Paracoccidioïdomycose cutanéo-muqueuse Premier cas diagnostiqué en Guyane Française

INTRODUCTION

Paracoccidio-domycosisis a deep mycosis due to a dimorphic fungus:Paracoccidioides brasiliensis. The principle endemic country is Brazil. We describe the first case of paracoccidio-domycosis, in its cutaneous-mucosal form, diagnosed in French Guiana.

OBSERVATION

A 20 year-old Brazilian man, having mover to French Guiana a few months earlier, presented with multiple disseminated cutaneous lesions, predominating on the face, and composed of multiple nodules and two ulcerations. The clinical examination also revealed voluminous superficial lymph nodes and ulcerations of the pharynx and larynx. Direct examination, anatomopathology and culture of cutaneous biopsies revealed specific images of Paracoccidioides brasiliensis. HIV serology was negative. Treatment combining cotrimoxazole and itraconazole eliminated the lesions in one month.

DISCUSSION

Because the patient had just moved to Guiana, this observation probably corresponded to an imported disease. The principle differential diagnosis was leishmaniosis.

External ophthalmomyiasis caused by Dermatobia hominis. A retrospective study of nine cases and a review of the literature

PURPOSE

To report nine cases of external ophthalmomyiasis caused by Dermatobia hominis.

METHODS

Retrospective, non-comparative, interventional case series. Participants consisted of patients (n = 9) presenting at Cayenne Hospital between 1968 and 2003. The location and number of larvae, the larval stage, and the medical and surgical procedures applied were studied in each case.

RESULTS

Seven patients had palpebral myiasis (including one with three larvae) and two had conjunctival myiasis. Every patient had palpebral oedema. The larval respiratory pore was located on the palpebral skin or free margin or on the conjunctiva. Movements were present within the lesion in at least three patients. Petroleum ointment or ivermectine solution was used in at least four patients to smother or kill the larvae. Extraction under local anaesthesia was possible in six patients, while three required general anaesthesia.

CONCLUSION

Several larvae may be present in a patient. Topical ivermectine may help to kill the larvae before extraction is attempted.

Disseminated cutaneous leishmaniasis due to Leishmania guyanensis: case of a patient with 425 lesions

Disseminated cutaneous leishmaniasis is characterized by the presence of a large (> or =10) number of lesions at several anatomic sites (head, limbs, and trunk). Most of the lesions are small, papular, and appear simultaneously with or secondarily to one or several ulcerated lesions of localized cutaneous leishmaniasis. We report the first case of disseminated cutaneous leishmaniasis in French Guiana. It concerns a 24-year-old woman who tested negative for human immunodeficiency virus (HIV). The disease began with three lesions that became ulcerated. One week later, multiple papulo-nodular lesions appeared. We counted a total of 425 lesions. Leishmania were observed in the lesions. The species involved was L. guyanensis, which has never been described in a case of disseminated cutaneous leishmaniasis. The patient was rapidly cured by a single course of pentamidine. Disseminated cutaneous leishmaniasis should be distinguished from other types of leishmaniasis with multiple lesions. These include anergic diffuse cutaneous leishmaniasis, post-kala-azar leishmaniasis, and leishmaniasis associated with HIV infection.

[Short treatment of donovanosis with azithromycin]

INTRODUCTION

Azithromycine is recommended in the treatment of donovanosis with a 7-day treatment cycle. We report the efficacy of a single cure of 1 gram in two patients.

OBSERVATIONS

Four patients, presenting with donovanosis, were treated with azithromycine according to 2 regimens. The first used 500 mg/d the molecule during 1 week, the second used azithromycine in single cure of 1 gram. The latter led to the complete cure of 2 patients.

DISCUSSION

Many antibiotics are used in the treatment of donovanosis. Since 1996, Australian authors have used azithromycine in this indication. A single dose of this molecule appears effective in recent and confined donovanosis.

[Infective dermatitis and recurrent strongyloidiasis in a child]

INTRODUCTION

Infective dermatitis is a chronic childhood dermatosis, associated with HTLV-1 infection. We report the observation of a young Haitian girl in French Guyana.

OBSERVATION

An 8 year-old girl presented recurring dermatosis on the scalp and armpits since she was 2 years old. The initial clinical examination showed the presence of centro-facial micro-papules, associated with a nasal pyodermatitis. A bacteriological culture isolated a Staphylococcus aureus. Phenotypic analysis did not indicate any production of exfoliatin or leucocidin. Serologic tests for HTLV1 were positive. In addition, the child presented recurring symptomatic anguillulosis, despite numerous antihelmintic treatments. A clinical and parasitological cure was obtained with a monthly treatment of ivermectin.

COMMENTS

This is the first case of infective dermatitis reported in french Guyana. The clinical analysis that led to this diagnosis showed a minor form of this dermatosis. The phenotypic analysis of the Staphylococcus aureus isolated from the cutaneous lesions did not indicate any factors of virulence habitually associated with pyodermatitis in Guyana. This is the first case of chronic digestive anguillulosis (a parasitic complaint usually associated with an adult HTLV-1 infection) associated with an infective dermatitis.

Unusual form of neurocysticercosis associated with HIV infection

Concurrent infection with Taenia solium and HIV would be expected to occur more frequently because of the increasing frequency of HIV infection in endemic areas of cysticercosis. However, little is known about the influence of HIV infection on the frequency and the clinical course of cysticercosis. Giant cysts and racemose forms of neurocysticercosis seem to be more frequent in HIV-infected patients and may be secondary to an uncontrolled parasitic growth because of an impaired cell-mediated immune response. We report an unusual case of epidural spinal racemose neurocysticercosis revealed by compression of cauda equina in an HIV-infected man and discuss the potential interactions between T. solium and HIV infections.

Leishmania and HIV co-infection: dermatological manifestations

Leishmania species can cause a wide spectrum of cutaneous disease in HIV-positive patients: asymptomatic, localized cutaneous, mucosal, muco-cutaneous, diffuse cutaneous or post-kala-azar leishmaniasis. In such cases, which are usually severely immunocompromised, the leishmanial parasites reach the skin of the human host by dissemination after either a new infection (resulting from the bite of infected sandfly or, probably, the sharing of contaminated syringes by intravenous-drug users) or the re-activation of a latent infection. Recent experience and past observations on the dermatology of leishmaniasis in those with Leishmania/HIV co-infection are reviewed here.

Differential production of systemic and intralesional gamma interferon and interleukin-10 in nodular and ulcerative forms of Buruli disease

Buruli disease, caused by Mycobacterium ulcerans, is the third most important mycobacterial disease in humans besides tuberculosis and leprosy. We have compared systemic and intralesional cytokine production in patients presenting with a nodular form and a necrotizing, ulcerative form of the disease. Gamma interferon (IFN-gamma) levels in response to whole M. ulcerans and Mycobacterium bovis BCG bacilli and in response to purified Ag85 protein from BCG were lower in peripheral blood mononuclear cells (PBMC) cultures from Buruli disease patients than in PBMC from healthy purified protein derivative-positive contacts. Interleukin-4 (IL-4) and IL-13 content was below the detection threshold in these PBMC cultures. IFN-gamma production after stimulation with M. ulcerans was significantly lower (P < 0.05) in PBMC cultures from patients with ulcers than in those from patients with nodules. On the other hand, PBMC from Buruli disease patients produced significant levels of IL-10 in response to M. ulcerans (but not to M. bovis BCG) and production was highest in patients with the ulcerative form. Third, semiquantitative reverse transcription-PCR analysis demonstrated a similar difference in the local, intralesional cytokine profile for the two forms of the disease: high IFN-gamma but low IL-10 mRNA levels in nodular lesions and high IL-10 but low IFN-gamma mRNA levels in ulcerative lesions. Intralesional IL-4 and IL-13 mRNA levels were low and only detected in patients with the ulcerative form. Our results indicate, although they do not formally prove, that production of IL-10 rather than production of IL-4 or IL-13 by Th2-type T cells may be involved in the low M. ulcerans-specific IFN-gamma response in Buruli disease patients.

Histoplasmosis and acquired immunodeficiency syndrome: a study of prognostic factors

We aimed to identify prognostic factors for AIDS-associated disseminated histoplasmosis. In a multivariate analysis, we found that dyspnea, a platelet count of <100,000 platelets/mm3, and lactate dehydrogenase levels of >2 times the upper limit of the normal range were significantly independently associated with the death of the patient during the first 30 days of antifungal treatment.

American cutaneous leishmaniasis, lepromatous leprosy, and pulmonary tuberculosis coinfection with downregulation of the T-helper 1 cell response

Cutaneous leishmaniasis, leprosy, and tuberculosis are caused by intracellular pathogens whose development depends on impaired cell-mediated immunity. We report an exceptional triple association of American cutaneous leishmaniasis, lepromatous leprosy, and pulmonary tuberculosis in a man with no recognized immunodeficiency. Normal immunological assessment of the interferon-gamma pathway does not support the hypothesis of a genetic defect in any of the genes involved in the T helper (Th)-1 cytokine cascade in this patient. Unresponsiveness to interleukin (IL)-12 of his T cells after stimulation with Leishmania guyanensis, Mycobacterium bovis bacille Calmette-Guérin, and Mycobacterium leprae antigens suggested the inability to mount an appropriate Th cell response to upregulate the IL-12 receptor expression.

Th1 cell development induced by cysteine proteinases A and B in localized cutaneous leishmaniasis due to Leishmania guyanensis

The cysteine proteinases CPA and CPB from Leishmania major induced Th1 responses in patients with leishmaniasis due to Leishmania guyanensis. Furthermore, cysteine proteinases induced neither interleukin 4 (IL-4) nor IL-13 and low levels of IL-10 in controls and patients. The results suggest that CPs would be quite good candidates for a vaccine against different Leishmania species.

Th2 responses predominate during the early phases of infection in patients with localized cutaneous leishmaniasis and precede the development of Th1 responses

Intralesional Th2 responses preceded the development of Th1 responses in localized cutaneous leishmaniasis due to Leishmania guyanensis. Although the number of parasites increased in Th2 lesions, no correlation was found between the levels of cytokine expression and the number of parasites. In contrast, the decreased number of parasites in Th1 lesions is negatively correlated to gamma interferon expression.

[Effectiveness of 20% salicylated vaseline in the treatment of profuse tungiasis. Report of 8 cases in French Guiana]

The treatment of tungiasis involves the mechanic extraction of the gravid females of Tunga penetrans. We have observed on 8 patients profuse tungiasis diagnosed in the centre hospitalier de Cayenne. We have carried out different types of treatment, including the occlusive application of 20% of salicylated vaseline during 12 or 24 hours. This procedure causes the death of the parasites and facilitates their extraction.

[Diagnosis of Mycobacterium ulcerans infection by PCR: report of 3 cases observed in French Guiana]

Mycobacterium ulcerans infection is the third most important mycobacterial infection in the world. It has been described in many different countries including French Guiana. The diagnosis of M. ulcerans infection by culture is often difficult because culture is hard to perform in endemic areas and their sensitivity is not reliable. As a result the diagnosis of this infection is often delayed. However, molecular methods are now available to diagnose rapidly infections by M. ulcerans and distinguish it from other mycobacteria. We report three cases of skin infection due to M. ulcerans observed in French Guiana. Diagnosis was initially made by polymerase chain reaction and was confirmed later by culture (in two patients) and inoculation to mice (in one patient). A faster diagnosis of M. ulcerans infection should lead to a better prognosis of this infection.

Influence of meteorological parameters on the clinical presentation of cutaneous leishmaniasis in French Guiana and on the efficacy of pentamidine treatment of the disease

In French Guiana, marked seasonal fluctuations have been observed in the numbers of individuals who present with cutaneous leishmaniasis (CL). To investigate the seasonal trends further, the clinical characteristics and responses to treatment of 455 cases of CL, who presented over a 3-year period (1995-1998), were compared against data on the weather for the calendar month of presentation (month 0) and for the month before presentation (month-1). Several statistically significant associations were observed. The number of sunlight hours in month -1 was lower for the treatment successes than for the treatment failures [adjusted odds ratio (AOR) for successful treatment=0.28; 95% confidence interval (CI)=0.13-0.6; P=0.001] and for those with long incubation periods than for those with relatively short incubation periods (multiple-regression coefficient=-0.003; P=0.002). However, the radiation intensity for month-1 was higher for the treatment successes than for the treatment failures (AOR=2.1; CI=1.1-3.8; P=0.02). Relatively high numbers of hours of sunlight on month-1 were associated with relatively high numbers of parasites on the skin smears (AOR=1.03; CI=1.01-1.04; P<0.001). Relatively high numbers of hours of sunlight during month 0 were associated with lymphangitis (AOR=0.4; CI=0.19-0.8; P=0.01). These results indicate that meteorological parameters may influence the evolution of CL, at least in French Guiana.

Acquired immunodeficiency syndrome-related oral and/or cutaneous histoplasmosis: a descriptive and comparative study of 21 cases in French Guiana

BACKGROUND

Oral or cutaneous acquired immunodeficiency syndrome (AIDS)-related histoplasmosis is a rare presentation of disseminated histoplasmosis.

OBJECTIVE

To describe this clinical presentation and to compare it with other forms of AIDS-related disseminated histoplasmosis.

METHODS

A cross-sectional study of patients with AIDS-related disseminated histoplasmosis was performed. CD4 counts and survival were compared between patients with oral or cutaneous histoplasmosis and patients with nonmucocutaneous disseminated histoplasmosis.

RESULTS

The mean CD4 lymphocyte count was lower in patients with mucocutaneous lesions than in patients with nonmucocutaneous disseminated histoplasmosis (29 vs. 72/mm3, P = 0.002). The proportion of survivors 1 month after diagnosis did not differ significantly between the two groups (13/21 vs. 32/45, P = 0.4). At 6 months, the proportion of survivors was significantly lower for patients with mucocutaneous lesions (6/21 vs. 22/39, P = 0.03).

CONCLUSIONS

These results suggest that mucocutaneous lesions occur at a later stage of human immunodeficiency virus infection, but are not, in themselves, associated with a higher level of mortality. The excess mortality at 6 months reflects deaths from other complications of severe immunodepression. This study confirms the polymorphism of mucocutaneous lesions, emphasizing the need for systematic testing for Histoplasma in all cases of mucocutaneous lesions in AIDS patients.

LACK-specific CD4(+) T cells that induce gamma interferon production in patients with localized cutaneous leishmaniasis during an early stage of infection

The profile of cytokines induced by soluble leishmania antigen (SLA) and the Leishmania homologue of the mammalian receptor for activated C kinase (LACK), a candidate vaccine against leishmaniasis, and the cellular source of the cytokines produced in response to these antigens were analyzed in patients infected with Leishmania guyanensis. Gamma interferon (IFN-gamma) and interleukin-10 (IL-10) were produced in response to LACK. Although LACK-specific CD4(+) cells producing IFN-gamma were isolated only during the early phase of infection (less than 30 days following the onset of infection), cells producing IL-10 in response to LACK were detected in all patients. CD4(+) T cells producing IFN-gamma and IL-13 were produced in response to SLA in all patients. SLA- and LACK-specific T cells are effector memory cells, as they are CD45RA(-) CCR7(-) CD4(+) T cells. CD4(+) T cells producing IFN-gamma are CD62L(-), and CD4(+) T cells producing IL-10 are CD62L(+), indicating that these cells have different tissue-homing capacities. These findings show that SLA and LACK induce both type 1 (IFN-gamma) and type 2 (IL-10 or IL-13) cell responses.

[Epidemiologic surveillance of cutaneous leishmaniasis in Guiana. Summary of military data collected over 10 years]

This report describes the results of epidemiological surveillance of cutaneous leishmaniasis in French military personnel in French Guiana. Data was collected regarding microscopic diagnosis, clinical manifestations, and lesion location as well as compliance with vector control measures. Year-to-year variations in the incidence in the general population have been attributed to changes in climatic conditions. Monitoring incidence and density curves, correlation of findings with local epidemiological data, and analysis of the most recent epidemic in 1998/99 (326 cases, attack rate 3.2% men years) highlight the importance of behavioral factors. The proportion of total cases involving military personnel varied widely from 20 to 85%. Investigation consistently showed that failure to apply elementary protective measures against sandfly bites was the most determinant factor in this proportion. Strict compliance with these measures appears to reduce the risk of infection considerably.

High intralesional interleukin-10 messenger RNA expression in localized cutaneous leishmaniasis is associated with unresponsiveness to treatment

The intralesional expression of cytokines (interleukin [IL]-4, IL-13, IL-10, and interferon-gamma) was analyzed in 65 patients with localized cutaneous leishmaniasis due to Leishmania guyanensis before specific treatment with pentamidine isethionate. The local expression of IL-10 was significantly higher in patients who responded poorly to treatment than in patients whose lesions were regressing. When an IL-10 level >10 (ratio of the concentration of IL-10 [pg/microL] to that of beta-actin [pg/microL]) was used as an indicator of treatment failure, the sensitivity of this test was 78.6, and the specificity was 72.5. Thus, high intralesional expression of IL-10 might predict a poor response to conventional treatment.

Staphylococcus aureus isolated in cases of impetigo produces both epidermolysin A or B and LukE-LukD in 78% of 131 retrospective and prospective cases

Clinical symptoms of impetigo and staphylococcal scalded skin syndrome may not only be expressed as the splitting of cell layers within the epidermis but are often accompanied by some localized inflammation. Toxin patterns of Staphylococcus aureus isolates originating from patients with impetigo and also from those with other primary and secondary skin infections in a retrospective isolate collection in France and a prospective isolate collection in French Guiana revealed a significant association (75% of the cases studied) of impetigo with production of at least one of the epidermolysins A and B and the bicomponent leucotoxin LukE-LukD (P < 0.001). However, most of the isolates were able to produce one of the nonubiquitous enterotoxins. Pulsed-field gel electrophoresis (PFGE) of genomic DNA hydrolyzed with SmaI showed a polymorphism of the two groups of isolates despite the fact that endemic clones were suspected in French Guiana and France. The combination of toxin patterns with PFGE fingerprinting may provide further discrimination among isolates defined in a given cluster or a given pulsotype and account for a specific virulence. The new association of toxins with a clinical syndrome may reveal principles of the pathological process.