HIV-Associated Disseminated Histoplasmosis and Rare Adrenal Involvement: Evidence of Absence or Absence of Evidence

Adrenal histoplasmosis and primary adrenal insufficiency are mostly described in immunocompetent patients. This particular tropism is attributed to the presence of cortisol within the adrenal gland, a privileged niche for Histoplasma growth. In French Guiana, disseminated histoplasmosis is the main opportunistic infection in HIV patients. Our objective was to search in our HIV-histoplasmosis cohorts to determine how frequent adrenal insufficiency was among these patients. Between January 1, 1981 and October 1, 2014, a multicentric retrospective, observational study of histoplasmosis was conducted. Patients co-infected by HIV and histoplasmosis were enrolled in French Guiana’s histoplasmosis and HIV database. Among 349 cases of disseminated histoplasmosis between 1981 and 2014, only 3 had adrenal insufficiency (0.85%). Their respective CD4 counts were 10, 14 and 43 per mm3. All patients had regular electrolyte measurements and 234/349 (67%) had abdominal ultrasonography and 98/349 (28%) had abdominopelvic CT scans. None of these explorations reported adrenal enlargement. Overall, these numbers are far from the 10% reports among living patients and 80-90% among histoplasmosis autopsy series. This suggests 2 conflicting hypotheses: First, apart from acute adrenal failure with high potassium and low sodium, less advanced functional deficiencies, which require specific explorations, may have remained undiagnosed. The second hypothesis is that immunosuppression leads to different tissular responses that are less likely to incapacitate the adrenal function. Furthermore, given the general immunosuppression, the adrenal glands no longer represent a particular niche for Histoplasma proliferation.

Reduced Severity in Patients With HIV-Associated Disseminated Histoplasmosis With Deep Lymphadenopathies: A Trench War Remains Within the Lymph Nodes?

Background

Disseminated histoplasmosis is a major killer of patients with advanced HIV. It is proteiform and often hard to diagnose in the absence of diagnostic tests. We aimed to describe disseminated histoplasmosis with lymphadenopathies in French Guiana and to compare survival and severity of those patients to patients without lymphadenopathies.

Methods

A retrospective cohort study was performed on data records collected between January 1, 1981 and October 1, 2014.

Results

Among 349 cases of disseminated histoplasmosis 168 (48.3%) had superficial lymphadenopathies and 133(38.1%) had deep lymphadenopathies. The median LDH concentration, ferritin concentration, TGO concentration, and WHO performance status were lower among patients with deep lymphadenopathies than those without deep lymphadenopathies. There was a significant decrease in the risk of early death (<1 month) among those with deep lymphadenopathies relative to those without (OR=0.26 (95%CI=0.10-0.60), P=0.0006) and in the overall risk of death (OR=0.33 (95%CI=0.20-0.55), P<0.0001). These associations remained strongly significant after adjusting for time period, CD4 counts, age, delay between beginning of symptoms and hospital admission, antifungal and antiretroviral treatment.

Conclusions

The present data show that in patients with advanced HIV and disseminated histoplasmosis, the presence of deep lymphadenopathies is associated with fewer markers of severity and a lower risk of death. To our knowledge it is the first study to show this. The presence of deep lymphadenopathies is hypothesized to reflect the patient's partially effective defense against H. capsulatum.

Gastrointestinal disseminated histoplasmosis in HIV-infected patients: A descriptive and comparative study

Disseminated histoplasmosis is one the main AIDS-defining opportunistic infections in HIV-infected patients, notably in Latin America. The non-specific and proteiform clinical presentation leads to diagnostic delays that may lead to fatal outcomes. This retrospective multicentric study aimed to describe the frequency and manifestations of gastrointestinal histoplasmosis in French Guiana, and to compare patients with disseminated histoplasmosis with or without gastrointestinal involvement.

Between January 1, 1981 and October 1, 2014 co-infections with HIV and histoplasmosis were enrolled. Inclusion criteria were: age >18 years, confirmed HIV infection; first proven episode of histoplasmosis.

Among 349 cases of disseminated histoplasmosis, 245 (70%) had a gastrointestinal presentation. Half of patients with gastrointestinal signs had abdominal pain or diarrhea, mostly watery. Half of patients with abdominal pain had diarrhea (63/124) and half of those with diarrhea (63/123) had abdominal pain. A significant proportion of patients also had hepatomegaly and, to a lesser degree, splenomegaly. After adjusting for potential confounding, the presence of lymphadenopathies >2cm (AOR = 0.2, IC95 = 0.04–0.7, P = 0.01), Haitian origin (AOR = 0.04, IC95 = 0.004–0.4, P = 0.006) were associated with a lower prevalence of gastrointestinal signs and positive gastrointestinal presence of H. capsulatum. Persons with a gastrointestinal H. capsulatum were more likely to have a decreased prothrombin time, lower ferritin, lower liver enzymes, and lower concentrations of LDH than those without gastrointestinal signs and symptoms. They also had a shorter interval between symptoms onset and diagnosis. Patients with a positive gastrointestinal identification of H. capsulatum were less likely to die at 1 month than those without a gastrointestinal presentation (respectively, 4.6% vs 18.5%, P = 0.01).

Subacute or chronic gastrointestinal presentations are very frequent during disseminated histoplasmosis, they seem less severe, and should lead to suspect the diagnosis in endemic areas. There were populational or geographic differences in the frequency of gastrointestinal manifestations that could not be explained.

This retrospective multicentric study aimed to describe the frequency and manifestations of gastrointestinal histoplasmosis in French Guiana, and to compare patients with disseminated histoplasmosis with or without gastrointestinal involvement. Between January 1, 1981 and October 1, 2014 co-infections with HIV and histoplasmosis were enrolled. Inclusion criteria were: age >18 years, confirmed HIV infection; first proven episode of histoplasmosis. Among 349 cases of disseminated histoplasmosis, 245 (70%) had a gastrointestinal presentation. Half of patients with gastrointestinal signs had abdominal pain or diarrhea, mostly watery. Half of patients with abdominal pain had diarrhea (63/124) and half of those with diarrhea (63/123) had abdominal pain. A significant proportion of patients also had hepatomegaly and, to a lesser degree, splenomegaly. After adjusting for potential confounding, the presence of lymphadenopathies >2cm, Haitian origin were associated with a lower prevalence of gastrointestinal signs and presence of H. capsulatum. Persons with a gastrointestinal presentation were more likely to have a decreased prothrombin time, lower liver enzyme concentration, ferritin, and lower concentrations of LDH than those without gastrointestinal signs and symptoms. The delay between symptom’s onset and diagnosis was also shorter and the proportion of deaths at 1 month was significantly lower among those with gastrointestinal presence of H. capsulatum. Subacute or chronic gastrointestinal presentations are very frequent during disseminated histoplasmosis, they seem less severe, and should lead to suspect the diagnosis in endemic areas.

Risk Factors for Mortality among HIV-Infected Patients with Disseminated Histoplasmosis

Identifying prognostic factors is important in order to guide the choice of first-line therapy for disseminated histoplasmosis. Our objective was to identify factors associated with death among a cohort of 330 patients compiled over 34 years of clinical practice in French Guiana. Survival analysis was performed with death as the failure event and date of symptom onset as the origin event. Incidence rates were and Cox proportional hazards models were computed. Overall, 330 HIV-infected patients with disseminated histoplasmosis were included in the analysis, with 126 deaths occurring. One-quarter of all patients died within 6 months of the first symptoms. Patients with dyspnea, renal failure, arterial blood pressure < 90 mmHG, and a WHO performance score > 2 had a greater incidence of death. Bivariate analyses showed that patients with increased LDH, low hemoglobin, low serum protein, low CD4 counts, and low platelets tended to have a greater incidence of death. After adjusting for potential confounders, patients with dyspnea, a WHO performance score > 2, serum protein < 60 g/L, and hemoglobin < 8.9 g/dL had an increased risk of dying. The interaction terms showed that patients treated with liposomal amphotericin B had a marked reduction in death among patients with renal failure; among renal failure patients, the elevation of LDH was associated with a significant risk of death.

Cytological and Histopathological Spectrum of Histoplasmosis: 15 Years of Experience in French Guiana

Background

Disseminated histoplasmosis remains a major killer of immunocompromised patients in Latin America. Cytological and histological methods are usually present in most hospitals and may represent a precious diagnostic method. We report 15 years of experience of the department of pathology of the Centre Hospitalier de Cayenne Andrée Rosemon in French Guiana.

Methods

Specimens from live patients from January 2005 to June 2020 with the presence of H. capsulatum on cytological and/or histological analysis were analyzed. All specimens were examined by an experienced pathologist. The analysis was descriptive.

Results

Two hundred two cytological and histological samples were diagnosed with histoplasmosis between January 2005 and June 2020. The 202 samples included 153 (75.7%) histopathological formalin-fixed and paraffin-embedded tissues (biopsy or surgical specimens) and 49 (24.3%) cytological analysis from all organs. One hundred thirty-four patients (82.7%) were HIV-positive, 15 patients (9.3%) had immunosuppressant treatment, and 13 patients (8%) were immunocompetent. Seventy-eight of 202 (38.5%) were samples from the digestive tract, mostly the colon (53/78 cases, 70%) and small intestine (14/78 cases, 18%). Microorganisms were more numerous in digestive samples (notably the colon) than in other organs. Lymphocyte and histiocyte inflammation of moderate to marked intensity were observed in all positive specimens. Tuberculoid epithelioid granuloma were present in 16/78 (20,5%) specimens including 14 colon and 2 small intestine specimens. There were 11/202 cases of liver histoplasmosis, 26/202 (12,8%) cases of pulmonary histoplasmosis. Bone marrow involvement was diagnosed in 14 (2%) specimens (8 aspiration and 6 biopsies). Lymph nodes were positive in 42 specimens (31 histology and 11 cytology). Histopathological analysis of the 31 lymph nodes showed a variable histological appearance. Tuberculoid forms were most frequent (24/31, 77,4%).

Conclusions

From the pathologist perspective, this is the largest series to date showing that digestive involvement was the most frequent, usually with a tuberculoid form and a greater load of Histoplasma. With awareness and expertise, cytology and pathology are widely available methods that can give life-saving results in a short time to help orient clinicians facing a potentially fatal infection requiring prompt treatment.

Temporal trends of cutaneo-mucous histoplasmosis in persons living with HIV in French Guiana: Early diagnosis defuses South American strain dermotropism

Histoplasmosis is the most frequent opportunistic infection and the first cause of mortality in HIV-infected patients in French Guiana and presumably in much of Latin America. Mucocutaneous lesions of histoplasmosis are considered as rare and late manifestations of the disease. It has been debated whether the greater proportion of cutaneo-mucous presentations in South America relative to the USA was the reflection of Histoplasma strains with increased dermotropism or simply delayed diagnosis and advanced immunosuppression. The objective of this study was to describe the clinical presentation, frequency, prognosis and temporal trends of cutaneomucous histoplasmosis in French Guiana. A retrospective study of patients with AIDS-related disseminated histoplasmosis followed in the three hospitals of French Guiana was performed between 1981 and 2014. Incident cases of histoplasmosis, proved by pathology and/or mycological examinations, were studied. Mucocutaneous histoplasmosis was confirmed by a positive cutaneous or mucosal biopsy. Mucocutaneous lesions were polymorphic. Ninety percent of patients were profoundly immunocompromised patients (CD4<50/mm3) and over 80% were not on antiretroviral treatment. The frequency of mucocutaneous forms and case fatality of disseminated histoplasmosis within one month of antifungal treatment significantly decreased over time (p<0,001). In this South American territory, diagnostic and therapeutic improvements have led to the quasi disappearance of cutaneous manifestations. There may be South American dermotropism in the laboratory but at the bedside early diagnosis seems to be the main parameter explaining the proportion of cutaneomucous presentations in South America relative to the USA.

Histoplasmosis is the most frequent opportunistic infection and the first cause of mortality in HIV-infected patients in French Guiana and presumably in much of Latin America. Mucocutaneous lesions of histoplasmosis are considered as rare and late manifestations of the disease. It has been debated whether the greater proportion of cutaneo-mucous presentations in South America relative to the USA was the reflection of Histoplasma strains with increased dermotropism or simply delayed diagnosis and advanced immunosuppression. The objective of this study was to describe the clinical presentation, frequency, prognosis and temporal trends of cutaneomucous histoplasmosis in French Guiana. A retrospective study of patients with AIDS-related disseminated histoplasmosis followed in the three hospitals of French Guiana was performed between 1981 and 2014. Incident cases of histoplasmosis, proved by pathology and/or mycological examinations, were studied. Mucocutaneous histoplasmosis was confirmed by a positive cutaneous or mucosal biopsy. Ninety percent of patients were profoundly immunocompromised patients (CD4<50/mm3) and over 80% were not on antiretroviral treatment. The frequency of mucocutaneous forms and case fatality of disseminated histoplasmosis within one month of antifungal treatment significantly decreased over time. Hence, in this South American territory, diagnostic and therapeutic improvements have led to the quasi-disappearance of cutaneous manifestations. There may be South American dermotropism in the laboratory but at the bedside early diagnosis seems to be the main parameter explaining the proportion of cutaneomucous presentations in South America relative to the USA.

Hemophagocytic Lymphohistiocytosis During HIV Infection in Cayenne Hospital 2012-2015: First Think Histoplasmosis

Introduction: Haemophagocytic Lymphohistiocytosis (HLH), during HIV infection is a rare complication with a poor prognosis. There are few data on HLH within the Amazon region. The objective was to describe epidemiological, clinical and therapeutic features of HIV-related HLH in French Guiana. Methods: A retrospective analysis of adult HIV patients at Cayenne hospital with HLH between 2012 and 2015. A diagnosis of HLH was given if the patient presented at least 3 of 8 criteria of the HLH-2004 classification. Results: Fourteen cases of HLH were tallied during the study period. The mean age was 46 years with a sex ratio of 1.8. The most frequent etiology of HLH was an associated infection (12/14). Confirmed disseminated histoplasmosis, was found in 10 of 14 cases, and it was suspected in 2 other cases. The CD4 count was below 200/mm3 in 13/14 cases. An HIV viral load >100,000 copies/ml was observed in 13/14 cases. An early treatment with liposomal amphotericin B was initiated in 12/14 cases. The outcome was favorable in 12/14 of all cases and in 10/12 cases involving histoplasmosis. Case fatality was 2/14 among all cases (14.3%) et 1/10 among confirmed disseminated histoplasmosis with HLH (10%). During the study period 1 in 5 cases of known HIV-associated disseminated histoplasmosis in French Guiana was HLH. Conclusion: Histoplasmosis was the most frequent etiology associated with HLH in HIV-infected patients in French Guiana. The prognosis of HLH remains severe. However, a probabilistic empirical first line treatment with liposomal amphotericin B seemed to have a favorable impact on patient survival.

Outbreak of Amazonian Toxoplasmosis: A One Health Investigation in a Remote Amerindian Community

Background:Toxoplasma gondii is a parasite of worldwide importance but its burden in indigenous communities remains unclear. In French Guiana, atypical strains of T. gondii originating from a complex rainforest cycle involving wild felids have been linked to severe infections in humans. These cases of Amazonian toxoplasmosis are sporadic and outbreaks are rarely described. We report on the investigation of an outbreak of acute toxoplasmosis in a remote Amerindian village. We discuss the causes and consequences of this emergence.

Methods: In May 2017, during the rainy season and following an episode of flooding, four simultaneous cases of acute toxoplasmosis were serologically confirmed in two families living the village. Other non-diagnosed cases were then actively screened by a medical team along with epidemiological investigations. Inhabitants from nine households were tested for T. gondii antibodies and parasite DNA by PCR when appropriate. Samples of water, cat feces and cat rectal swabs, soil, and meat were tested for T. gondii DNA by PCR. Positive PCR samples with sufficient DNA amounts were genotyped using 15 microsatellite markers.

Results: Between early May and early July 2017, out of 54 tested inhabitants, 20 cases were serologically confirmed. A fetus infected at gestational week 10 died but other cases were mild. Four patients tested positive for parasite DNA and two identical strains belonging to an atypical genotype could be isolated from unrelated patients. While domestic cats had recently appeared in the vicinity, most families drank water from unsafe sources. Parasite DNA was recovered from one water sample and nine soil samples. Three meat samples tested positive, including wild and industrial meat.

Conclusions: The emergence of toxoplasmosis in such a community living in close contact with the Amazon rainforest is probably multifactorial. Sedentary settlements have been built in the last few decades without providing safe water sources, increasing the risk of parasite circulation in cases of dangerous new habits such as cat domestication. Public health actions should be implemented in these communities such as safe water supply, health recommendations, and epidemiological surveillance of acute toxoplasmosis. A “One Health” strategy of research involving medical anthropology, veterinary medicine, and public health needs to be pursued for a better understanding of the transmission routes and the emergence of this zoonosis.

Heterogeneity of Clinical Presentations and Paraclinical Explorations to Diagnose Disseminated Histoplasmosis in Patients with Advanced HIV: 34 Years of Experience in French Guiana

We aimed to describe the ways patients with disseminated histoplasmosis—a multifaceted and often lethal disease—present themselves and are explored. A retrospective, observational, multicentric study spanned the period between 1 January 1981 and 1 October 2014. Principal component analysis was performed for the sampling sites and for the clinical signs and symptoms. The factor loadings of the principal components were selected for eigenvalues > 1. The most frequent signs and symptoms were an alteration of the WHO general performance status, fever, digestive tract, respiratory signs and symptoms and lymphadenopathies. The most common sites sampled were bone marrow, respiratory tract, blood, lymph node and liver biopsies, with significant variations in the number of sites from which samples were taken to try to identify the pathogen. The principal component analysis clinical signs and symptoms leading to the diagnosis showed four main lines of variation. The factor loadings of the four main components were compatible with four broad types of clinical presentations and four types of exploration strategies. Extracting simple algorithms was difficult, emphasizing the importance of clinical expertise when diagnosis depends on obtaining a sample where Histoplasma can be seen or grown. Histoplasma antigen detection tests will help simplifying the algorithms.

Leishmania naiffi and lainsoni in French Guiana: Clinical features and phylogenetic variability

In French Guiana, five species are associated with Cutaneous Leishmaniasis (CL). Though infections with Leishmania guyanensis, L. (V.) braziliensis and L. (L.) amazonensis have been extensively described, there are few available clinical and genetic data on L. (V.) lainsoni and L. (V.) naiffi. We determined the clinical and epidemiological features of all cases of CL due to L. (V.) naiffi and L. (V.) lainsoni diagnosed in French Guiana between 2003 and 2019. Phylogenetic analysis was performed by sequencing a portion of HSP70 and cyt b genes. Five cases of L. naiffi and 25 cases of L. lainsoni were reported. Patients infected by L. (V.) lainsoni were usually infected on gold camps, mostly along the Maroni river (60%), while L. naiffi was observed in French patients infected on the coast (100%). A high number of pediatric cases (n = 5; 20%) was observed for L. (V.) lainsoni. A mild clinical course was observed for all cases of L. (V.) naiffi. HSP70 and cyt b partial nucleotide sequence analysis revealed different geographical clusters within L. (V.) naiffi and L. (V.) lainsoni but no association were found between phylogenetic and clinical features. Our data suggest distinct socio-epidemiological features for these two Leishmania species. Patients seem to get infected with L. (V.) naiffi during leisure activities in anthropized coastal areas, while L. (V.) lainsoni shares common features with L. (V.) guyanensis and braziliensis and seems to be acquired during professional activities in primary forest regions. Phylogenetic analysis has provided information on the intraspecific genetic variability of L. (V.) naiffi and L. (V.) lainsoni and how these genotypes are distributed at the geographic level.

Clinical and histological characteristics, and management of melanoma in French Guiana, 2007-2018

There are few studies available on melanoma in Afro-Caribbean and Amerindian populations of South America. French Guiana deserves a study due to its specific health system and diversity of phototypes. The objectives of this study were to evaluate the incidence, histological and clinical characteristics of melanoma in French Guiana. A retrospective study was conducted from October 2007 to January 2018 on all primary melanomas observed at the Cayenne Hospital Centre. Thirty-nine patients were included. The incidence rate (1.61/106 inhabitants/year) was low compared with mainland France. Median age was 58, and gender ratio 1 : 16. Clear phototype (I/II) patients were the most frequent (38.5%), but a significant amount of melanoma also occurred in darker skin. Median Breslow was higher in dark phototypes than in fair-skinned patients. Superficial spreading melanoma (SSM) was the most common histological type (33.3%), particularly in patients with clear phototype (61.5%). Acral lentiginous melanoma was found only in darker-skinned patients (29.1%). The trunk was involved in 66.6% in the clearest group whereas foot was the most common location in the darkest group (60% in V/VI phototypes). Surgery was the most frequently used treatment (79.5%). At the end of the study period, 53.8% had been lost to follow-up. In conclusion, the incidence of melanoma in French Guiana is lower than in mainland France but remains a public health concern, as dark-skinned populations often present with advanced diseases. Awareness and prevention in these communities must be improved.

Utility of PCR in Patients with Strongyloides stercoralis and HTLV-1 Coinfection in French Guiana

Strongyloides stercoralis and human T-lymphotropic virus 1 (HTLV-1) coinfections have been extensively reported in the literature, but the diagnosis and treatment of strongyloidiasis remains a challenge, particularly in HTLV-1 carriers. Our objectives were to evaluate the efficacy of a new PCR method for the detection of S. stercoralis in HTLV-1-positive patients. Stools were collected over a 1-year period across the endemic region of French Guiana, including remote forest areas. Two systems of real-time PCR were then used comparatively, with small subunit and specific repeat as respective targets, and compared with the results of microscopic examinations. One-hundred and twelve stool samples were included. Twenty-seven patients (24.1%) presented a positive HTLV-1 serology. The overall prevalence of strongyloidiasis among the 112 patients was 30% with small-subunit PCR and 11.6% with microscopic examinations. In the seropositive population, all tested stools were negative, whereas 51.2% were positive using small-subunit PCR. Thus, PCR allowed a much-improved sensitivity, particularly in HTLV-1 carriers. Among the two systems investigated, small subunit yielded better results than specific repeat PCR, with prevalence rates in HTLV-1 carriers of 51.2% and 22.2%, respectively. Therefore, PCR should be considered as a useful tool for the diagnosis of strongyloidiasis, particularly in HTLV-1 carriers who often present a light parasitic load due to erratic administration of anthelmintic drugs.

Spectrum of skin diseases in Amerindian villages of the Upper Oyapock, French Guiana

Background

Due to their genetic characteristics, their isolation in rainforest areas, and their traditional way of life, Amerindian populations are likely to suffer from a specific spectrum of dermatoses. However, there are few available data on such skin disorders. Our aims were to describe all skin disorders in two Amerindian villages of French Guiana.

Methods

This retrospective study concerned all patients who consulted in the Health Centres of Camopi and Trois‐Sauts between July 1, 2017, and December 31, 2018. We included all patients classified with an ICD code linked to a skin disorder. All medical records were cross‐checked by two dermatologists to correct misclassifications.

Results

A total of 639 patients formed the study population, for 866 different skin disorders. Non‐sexually transmitted infections represented 57.6% of all skin disorders, followed by eczema (11.5%) and bites/envenomations (9.1%). Bacteria were responsible for 238 skin infections, followed by fungi (141 cases) and parasites (69 cases, including 43 scabies, nine cutaneous leishmaniasis, and two tungiasis). We reported a low prevalence of sexually transmitted infections (10 cases) and an absence of skin cancers.

Conclusions

This study revealed the absence of skin cancer in the Amerindian population of the Upper Oyapock and the important burden of infectious and animal‐related diseases. Future studies should assess a possible underestimation of sexually transmitted diseases in this area. Public health policies should target neglected diseases such as cutaneous leishmaniasis, tungiasis, scabies, and envenomations. Atopic dermatitis was a significant and unexpected cause of consultations.

Dermatoses in international travellers seen at Bordeaux teaching hospital travel clinic, 2015-2018: a GeoSentinel-based study

Skin disorders are frequent in travellers, but data vary between different studies. The objectives of the current study were to describe imported dermatoses in the Bordeaux GeoSentinel prospective database between August 2015 and March 2018. During the study period, 1025 travellers were seen in the clinic, 201 of them with dermatoses. Patients with skin disorders were more likely to be aged > 60 years (OR = 1.88, 95% CI 1.22–2.89), to be tourists (OR 3.04, 95% CI 2.03–4.55) and to have travelled to South America (OR = 2.18, 95% CI 1.29–3.67), and less likely to have sought pretravel advice (OR = 0.53, 95% CI 0.31–0.91). Skin bacterial infections (19.4%) and Zika virus infections (18.4%) were the most common dermatoses. Dengue fever and bacterial skin infections were the leading causes of hospitalization. The contribution of tropical diseases to imported dermatoses remains important. Lack of pretravel advice puts tourists at risk of significant diseases such as dengue fever, Zika virus and bacterial infections.

Actinomycetoma caused by Gordonia westfalica: first reported case of human infection

Bacteria of the genus Gordonia are rarely involved in human infections. We report here the case of a 30-year-old man from Guinea Buissau with mycetoma of the foot. 16S DNA sequencing after surgical biopsy identified Gordonia westfalica. To our knowledge, this is the first report of human infection caused by G. westfalica.

Teledermatology Use in Remote Areas of French Guiana: Experience From a Long-Running System

Introduction: French Guiana is an overseas region of France on the north coast of South America and is mostly covered by tropical rainforest. Most human settlements are located along the coast while some settlements are scattered across the hinterland. In 2001, the French public health service launched a telemedicine pilot project between the main hospital in Cayenne and remote health centers in French Guiana to tackle healthcare access inequalities. The aim of the present study was to review dermatology cases of the French Guiana telemedicine network to assess the use of telemedicine in dermatology, in order to evaluate its usefulness and propose ways to improve the system.

Methods: A retrospective study was conducted on all dermatology cases referred between July 2015 and December 2016 through the French Guiana platform. The Model for Assessment of Telemedicine (MAST) methodology was used as recommended by the European Union.

Results: A total of 254 cases were reviewed by dermatologists at Cayenne hospital over the 18-month study period, with a mean of 14 cases per month. All the 16 peripheral health centers used the telemedicine service during the study. In most cases (202/254, 80%), specialists provided a single diagnosis to the referrers. Infectious diseases represented the main reasons for requests (92/202, 46%) including 32% (29/92) of neglected tropical diseases like leprosy and cutaneous leishmaniasis. A total of 39% (100/258) peripheral centers answered the end-users' survey, and more than 85% found the answer delay was fast, the service useful and with an educational benefit. Overall, the accuracy of the diagnosis increased with the quality of the pictures provided, though the latter was good in only 60% (75/125) of the cases. Most patients for whom a teleconsultations has been required (234/254, 92%) have been managed in the peripheral health centers, while referring the patient to Cayenne was necessary for only 20/254 (8%).

Conclusion: The telemedicine system in French Guiana appears to be an interesting solution to the lack of specialists and allowed a better access to specialized dermatology care for people living in the remote areas of this region.

The Broad Clinical Spectrum of Disseminated Histoplasmosis in HIV-Infected Patients: A 30 Years' Experience in French Guiana

Histoplasmosis is a common but neglected AIDS-defining condition in endemic areas for Histoplasma capsulatum. At the advanced stage of HIV infection, the broad spectrum of clinical features may mimic other frequent opportunistic infections such as tuberculosis and makes it difficult for clinicians to diagnose histoplasmosis in a timely manner. Diagnosis of histoplasmosis is difficult and relies on a high index of clinical suspicion along with access to medical mycology facilities with the capacity to implement conventional diagnostic methods (direct examination and culture) in a biosafety level 3 laboratory as well as indirect diagnostic methods (molecular biology, antibody, and antigen detection tools in tissue and body fluids). Time to initiation of effective antifungals has an impact on the patient's prognosis. The initiation of empirical antifungal treatment should be considered in endemic areas for Histoplasma capsulatum and HIV. Here, we report on 30 years of experience in managing HIV-associated histoplasmosis based on a synthesis of clinical findings in French Guiana with considerations regarding the difficulties in determining its differential diagnosis with other opportunistic infections.