Seven years of recurrent severe strongyloidiasis in an HTLV-I-infected man who developed adult T-cell leukaemia.

OBJECTIVE: Human T-cell leukaemia/lymphoma virus type I (HTLV-I) is endemic in Japan, the Caribbean basin and Africa, where it has been aetiologically linked to certain chronic myelopathies and adult T-cell leukamia (ATL). We sought to investigate whether strongyloidiasis, a parasitic disease common in these areas, might be a cofactor in the pathogenesis of ATL, as some reports have suggested. PATIENTS, PARTICIPANTS: One 35-year-old HTLV-I-seropositive French West Indian man with a 7-year history of recurrent strongyloidiasis associated with episodic hyperinfestation presenting at the Centre Hospitalier Intercommunal, Villeneuve St Georges, France. INTERVENTIONS: Treatment with various chemotherapeutic agents and symptomatic therapy for hypercalcaemia and antiviral therapy (zidovudine and interferon). RESULTS: The patient developed ATL and died shortly after, despite chemotherapy. Immunological and virological studies performed during the last 15 months of his life showed an increase of the percentage of peripheral ATL cells, and progression from a polyclonal to a monoclonal integration of HTLV-I proviral DNA in the peripheral blood mononuclear and lymph-node cells. CONCLUSIONS: Recurrent strongyloidiasis appears to have been a possible cofactor associated with progression from healthy carrier state to ATL in our patient.

Risk factors for preterm delivery in Burkina Faso (west Africa).

The environmental and socioeconomic risk factors for preterm delivery were assessed in a West African urban population (Bobo-Dioulasso, Burkina Faso). The study population were 102 cases of preterm delivery matched with 102 controls obtained from 4124 sequential deliveries which occurred between May and October 1989 in the three maternity centres in the city. The univariate analysis identified the risk factors as age (< 20 years), primiparity, marital status (single), low frequency of antenatal visits, death of a previous child and level of education of the mother. The following risk factors identified by multivariate analysis (logistic regression) are consistent with those identified in previous studies: youth of the mother, primiparity (P = 0.01) and death of a previous child (P < 0.05). On the other hand, in this study, the level of education of the parent was identified as an independent risk factor (P < 0.001). This finding could be used to determine a target population for prevention programmes.

PIP: Between May and October 1989 in Burkina Faso, a pediatrician daily visited the clinic at the maternity hospital, the Farakan maternity clinic, and the Guimbi maternity clinic (the only 3 maternity clinics) in Bobo-Dioulasso to confirm the diagnosis of preterm delivery (gestational age 28-37 weeks) and to collect data on 102 deliveries and on 102 full-term deliveries occurring at the same time. The physician and epidemiologists conducted perhaps the first case control study of preterm delivery risk factors in West Africa. The incidence of preterm deliveries was 2.6%. The univariate analysis identified the following to be risk factors of prematurity: being 20 years old (odds ratio [OR] = 6.9 for 15-19 year olds vs. older women; p .01), primiparity (OR = 2.88; p = .03), being single (OR = 3.44; p .01), having less than 3 prenatal care visits (OR = 7.9; p .001), death of a previous child (OR = 3.1; p .01), and malaria prophylaxis (OR = 1.7; p = .05). Absence of schooling of parents appeared to be a protective factor (OR = .47; p .001). The multivariate analysis uncovered 3 significant risk factors of prematurity: young mother and primiparity (OR = 4.4; p = .01), less than 3 prenatal visits (OR = 9.3; p .001), and death of a previous child (OR = 2.2; p .05). Lack of schooling continued to have a protective effect when researchers adjusted for other variables (OR = .37; p .001). As a possible explanation for education being a risk factor of prematurity in Burkina Faso, the researchers suggested that educated parents are more likely to use motorized transport on bumpy roads for 6-7 hours at a time which caused intrauterine vibrations, resulting in preterm delivery. In developed countries, education reduces the risk of preterm delivery.

Acute respiratory infections: a longitudinal study of 151 children in Burkina-Faso.

A longitudinal study of 151 children under five years of age was performed in a rural village of Burkina-Faso (West Africa). During systematic examinations by a physician during the rainy season, 44% of the children were found to be ill and 59% of these had an acute respiratory infection (ARI). During the dry season, the rates were 48% and 73% respectively. Weekly interviews by a field worker showed 6.2 attacks of ARI during the six months of the rainy season and 7.0 during the six months of the dry season. Risk factors for ARI were malnutrition assessed by arm circumference, and a high birth rank. At the 'field-dispensary', ARI accounted for 41% of the visits; lower respiratory infections (LRI) accounted for 24%, similar to the proportion of LRI among illnesses found during the systematic examination.

Unusual neurologic manifestations occurring during dengue fever infection.

This is a report on dengue fever in two young patients in France that were infected in New Caledonia and Thailand. Both presented with unusual neurologic manifestations. The first patient developed a focal subarachnoid hemorrhage that was associated with transient thrombocytopenia. No neurologic vascular malformation was detected; a mild dengue hemorrhagic fever after a previous dengue infection was suspected. The second patient showed peripheral facial palsy one week after apyrexia without any other etiology except the dengue infection. This case was probably a postinfectious syndrome associated with dengue virus. Both patients recovered spontaneously. The circumstances of the neurologic manifestations in these patients may be attributed to the dengue fever virus. However, although neurologic complications reported for dengue fever are unusual, it is reasonable to consider these manifestations as being due to immunopathologic consequences.

Stability of essential drugs in the field: results of a study conducted over a two-year period in Burkina Faso.

To evaluate the stability of essential drugs stored in realistic tropical conditions, we have carried out a two-year prospective study in western Burkina Faso. Twenty-seven essential drugs were stored in a rural site and a urban one where temperature and hygrometry were recorded daily. Samples of each drug were taken for further analysis to the World Health Organization Collaborative Center for the Study of Stability of Drugs in Nantes, France every three months. Quantitative analysis showed that the majority of samples suffered no significant loss of their active ingredient. In contrast, ampicillin, erythromycin, sulfaguanidine, injectable furosemide, penicillin G, trimethoprim, and chloroquine showed more than a 10% quantitative loss of their active ingredient. Thus, it is not recommended that these essential drugs be stored for more than one year in a tropical climate.

Tuberculosis and human immunodeficiency virus infection in west Burkina Faso: clinical presentation and clinical evolution.

OBJECTIVE: To study the relationship between human immunodeficiency virus (HIV) infection and tuberculosis (TB) in a West African country. DESIGN: A cohort study in TB patients at the TB centre of Bobo Dioulasso, Burkina Faso. RESULTS: HIV seroprevalence rose from 12.5% in 1987 to 24.7% in 1990. Analysis of clinical findings showed that extra-pulmonary TB was not more frequent in HIV-positive patients (18.5%) than in HIV negative patients (17.3%). Four symptoms were independently associated with HIV infection: diarrhoea, lymphadenopathy, weight loss and oral candidiasis. At the end of six months of chemotherapy for TB (2SHRZ/4HR), the mortality rate among HIV-positive TB patients was 27%, versus 10% among HIV-negative TB patients (P < 0.001). There was no difference between treatment failure rates among HIV-positive patients (3.8%) and HIV-negative patients (3.9%). At the final evaluation, 18 months after the start of chemotherapy, the relapse rate was 8% in HIV-positive patients versus 5.6% in HIV-negative patients (NS). Global mortality rate during the whole study period was significantly higher in HIV-1 (40.3%) and HIV-1 + 2 (20%) patients than in HIV-2 (11.1%) and HIV-negative (12.9%) patients. CONCLUSION: We conclude that, according to previous African studies, despite a higher mortality rate due generally to HIV disease itself, short-course chemotherapy of 6 months is as effective in HIV-positive patients as in HIV-negative patients, and must be continued.

Single-dose amoxycillin-clavulanic acid vs. cefotetan for prophylaxis in elective colorectal surgery: a multicentre, prospective, randomized study. The PRODIGE Group.

A prospective, multicentre, randomized trial was carried out in 19 hospitals in order to compare the efficacy of amoxycillin-clavulanic acid with cefotetan as antibiotic prophylaxis in patients undergoing elective colorectal surgery. Since the main purpose of the study was to demonstrate equivalence between the two regimens, the protocol planned the inclusion of 200 patients. Eligible patients were randomly assigned to receive either amoxycillin-clavulanic acid (2.2 g) or cefotetan (2 g) in a single infusion on the induction of anaesthesia. Failure of prophylaxis was defined as occurrence of infection of intestinal origin, either minor (wound cellulitis) or major (abscess, peritonitis, septicaemia) within the 30-day postoperative period. Among 221 randomized patients, 208 (105 amoxycillin-clavulanic acid, 103 cefotetan) aged 66 +/- 12 years (mean +/- SD) were evaluated while 13 were withdrawn. Colorectal cancer was the indication for surgery in 73% of cases. Eleven (10 +/- 6%, 95% confidence interval) and 13 (13 +/- 7%) failures were observed in the amoxycillin-clavulanic acid and cefotetan groups (P = 0.63 chi-square test) respectively. Most infections occurred before the 10th postoperative day (8% failures at this time, estimated by the Kaplan-Meier method). The results of the trial demonstrate that amoxycillin-clavulanic acid and cefotetan have similar efficacy when used for prophylaxis of infection after elective colorectal surgery.

Malaria chemoprophylaxis of 3,446 French travelers departing from Paris to eight tropical countries.

BACKGROUND: Each year more and more French travelers are visiting areas where malaria is endemic. The aim of this study was to assess prophylactic regimens used by French travelers and to determine whether they meet current published recommendations. METHODS: This 12 month transversal study (May 1, 1995 to April 31, 1996) was conducted in embarkment lounges of Roissy Charles de Gaulle Airport to eight "tropical" destinations. RESULTS: 3,446 French travelers were enrolled. Twenty two and three-fifths percent of travelers had not sought any advice. The percentages of travelers staying less than 3 months (n = 2899) at risk of malaria (i.e., using none or inadequate chemoprophylaxis) were, according to the destination: Brazil (20%), Gabon (83%), Ivory Coast (26%), Kenya (43%), Madagascar (39%), Thailand (22%), Venezuela (41%) and Vietnam (8%). The suitability of the prophylaxis according to the information source for travelers staying less than 3 months varied as follows: specialist physician (OR = 1), travel agent (OR = 1.01, CI = 0.9 - 1. 1), occupational physician (OR = 1.13, CI = 0.6 - 2.1), GP (OR = 1. 58, CI = 1.1 - 2.3), none (OR = 1.95, CI = 1.3 - 2.9), friends (OR = 3, CI = 1.8 - 5) and pharmacist (OR = 3.94, CI = 2.1 - 7.5). Suitability of prophylaxis also varied according to the type of trip: organized tour (OR = 1), business trip (OR = 1.04, CI = 0.8 - 1.4), adventure tourism (OR = 2.1, CI = 1.6 - 2.9) and visit to family or friends (OR = 2.3, CI = 1.7 - 3.1). CONCLUSIONS: This study shows that the quality of advice on antimalarial chemoprophylaxis varies markedly according to the source, and that nearly one in three French travelers (29.3 %, 850/2899) to tropical areas is at risk of malaria.

Health hazards in international tourists visiting Paris in August: a five-year retrospective epidemiologic survey.

BACKGROUND: Travel-related illnesses have been studied in visitors to developing countries, but no studies have examined the incidence of health problems in visitors to developed countries. METHODS: 4, 093 foreign tourists visiting Paris in August and attending to emergency medical care for acute health problems were included in an epidemiological survey conducted over 5 consecutive years. The objective was to determine what types of acute health problems occur in a foreign tourist population and to estimate the incidence of the main health hazards. RESULTS: Gastroenteritis represented the main cause of medical care in that population (from 14.5-21.9%) followed by traumatology, ENT problem, viral syndrome and dermatology which represented altogether 60-64% of all medical problems. Two factors were related to the distribution of diseases observed: age and nationality. The monthly incidence of gastroenteritis was estimated to be between 1.33 to 2.92 per 10,000 visitors, and the overall incidence of health problems between 8 to 10 per 10,000. CONCLUSIONS: Even if the incidence rate of gastroenteritis is low compared with developing countries, further studies are needed to support the hypothesis that gastroenteritis could be attributed to sanitary conditions in some restaurants of the French capital.

[Abdominal lymph node tuberculosis: diagnostic value of echography and x-ray computed tomography]. / Tuberculose ganglionnaire abdominale: intérêt diagnostique de l'échographie et de la tomodensitométrie.

The aspects of abdominal ultrasonography and computed tomography (CT) were studied in 4 patients (3 African and 1 Haitian) with abdominal tuberculosis. All were markedly debilitated and three patients had protracted fever. Tuberculosis was documented in all cases by demonstrating Mycobacterium tuberculosis in cultures of lymph nodes taken during laparotomy and/or cultures of products of gastric aspiration. Ultrasonography showed enlarged lymph nodes in the pancreatic and peripancreatic areas and also in the mesenteric, perivascular and hepatic pedicle areas. CT showed hypertrophied lymph nodes with low tissue density ranging from 20 to 35 Hounsfield units. Although non pathognomonic, these aspects were suggestive of tuberculosis. Intravenous contrast medium administration failed to increase the density in the center of lymph nodes but disclosed the existence of a thick hyperdense rim surrounding the hypodense center of the caseous lymph nodes. Repeated ultrasound and CT examination allowed to control the efficacy of antituberculous chemotherapy.

[Endoscopic diagnosis of a biliodigestive fistula of tuberculous origin revealing acquired immunodeficiency syndrome]. / Diagnostic endoscopique d'une fistule bilio-digestive d'origine tuberculeuse révélatrice d'un syndrome d'immunodéficience acquise.

We report the case of a 32-year-old Malian man with abdominal tuberculosis revealing acquired immunodeficiency syndrome. A gastroscopy was made for epigastric pain and showed caseum in a digestive fistula with acid fast bacilli. Mycobacterium tuberculosis infection was confirmed by sputum culture. An early antituberculous therapy was prescribed. Outcome was good with rapid fistula closing and slower mass diminution of the abdominal lymph nodes. This case report confirms nodal tuberculosis as a possible cause of digestive fistulae. Rapid endoscopic diagnosis of this tuberculous fistula led to diagnosis of acquired immunodeficiency syndrome and early adapted medical treatment without invasive diagnostic methods.

[Risk factors for neonatal tetanus in western Burkina Faso. Case-control study]. / Facteurs de risque du tétanos néonatal dans l'ouest du Burkina Faso. Etude cas témoin.

A case control study was done in Bobo-Dioulasso (Burkina Faso) during a one year period (1989), to identify practices during the pregnancy and childbirth, environmental and sociocultural factors associated with the occurrence of neonatal tetanus.

[Emergency consultations of foreign tourists in Paris in the month of August. 5 years of prospective surveillance (1992-1996)]. / Consultations d'urgence des touristes étrangers à Paris au mois d'août. Cinq années de surveillance prospective (1992-1996).

For five consecutive years, five major Parisian institutions in charge of emergencies have participated in a prospective collection of medical data for foreign patients visiting Paris in August; 4093 subjects have been studied. Gastroenteritis represented the main cause in calling on emergency medical care (14.5 to 21.9%), followed by traumatology, ear-nose-throat problems, syndromes labelled as viral, skin problems: these five categories represented 60 to 64% of all the serious problems encountered by tourists. The statistical frequency of different causes in calling on emergency care varied significantly according to two variables: the tourists' age and nationality. The incidence of gastroenteritis is estimated at between 13 and 30 per 100,000 visitors and the incidence of pathological problems taken all together--at 80 to 100 per 100,000.

[Toward a rational strategy in the treatment of postoperative bacterial endophthalmia]. / Vers une stratégie raisonnée du traitement des endophtalmies bactériennes post-opératoires.

18 cases of bacterial endophthalmitis are reported. From bacteriological, epidemiological, pharmacokinetic data, we can propose a management of infectious endophthalmitis based on the two following rules: systematic intraocular fluid aspiration, on emergency, for stained smears (as real bacteriological extemporaneous investigations) and cultures; initial wide spectrum antibiotherapy with a quick adaptation to gram stain and culture identification. The antibiotics are selected according to their intraocular penetration, safety and spectrum. The intraocular bactericidal concentration requires the association of systemic, peri-ocular, and intraocular antibiotherapy, before the settlement of irreversible retinal lesions. By vitrectomy, the infected vitreous may be cleared, and intraocular drugs diffuse more easily.

[Diffusion of pefloxacin in the aqueous humor and crystalline lens after repeated oral administration in man]. / Diffusion oculaire dans l'humeur aqueuse et le cristallin de la péfloxacine après administration orale répétée chez l'homme.

The intraocular penetration of pefloxacin was evaluated in 38 patients undergoing extracapsular cataract extraction. Patients were treated for three days with 400 mg of pefloxacin every twelve hours (the first dose being 800 mg). The mean maximum concentration of pefloxacin reached six hours after the last dose in the aqueous humor was 7.69 +/- 3.50 mg/l and reached twelve hours after the last dose in the lens was 4.59 +/- 3.15 micrograms/g. Antibiotic levels were measured by high performance liquid chromatography. Several doses until plasma steady state were effective in obtaining a higher level than a single dose of 400 mg. The ratio between aqueous humor and serum concentrations ranged between 0.50 and 0.89 (mean 68%). These concentrations in aqueous humor were higher than the MIC90 of pefloxacin for most bacterial pathogens involved in endophthalmitis 24 hours after the last dose.

[Pneumococcal postoperative endophthalmitis]. / Endophtalmies post-opératoires à pneumocoques.

Three cases of pneumococcal endophthalmitis proven by paracentesis and direct bacteriologic evaluation were studied. Cultures were positive for pneumococcus in two the three cases. The fulminant course, and poor visual outcome emphasize the urgency of proper diagnosis by microscopic identification, and of intra-vitreal of injection of antibiotics sometimes associated with vitrectomy. Subconjunctival gentamicin commonly used in ophthalmologic surgery as prophylactic treatment, is often not effective against pneumococcus. It seems advisable to associate subconjunctival chloramphenicol with the gentamicin to help prevent this bacterial infection.

[Salmonellosis in Dakar: bacteriological, clinical, epidemiological and therapeutic aspects. Ten years records (author's transl)]. / Salmonelloses à Dakar. Aspects bactériologiques, cliniques épidémiologiques et thérapeutiques. Bilan de 10 Années.

A study on salmonellosis in Senegal has been carried out in Dakar at the University Hospital of Fann from 1966 to 1976. The authors describe the various methods of isolating the germs (mainly hemoculture and coproculture) and the techniques used for bacteriological research (antibiograms, tests on plasmidic resistance). The results of these investigations, which took the whole of 10 years, are presented below, in accordance with their different aspects: - bacteriological: 1 335 strains of Salmonella have been isolated. Significantly, S. typhi is predominant (56,6 p. 100). But 7 serotypes represent 90 p. 100 of the total strains which are now in existence in Dakar; - clinical: the aspects of these diseases vary: typhoïd fever, encephalitis, diarrheic syndrome, especially among infants, and purulent meningitis, which is generally severe; - therapeutic: 880 strains have been tested with 10 antibiotics. Two groups of Salmonella serotypes are opposed: those which are sensitive (S. typhi, S. typhi murium, S. enteritidis, S. paratyphi C), those which have become resistant (S. stanleyville, S. havana, S. ordonez). The most frequent antibiotype of this kind is ASKCTSu. This is a phenomenon of plasmidic resistance, demonstrated by in vitro experiments; - epidemiological: the lysotypes of 86 strains have been determined. Two epidemiological features must be described: either a stable endemic situation with sensitive strains - or epidemics, lasting several years, with resistant serotypes. Different therapeutic schemes can be used: chloramphenicol for typhoid fever, or sometimes cotrimoxazole, or ampicillin for meningitis. In diarrheic syndrome, symptomatic treatment is enough. Then, the authors give their comments on the special characteristics of salmonellosis in Dakar: - the influence of environment on the various clinical aspects of these diseases: very serious cases of meningitis, typhoid fever, which is more severe than in France, and complications when treatment has gone wrong at the beginning; - antibiograms, which are essential, in order to choose the adequate therapeutics; - and the different aspects of epidemillogy, which are linked to the sensitivity of the serotypes to the most active antibiotics. The existence of several resistant serotypes in Senegal is a real danger: plasmidic resistance could be transferred to S. typhi. In such a situation, epidemiological surveillance of salmonellosis is absolutely necessary, and control of enteric diseases, characterized by foecal transmission, must be carried out, with the techniques available in the country.

[Pneumococcal vaccination. Assessment and prospects]. / Vaccination pneumococcique. Bilan et perspectives.

Licensed in 1977, the pneumococcal vaccine is sparsely used in France. By contrast most recent epidemiological studies demonstrated that this vaccine is capable to significantly lower the incidence of pneumococcal pneumonia in groups in which this infection is frequently life-threatening. The efficacity of such immunisation is high unless subject are immunocompromised. Recommendations for immunisation practices should be based these data and durely enforced.

[Thoracic actinomycosis. Report of 8 cases]. / L'actinomycose thoracique. A propos de 8 observations.

We report 8 cases of thoracic actinomycosis, a disease which is now uncommon owing to the widespread use of antibiotics and which is caused by anaerobic filamentous bacteria living as saprophytes in natural cavities. Recent pathogenetic data, such as propagation by continuity or blood stream, as well as bacteriological and clinical data (mediastino-pulmonary, pleural, parietal, cardiac and disseminated lesions) are reviewed. Diagnostic problems are due to the difficulties encountered in trying to isolate the saprophytic organism, and pathological examination is often required for the diagnosis. Treatment is basically medical and consists of penicillin G or A administered for prolonged periods. Nitroimidazoles are ineffective against these anaerobic bacteria.