Severe leptospirosis in hospitalized patients, Guadeloupe

We evaluated prognostic factors for leptospirosis in 168 consecutive hospitalized patients in Guadeloupe. Factors independently associated with severity included chronic hypertension or chronic alcoholism, late initiation of antibacterial therapy, abnormal chest auscultation results, icterus, oligoanuria, disorders of consciousness, elevated aspartate aminotransferase levels, hyperamylasemia, and Leptospira interrogans serovar Icterohemorrhagiae.

Retrospective review of leptospirosis in Guadeloupe, French West Indies 1994-2001

Demographic, clinical, biological and personal data were obtained from patients hospitalized with symptoms of leptospirosis in the Hospital of Pointe a Pitre, Guadeloupe, French West Indies from 1994 to 2001. Of the 897 screened patients, 212 were acute cases, 607 were non-infected and 78 were undetermined cases. There was no predominant age group. Leptospirosis transmission followed the rainfall cycle and was greater in rural areas. Jaundice and conjunctival suffusion were significantly more frequent in cases than non-cases. Males, professions considered to be at risk and contact with swine or bovine were associated with infection. Serogroups Icterohaemorrhagiae, Cynopteri, Australis, Sejroe, Pomona and Ballum were serovars presumed responsible for acute cases.

[Causes of death among HIV infected adults in French Guyana and the French West Indies in the era of highly active antiretroviral therapy (HAART)]

OBJECTIVE

The survey "Mortality 2000" had for aim to describe the distribution of causes of death in HIV-infected adults in France.

METHOD

Hospital wards involved in the management of HIV infection prospectively reported deaths occurring in 2000. The causes of death were documented using a standardized questionnaire.

RESULTS

In French Guyana and the French West Indies the five referent wards reported 81 deaths. The main underlying causes of death were AIDS-related (67%), non-AIDS and non-hepatitis related cancer (9%), cardiovascular disease (7%), bacterial infections (5%), and end stage liver disease (4%). Among AIDS-related deaths, the more frequent diseases were histoplasmosis and toxoplasmosis in Guyana and atypical mycobacterial infection, tuberculosis, and cytomegalovirus disease in the West Indies. Median age was 43 years, transmission of HIV infection was heterosexual in 79%; 56% lived in poor socio-economic conditions, and 30% were born abroad. One out of five had been recently diagnosed with HIV infection and one out of three had never received antiretroviral treatment.

CONCLUSION

In 2000, two in three death cases in HIV-infected adults were AIDS-related in French Guyana and the French West Indies. Improved strategies for screening HIV infection before the occurrence of AIDS are still needed taking into consideration poor socio-economic and migrant conditions.

Drug Hypersensitivity Syndrome in a West-Indian population

Some studies have suggested an ethnic susceptibility to Hypersensitivity Syndrome. We did a 7-year-prospective study in Guadeloupe whose population is mainly of African ancestry, and has free access to modern care facilities. Most patients included were Afro-Caribbeans (26/28), and females (20/28). However, ethnic distribution did not reach significant conclusions. Annual incidence rate was estimated at 0.9/100,000. Medium incubation and duration were 33 and 66 days respectively. Two patients with grade 4 hepatitis died from the syndrome. Two thirds of the patients were given prednisone, which usually alleviated the systemic symptoms, but did not prevent their development (in 5 patients) nor death. Carbamazepine, allopurinol, and minocycline accounted for 2/3 of the cases. Sixty four percent of the causative prescriptions were judged inappropriate. DHS appeared as the most frequent type of severe systemic drug reaction in this population, and may largely be prevented by rational prescribing.

Neurological manifestations of Behçet's disease in a Caribbean population: clinical and imaging findings

Behçet's disease (BD) is a chronic relapsing multisystem disorder. While most frequently occurring around the Mediterranean and in Japan, isolated cases of BD have been reported in Africa south of the Sahara and in the Caribbean. The aim of this study was to describe our experience of BD in Guadeloupe (French West Indies) where the presence of the disease has not been reported previously. We analysed retrospectively the charts, and clinical and imaging features of patients native to Guadeloupe who were diagnosed with neurological manifestations of BD between 1989 and 1999. In our series of 13 cases, seven had neurological involvement. Neurological manifestations included meningoencephalitis or meningoencephalomyelitis in four cases, cerebral venous thrombosis in one case and peripheral neuropathy in two cases associated with myositis in one. Patients received treatment with colchicine (n=7), corticosteroids (n=6), immunosuppressive therapy (azathioprine and/or cyclophosphamide; n=4), acetylsalicylic acid (n=2) and oral anticoagulation for venous thrombosis (n=1). Long-term sequelae occurred only in patients with recurrent neurological disease. This study suggests that the frequency of BD in this Afro-Caribbean population is higher than this reported in Caucasian populations. Meningoencephalitis is associated with a poor prognosis while other patients achieved recovery.

Dengue fever: a harmful disease in patients with thrombocytopenia?

We describe 2 patients with autoimmune thrombocytopenic disease who developed classic dengue fever associated with serious bleeding and extremely low platelet counts (1000 cells/mm(3) and 3000 cells/mm(3), respectively). Such patients should be properly advised as to the possibility that common dengue fever may substantially enhance their risk for hemorrhagic complications.

[Dengue fever: a review]

INTRODUCTION

Transmitted by Aedes mosquitoes all over the inter-tropical area, Dengue fever is the leading arboviral disease in humans. It is also an emerging disease.

CURRENT KNOWLEDGE AND KEY POINTS

Increasing morbidity-mortality, and geographical expansion are the drastic changes noted in the recent epidemiology of the disease. They are related to those occurring at the bio-climatic, socio-demographic and behavioural levels, which in turn may have led to enhanced viral circulation and virulence, and also vectorial resistance. The various clinical patterns (undifferentiated febrile episode of children, acute and algid classic form, the potentially fatal dengue hemorrhagic fever/dengue shock syndrome, and the atypical forms) are reviewed, as well as the diagnostic methods, and the pathogenesis (sequential infections, facilitating antibodies, capillary leakage).

FUTURE PROSPECTS AND PROJECTS

Dengue fever is actually much more than a traveller's fever or an exotic curiosity. It presently threatens half the world's population, and remains a puzzling disease in many aspects, such as the virus-vector and host-virus relationships, and clinical expression variability. In this respect, dengue fever appears as a model of viral disease. The current molecular approach is expected to provide us with new insights into pathophysiology, more efficient tools for disease control, and also an efficient vaccine in the near future.

[Dengue fever with neurologic expression. Three cases in adults]

Dengue fever, unlike most other arboviral diseases, does not usually cause encephalitis. However, neurologic symptoms with poor prognosis have been regularly reported, mostly in Asian children affected by the severe dengue hemorrhagic fever/dengue shock syndrome, and attributed to a non specific, anoxic or metabolic encephalopathy. Recently, first isolations of dengue viruses from CSF or brain tissue, have renewed this concept. We report 3 dengue fever cases with neurologic manifestations and favorable outcome. Occurrence in adult age, during classic (benign) dengue fever (2 cases), and neurologic sequellae (1 case) were the three outstanding features. We point out the proteiform expression of these neurologic changes and their low incidence rate (< 3% in our series of adult dengue fever). Although their pathogenesis is poorly understood, different mechanisms are suggested: encephalopathy (case n. 1), acute specific encephalitis (questionable in case n(o) 2), or post-infective encephalitis (case n(o) 3).

[Mucocutaneous manifestations of dengue]

CHANGING EPIDEMIOLOGY: During the last half of the 20th century, dengue has spread to most countries in the inter-tropical zone and today is the most common cause of human arbovirus infection. In tropical zones, dengue is a frequent cause of fever and can be observed in travellers returning from an endemic zone.

SKIN AND MUCOSAL MANIFESTATIONS

Though variable, skin and mucosal manifestations are important to recognize. Exanthema occurs late after constitutional symptoms and is suggestive. Minimal hemorrhagic lesions involving the skin and mucosa are observed in common dengue. They usually do not signal progression to authentic hemorrhagic dengue or shock.

DIAGNOSIS

Skin manifestations of dengue raise the more general problem of diagnosis in travellers returning from tropical zones who develop fever and rash.

[Emergence of dengue hemorrhagic fever in French Antilles. 3 initial fatal cases in Guadeloupe]

BACKGROUND

Two outbreaks of dengue hemorrhagic fever occurred in Guadeloupe (French West Indies) in successive epidemics in 1994 and 1995. The first outbreak was caused by DEN-2 virus and the second by DEN-1.

CASE REPORTS

Seven life-threatening infections (WHO grade 3/4) were identified. Three previously healthy adults (including two brothers) died. Autopsy reports (2 patients) disclosed hemorrhagic serous effusions, disseminated intravascular coagulation, and in one case a spontaneous spleen rupture.

DISCUSSION

Dengue fever is an emerging disease. Its severe hemorrhagic form tends to an uprising incidence and can no longer be considered a disease limited to children in Far-Eastern Asia. Fatalities may occur very suddenly and unexpectedly, even in optimal health care settings, in healthy adults living or travelling in endemic areas, notably the Caribbean.

[Cutaneo-mucous manifestations of dengue]

OBJECTIVES

To describe muco-cutaneous manifestations of dengue fever, assessing their incidence and histopathological aspects.

PATIENTS AND METHODS

During a dengue 2 epidemic, occurring in Guadeloupe in 1994, all patients admitted with a confirmed diagnostic of dengue fever were assessed for dermatological changes by 2 clinicians; 5 patients underwent skin biopsy with immuno-fluorescence staining.

RESULTS

Among 39 adult inpatients (Sex ratio 1.1, medium age 41 years) none presented a severe form of the disease, whereas 18/39 (46 p. 100) had some muco-cutaneous changes, associating rash (13 cases (33 p. 100)), mucous membranes involvement (7 cases (18 p. 100)), or minor haemorrhages (6 cases (15 p. 100)). The rash appeared macular, discrete, itching, troncular with peripheral extension, rather than maculo-papular (morbiliform) as usually described. Apart from cases which minor haemorrhagic changes, significatively associated with marked thrombocytopenia (medium 37 x 10(9)/1), dengue cases either with or without muco-cutaneous changes had similar clinical (duration, severity) or biological (neutro-lympho-thrombocytopenia, transaminases) features, and evolution. Histological changes appeared non specific (minor lymphocytic dermal vasculitis, non contributive immuno-fluorescence).

DISCUSSION

Clinical and histological features of the rash are unspecific and inconstant: they do not allow an easy and accurate diagnosis. Complete clinical, epidemiological (very recent travel in endemic areas) or biological data should be collected, and early virological or later serological confirmation is needed. As well as travel facilities are growing, the dengue area is extending: dengue fever should therefore be considered in every traveller with fever and rash.

[Primary Vibrio vulnificus septicemia. 1st documented case in the French West Indies]

BACKGROUND

Vibrio vulnificus is a non-choleric halophilic vibrion widely distributed in marine environments. Contamination in humans is uncommon except in coastal areas of the United States and Asia. We report the first documented case in the French West Indies.

CASE REPORT

A 57-year-old native with alcoholic cirrhosis was hospitalized for septic shock. The infectious syndrome began suddenly a few hours earlier with fever, diarrhea, and intense pain in the calf muscles. In the absence of a suspected agent, a wide spectrum antibiotic was prescribed. On day 3, bullae developed over the legs and progressed, despite early surgical debridement, to bilateral rapidly extensive necrosing cellulitis. An above the knee amputation was required but did not prevent death on day 9 due to irreversible multiple organ failure. Blood cultures were positive for V. vulnificus.

DISCUSSION

Primary septicemia due to V. vulnificus is mainly observed in subjects with an underlying liver disease and usually occurs after ingestion of contamined raw halieutic products such as oysters. The clinical presentation is characteristic with secondary necrotic ulcerations on the lower limbs. Improvement in the extremely poor prognosis of these infections depends on early initiation of an effective antibiotic with wide exeresis of necrotic tissue. Physicians should be aware of this severe infection despite its low frequency.

[Aseptic purulent meningitis in two patients co-infected by HTLV-1 and Strongyloides stercoralis]

Occurrence of anguilluliasis always progresses to hyperinfestation or disseminated anguilluliasis with severe clinical manifestations in carriers of HTLV-1. This prognosis is further illustrated by two new cases of non-septic purulent meningitis observed in two male patients from Guadalope. Ages were 61 and 64 years. In both cases examination of cerebrospinal fluid (CSF) demonstrated pleiocytosis with more than 3000 cells (mostly polynuclear neutrophils) per mm3, protein content greater than 3 g/l, and low sugar level. No soluble germs or antigens were found in the CSF. In both patients Strongyloides stercoralis larvae were detected in stools but not in CSF. Meningitis responded to antibiotic treatment but follow-up tests showed the persistence of larvae in stools despite treatment using thiabendazole. While similar cases of meningitis have been reported in carriers of HTLV-1, the underlying mechanism is still unclear. Co-infection with Strongyloides stercoralis appears to be a predisposing factor. This association may warrant preventive anti-parasitic treatment in patients infected by HTLV-1.