[Extensive bone marrow necrosis as presenting manifestation of sickle cell disease in Africa]

Extensive bone marrow necrosis is a rare but severe complication of sickle cell disease. A formerly healthy man was admitted for bone pain, fever, and jaundice with severe aregenerative anemia. Bone marrow aspiration and biopsy showed extensive bone marrow necrosis while hemoglobin electrophoresis demonstrated homozygotic sickle cell disease. Despite early onset of septic arthritis of the right shoulder, outcome after blood transfusion and nonspecific treatment was favorable. Six months later, hemoglobin level remained stable up to 97 g/L. This first African case report illustrates typical features and good prognosis of extensive bone marrow necrosis in sickle cell disease. Extensive bone marrow necrosis is a highly unusual presenting manifestation of sickle cell in an adult.

[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.

[Management of American cutaneous leishmaniasis. Outcome apropos of 326 cases treated with high-dose pentamidine isethionate]

The purpose of this retrospective analysis was to evaluate the outcome of pentamidine isethionate treatment (4 mg/kg of Pentamidine by the intramuscular route on Days 1 and 3) of cutaneous leishmaniasis in 326 cases that occurred during an outbreak among French military personnel in French Guyana from 1998 to 1999. A great difference was found between the 205 patients treated in French Guyana (series G) and 32 patients treated at the Laveran Military Hospital in Marseille, France (series L). Failure rate, i.e. 25% in series L versus 5% in series G, was significantly correlated with the delay to treatment which was much longer in series L. Extensive rhabdomyolysis was observed in all cases tested: this side-effect has not been reported. Based on these findings and a review of the literature on pentamidine isethionate, the authors recommend prompt treatment using lower doses. Other treatment alternatives for American cutaneous leishmaniasis are also presented including two of the latest developments in the field, i.e., oral treatment using miltefosine and topical treatment using agents such as paromomycine.

[Concurrent mycetoma and chromomycosis: case report from Senegal]

A 68-year-old cattle farmer from northern Senegal sought medical attention for tumefaction that had been progressing on the right foot and leg for 20 years. Physical examination of the right extremity revealed very firm tumefaction involving the foot and whole leg associated with numerous nodules. Bone radiographs and CT-scan of the foot and leg disclosed extensive osteolytic involvement. A specimen of squamous tissue from the top of nodules showed the presence of fumagoid cells characteristic of chromomycosis. Histologic examination after skin biopsy demonstrated fungal myocetoma. Due to the extent of involvement surgical and antifungal treatment was proposed but the patient refused to undergo surgery. Only one previous case of concurrent chromomycosis and mycetoma has been described. However the previous case involved actinomycetoma. The rarity of this combination of diseases despite their common contamination mode is due to different geographical distribution with mycetoma being found in the Sahelian region and chromomycosis in the humid equatorial region.

[Malaria in military personnel: the case of the Ivory Coast in 2002-2003]

French troops were sent to the Ivory Coast on September 22, 2002 within the framework of Operation Unicorn in response to the political unrest. From September 22 to October 20, a total of 37 cases of malaria were reported, i.e., 35.7 cases per 1000 man-months. As of October 11, the central headquarters of the Armed Services Health Corps decided to use doxycycline as the exclusive agent for drug prophylaxis in military personnel on duty in the Ivory Coast and to enhance vector control measures. The incidence of malaria decreased to 2 cases per 1000 man-months at the sixth month. A recrudescence of malaria to 15 cases per 1000 man-months was observed with the rainy season in April. During this period one person presenting severe malaria with coma required emergency evacuation to France. In May 2003, several studies were undertaken to determine the factors that caused this recrudescence. These studies included surveys to evaluate awareness concerning malaria and monitor compliance with drug prophylaxis and tolerance of doxycycline, a case-control study to identify factors related to malarious episodes and an entomological study. Awareness of malaria was high with 75% of the 477 respondents stating that malaria could be transmitted by single mosquito bite. The case-control study showed a correlation between occurrence of malarious bouts and non-compliance with drug prophylaxis (p < 10(-5)). The odds-ratio was 3.05 (95% confidence interval, 1.52-6.14) for subjects claiming zero to one incident of non-compliance per week and 7.51 (IC95%, 3.24-17.40) for those claiming more than one incident of non-compliance per week. Tolerance of doxycyline was good since 72% of respondents reported no adverse effects. The main vector was Anopheles gambiae. The number of bites per man per night ranged from 25 to 2 and the number of infected bites ranged from 2 to 3 per week. Treatment was initiated promptly using quinine at a total dose of 25 mg/kg in 3 daily doses for 7 days by the intravenous then oral route. This experience shows that malaria remains a major concern for military forces, that standardization of preventive measures in emergency situations is needed, and that enhanced vector control, verification of compliance with drug prophylaxis and prompt treatment based on the presence of a physician in each emergency outpost is crucial. These recommendation must be applied to all French military personnel in the Ivory Coast.

[Listeria disease. The first 2 cases reported at the Principal Hospital of Dakar]

Infection disease due to Listeria monocytogenes, which is a ubiquitous positive Gram bacillus to the essentially alimentary transmission, listeriosis happens on patients presenting an immunodeficiency. The authors report the two first cases of listeriosis diagnosed at Hopital Principal de Dakar. The first case was observed on a 73 years old man, hospitalised for a feverish coma scored at 9 using Glasgow scale, with neither meningitis syndrome, nor sign of neurological localisation. The analysis of the RLC reveals a hypercytosis at 126 GB/mm3, with prevailing neutrophile polynuclears, a hyperproteinorachia at 3.2 g/l. The culture of the RLC was sterile but the blood culture showed the presence of L. monocytogenes. The other paraclinical tests has revealed a glycaemia at 2.45 g/l, an imporant hepatic cytolisis with ASAT at 13 N and ALAT at 20 N. The patient was also presenting a cerebromeningitis and hepatic listeriosis on a diabetic field. The second case was observed on a 58 years old patient admitted for headaches, fever and an important degradation of the general state with an emaciation of 17 kg in 5 months. The physical screening revealed a bad general state, a fever at 38 degrees 2 and was without other particularity. The analysis of the RLC showed a hyperproteinorachia at 1.35 g/l with neither hypercytosis nor germ at the culture. Haemoculture isolated Listeria monocytogenes. HIV serology was positive. CD4 were counted to 61/mm3. and the viral charge was at 110.000 copies / mm3. The patient was presenting a Listeria monocytogenes at meningo-encephalitis on HIV-1 field. stade B of the CDC classification. This ubiquitous anthropozoonosis should be searched through early haemocultures before antibiotherapy. in case of long lasting fever, endocarditis, meningo-encephalitis, localised infections on children. pregnant women, diabetic persons, and people infected with HIV and some others presenting immunity troubles.

[Pulmonary strongyloidiasis complicated by E. coli meningitis in a HIV-1 and HTLV-1 positive patient]

INTRODUCTION

Disseminated strongyloidiasis occurs in immunodepressed patients, notably those infected by retroviruses.

OBSERVATION

A pulmonary strongyloidiasis, complicated by an Escherichia coli meningitis, occurred in a patient exhibiting seropositivity HIV1 for the past year. The status of cell immunity, with 354 lymphocytes T CD4+/mm3, could not explain this severe complication. This led to the diagnosis of an HTLV1 infection. The strongyloidiasis was treated with two cycles of ivermectine, which cured the patient.

COMMENTS

In HIV-infected patients exhibiting severe strongyloidiasis, research for an HTLV co-infection is recommended.

[Salmonella enteritidis splenic abscess complicating a Plasmodium falciparum malaria attack]

INTRODUCTION

Salmonella splenic abscesses are rare and usually occur on pre-existing lesions.

OBSERVATION

A Moorish 16 year-old woman from Senegal presented with a S. enteritidis abscess without any factor other than an attack of P. falciparum malaria. Treatment associated quinine salts, antibiotherapy and splenectomy.

COMMENTS

P. falciparum malaria attacks not only induce humoral and then cellular immunodepression but are also at the origin of infarction or splenic hematoma that may enhance bacterial infection and the development of abscesses. Splenectomy or percutaneous drainage associated with antibiotherapy is the usual treatment for splenic abscesses. Prognosis remains severe (13 to 16% mortality).

[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.

[Mechanism of action of antimalarials. Value of combined atovaquone/proguanil]

Determining the mode of action of different antimalarial drugs at the cellular level is essential to optimizing their use and to understanding the mechanisms underlying plasmodial resistance. The main targets for antimalarial drugs in Plasmodium falciparum have been the food vacuole and mitochondrial system. A new target is recently discovered organelle named the apicoplast. The apicoplast is the site of a number of metabolic pathways crucial to the survival of the parasite. It may also be involved in DNA replication and transcription. Antimalarial drugs are classified into three groups according to site of action, i.e., drugs that act on the food vacuole, drugs that block metabolic synthesis and oxidative processes, and drugs that interfere with membrane processes. Knowledge of these sites of action has enabled identification of new drugs with the most promising potential for development. Current antimalarial strategies prioritize combination therapies such as atovaquone/proguanil or artemether/lumefantrine and prolonged treatments to limit the risk of inducing drug resistant Plasmodium.

[Does emergency tropical medicine exist? The physician's point of view]

The existence of tropical medical emergencies is a recurrent issue that joins the debate over the definition of tropical medicine. Is it medicine practiced in warmer climates, medicine practiced with poor diagnostic and therapeutic facilities or medicine involving only tropical diseases? Presentation of a few case reports provides a better response to this question than a long speech. The first case involves a 57-year-old man presenting a complicated attack of Plasmodium falciparum malaria and severe respiratory distress. The second case involves a pregnant AIDS patient presenting multifocal miliary tuberculosis associated with renal abscess and bacteremia. The third case involves a 34-year-old soldier hospitalized for right hilar pneumonia in whom work-up demonstrated co-infection by HIV 1 and 2, thick drop tests revealed uncomplicated Plasmodium falciparum malaria, and cytobacterial examination of sputum samples identified Salmonella enteritidis and acid-alcohol resistant germs. The fourth case involves a 60-year man hospitalized for febrile collapse in whom work-up revealed amebic pericarditis. These four case reports illustrate the main features of tropical medical emergencies: adult patients (frequently young), associated deficiencies or immunocompromise (HIV infection/AIDS), severe or complicated tropical disease, severe advanced stage disease because of inability to pay for care, multiple pathology, poor diagnostic/therapeutic facilities, and high mortality.

[Cerebromeningeal listeriosis associated with a cytolytic hepatitis. First case report in Senegal]

Hepatitis due to Listeria monocytogenes is uncommon in adults. This report describes the first case observed in Senegal. The patient was a 73-year old man presenting listeria-related hepatitis presumably secondary to low-grade meningeal encephalitis. Treatment using ampicillin was unsuccessful and the patient died four days after hospitalization. The authors note that the incidence of adult listeriosis has risen constantly for the past twenty years in relation with alcohol abuse, cirrhosis, diabetes, kidney insufficiency, cancer, AIDS, and organ transplantation. However no predisposing factors were observed in the present case.

[Infective etiology of diarrhea in adults with HIV infection in Dakar: a case-control study on 594 patients]

A survey was conducted in Dakar, Senegal from May 1997 to May 1999, to identify major types and prevalences of bacteria, parasites, fungi and Rotaviruses associated with diarrhea in relation to human immunodeficiency virus serostatus with the aim to provide guidance to physicians for case management. Etiologic agents were identified in a case-control study: cases were HIV-infected patients with diarrhea (HIV+ D+) and HIV seronegative patients with diarrhea (HIV- D+); controls were HIV-infected patients without diarrhea (HIV+ D-) and seronegative controls without diarrhea (HIV- D-). Strict enteric pathogens were identified by conventional methods. Different E. coli pathotypes were characterized by PCR. Opportunistic parasites such as Cryptosporidium and Microsporidium were identified by the Kinyoun method and trichromic stain of Weber respectively. Rotaviruses were identified with a commercial latex agglutination kit. Antimicrobial susceptibility testing was carried out by the disk diffusion method. A total of 594 patients were examined (158 HIV+D+, 121 HIV- D+, 160 HIV+ D- and 155 HIV- D-). In immunocompetent adults the main causes of diarrhea were: Shigella sp. (12.4%), Entamoeba histolytica (10.7%), Salmonella enterica (6,6%) and Giardia lamblia (4.9%). In the immunocompromised host the more frequent pathogens were: enteroaggregative E.coli (19,6%), Microsporidium(9.4%), Cryptosporidium sp.(8.2%), Rotavirus (8.2%), Shigella sp. (7.6%), Candida albicans (7.6%), Entamoeba histolytica (5,1%), Salmonella enterica (4.4%), Isospora belli (4.4%) and Blastocystis hominis (2,5%). Isolated enteropathogenic strains displayed high resistance to most antibiotics used in Senegal for treating diarrhea (tetracycline, cotrimoxazole); they were susceptible to quinolons and cephalosporins III .

[Pleuropulmonary manifestations of salmonellosis]

Salmonella infections are widespread particularly in tropical zones. Each year, 12.5 million cases of typhoid fever are reported with an incidence of 540 cases for every 100,000 inhabitants in developing countries versus 0.2 cases in industrialized countries. Pleuropulmonary manifestations constitute the most common extra-intestinal manifestation of salmonella infection. Counts are usually carried out in the digestive tract. Respiratory tract manifestations result from blood-borne diffusion from mesenteric lymph nodes, but gastroenteritis goes unnoticed in 2 of 3 cases. Predisposing factors are frequent including cancer, previous graft placement and immunosuppressant therapy, sickle cell disease, alcohol abuse, and pre-existing pulmonary disease. Clinical manifestations are usually acute but subacute forms cannot be ruled out. Cough is a common symptom observed in 25% of patients with typhoid fever. Pneumonia is uncommon overall (1%) but occurs in 50% of patients with pleural effusion, empyema, lung abscess, or bronchopleural fistula. A few cases of adult respiratory distress syndrome have been described in the literature. Recognition is important since these manifestations may signal previously unsuspected underlying pulmonary disease. Treatment requires appropriate antimicrobial therapy and close surveillance to prevent recurrence or complications.

[Intracranial subdural hematoma during spinal anesthesia]

Spinal anesthesia (SA) is frequently used in tropical zones. Intracranial subdural hematoma is an uncommon complication of SA. The purpose of this report was to describe a case of intracranial subdural hematoma observed during SA performed for cesarean section in a 22-year-old women in Senegal. After one month of persistent intense headache, diagnosis was confirmed by computerized tomography. The hematoma was successfully treated by drainage under general anesthesia. Intracranial subdural hematoma has been attributed to cerebrospinal fluid hypotension due to leakage through the dural puncture site. Diagnosis, which may be difficult in Africa, should be suspected in patients with persistent headaches after SA. Confirmation requires computerized tomography of the brain. Prevention of this complication depends on the use of fine beveled-tipped puncture needle which are rarely available in the African setting.

[Pulmonary manifestations associated with malaria]

Pulmonary manifestations are frequently observed in children, pregnant women and travellers with malaria. The pathophysiology of these pulmonary manifestations is poorly understood but would appear to be secondary to an interaction between the parasitized red cells and the pulmonary capillary endothelium. Bronchitis and pneumonia do not directly compromise outcome but, left unrecognized, the delay in diagnosis and treatment may be fatal. Acute respiratory distress in children is the first cause of overmortality, coming before neurological involvement. The acute respiratory distress caused by severe malaria has no specific characteristics. Iatrogenic complications and pulmonary superinfections must be differentiated. The prevention of pulmonary manifestations associated with malaria can easily be accomplished by limiting water intake and carefully monitoring urinary output and weight. Treatment is the same as for acute flare-ups in combination with symptomatic respiratory treatment when required.

[Pulmonary parasitoses. General aspects]

Parasite diseases of the lung comprise a wide group of nosological entities. The main parasite diseases of the lung (malaria, ambiasis, bilharziosis, distomatosis, hydatidiasis) as well as the eosinophilic lung will be discussed in specific articles in the journal. Other parasite diseases of the lung are discussed here after studying the general aspects of pulmonary parasite diseases.

[Pleuropulmonary manifestations of amebiasis]

Amibiasis is the third leading cause of death due to parasitic infections in the world. Amibiasis is endemic in the warm regions of the world with deficient hygiene and socio-economic situations. Entamoeba histolytica is the causal agent of invasive amibiasis, unlike Entamoeba dispar which is not a pathogen for humans. Amibian colitis and amibian abscess of the liver are the most frequent intestinal and extra-intestinal manifestations. Pleuropulmonary complications almost always occur in patients with a liver abscess, the intrathoracic contamination via transphrenic dissemination predominating. Respiratory signs are inaugural in 80% of the cases. Pleuropulmonary ambiasis designates the localization of the amibian infestation, but the clinical expression may vary: pneumonia, lung abscess, pleurisy, hepatobronchial fistulization and more infrequently pulmonary embolism. The preferential localization is the right hemithorax related to abscess in the right lobe of the liver. Left lobe abscesses lead to left-sided pleuropulmonary complications with the risk of rupture into the pericardium. Chocolate-colored pus from a pleural or abscess puncture or vomitus strongly suggests the diagnosis, which is confirmed by highly-positive serology. Metronidazole is the treatment of choice, providing cure without sequellae. In Africa, mortality and morbidity due to ambiasis are high. In Abidjan, 92% of cured patients have sequella, and mortality reaches 15%, the consequence of late diagnosis.

[Pulmonary manifestations of schistosomiasis]

Bilharziosis or schistosomiasis is the third leading endemic parasitic disease in the world, following malaria and ambiasis. More than 300 million individuals are infested. Schistomosomes are blood flukes which live in the perivisceral veins. Clinical signs result from ova migrations. Transmitted by urine and feces, the parasite cycle requires intermediary host, usually fresh water snails. Bilharsiosis is endemic in tropical zones where it is a major public health problem closely correlated with the socio-economic conditions. Liver, intestinal or urinary complications, depending on the species, lead to underestimated morbidity and mortality. Pulmonary lesions are attributed to 3 species: S. haematobium, S. mansoni and S. japonicum. Although the lung is mandatory step in the parasite cycle, pulmonary manifestations are limited. They can be acute or chronic depending on the phase of the cycle, but are the most frequent extradigestive localization for S. mansoni. Morbidity due to chronic manifestations is particularly severe and should be prevented whenever possible.

[Pulmonic plague]

One hundred years after Yersin discovered Yersinia pestis during the plague epidemic in Hong Kong in 1894, human plague still has not been eliminated. The epidemic in 1994 in India, a country where no cases had been observed since 1996, raised great concern. Plague is an epizootic bacterial infection caused by a Gram negative coccobacillus, Y. pestis, transmitted by the bite of infected fleas. Bubonic plague is the most common form. Other clinical presentations include asymptomatic plague, abortive plague, pharyngeal plague, septicemic plague, meningeal plague, and primary or secondary pneumonic plague which is observed in 5 to 20% of cases. Plague is a highly communicable disease between humans despite antibiotic therapy which has reduced mortality by 80%. The prognosis depends on early diagnosis. Streptomycin and cyclines are the gold standard treatment.