[Pseudomonas aeruginosa in dermatology]

Pseudomonas aeruginosa, a ubiquitous Gram-negative bacillus characterized by its greenish color and sweetish smell, is at the origin of potentially severe forms of dermatosis, such as ecthyma gangrenosum which marks immunosuppression or reveals blood-poisoning, especially in children. It frequently colonizes chronic wounds and serious burns, and spongiotic or acantholytic dermatosis, especially when severe or localized in skinfolds. It requires special care because of its high resistance to antibiotics and antiseptics. It can also involve folliculitis favored by water sports or a nail disorder (chloronychia).

Review of poxvirus: emergence of monkeypox

This article reviews the different types of poxvirus infections. Smallpox, although eradicated, must continue to be monitored because of the potential risk of accidental or voluntary (by bioterrorism) reintroduction. Monkeypox and cowpox viruses are considered to be emergent today ; their high risk of dissemination is due to the increase in international transport as well as trends for new animals as pets and the loss of vaccinal protection against smallpox. Molluscum contagiosum (molluscipoxvirus) causes mild infections, is particularly frequent in children ; in adults it is a marker of the risk of sexually transmitted infections and can, in cases with profuse lesions, reveal AIDS.

Antibiotic therapy and staphylococcal skin infections in a tropical malarial zone (Guyana). Practices in conventional and exceptional situations

A problem of community-acquired Staphylococcus aureus skin infections emerged in the French armed forces in 2004, in a malaria-endemic areas. The high incidence rate led us to evaluate military staff practices. This was a cross-sectional survey of doctors and nurses deployed as officers in French Guyana since 2006. The definition of skin and soft-tissue infection came from the criteria for epidemiological surveillance of the armed forces. We studied the management of antibiotic therapy and its related difficulties. In all, 47 officers responded. At the Military Medical Center (MMC), 23.4% of respondents routinely prescribed antibiotics, compared with 36.2% when stationed in the jungle (p<0.05%). Complication led 68.1 of staff to prescribe antibiotic prescriptions at the MMC, compared with 46.8% in the jungle (p<0.05%). Finally, 22.5% of those at MMC prescribed antibiotic coverage of surgical drainage, compared with 14.8% in the jungle (p<0.05%). Pristinamycin and fusidic acid were the preferred antibiotics. Two-thirds of the staff reported difficulties in jungle management. This first study indicates the need for an update of military medical recommendations. Personnel training must continue to enable them to provide appropriate aggressive management in the current endemic context.

[A case of donovanosis acquired in France]

INTRODUCTION

Donovanosis (granuloma inguinale) is a bacterial infection caused by Klebsiella granulomatis that occurs mainly in the genital area and is primarily sexually transmitted; it is seen predominantly in the tropics. Herein, we report a case of the disease contracted in metropolitan France.

PATIENTS AND METHODS

A 47-year-old man presented with painless ulceration of the glans, present for one month, with progressive extension; there was no history of any recent trip abroad. Skin biopsy with Whartin-Starry and Giemsa staining revealed Donovan bodies in the cytoplasm of macrophages. Based on these findings, further questioning of the patient revealed unprotected sexual contact two months earlier in France. Treatment was initiated with azithromycin 1g on the first day followed by 500mg per day for three weeks. The clinical outcome was spectacular, with almost complete regression of the ulcer at 7 days.

DISCUSSION

This case demonstrates that donovanosis can occur in metropolitan France.

[Glance at tropical dermatitis]

We report a case of a French soldier, among more than fifteen others, who looked for dermatitis occurred in Central African Republic revealing a lepidopterism. We detail the Anaphae venata etiologic agent, what to do diagnosis and treatment.

[Drug patch tests in the investigation of a fixed drug eruption subsequent to 2 courses of cyclophosphamide in combination with mesna]

BACKGROUND

When fixed drug eruption occurs following use of cyclophosphamide and mesna, it is difficult to establish which drug is responsible. We report a new case of patch tests that resulted in withdrawal of mesna and enabled continued treatment with cyclophophamide.

PATIENTS AND METHODS

A 57-year-old female patient with multiple sclerosis presented increasingly severe cutaneous lesions after successive courses of cyclophosphamide. Twenty-four hours after her latest treatment, she presented at the ER with a worse eruption than those to date and including facial lesions. The clinical diagnosis was a fixed drug eruption, and patch tests for mesna one month later were positive.

CONCLUSION

Fixed drug eruption always occurs after recurrent treatment and the investigation must be precise. Patch tests may be used to determine which drug could be responsible. The most conclusive test comprises withdrawal of the incriminated drug with no further signs of drug eruption on resumption of the other medication.

[Desmoplastic melanoma: a study of 23 cases at 3 centres in the Bouches-du-Rhône region]

BACKGROUND

Desmoplastic melanoma (DM) is a rare form of melanoma, often with atypical and potentially misleading aspects that result in difficult and late diagnosis. Because of the high likelihood of local relapse, practitioners must have a good knowledge of such tumours.

PATIENTS AND METHODS

A retrospective study of the activities of 3 centres in the Bouches-du-Rhône region between 1998 and 2010 enabled us to collate 23 cases of DM and analyse the clinical and histological features of the disease as well as patient survival.

RESULTS

Fifteen of the 23 patients (65.2%) were male with a median age of 64.4 years. Mean Breslow thickness was 7.56 mm. The numbers of AJCC (American Joint Committee for Cancer) stages I, II, III, IV were respectively 4.1, 66.7, 20.8 and 4.1%. Thirteen patients presented relapse, with a mean time to onset of 21 months. The initial relapse involved the skin in 1 case, the lymph nodes in 2 cases, the organs in 5 cases, the organs and subcutaneous region in 1 case, the organs and lymph nodes in 2 cases, and the organs, lymph nodes and skin in 1 case.

DISCUSSION

While DM presents a higher rate of local relapse than classical melanoma, this trend appears to subside in the case of thick DM, in which relapse also involves the lymph nodes and/or organs.

[Epidemiological survey of leprosy conducted in metropolitan France between 2009 and 2010]

BACKGROUND

There is no official leprosy register in France. The last epidemiological survey on leprosy in metropolitan France was done between 1995 and 1998. We performed a new epidemiological study of leprosy in metropolitan France in 2009 and 2010.

PATIENTS AND METHODS

We contacted 85 dermatology and infectious disease units by e-mail or by telephone in order to determine the number of leprosy patients either being followed up or newly diagnosed in 2009 and 2010.

RESULTS

The response rate was 87%. In 2010, 127 patients were being followed up in metropolitan France, mostly at dermatology units (78%). Seventy-five patients were on anti-bacillary treatment and the prevalence was 0.011/10,000. There were 39 new cases diagnosed in 2009 and 2010 (mean 19 cases/year) (low case-detection rate: 0.003 per 10,000 inhabitants). Among the new cases, seven patients (18%) were of French origin, with two from metropolitan France and five from French overseas territories.

DISCUSSION

Our study confirms the persistence of imported leprosy in France and shows no significant decrease in the number of new cases since 1998 (19 vs. 18 new cases/year) or in disease prevalence (0.013 vs. 0.011 per 10,000 inhabitants). This prevalence is very far removed from the one per 10,000 inhabitants proposed by the World Health Organization as the criteria for endemic disease. Most patients in our survey were immigrants (82%). Lepromatous forms (46%) were more frequent than the tuberculoid forms (33%). All patients had either travelled to or lived in areas of high leprosy prevalence, including metropolitan subjects.

CONCLUSION

Leprosy remains present in metropolitan France, and it is still important to continue teaching about it at medical faculties in order to ensure diagnosis of new patients as early as possible.

[Ulceration of the heel in a woman from Djibouti: squamous cell carcinoma with carcinomatous lymphangitis]

The purpose of this report is to describe a case in which a heel ulcer with atypical features, i.e., large size and rapid progression, led to diagnosis of squamous cell carcinoma. Patient management was based on specialist advice obtained by "tele-dermatology" based on pictures and comments transmitted over the Internet. However, due to the risk of spreading and impossibility of providing other medical treatment (radiotherapy-chemotherapy), the lower limb was amputated at the top of the thigh.

Resurgence of bedbugs in southern France: a local problem or the tip of the iceberg?

BACKGROUND

Bedbugs (Cimex lectularius) have been feeding on sleeping human beings since prehistory. In Europe, bed bugs were common and endemic until World War II when improved body and home hygiene, and widespread use of insecticides led to almost complete eradication. Current evidence indicates that bedbugs are making a comeback in Europe, USA, Canada and Australia. In our practice in Southern France, we observed several cases within a period of only 1 year.

OBJECTIVES

Based on this experience, we conducted an epidemiological study to evaluate the status of bedbugs in France.

METHODS

During summer 2009, we mailed a short questionnaire to all hospital professors in the CEDEF (Collège des Enseignants de Dermatologie de France) asking four questions: number of suspected diagnosis of bedbugs in the year 2009, and number of certain positive diagnosis, difficulties in treatment, use of a pest control professional for treatment, and finally personal opinion on actual incidence of bedbugs, compared with past years.

RESULTS

Of the 84 questionnaires sent, there were only 26 responses despite two reminders. The responses were predominantly southern France, probably as a result of intensive immigration and increased travel and trade. Difficulties encountered during diagnosis and treatment are also mentioned. Utilizing the services of entomological experts and pest control professionals is essential.

CONCLUSIONS

  France has the same experience regarding the resurgence of bedbugs as several European countries, USA, Canada and Australia, especially the southern regions. This emerging health problem has to be known by dermatologists. A national programme has been launched in France to assess actual incidence and study C. lectularius- related diseases.

[Febrile algo-eruptive illness in a French foreign legionnaire returning from Djibouti: gonococcal arthritis]

A French foreign legionnaire returning from Djibouti developed feverish polyarthritis with acral purpura. Diagnostic workup demonstrated gonococcemia contracted during unprotected fellatio. Based on this case report, diagnostic and therapeutic management is described.

[Sexual exposure to HIV in the French armed forces between 2005 and 2007]

BACKGROUND

Non-occupational HIV exposure in the French forces has been placed under epidemiological surveillance since 2000. This surveillance programme provides an indirect indicator of risky sexual behaviour among military personnel.

PATIENTS AND METHODS

All cases of non-occupational exposures in French military personnel that meet the notification criteria, wherever they occur, are reported by a military physician, with data being collected from 2005 to 2007.

RESULTS

Between January 2005 and December 2007, 2241 cases of sexual exposure within the French forces were filed. The annual incidence was 214.3 per 100,000 with an average patient age of 26 years. Sexual exposures concerned men in 99.2% of cases and occurred overseas in 92.9% of cases. Partners were sex-workers in 66.7% of cases. Failure to use condoms adequately during sexual intercourse was reported in 15.5% of cases. In cases where condoms were used, exposure to HIV resulted either from condom rupture or slippage. Postexposure HIV prophylaxis was prescribed in 70.5% of cases.

DISCUSSION

The majority of cases of sexual exposure reported in the French armed forces involved high risk of HIV transmission. However, since the beginning of surveillance in 2000, no cases of HIV seroconversion have been reported following postexposure antiretroviral prophylaxis. The non-occupational postexposure prophylaxis strategy is not in question.

[Keloids: pathogenic and therapeutic advances]

Keloids are benign fibroproliferative tumors but often cause serious cosmetic problems. Considered as scars results from abnormal wound healing, keloids appear at preferential sometimes highly unsightly locations (e.g. the ear) and often involve predisposed individuals with genetically pigmented skin. The underlying pathophysiological mechanisms are unclear and no consensus on treatment.

[Teleconsultation in dermatology: lessons from 13 cases]

Modern communications technologies have facilitated access to information and development of databases. Teleconsultation especially over the internet is a promising technique that allows transfer of clinical, laboratory and radiological files to outside specialists. The purpose of this report is to describe the value and limitations of teleconsultation in dermatalogy based on a selection of internet messages sent to the military hospital in Marseille, France by physicians carrying out overseas missions or assigned to remote locations. The quality of the message including proper description of symptoms, thorough history-taking, and definition of attached images as well as the field experience of the specialists receiving the message were determinant factors for the effectiveness of the response. Feedback is also of fundamental importance in improving expertise. The main problem is that conclusive diagnosis is often prevented by inadequacies in the field, i.e., inability to perform confirmation testing, lack of therapeutic capability, and inability to obtain sufficient follow-up information to evaluate the outcome of presumptive treatment. Work is currently underway to standardize messaging techniques based on pre-establish decision-tree algorithms.

[Tubercular fibrosing conjunctivitis associated with facial cutaneous tuberculosis]

BACKGROUND

Tuberculous conjunctivitis has been described only rarely during the course of lupus vulgaris. We report a case of hemifacial cutaneous tuberculosis, diagnosed as atypical lupus vulgaris, associated with homolateral fibrosing tuberculous conjunctivitis.

PATIENTS AND METHODS

An 83-year-old woman presented inflammatory conjunctivitis without bullous involvement in the left eye leading to corneal neovascularisation, symblepharons and ptosis. Erythematous and atrophic papules were seen on the left side of the face. Biopsy of the skin and conjunctiva revealed a tuberculoid granulomatous infiltrate. Bacterial culture and PCR were both positive for Mycobacterium tuberculosis.

DISCUSSION

This case illustrates the need to consider tuberculosis when faced with an atypical facial eruption and ocular involvement.

[Hemiparesia with cutaneous and mucosal ulcerations in a black-skinned man]

The purpose of this report is to describe the case of a 46-year-old Comorian man in whom presentation with right hemiparesia with buccal and genital ulcerations lead to diagnosis of Behçet's disease. The most remarkable aspect of this case is the patient's ethnic group since Behçet's disease is less frequent in Africans than Caucasians. The most likely explanation for this difference is the absence of genetic susceptibility linked to HLAB51 that is rare in Africans. However lack of awareness of Behçet's disease and changes in environmental triggers in Africa cannot be ruled out.

[Foot health in the tropics]

The foot is particularly exposed to injury and infection in the tropical areas. This article provides a review of the main diseases affecting the foot in the tropics including leprosy, ainhum, ulceration due to Mycobacterium ulcerans, mycetoma, chromomycosis, Kaposi's sarcoma, elephantiasis, podoconiasis, dracunculosis, tungiasis, syphilis and endemic treponematosis, larva migrans, scytalidiosis, and envenomation. Prevention is essential.

[Complications of cosmetic skin bleaching in Africa]

Use of cosmetic products to bleach or lighten the skin is common among dark-skinned women in some sub-Saharan African countries. Long-term use of some pharmacologic compounds (e.g. hydroquinone, glucocorticoids and mercury) can cause adverse effects including dermatologic disorders such as dyschromia, exogenous ochronosis, acne and hypertrichosis, prominent striae, tinea corporis, pyoderma, erysipelas, scabies, and contact dermatitis and systemic complications such as hypertension, hypercorticism or surrenal deficiency, and mercurial nephropathy.

[Update on Kaposi's sarcoma]

Kaposi's sarcoma (KS) is a mesenchymal tumor involving blood and lymphatic vessels and induced by viral growth factors (HHV8-IL6). This article reviews the epidemiology, pathogenesis, clinical spectrum (classic KS, iatrogenic immunosuppressive KS, endemic African KS, and AIDS-KS), histological features, staging criteria and treatment of KS. Unlike industrialized countries that have benefited from widespread use of highly active antiretroviral therapy (HAART), developing countries continue to have a high incidence of AIDS-KS. Future therapeutic targets for KS are enhancement of immune function and treatment with angiogenesis inhibitors

[Thoracic aortic dissection revealed by systemic cholesterol embolism]

Systemic cholesterol embolism is a rare complication of atherosclerosis, and has various presentations. Arterial catheterisms are a common cause. However, the association with an aortic dissection has been exceptionally reported. We report the observation of a 70 year-old man, with coronary artery disease, hypertension, diabetes and dyslipidemia. Six months before hospitalization, a coronary angioplasty was performed due to recurrent angina. The association of purpuric lesions on the feet, with acute renal failure confirmed cholesterol embolism syndrome. Transoesophageal echocardiography showed a dissection of the descending thoracic aorta associated with complex atheroma. The evolution was marked by the pulpar necrosis of a toe and by a worsening of the renal failure, requiring definitive hemodialysis. Further echographic control highlighted the rupture of the intimal veil of the dissection. Cholesterol embolism syndrome may reveal an aortic dissection in patients without thoracic symptoms. In such cases, transoesophageal echocardiography is a useful and non-invasive examination.

Chikungunya : un syndrome algo-éruptif fébrile au retour de l’Océan Indien

A 40-year-old woman presented with invalidating polyarthritis associated with high fever and diffuse macular exanthema after returning from a two-week visit to Reunion Island. In this paper, we discuss the different diagnoses to be considered in a case of fever with pain and rash and we examine the epidemiology, clinical features, diagnostic methods and management of Chikungunya virus.

[Cutaneous tuberculosis overview]

Cutaneous tuberculosis is now uncommon in industrial countries despite the rising incidence of extrapulmonary tuberculosis in areas with high prevalence of HIV infection. Nevertheless it is still important to know the multiple clinical manifestations of cutaneous tuberculosis and to be aware of new laboratory diagnostic methods such as polymerization chain reaction gene amplification.

[Overview of endemic treponematoses]

Endemic treponematoses including yaws, bejel, pinta are distinguished from venereal syphilis on the basis of epidemiological characteristics and clinical manifestations. They cannot be differentiated by morphological and serological methods. A few minor genetic differences have been identified among the subspecies (Treponema pallidum sp. pallidum, pertenue, endemicum, carateum). Although penicillin therapy is effective, these infectious diseases have yet to be eliminated.

[Experience of a dermatologist on an overseas military mission: Operation Licorne in Cote d'Ivoire]

The authors report their experience as tropical physicians and as dermatologists within the Medico-surgical group during Operation Licorne an overseas mission with the French Army near Yamussoukro in Côte d'Ivoire. Most of the major endemic diseases were encountered. Only acute infections were treated. The Buruli ulcer epidemic due to Mycobacterioum ulcerans ulcer epidemic is a scourge that mainly affects children with a high incidence of osteitis.

[Review: update on erythema nodosum leprosum]

Erythema nodosum leprosum (ENL) is an immunological reaction corresponding to vascularitis due to circulating immune complexes usually occurring during treatment of lepromatous leprosy. The precise mechanism underlying ENL are unclear but involvement of tumor necrosis factor alpha (TNFalpha) is suspected. Based on this suspicion pentoxifylline has been used instead of conventional treatments such as corticosteroids and thalidomide.

[Clinical overview of New World tegumentary leishmaniasis]

This richly illustrated article (80 color photographs) based on the authors' experience in French Guyana documents the clinical diversity of American tegumentary leishmaniasis. Main highlights include the often outstanding aspect of lesions, the high frequency of forms not associated with ulceration or scab formation that must be recognized to achieve diagnosis in travellers returning from endemic zones, and the special prognosis of clinical forms associated with intradermic, lymphatic or hematogenous spread. The article also reviews an original diagnostic method based on culture of cutaneous biopsy specimens on specific nutrient mediums that provides isolates in a high percentage of cases (80%) and thus allows identification of offending parasite.