3 consecutive days were negative for acid-fast bacilli (AFB), but broth cultures (BacT/ALERT 3D system; bioMerieux, Marcy l’Etoile, France) yielded mycobacterial growth. We used 4 multiplex line-probe assays to identify the mycobacteria: GenoType MTBC (Hain Lifescience, Nehren, Germany) identified the organisms as members of the M. tuberculosis complex (MTBC; with a nonspecific reaction, banding pattern 1, 2, 3); GenoType Mycobacterium CM (Common Mycobacteria) (Hain Lifescience) kit and GenoType Mycobacterium AS (Additional Species) (Hain Lifescience) kit identified the strains as members of the MTBC and as unspecified Mycobacterium species, respectively; and INNO-LiPA MYCOBACTERIA v2 (Innogenetics, Ghent, Belgium) yielded a Mycobacterium-positive reaction by genus probe but no species-specific result. Following the criteria of the American Thoracic Society, we considered the isolates as the pathogens responsible for the patient’s respiratory disease (2). The patient was treated with a combination of isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA). EMB and PZA were continued for 2 months; INH and RIF were continued for 10 months (Table), at which time the patient was considered cured. Table Clinical characteristics, drug susceptibility testing, and outcome for 3 case-patients with Mycobacterium riyadhense infection, France and Bahrain* The second case of infection was in a 43-year-old man who was admitted to Awali Hospital, Awali, Bahrain, in November 2006. The patient reported malaise, insomnia, cough, weight loss, and anorexia. Radiographs showed features suggestive of tuberculosis (left upper lobe consolidation with focal cavitation). Sputum specimens collected on 3 consecutive days were positive for AFB and mycobacterial growth. To identify the pathogen(s), we used the same 4 mutiplex line-probe assays as used for case-patient 1, and results were similar. The identified strain was considered to be the pathogen responsible for the respiratory disease (2). The patient was treated with a combination of clarithromycin (CLR) and ciprofloxacin (CIP) for 12 months; however, he had a clinical and microbiological (i.e., positive for AFB and culture results with the same NTM) relapse during this treatment. In November 2007, 3 sputum specimens from the patient were positive for AFB, and cultures yielded a mycobacterial strain identical to that identified by the assays. The patient was treated with antituberculous drugs (INH, RIF, EMB, PZA, plus CLR and CIP) for 6 months, and then INH, RIF, CLR, CIP were continued for 2 additional months (Table), after which the patient showed clinical improvement. In the 2 cases, molecular identification of the isolates as M. riyadhense was achieved by using partial hsp65 and rpoB gene sequencing, which was based on the high level of sequence identities with the type strain of M. riyadhense and a distance score of 3.5 and 4.6, respectively, to the next species, “M. simulans” (Table). Broth microdilution panels (SLOMYCO Sensititer; Trek Diagnosis Systems, Cleveland, OH, USA) were used to determine drug susceptibility (Table) (3). Commercial probes are frequently used for rapid identification of mycobacterial species (4); however, M. riyadhense and other recently proposed NTMs (e.g., M. kumamotonense and “M. simulans”) cross-react with MTBC DNA probes and may be missed by line-probe assays (5,6). With the emergence of new NTM species, commercial probes could fail to discriminate between species, leaving clinical isolates either unidentified or misidentified. Because of its ease of use, accuracy, and discriminatory power, multilocus sequence analysis may soon become the standard for routine NTM species identification. We have shown evidence for the pathogenic role of M. riyadhense in pulmonary diseases, a pathogen that has previously been reported to have extrapulmonary pathogenicity (1). Clinical and radiologic signs and symptoms of pulmonary infection caused by M. riyadhense, including cough, weight loss, fever, and cavitating lung lesions, were similar to those in typical cases caused by MTBC strains. van Ingen et al. (7) suggested that the region of difference 1 (RD1) virulence locus identified in MTBC members may also play a crucial role in virulence of some NTM species. These authors found RD1 genes in NTMs that were causing human disease, including M. kansasii, M. szulgai, M. marinum, and the type strain of M. riyadhense (7). We confirmed the presence of RD1 esat-6 and cfp-10 genes in the M. riyadhense isolates reported here (GenBank accession nos. {"type":"entrez-nucleotide-range","attrs":{"text":"JF896090-JF896093","start_term":"JF896090","end_term":"JF896093","start_term_id":"348167248","end_term_id":"348167254"}}JF896090-JF896093). Because M. riyadhense is an emerging pathogen with, to our knowledge, only 1 previously reported extrapulmonary case of infection (1), the optimal treatment for infected patients is unknown. Our results and drug susceptibility testing indicate that antituberculous drugs, including INH, RMP, and EMB, are effective against M. riyadhense infection (Table), but the combination of CLR plus CIP was not effective in 1 case-patient reported here, despite in vitro susceptibility to both drugs.

We report a 49-year-old man suffering from chronic hypereosinophilia whose biological tests revealed a gene rearrangement between FIP1L1 and PDGFRA as well as a T-cell clonality. After 1 year of therapy with imatinib mesylate (100 mg daily), the patient was clinically asymptomatic, the fusion transcript was undetectable using RTQ-PCR and no lymphoproliferative disorders occurred. This unique combination raises the question of the physiopathology of such a grey zone hypereosinophilia and their management.

Resume Le syndrome d’activation macrophagique (SAM) est un syndrome immunologique rare, d’evolution rapidement fatale en l’absence de traitement. Si les lymphomes sont des causes classiques de SAM, l’association a un lymphome de Hodgkin est exceptionnelle. Nous rapportons l’observation d’un homme de 79 ans chez qui le diagnostic de SAM revelait un lymphome de Hodgkin d’issue fatale. Nous discutons l’interet des dosages du sCD25 et de l’interleukine 18 lorsque le diagnostic est difficile, ainsi que les donnees recentes sur le SAM associe a un lymphome de Hodgkin.

To the Editor: Infectious diseases are the main cause of illness for armed forces in conflict (1), resulting in decreases in operational efficiency. The International Security Assistance Force (ISAF) in Afghanistan is a multinational force operating under the auspices of the North Atlantic Treaty Organization (NATO). As part of ISAF, French troops operate in Kabul and its surroundings, within a 70-km radius. French medical facilities consist of a French field hospital and a primary care center. The facilities support 4,000 soldiers, 1,048 of whom are French. Troop disease, including acute respiratory disease (ARD), is routinely monitored through French Army and NATO surveillance systems. We report an outbreak of ARD in the multinational force in which pertussis cases were identified by using laboratory tests and epidemiologic criteria. In November 2006, a substantial increase of ARD was detected in soldiers of different nationalities (Figure), with a 10-fold increase among French troops at week 51. Patients with persistent cough or dyspnea were referred to the field hospital, in a nonrandomized manner, and those with a 2-week history of cough underwent serologic tests. Samples were sent to France and were analyzed at Hopital Saint Anne, Toulon, France. Immunoglobulin (Ig) G antibodies to Bordetella pertussis antigens (pertussis toxin, filamentous hemagglutinin, and adenylcyclase) were determined by a Western blot assay (MarDx Diagnostics, Carlsbad, CA, USA). Recent infection was diagnosed by finding high levels of antibodies to pertussis toxin compared to results for standardized positive and negative samples, in concurrence with the fact that no soldier had been vaccinated against pertussis after childhood. IgG and IgA antibodies to Chlamydia pneumoniae were determined by a semiquantitative method that assessed samples’ absorbance value in optical density (SeroCP Quant IgG and Quant IgA, Savyon Diangostics, Ashdod, Israel). Recent infection to Mycoplasma pneumoniae was assessed by detecting IgM antibodies with a specific enzyme immunoassay (Platelia Mycoplasma pneumoniae, Biorad, Hercules, CA, USA) and by using a semiquantitative method to detect IgM and IgG antibodies with patented gelatin particles sensitized with cell membrane components of M. pneumoniae (Serodia Myco II, Fujirebio, Malvern, PA, USA). Coxiella burnetii infection was assessed by indirect immunofluorescence assay (Coxiella burnetii Spot IF, bioMerieux, Marcy l’Etoile, France). Figure Number of acute respiratory diseases cases, according to troop nationality. UK, United Kingdom. A color version of this figure is available online: www.cdc.gov/EID/content/14/7/1173-G.htm Statistical analysis was performed with Epi Info v3.4 software package (Centers for Disease Control [CDC], Atlanta, GA, USA). Quantitative variables were compared by using the Kruskall-Wallis test. From the third week of December 2006 until the third week of January 2007, 209 French soldiers sought treatment at the French medical facilities for stereotyped acute febrile respiratory infection, which represents a cumulative attack rate of 20% on clinical grounds. Thirty-nine French soldiers and 10 non-French soldiers or local civilian workers were then referred to the field hospital. All patients had a 24-h history of fever >38.5°C and nonspecific ear, nose, and throat symptoms, mainly a sore throat. Cough was unremarkable, without whoops. Fourteen of the 49 patients were hospitalized for severe dyspnea. The difference in median age was not significant between inpatients (26 [range 20–57] years) and outpatients (36 [range 21–53] years, p = 0.15). Twenty-seven blood samples were taken, 24 from French troops, 2 from British troops, and 1 from Polish patients. Six patients, including 3 French soldiers, had recent pertussis. No significant difference in age was found between patients with pertussis and those with non–pertussis ARD (36 [range 27–51] versus 33 [range 20–63] years; p = 0.39). No pertussis patient had been vaccinated against the illness since childhood. One patient had evidence of recent infection with M. pneumoniae, and another with C. pneumoniae. No recent infection involved C. burnetii. All patients with ARD had a favorable outcome. This outbreak of ARD among troops in Afghanistan highlights the importance of nontraumatic illness in wartime when military field conditions enhance exposure to, and incidence of, endemic diseases. Although our study did not include systematic laboratory confirmation for all cases of ARD in soldiers because of field conditions, this outbreak was mainly due to pertussis: most cases were defined by a cough lasting >2 wk, took place in an outbreak setting, and were (for 6 patients) confirmed by laboratory tests. CDC requirements were followed to ascertain confirmed cases (2). This outbreak also involved British troops; after the 2 cases we described, 2 additional serologically confirmed cases and 1 probable confirmed case were discovered among symptomatic British returnees (3). Pertussis, which remains endemic in developing countries (4), was reported in northeastern Afghanistan in 2002 (5), but was never biologically ascertained nor reported in Kabul. This outbreak elicits 3 main questions. First, how can ARD transmission be stopped under field conditions? Besides prophylactic antibiotherapy, isolation of suspected case-patients is not achievable because of limited number of beds in medical facilities and high-person density in barracks and dining halls. To minimize transmission, patients and caregivers should wear masks. Second, what prophylactic antibiotherapy should be given? We recommend a 3-day regimen of azithromycin because it is as efficient as erythromycin in preventing spread of pertussis (6), targets most intracellular bacteria involved in ARD, and offers the best compliance (7). Finally, should soldiers be vaccinated against pertussis for overseas campaigns? In France, no booster vaccination is given after 13 years of age (8). Because acellular vaccines do not ensure immunity for >6 years (5), no French soldier has immunity to pertussis. We therefore advocate booster vaccination before overseas campaigns. Pertussis vaccination is widely available in combination with vaccination against, at minimum, diphtheria and tetanus, but these combination vaccines can only be administered once in an adult’s life and only 2 years after previous vaccination against diphtheria or tetanus. Monovalent vaccines against pertussis must be made more widely available for multinational troops in field conditions.

Resume Afin de determiner l'epidemiologie locale de la region provencale vis-a-vis de S. pneumoniae , 14 laboratoires de microbiologie ont participe a cet observatoire durant la totalite de l'annee 1995 permettant ainsi le recueil exhaustif de donnees concemant 516 souches isolees de 460 patients. La repartition par âge (187 enfants), sexe (293 hommes et 165 femmes) et serotype a ete etudiee pour l'ensemble des souches et pour les diverses categories de resistance a la penicilline puis comparee aux donnees de la litterature. Enfin une etude de la performance du depistage des souches de sensibilite anormale a la penicilline et au cefotaxime a ete realisee en utilisant des disques d'oxacilline (charges a 1 ou 5 mg/l) et de loracarbef. Cette etude confirme l'augmentation de la resistance de ces souches a la penicilline (29 %) et le caractere multiresistant des souches de sensibilite anormale a la penicilline. On constate une activite bien conservee de l'amoxicilline et du cefotaxime (2 % et 0,2 % de souches resistantes seulement).

We report 3 clinical cases of septic nonunions of lower limb long bones in which the pathogenicity of Propionibacterium acnes was retained after several weeks of poor outcome. The patients had fractures that were treated by internal fixation, without initially suspected infection. The diagnosis of delayed union coincided with the onset of treatment. Support was performed in 2 steps, allowing for the collection of several deep samples that were referred for microbiological analysis. Molecular techniques for microbiological investigation were performed on perioperative samples and were not contributive. The detection of P acnes, which was identified after several days of incubation, prompted us to consider the role of this bacterium. The presence of P acnes is regularly interpreted as contamination of samples during collection or handling in the laboratory. A multidisciplinary decision to make the diagnosis of surgical site infection with P acnes and specific antibiotic treatment for several months led to consolidation in all the patients. The ability of bacteria of the genus Propionibacterium to cause insidious surgical site infections should not be underestimated, and more extensive sample incubation is essential to diagnose such infections.

Answer: Cyclospora cayetanensis. Cyclospora cayetanensis is an intestinal coccidian protozoon that has emerged as a significant human infectious agent worldwide, causing self-limiting gastroenteritis in immunocompetent hosts. Human-to-human spread of the parasite occurs indirectly via the environment through oocysts in contaminated water, food, or soil. The parasite has a cosmopolitan distribution and is endemic in tropical and subtropical areas (3). The parasite is commonly limited to travelers to Latin America, the Indian subcontinent, and Southeast Asia, including China (4); therefore, infection with Cyclospora cayetanensis is known as traveler's diarrhea (5). Cyclospora cayetanensis is an important cause of waterborne and food-borne outbreaks due to imported fruits and vegetables from developing countries. The underreporting of infection with this parasite likely occurs because standard examinations for ova and parasites may not include the identification of Cyclospora oocysts. This oversight is at least partly due to the lack of awareness of this disease among the public and medical workers (1). The following criteria have been established for the diagnosis of cyclosporiasis (by the CDC in 1997): detection of oocysts in stool, intestinal fluid, or small bowel biopsy specimens by microscopic examination; demonstration of oocyst sporulation; and detection by molecular methods (not a routine parasitology screening tool) (2). Cyclospora cayetanensis oocysts are spherical and between 8.0 and 10 μm in diameter, with a 50-nm-thick wall and an outer threadlike coat, which is referred to as a wrinkle by some researchers (see Fig. 1a and b in the photo quiz). Diagnostic tests also include phase-contrast microscopy, modified acid-fast staining with variable staining (from pale to red) (see Fig. 1c and d in the photo quiz), and autofluorescence with UV illumination. Ova and parasite exams typically include only direct and concentrated microscopic exams and trichrome stains without modified acid-fast staining or autofluorescence testing. Multiple stool specimens collected on subsequent days are required because parasites are shed intermittently. Of note, two of our patient's specimens were positive, and one was negative. The treatment for Cyclospora infection is a 7-day course of oral trimethoprim-sulfamethoxazole, which proved to be effective for our patient. Health care providers should evaluate Cyclospora infection in patients presenting long-lasting diarrheal illness and order the appropriate tests for this parasite. (See page 3821 in this issue [doi:10.1128/JCM.00256-12] for photo quiz case presentation)

A 43-year-old man presented to our hospital with a 15-day history of watery diarrhea. He did not report any unusual medical history except for multiple stays in Southeast Asia, including China, where he ate local and fresh food products. He had symptoms of gastroenteritis with watery diarrhea, loss

Clinicians are generally familiar with Acinetobacter baumannii as an aetiological agent of serious nosocomial infections in intensive care units. Other Acinetobacter species can also be responsible for life-threatening sepsis. Here, we report about a bacteraemia caused by Acinetobacter parvus, community-acquired, identified with a 16S rRNA gene sequence analysis and the MALDI-TOF mass spectrometry system.