[Preparedness for influenza A/H5N1 pandemic in Niger: a study on health care workers' knowledge and global organization of health activities]. / Pandémie grippale A/H5N1 et niveau de préparation du Niger: une étude sur les connaissances des soignants et l'organisation générale des soins.

In industrialized countries, the emergence of potentially pandemic influenza virus has invited reactions consistent with the potential threat represented by these infectious agents. However, with globalization, controlling epidemics depends as much on an effective global coordination of control methods as on preparedness of northern and southern national health care systems, at the core of which are health care workers. Our study was conducted in the National Hospital of Niamey, the main Nigerian hospital. Its objective was to evaluate the knowledge of health care professionals regarding flu pandemic and control of infection. We interviewed 178 nursing staff, doctors and paramedics on the basis of a survey. This study - the first to our knowledge to explore these issues in the African context-revealed that caregivers have a rather good mastery of theoretical knowledge. Nevertheless, beyond theoretical knowledge, miscellaneous factors compromise the effectiveness of the health care structure. Some of them seem to occupy a critical position, particularly the absence of shared references among sanitary authorities and health care professionals, and the weaknesses of global coordination of preventive activities and case management.

[Hyperreactive malarial splenomegaly: three clinical cases and literature review]. / Splénomégalie palustre hyperimmune : à propos de trois cas cliniques et revue de la littérature.

Hyperreactive malarial splenomegaly (HMS) is the chronic stage of a long-term stimulation of the immune system secondary to plasmodial infections, more frequently in genetically predisposed patients. HMS is a leading cause of large tropical splenomegaly in endemic zones but has been described in immigrants from Africa and in some European expatriates living in endemic countries. Diagnostic criteria include: long-term stay in a endemic zone, often large splenomegaly, high IgM titer, high antiplasmodial antibody titer, regression by at least 40% of splenomegaly six months after curative antimalarial treatment. In tropical settings, B-cell lymphoma and splenic lymphoma are the main differential diagnoses, which may be identified by a clonality analysis. Recent studies suggest that HMS can be treated by a short-term antimalarial therapy as long as the patient resides out of a malarial endemic country.

Nutritional approach to management of Buruli ulcer in Côte d'Ivoire.

Children in developing tropical countries are frequently undernourished. In rural areas, they are also often affected by Buruli ulcers. The treatment of this mutilating disease is sometime long and difficult for malnourished patients. Moreover, the eating behavior of patients with Buruli ulcers does not promote its quick healing, with numerous foods prohibited. They eat fewer fruits and legumes, which are rich in vitamins and minerals. Our survey in two health centers showed that only 8% ate fruits and legumes, and 29% leafy greens. This food deprivation increases their nutritional deficiencies. We conducted a nutritional intervention among Buruli ulcer patients (30 patients) in one center, and compared their healing with that of Buruli patients without nutritional care (n = 21). Those patients who received the intervention spent less time at the hospital (less than six months). Our study shows the association between the healing of Buruli ulcers in Côte d'Ivoire and good nutritional status: those with the intervention healed faster and presented fewer disabilities than the control patients.

[Quinquina and man]. / Du quinquina et des hommes.

Many great discoveries have been made by chance but some have been the result of human perseverance and ingenuity. A sterling example of the second case is quinquina that was discovered in Peru and is now produced in Java. Quinquina has gone through centuries without losing its medical efficacy that efficacy allowed the exploration and colonization of Africa and played a key role in the ability to conduct overseas military campaigns. Because of its strategic importance, it was a coveted resource. It led to the discovery of homeopathy and dyes, allowed the development of organic chemistry, and has been used to make alcoholic bitters and soft drinks.

[Popular nosology of infantile diseases in West Côte-d'Ivoire and consequences for malaria care management]. / Nosologie populaire des maladies infantiles dans l'Ouest de la Côte-d'Ivoire. Implications pour le paludisme.

In a rural area of intense and permanent malaria transmission in Southwest Côte-d'lvoire, traditional midwifes of the Yacouba ethnic group, with also an important function for the children health and care, were interviewed in 2002 about their knowledge of the infantile pathologies. Their nosology is greatly based on symptoms and etiologic explanations of the disorder of secretions. The accumulation of a viscous liquid in different parts of the body, especially in the chest, the throat or the head, explains numerous febrile or afebrile diseases, including malnutrition. Some pathologies, particularly convulsions, are described by analogy with animals behaviour Relations between these entities and the biomedical ones are difficult to establish. The traditional care and treatments result from these concepts. A vomiting child or a child suffering from diarrhoea is subject to devices to evacuate his excess of liquid. Yellow brews are used against jaundice. Furthermore, an important mistrust remains towards medical treatments particularly for all parenteral therapies. Health facilities are only used as a the last resort. Their bad reputation is confirmed by the high rate of mortality of patients coming often too late. To improve malaria care management, health-care workers have to take into consideration these concepts and also prove their abilities to ensure good medical practices.

Treatment of imported malaria in adults: a multicentre study in France.

BACKGROUND: Data about anti-malarial drugs prescription practices in Europe and the safety of imported malaria treatments are scanty. In 1999, a French consensus development conference published guidelines for the prevention and treatment of imported P. falciparum malaria. The impact of these guidelines has not been evaluated. AIM: To investigate the impact of these guidelines on the prescription of anti-malarials, and to evaluate the incidence of acute drug events (ADEs) leading to discontinuation of treatment. DESIGN: Cross-sectional survey. METHODS: Members of the medical staff in 14 French infectious and tropical disease wards completed a standardized form for each patient treated for imported malaria in 2001. A propensity score matching technique was used to estimate the risk of ADEs leading to discontinuation of the regimen. RESULTS: In the 474 patients studied, quinine was the first-line anti-malarial most often prescribed. Only 3% of patients received halofantrine. Mefloquine was associated with a RR of 4.9 (95%CI 3.2-7.4, p < 0.00001) risk of discontinuation of treatment due to ADEs. DISCUSSION: The very limited use of halofantrine indicates that the main practice recommendations of the guidelines have been taken into account. Mefloquine was associated with a substantial risk of discontinuing the treatment because of ADEs. This is a serious limitation for the use of mefloquine in the treatment of out-patients with imported malaria.

African tick-bite fever. An imported spotless rickettsiosis.

OBJECTIVES: To characterize the clinical presentation and course of African tick-bite fever, a recently rediscovered rickettsiosis caused by Rickettsia africae (a new species within the spotted fever group of rickettsiae), to establish its relationship with Amblyomma tick species, and to discuss its role in the etiology of fever in patients who are returning from the tropics. PATIENTS: Seven patients who returned from Zimbabwe of the Republic of South Africa and presented with fever. METHODS: Cases were recognized clinically by the presence of multiple taches noire and were diagnosed as having a rickettsial infection by identification of the organisms in circulating endothelial cells. The causative role of R africae was further demonstrated using cross-absorption and immunoblotting of patients' serum samples and isolation of the agent from blood and skin biopsy specimens. Isolates were characterized using the restriction fragment length polymorphism-polymerase chain reaction and sequence analysis of the gene that encodes for the 190-kd Rickettsia-specific antigen. RESULTS: All 7 patients presented with fever and multiple taches noire. Further physical examination of patients revealed lymphadenopathy, lymphangitis, and edema, but there were virtually no signs of a rash. These findings are characteristic of R africae-infected patients and are distinct from those observed in patients with Rickettsia conorii-induced Mediterranean spotted fever. All 7 patients were infected with R africae as demonstrated by immunoblotting or isolation of the agent, and all were cured. CONCLUSIONS: With increasing international travel, a need for the recognition of rickettsial diseases by physicians is becoming more important. Tick-bite fever, a disease caused by R africae and transmitted by Amblyomma ticks, is characterized by multiple taches noire, lymphadenopathy, lymphangitis, and edema, but no rash or a discrete rash. It is a frequent but benign disease that physicians should consider when presented with febrile patients returning from southern Africa.

Pseudo-tumor of the lung, a rare clinical presentation of dirofilariasis.

INTRODUCTION: Pulmonary dirofilariasis is an uncommon entity. Known as a zoonotic disease it can affect humans as a secondary host. A pseudo-tumor of the lung called "coin" lesion is usually detected while performing a chest X-ray for another reason. OBSERVATION: We present a case of pulmonary dirofilariasis due to Dirofilaria sp. in a 72 year old immunocompetent patient who underwent surgery for suspicion of a neoplasm. DISCUSSION: Human pulmonary dirofilariasis should be evoked in asymptomatic patient from endemic area of canine dirofilariasis presenting with a pseudo tumor of the lung.

[Imported malaria at the Marseilles Hôpital-Nord, France: a prospective study on 352 cases between 2001 and 2003]. / Le paludisme d'importation à l'Hôpital-Nord de Marseille en 2001-2003: étude prospective de 352 cas.

OBJECTIVE: The authors had for aim to study epidemiological, clinical, and parasitological characteristics, as well as regimen received, of imported malaria cases hospitalised at the North University Hospital, in Marseilles, France. DESIGN: The patients presenting with imported malaria included in this study were hospitalised in the infectious and tropical diseases unit and in the pediatrics unit at the North University Hospital, from January 1, 2001 to December 31, 2003. Variables were prospectively collected and recorded. RESULTS: 352 patients including 240 adults and 112 children were included. Most of them (67% of the adults and 92% of the children) were contaminated during a trip to the Comoros Islands. Plasmodium falciparum was the most common species identified. 97.5% of adult and 98% of child patients back from Comoros did not take any chemoprophylaxis against malaria or took inadequate regimens. Halofantrin was the most commonly used drug for children to treat uncomplicated P. falciparum malaria. In adults, atovaquone-proguanil was used as a first line drug in the absence of vomiting, and a 3-day intravenous regimen of quinine-clindamycin in case of vomiting. CONCLUSION: The specificity of imported malaria in Marseilles is the high proportion of Comorian patients who go back home periodically to visit friends and relatives. A better education of the Comorian population in Marseilles, regarding malaria risks and prophylaxis, needs to be implemented.

Imported Falciparum malaria in Europe: sentinel surveillance data from the European network on surveillance of imported infectious diseases.

Malaria continues to have a high morbidity rate associated among European travelers. Thorough recording of epidemiological and clinical aspects of imported malaria has been helpful in the detection of new outbreaks and areas of developing drug resistance. Sentinel surveillance of data collected prospectively since 1999 has begun within TropNetEurop, a European network focusing on imported infectious diseases. TropNetEurop appears to cover approximately 10% of all patients with malaria seen in Europe. Reports of 1659 immigrants and European patients with Plasmodium falciparum malaria were analyzed for epidemiological information and data on clinical features. Regional data were quite diverse, reflecting local patterns of immigration and international travel. By far, the most infections were imported from West Africa. Europeans had more clinical complications; consequently, all deaths occurred in this group. Compared with European standards, the mortality rate was low (0.6% in Europeans). Data from TropNetEurop member sites can contribute to our understanding of the epidemiological and clinical findings regarding imported falciparum malaria.

Schistosomiasis as an unusual cause of appendicitis.

Millions of people originating from tropical areas now live outside the country of their birth. As a consequence, the number of cases of diseases imported from the tropics and being seen by European physicians in immigrants is growing. As an example of such diseases, schistosomal appendicitis is a specific trait of infection with Schistosoma haematobium and is an uncommon cause of appendicitis in non-endemic areas. Treatment requires anti-schistomal medication in addition to surgery. Physicians, including surgeons, need to be aware of the possibility of seeing atypical presentations of parasitic diseases in immigrant patients.

Eosinophilic pancreatitis mimicking pancreatic neoplasia: EUS and ERCP findings--is nonsurgical diagnosis possible?

Eosinophilic pancreatitis is a rare disease with, to date, only 10 reported cases. We report two patients whose presentation was suggestive of a pancreatic tumor. An 18-year-old man presented with a short history of obstructive jaundice, epigastric pain, and weight loss. Endoscopic ultrasonography revealed a 12-mm round, hypoechoic lesion in the head of the pancreas, suggestive of a pancreatic endocrine tumor. A duo-denopancreatectomy was performed, and the patient made an uneventful recovery. A 64-year-old man was referred with weight loss and obstructive jaundice due to a stricture of the common bile duct. Retrograde pancreatography demonstrated a very narrow, regular main pancreatic duct and early parenchymography. Endoscopic retrograde cholangiopancreatography revealed a tight, regular stenosis of the intrahepatic portion of the common bile duct. A gastrojejunal anastomosis and biliary-digestive bypass were performed without postoperative complications. In both cases, the diagnosis of eosinophilic pancreatitis was revealed after surgical resection. The features of eosinophilic pancreatitis, including eosinophilic infiltration of the digestive wall, a history of atopy, and the radiological characteristics are described. If these are of sufficient discriminatory value, unnecessary surgery may be avoided.

The natural history of hereditary chronic pancreatitis: a study of 12 cases compared to chronic alcoholic pancreatitis.

The aim of this study was to document the natural history of chronic hereditary pancreatitis and to compare its evolution to that of chronic alcoholic pancreatitis. Twelve subjects with chronic hereditary pancreatitis were followed up for a mean duration of 15.8 years (range, 1-23) and compared to subjects with chronic alcoholic pancreatitis who were followed up from 1972 to 1980. The subjects with chronic hereditary pancreatitis, when compared to those with chronic alcoholic pancreatitis, were found to have an earlier onset of symptoms (10.5 vs. 46.0 years, p < 0.05); a significant delay in diagnosis (14.3 vs. 3 years); a similar prevalence of pancreatic calcification (58 vs. 57%); a similar amount of pancreatic insufficiency; both endocrine (50 vs. 70%) and exocrine 42 vs. 38%); and a higher prevalence of pseudocysts (33 vs. 10%, p < 0.05). Only one pancreatic adenocarcinoma was diagnosed in a patient with chronic alcoholic pancreatitis. Apart from the earlier onset and the delay in diagnosis, chronic hereditary pancreatitis has a natural history similar to that of chronic alcoholic pancreatitis. The disease is progressive with a high incidence of complications, but all subjects were alive after follow-up.

The comparative efficacy and tolerability of CGP 56697 (artemether + lumefantrine) versus halofantrine in the treatment of uncomplicated falciparum malaria in travellers returning from the Tropics to The Netherlands and France.

CGP 56697 (Riamet) is a new oral anti-malarial drug composed of artemether and lumefantrine (benflumetol) which combines the fast, short-acting artemether for rapid parasite clearance with the prolonged action of lumefantrine for intended radical cure. In this double-blind, comparative trial, the efficacy and tolerability of CGP 56697, given as a course of 4 x 4 tablets over 48 h, was compared to halofantrine, given as 3 x 2 tablets over 12 h with a second course 1 week later. Patients (mostly non-immune) with acute, uncomplicated Plasmodium falciparum infection were randomly assigned to either CGP 56697 (n = 51) or halofantrine (n = 52). CGP 56697 proved superior with respect to parasite clearance time (median 32 vs. 48 h, P < 0.001) and parasite reduction at 24 h (median 99.7 vs. 89.6%, P < 0.001) with a non-significant difference in resolution of fever (median 24 vs. 32 h, P = 0.835). However, a 28-day cure rate of 82% was observed for CGP 56697 and 100% for halofantrine. Significant QTc prolongations (> 30 ms) were seen 6-12 h after halofantrine intake but not after CGP 56697 intake. CGP 56697 is an effective, well-tolerated treatment for uncomplicated falciparum malaria but for this dosing regimen the recrudescence rate is unacceptablyhigh (18%). For travellers contracting malaria abroad, we propose a six-dose regimen of CGP 56697 over 3 days.

Imported cutaneous gnathostomiasis: report of five cases.

Gnathostomiasis has rarely been described outside endemic countries. We report on a series of 5 patients (4 females, 1 male, mean age 42.2 years) who returned to France from South-East Asia and presented with cutaneous gnathostomiasis. The cutaneous lesions appeared within a mean period of 62 d (range 10-150 d) after return. They consisted of creeping eruptions in 3 patients (in addition one also had papules, one had nodules and hepatitis, and one had hepatitis; all 3 had profound asthenia) and recurring migratory swellings in 2 patients. The mean eosinophil count was 1546/mm3 (range 398-3245/mm3). Diagnosis was based on positive serological tests in 3 patients and seroconversion in 2 patients, and was confirmed by identification of Gnathostoma hispidum in a biopsy specimen from one of the seropositive patients. Albandazole (1-4 courses) was given as treatment. Recurrences may occur up to 24 months after apparent cure without reinfection. Gnathostomiasis should be considered when patients return from tropical countries and present with migratory swellings or creeping eruption that does not respond to the usual treatment for cutaneous larva migrans. Serological tests may be negative initially and thus need to be repeated to check for seroconversion. Treatment may require multiple courses of albendazole and a prolonged period of follow-up is necessary before cure can be confirmed.

Ursodeoxycholic acid modulates cyclosporin A oral absorption in liver transplant recipients.

The aim was to study the ursodeoxycholic acid (UDC) effect on the cyclosporin A (CsA) pharmacokinetics after oral administration of the microemulsion formulation Neoral (CsA-ME) in liver transplant recipients, and test the potential protective effect of this bile acid on liver and renal CsA-ME-induced toxicity. At entry into the study, 12 patients who underwent orthotopic liver transplantation received CsA-ME, for at least 6 months. They then received a cotreatment CsA-ME plus UDC (13.8 mg x kg(-1) x day(-1)) for three months. Blood concentrations of CsA were measured using a monoclonal antibody specific for the parent compound. The kinetic data were analysed by a mathematical model incorporating a time dependent rate coefficient for CsA intestinal absorption, before and after UDC treatment. Changes in serum markers of hepatic and renal injury were assessed. Individual serum bile acids were determined by chromatography. Serum levels of UDC increased from 3 to about 45% of total serum bile acids after UDC treatment. The estimated model parameters indicate that UDC administration modulates CsA intestinal absorption. In the nine non-cholestatic patients, UDC reduced the absorption rate and the bioavailability of CsA without modifying the elimination rate constant of CsA and the CsA pre-drug levels. In contrast, in the three cholestatic patients, the bioavailability tended to be higher and the absorption rate faster when CsA was combined with UDC. UDC significantly decreased elevated gamma-glutamyl transferase and creatinine serum levels and induced some clinical improvements such as disappearance of headaches in four patients. In conclusion, a 3-month UDC treatment modifies CsA intestinal absorption without affecting CsA elimination rate constant. On the other hand, UDC supplementation appears to improve CsA tolerability.

Endoscopic treatment of wirsungo-cysto-pleural fistula.

A case is reported of a female with chronic alcoholic calcifying pancreatitis who presented with a wirsungo-cysto-pleural fistula. Endoscopic retrograde pancreatography demonstrated the fistulous tract and a naso-pancreatic drain was inserted. Subsequently, this drain was replaced by a pancreatic endoprosthesis. This endoscopic therapy led to full resolution of the fistula. We suggest that endoscopic intervention is the first-line treatment for this condition and that surgical intervention should be reserved as a second-line treatment.

Extensive aetiological investigations in acute pancreatitis: results of a 1-year prospective study.

BACKGROUND: Epidemiological data on acute pancreatitis are poorly defined. AIMS: To prospectively evaluate the aetiology of acute pancreatitis and to assess the benefits of intensive investigations. METHODS: In a prospective, 1-year study all cases of acute pancreatitis in the Nice catchment area were enrolled. Subjects underwent routine (serum calcium, phosphate and triglycerides; abdominal ultrasonography and CT scan) and additional, delayed intensive investigations (ERCP with bile sampling and/or endoscopy ultrasonography). RESULTS: One hundred and twenty-one cases were included. After routine investigations, a biliary, alcoholic, miscellaneous or unknown origin was diagnosed in 43%, 31.4%, 9.9% and 15.7%, respectively. In subjects with biliary pancreatitis, 43% had no previous history of biliary disease. In the alcohol-related subgroup, pancreatitis recurred in 18.5% during 114.5 days mean follow-up. In subjects with a first episode of alcoholic pancreatitis, delayed supplemental investigations revealed underlying chronic pancreatitis in 92.8%. After routine investigations, a diagnosis of pancreatitis of unknown origin was made in 15.7% (n = 19) of subjects. Additional investigations revealed an underlying cause in 57.8% of these patients (n = 11), including malignancy (n = 3) and biliary disease (n = 4), reducing the overall rate of pancreatitis with no apparent cause to 6.6%. CONCLUSIONS: Investigative techniques, particularly ERCP, will reveal the underlying aetiology of pancreatitis in the majority of patients presenting with 'idiopathic' pancreatitis and should be considered when routine tests are negative.

Extension of multiple drug resistant Plasmodium falciparum malaria in Africa: report of a Central African case.

A 24-year-old Caucasian male, living in the Central African Republic, presented with fever due to Plasmodium falciparum infection, although he steadily took chloroquine and sulfadoxine-pyrimethamine chemoprophylaxis. Despite treatment with the same drugs at high doses, the parasitaemia persisted. Clinical and parasitological recovery was obtained by the use of quinine. Chloroquine-resistant Plasmodium falciparum strains have spread in all tropical areas. Multiple drug resistance, already described in Asia, has also begun to appear in Africa.

A radiologic study of chronic radiation-induced injuries of the small intestine and colon.

On the basis of 144 radiation-induced intestinal and colorectal lesions seen in 109 patients, the authors review the radiologic aspects associated with such affections. Two points are emphasized: (1) the chronic and still active nature of radiation-induced injury which can explain the appearance of lesions more than 10 years after irradiation, and (2) the locoregional nature of the affection which warrants systematic exploration of the urinary tract by intravenous pyelography in addition to radiologic and endoscopic investigation of the digestive tract. The authors also advise an echography and/or CT scan to detect any neoplastic recurrence.