Serological, epidemiological, and molecular differences between human T-cell lymphotropic virus Type 1 (HTLV-1)-seropositive healthy carriers and persons with HTLV-I Gag indeterminate Western blot patterns from the Caribbean

To investigate the significance of serological human T-cell lymphotropic virus type 1 (HLTV-1) Gag indeterminate Western blot (WB) patterns in the Caribbean, a 6-year (1993 to 1998) cross-sectional study was conducted with 37,724 blood donors from Guadeloupe (French West Indies), whose sera were routinely screened by enzyme immunoassay (EIA) for the presence of HTLV-1 and -2 antibodies. By using stringent WB criteria, 77 donors (0.20%) were confirmed HTLV-1 seropositive, whereas 150 (0.40%; P < 0.001) were considered HTLV seroindeterminate. Among them, 41.3% (62) exhibited a typical HTLV-1 Gag indeterminate profile (HGIP). Furthermore 76 (50.7%) out of the 150 HTLV-seroindeterminate subjects were sequentially retested, with a mean duration of follow-up of 18.3 months (range, 1 to 70 months). Of these, 55 (72.4%) were still EIA positive and maintained the same WB profile whereas the others became EIA negative. This follow-up survey included 33 persons with an HGIP. Twenty-three of them (69.7%) had profiles that did not evolve over time. Moreover, no case of HTLV-1 seroconversion could be documented over time by studying such sequential samples. HTLV-1 seroprevalence was characterized by an age-dependent curve, a uniform excess in females, a significant relation with hepatitis B core (HBc) antibodies, and a microcluster distribution along the Atlantic coast of Guadeloupe. In contrast, the persons with an HGIP were significantly younger, had a 1:1 sex ratio, did not present any association with HBc antibodies, and were not clustered along the Atlantic façade. These divergent epidemiological features, together with discordant serological screening test results for subjects with HGIP and with the lack of HTLV-1 proviral sequences detected by PCR in their peripheral blood mononuclear cell DNA, strongly suggest that an HGIP does not reflect true HTLV-1 infection. In regard to these data, healthy blood donors with HGIP should be reassured that they are unlikely to be infected with HTLV-1 or HTLV-2.

Step edge diffusion and step atom detachment in surface evolution: ion erosion of Pt(111)

The temperature dependent morphological evolution of Pt(111) under 1 keV Xe+ normal incidence ion bombardment has been investigated up to 600 monolayers removed. Coarsening of the surface structures during erosion and a qualitative change in roughness evolution between 650 and 700 K are found to be caused by different atomic processes: the former by diffusion of atoms along steps, the latter by the onset of step atom detachment.

Improved method for rapid determination of vitamin A in small samples of breast milk by high-performance liquid chromatography

Employing a short, potassium hydroxide (KOH) saponification (25 min) and rapid extraction with n-hexane-toluene (1:1) and a <4-min retention time, a convenient, rapid, accurate and precise determination of vitamin A in breast milk was developed. The recovery rate was 102.3 +/- 2.5% and the small relative standard deviation (intra-assay 1.9%, inter-assay 2.3%) resulted in high precision. The amount of breast milk needed is very low (1 ml) which makes the method suitable for the use in free field studies with large sample sizes. The simple extraction and separation steps allow a high throughput screening under routine laboratory conditions.

[Therapy and prognosis of enchondroma of the hand]

Enchondromas are the most common bone tumors of the hand. In a retrospective study, medical records and radiographs of 112 patients were reviewed. These patients were operated on between January 1973 and June 1997. After extirpation of the tumor, the defect was preferably treated with bone grafting in 102 patients. A malignant transformation (chondrosarcoma) was diagnosed in 2 patients. Follow-up examination of 92 patients with a mean follow-up of 1.6 years (range: 7 months to 14 years) yielded excellent or good results in 76 patients (82.6%), according to the evaluation scheme of Wilhelm and Feldmeier. Four recurrences were probably related to an incomplete resection of the tumor. The authors conclude that enchondromas of the hand should be treated surgically to prove the diagnosis and to prevent a pathologic fracture.

Trends of AIDS in Guadeloupe (French West Indies) a longitudinal survey from 1988 to 1997

The study objective was to describe morbidity and mortality from HIV infection and the acquired immunodeficiency syndrome (AIDS) in Guadeloupe from 1988 to 1997 and to evaluate survival and prognostic factors. The HIV infected patients database of Guadeloupe included 1771 adult patients up to December 31, 1997. Annual incidence of AIDS defining illnesses was calculated and compared using Poisson regression. Survival analysis with log-rank test and multivariate analysis with Cox's model were performed for patients with AIDS. At the end of December 1997, 599 cases of AIDS (33.8%) and 367 deaths (20.7%) were reported. For 32.1% of the patients, AIDS was diagnosed before inclusion. Incidence of most AIDS-defining events decreased over time, especially after the introduction of protease inhibitor therapy. Before the introduction of protease inhibitors in September 1996, overall median survival after AIDS diagnosis was 11.8 months (95% Confidence Interval (CI), 95% CI 10.2-14.1). After this date median survival increased to 17.8 months (95% CI 18.6-22.5) and probability of survival was significantly higher for patients treated with protease inhibitor in combination regimen (mean 19.0 months, Standard deviation (SD) 1.3) compared to those who were not (mean 7.9 months, SD 0.6, p < 0.0001). Prognosis factors of death after AIDS were older age (Relative Hazard, RH: 1.17, 95% CI 1.07-1.28), occurrence of two or more AIDS-defining events at the beginning of the disease (RH: 1.70, 95% CI 1.32-2.19), and a CD4 cell count less than 50/mm3 (RH: 2.33, 95% CI 1.71-3.17). On the other hand, occurrence of AIDS during follow-up had a better prognosis (RH: 0.68, 95% CI 0.52-0.89) and protease inhibitor therapy was strongly associated with a longer survival (RH 0.26, 95% CI 0.13-0.53). We concluded that HIV infection in Guadeloupe was frequently diagnosed at the stage of AIDS. However, survival of patients and trends of major AIDS defining illnesses were more similar to the European pattern than to the Caribbean one, as a consequence of the availability of modern therapy.

[Pneumococcus: an unusual agent of maternal-fetal infection]

BACKGROUND

Since the advent of antibiotics, Streptococcus pneumoniae has become a very unusual agent of materno-fetal infection. We report two cases.

CASE REPORTS

In case n(o) 1, early neonatal meningitis was caused by a penicillin-resistant strain. In case n(o) 2, the mother developed meningitis 16 days after delivery. In both cases, premature rupture of the membranes in otherwise asymptomatic mothers was the initial event and outcome was favorable under amoxicillin alone. The pneumococci were easily recovered fom placental, amniotic and neonatal samples, less easily from the maternal samples.

DISCUSSION

The increasing prevalence of penicillin-resistant pneumococci is an emerging problem of real concern. It might increase the very low present incidence of pneumococcal neonatal materno-fetal infection which is a particularly serious infection with up to 60% neonatal mortality. Any type of S. pneumoniae infection, or even colonization, occurring in the peripartum should prompt adequate treatment and suggests considering first line vancomycin for the newborn.

Human T-lymphotropic virus type I among blood donors from Guadeloupe: donation, demographic, and biologic characteristics

BACKGROUND

Epidemiologic data on human T-lymphotropic virus type I (HTLV-I) in Guadeloupe (French West Indies) are scant.

STUDY DESIGN AND METHODS

From January 1989 to December 1996, 59,426 blood donors were screened by enzyme immunoassay for antibodies to HTLV-I. All repeatedly reactive samples were confirmed by Western blot. Temporal trends in HTLV-I seropositivity rates were examined during the study period. A multivariate analysis of donation, demographic, and biologic characteristics was performed.

RESULTS

Of the screened blood donors, 195 were confirmed as seropositive, for an overall prevalence of 0.33 percent (95% CI 0.28-0.38). A marked decrease in overall HTLV-I prevalence with time (from 0.47% in 1989 to 0.13% in 1996) was observed, which can be explained mainly by the decreasing percentage of recruited new donors during the study period. Four independent risk factors for HTLV-I were identified: new donor status (odds ratio [OR] 12.5), female sex (OR 1.7), increasing age (30-39 years: OR, 2.4; 40-49 years: OR, 3.7; >50 years: OR 6.6), and positive antibodies to hepatitis B virus core antigen (OR, 1.7). Selection of specific locations for blood collection was inversely associated with HTLV-I (OR 0.5).

CONCLUSION

New donor status, advancing age, female sex, and positivity for hepatitis B virus core antibodies were the major factors associated with HTLV-I infection in Guadeloupe.

Geographical clustering of human T-cell lymphotropic virus type I in Guadeloupe, an endemic Caribbean area

Between January 1989 and December 1996, 59,426 blood donors from Guadeloupe (French West Indies) were screened for antibodies to human T-cell lymphotropic virus type I (HTLV-I). Of these, 195 were confirmed as being positive for HTLV-I, yielding an overall prevalence of 0.33% [95% confidence interval (CI) 0.28-0.38]. On multiple logistic regression analysis, risk factors for HTLV-I were female gender [odds ratio (OR) 1.8; CI 1.3-2.4], increasing age (30-39 years, OR 2.2, CI 1.4-3.4; 40-49 years, OR 3.1, CI 2.1-4.7; > or =50 years, OR 5.6, CI 3.6-8.6) and positive hepatitis B core antibodies (OR 2.0; CI 1.5-2.8). HTLV-I seropositivity was also significantly associated with current residence in certain areas, highlighting microgeographic clustering: individuals living along the Atlantic Facade of Guadeloupe, which is a traditional sugar cane plantation area where Africans were brought during slave trading, were at increased risk for HTLV-I infection (OR 1.9; CI 1.3-2.7) compared with other areas in Guadeloupe devoted to other activities. Our report of HTLV-I cluster identification in Guadeloupe probably reflects both its low spread and its highly intrafamilial restricted transmission within this endemic Caribbean population.

[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.

[Cerebral cysticercosis: why it should be treated]

BACKGROUND

In Guadeloupe, cases of neurocysticercosis have been rarely observed in people recently immigrated from Haiti. We followed 2 women with seizures, associated with meningitis or encephalitis.

CASE REPORT

Computed tomography scan and muscle X-ray have displayed specific features of cysticercosis with small diffuse calcifications. This was associated with positive antibodies for cysticercosis. After respectively 5 and 17 years, these patients developed recurrent manifestations of neurocysticercosis with subacute, quite silent meningitis after pregnancy, with CSF increased cells count (180 lymphocytes/mm3), raised protein level (0.6 g/l) and positive antibodies for cysticercosis in the first case, and cortical granuloma with fever and repetitive seizures in the second.

DISCUSSION

These observations suggest that the patients were chronically infested, for more than 5 years. Although the brain lesions were quiescent for many years, new lesions responsible for inflammatory cysts occurred while they still lived outside her native endemic area. In such cases, treatment would benefit to the patient by breaking down the auto-infestation cycle.

[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.

[Mutilating acrodystrophic neuropathy of alcoholic origin in the French West Indies]

Among principal causes of acrodystrophic neuropathy-ie, leprosy, diabetes, amyloid neuropathy, hereditary sensory neuropathies-alcoholism is controversial since first descriptions (Bureau et al, 1957) incriminating heavy drinking. This retrospective review of 38 cases occurring in West-Indian rhum abusers, tends however to confirm its etiologic role. Patients present with three non specific signs or symptoms of the lower extremities: anaesthetic foot, plantar ulcers, and chronic, indolent, mutilating arthropathies. Motor function is spared. Male gender, massive (> or = 150 g pure alcohol daily) and prolonged (> or = 12 years) rhum intake, hygiene deficiency, poverty and social distress, exposition to repeated foot microtrauma and a protracted, non fatal, but disabling course leading to amputation, are the main features of this syndrome. The pathophysiology is poorly documented, and many questions remain unanswered including a genetic predisposition or a particular neuro-toxicity of West Indian rhum. However, the clinical and epidemiologic data presented here favour the concept of an "alcoholic foot" or true alcoholic acrodystrophic neuropathy, quite different from the most common sensory-motor form.

[Cerebrovascular accidents and AIDS]

A number of pathological and clinical data suggest that AIDS could be an underestimated cause of cerebro-vascular disease, especially in young individuals. Eight retrospective cases of stroke in AIDS patients are reported. Mean age was 39 years, mean CD4 cells count 57/mm3. Pathogenic mechanism, particularly the role of opportunistic infections remains unclear. Prognosis does not seem constantly pejorative: only one patient died from stroke, six are still alive with a 6 months follow-up, without relapse and with minor or no sequellae. Alcohol or cocaine (crack) abuse was present in half the cases. The role of specific risk factors and consequently adapted prophylaxis is questionned.

[Enchondroma of the hand]

Enchondromata are the most frequent benign tumours of the bones of the hand. From 1973 to 1990 77 patients were treated at the trauma- and hand surgery department of the Westfälische Wilhelms-University in Münster because of a histologically confirmed enchondroma. Those 52 patients (32 female, 20 male, average age 32 years), who were operated on until 1986 were reviewed. After an average history of 16 months the diagnosis was made most often because of a painful swelling. In 15% a spontaneous fracture was seen and in 17% the enchondroma was diagnosed by chance. The enchondroma was merely exstirpated or in other cases the defect was filled with a bone graft. The follow-up with a maximal time of 14 years postoperatively yielded in 81.6% an excellent and good result. A 5.7% (3 pat.) recurrence rate was observed and was attributed to an incomplete resection of the underlying pathology. Follow up X-rays are therefore recommended.

[Recurrent metabolic encephalopathy, self-administered gastric lavage and Munchausen syndrome]

A case report of recurrent metabolic encephalopathy with disorders of hydro-electrolytic balance, predominantly severe hypochloremic alkalosis, resulting from self-induced vomiting and self-administered gastric tubage and lavage. Munchausen syndrome was diagnosed. Some established characteristics of this syndrome as well as some atypical features concerning patient-doctor relationship and natural history are discussed.

[Long-term results of surgical management of patellar fractures]

Between 1973 and 1989, 129 patients with 135 fractures of the patella were treated operatively. More than two-thirds of these patients were younger than 40 years at the time of the accident. The main cause of trauma was a traffic accident in 65.9%. Sixty patients had polytraumata. There were 74 comminuted, 28 transverse, 17 starlike, 10 longitudinal and 6 fractures with one large fragment. Eighty-two patients with 85 fractures were followed up after 8.4 years on average (1.2-16.3 years). The overall results were excellent or good in 64.7%, fair in 18.8% and poor in 16.5%. The best results were seen in transverse fractures after modified tension-band wiring using two longitudinal K wires, and in longitudinal fractures applying screws. Sixty-three percent of the fair and poor results were seen after osteosynthesis of comminuted fractures. In these cases primarily partial or complete patellectomy seems to be indicated instead of just insufficient reconstruction of the retropatellar face. Early functional physiotherapy is very important for all kinds of patellar fractures to gain full range of motion.

Mos and the cell cycle: the molecular basis of the transformed phenotype

The product of the mos proto-oncogene is a serine/threonine kinase that is expressed at high levels in germ cells. Mos is a regulator of meiotic maturation, and is required for the initiation and progression of oocyte meiotic maturation that leads to the production of unfertilized eggs. Mos is also a component of cytostatic factor, an activity that is believed to arrest oocyte maturation at meiotic metaphase II. There is evidence showing that the Mos protein is associated with tubulin in unfertilized eggs and transformed cells, raising the possibility that it is involved in the microtubular reorganization that occurs during M-phase. Inappropriate expression of its M-phase activity during interphase of the cell cycle may be responsible for its transforming activity.

[Prurigo in tropical area. Importance of its association with HIV infection]

The term prurigo applies to a classic chronic skin disease of children (P. strophulus) which is becoming found very seldom in developed countries, but remains extraordinarily prevalent in tropical areas. This striking geographical distribution relies on its ectoparasitic origin. Some peculiar aspects of prurigo, observed in French Guyana (South America), are reported. The original point is a new aspect of adult acquired prurigo, associated with HIV infection, which appears to be one of the features characteristic of tropical AIDS. This HIV associated prurigo (HAP) is the revelating event, in as high as 20% of HIV infected people, significatively those with less than 200 CD4 cells. HAP appears as a marker of HIV infection with poor sensitivity, but much higher specificity (92%), with no correlation with acquisition's risk factors. Just like infantile prurigo, HAP can be considered an arthropod bite reaction which seems to be enhanced in HIV infected people living in tropical environment.

[Alcoholism and severe pneumococcal infection. Apropos of a case of purpura fulminans caused by Streptococcus pneumoniae]

A 43-year old woman presented with lethal purpura fulminans caused by a Streptococcus pneumoniae infection with pneumonia, bacteraemia and meningitis. The only predisposing factor identified was severe chronic alcoholism. The high morbidity and mortality rates of pneumococcal infections in alcoholics are emphasized.