[Campylobacter fetus bacteremia and cellulitis complicating a venous access port infection in an HIV infected patient]. / Bactériémie et dermohypodermite à Campylobacter fetus sur cathéter à chambre implantable au cours d'une infection par le VIH.

Campylobacter fetus subspecies fetus is an opportunist Gram-negative bacillus, which is known to be a cause of systemic infections, mainly in immunocompromised patients. We report a C. fetus bacteremia and cellulitis complicating a venous access port infection in a patient with acquired immunodeficiency syndrome (AIDS). This bacillus seems to have a predilection for the vascular endothelium and its isolation is difficult. Physicians should be aware of C. fetus infection in patients with vascular devices. Microbiologists should accurately isolate this organism from clinical specimens by modifying incubation techniques and performing molecular biology. The prognosis seems to be improved by a prolonged betalactam antibiotic regimen, especially amoxicilline plus clavulanic acid. In HIV infected patients, quinolones that were successful in our case, should be used with caution because of increasing resistance to antibiotics.

[Outbreak of cutaneous leishmaniasis in military population coming back from French Guiana]. / Epidémie de leishmaniose cutanée chez des militaires de retour de mission en Guyane.

BACKGROUND: An outbreak of cutaneous leishmaniasis occurred among 71 soldiers who had participated in various missions during a 4-month's period in French Guiana. The aims of this study were (i) to describe outbreak and (ii) to determine risk factors of cutaneous leishmaniasis. METHODS: All patients were hospitalised. Cutaneous lesions were biopsied and cultured for species identification. Individual information was collected by a physician or a nurse, using on a standardised, anonymous chart. Data were processed with EpiInfo 6.04 and SAS. RESULTS: Mean age of the 71 soldiers was about 25.9 years (19-37 years). Twelve soldiers presented 56 lesions due to Leishmania (Viannia) guyanensis (attack rate = 16.9 for 100). Among 56 lesions, 13 lesions were localized on the trunk, usually an unexposed body area. Logistic regression highlighted military exercises in the forest during a high risk period of leishmaniasis transmission (OR = 11.2; p < 0.01), and the young age (OR = 1.33; p = 0.04). Vector control measures were not statistically significant. CONCLUSION: Military authorities should restrict deep forest activities during periods of high risk transmission. Vector control measures are essential. Officers should motivate their soldiers and supervise vector control measures. As ecotourism is developing, tourists as well as workers staying in deep forest must be informed of the risk and about vector control measures.

[Dermatological aspects in the risk of biological warfare]. / Aspects dermatologiques du risque biologique provoqué

The possible cutaneous manifestations of infectious biological warfare are multiple and vary depending on the agent used. An ulcerous and/or necrotic syndrome and/or regional lymphadenitis syndrome are possible with anthrax, tularaemia, bubonic plague and emission of trichotecene mycotoxins. A vesiculo-pustular syndrome with fever is provoked by smallpox, melioidosis and glanders. A purpural and/or haemorrhagic syndrome is seen during haemorrhagic fever viruses and septicaemic plague. These cutaneous manifestations are excellent markers that orient and alert when they occur in a context of a situation at risk, when several cases are observed in a usually non-exposed population and with extra-dermatological syndromes. They permit the early initiation of treatment.

Increased priming for interleukin-12 and tumour necrosis factor alpha in CD64 monocytes in HIV infection: modulation by cytokines and therapy.

BACKGROUND: A key factor leading to impaired immunity in HIV infection is an alteration of the pattern of cytokine response, although its precise nature remains controversial, particularly the in vivo influence of HIV on interleukin (IL)-12 synthesis. DESIGN: A cross-sectional study in 73 HIV-infected persons (28 of them receiving highly active antiretroviral therapy) and 18 HIV-seronegative healthy donors. METHODS: The frequency of monocytes/macrophages (M/M) synthesizing IL-12, IL-10 and tumour necrosis factor alpha (TNF-alpha) was determined in peripheral blood mononuclear cells. The cells were cultured in medium or were stimulated with lipopolysaccharide; proportions of CD64 M/M producing IL-12, TNF-alpha or IL-10 was determined by cytofluorometric analysis. The influence of exogenous interferon gamma (IFN-gamma), IL-10 or IL-15 on IL-12 synthesis was tested. RESULTS: Chronic HIV disease is associated with increased priming of M/M for IL-12 (involving both p40 and p70 molecules) and TNF-alpha synthesis; this was associated with cosynthesis of both cytokines by a fraction of M/M. Priming for IL-12 was physiologically enhanced by IFN-gamma and decreased by IL-10; IL-15 had no effect. The proportion of IL-10-producing CD64 M/M was not altered in patients compared with controls but there was an inverse correlation between IL-10-producing M/M and viral load. IL-12 production was not correlated with viral load but was increased following antiretroviral therapy. Following LPS stimulation, IL-12 and TNF-alpha responses were not altered in HIV-positive patients; however, the IL-10 response was decreased but restored by antiretroviral therapy. CONCLUSION: These observations argue for a preserved intrinsic CD64 M/M of IL-12 production in HIV pathogenesis.

Results of the ALBI trial: a randomized comparison of stavudine/didanosine, zidovudine/lamivudine and alternating treatment in antiretroviral-naive patients.

In the ALBI trial, 151 antiretroviral-naive patients with plasma human immunodeficiency virus type 1 (HIV-1) RNA levels of 10,000 to 100,000 copies/ml and CD4 cell counts > or = 200 cells/mm3 received 24 weeks of treatment with stavudine/didanosine (n=51), zidovudine/lamivudine (n=51) or stavudine/didanosine for 12 weeks followed by zidovudine/lamivudine (n=49). Baseline plasma HIV-1 RNA and CD4 cell counts were comparable in the treatment groups. The mean decrease in plasma HIV-1 RNA at 24 weeks in the stavudine/didanosine group (2.26 log10) was significantly greater than that in either the zidovudine/lamivudine group (1.26 log10) or the alternating treatment group (1.58 log10) (P<0.0001 for both). Proportions of patients with plasma HIV-1 RNA level <500 copies/ml (91% vs 42% and 60%) and <50 copies/ml (47% versus 4% and 9%) were significantly greater in the stavudine/didanosine group (P<0.001 for pairwise comparisons). Stavudine/didanosine was associated with a mean increase in CD4 cell count (124 cells/mm3) significantly greater than that in the zidovudine/lamivudine group (62 cells/mm3, P<0.01) and comparable to that in the alternating group (118 cells/mm3). All study regimens were well tolerated. These findings, indicating superiority of stavudine/didanosine over zidovudine/lamivudine in virological and immunological response over 24 weeks, suggest that the combination should be considered as a basis for highly active antiretroviral therapy.

Unusual presentation of typhoid fever: cutaneous vasculitis, pancreatitis, and splenic abscess.

We report a case of typhoid fever with an unusual presentation: prolonged fever with cutaneous vasculitis, pancreatitis, and splenic abscess. This is the first case of cutaneous leukocytoclastic vasculitis associated with Salmonella typhi. The diagnosis was made upon isolation of S. typhi in blood cultures, and after ruling out other causes of leukocytoclastic vasculitis. The outcome was favourable with antibiotics alone without surgery.

[Viral hepatitis of enteric origin]. / Les hépatites virales d'origine entérique.

Hepatitis viruses of oral-fecal origin are responsible for a high morbidity and mortality throughout the world, even if they never result in chronic hepatitis. Two viruses, the virus of hepatitis A (VHA) and of hepatitis E (VHE) are at present the cause of severe viral hepatitis of enteric origin. Water is the principle vector in the spread of these viruses. However, the epidemiological aspects vary according to the pathogenic agent. VHA is excreted in a highly concentrated form in the feces for a relatively short period of time. Since it resists in an exterior environment, the virus remains infectious for a long time. VHE is excreted for a short period of time and in low concentrations. The viral particles are fragile in vitro and their variability in the environment is little known. The possible reservoir role of certain animals has been envisaged. Epidemics arise especially in countries suffering from poor hygiene and massive water pollution. Hepatitis A should no longer be considered a benign disease of childhood. The progress made in hygiene and economic development in industrialized countries have made contacts with this virus scarce, rendering the populations more receptive to it and epidemics more widespread. When the sickness occurs later in life, infection is more often symptomatic and can be serious, resulting sometimes long-term indisposition. Hepatitis E has a vast distribution throughout the world and manifests itself either in epidemic or endemic-sporadic form in many poor countries. In developed countries, it comes about mostly as a result of imported pathology, even if there exists a "substratum" of infection in these areas. The main clinical aspects, such as we were able to study them in 39 cases of military men from Tchad, Guyana and Somalia, are comparable to those of hepatitis A. The reasons for the particular gravity of symptoms in pregnant women are unknown. These affections have no specific treatment. In the field of prevention, vaccination is at present the best means for hepatitis A prophylaxis. Until a vaccine against hepatitis E is found, prevention depends on hygiene, sanitation measures et distribution of drinking water.

[Liposomal amphotericin B treatment of cutaneous leishmaniasis contracted in Djibouti and resistant to meglumine antimoniate]. / Traitement par amphotéricine B liposomale d'une leishmaniose cutanée contractée à Djibouti et résistante à l'antimoniate de méglumine.

Pentavalent antimony (PA) compounds remain the main therapeutic agents of cutaneous leishmaniasis (CL). CL infection resistant to PA is difficult to cure, limited by severe side effects and requiring a long course treatment of parenteral administration of recommended second line drugs. We report a case of CL unresponsive to meglumine antimoniate contracted in Djibouti, successfully treated with a short course treatment of AmBisome. In this case the subject had a recurrent thick crusted erythematous lesion on his left elbow associated with spreading micropapula on arms and thorax. The diagnosis of CL was confirmed by direct examination and genomic amplification by PCR of skin samples, cultures were negative. A short course treatment of parenteral AmBisome (18 mg/kg) has lead to clinical cure with no side effects and no relapse. In our hospital, the high cost of medication was counterbalanced by easiest administration, reduction of hospitalization duration, absence of adverse events and a gain of comfort. For this patient, a short course treatment of AmBisome proved to be a suitable alternative to traditional drugs used in CL resistant to PA.

[Splenic rupture in infectious disease: splenectomy or conservative treatment? Report of three cases]. / Ruptures de rate au cours des maladies infectieuses: splénectomie ou traitement conservateur? A propos de trois cas.

INTRODUCTION: Spontaneous splenic ruptures are rare but life-threatening complications of infectious diseases. Splenectomy is still the treatment of choice but numerous recent reports have documented favorable outcome with conservative treatment. EXEGESIS: We report three cases of splenic rupture occurring respectively with infectious mononucleosis, P. vivax infection and dengue fever. Diagnosis, treatment and indications are reviewed, an approach to management is suggested. The study included three military men respectively aged 23, 24 and 35 years, admitted for acute abdominal pain in the left upper quadrant. The abdominal computed tomography confirmed partial rupture (splenic hematoma) in the first two cases, and an hemoperitoneum in the dengue case. Splenic ruptures can reveal or complicate an evolving infection. Rupture can happen spontaneously or as a result of trauma, which may be minor and unnoticed. The typical presentation is acute, but progressive forms are described. The diagnosis is made by ultrasound and CT scan. Splenectomy dogma tends to be supplanted by conservative treatment. Non-operative management can be successful if appropriate criteria and a long period of follow-up are applied in carefully selected cases. When an operative approach is selected, conservative surgical treatment is attractive. Splenectomy should be reserved for patients with uncontrollable rupture or with recurrent splenic bleeding. CONCLUSION: Spontaneous splenic rupture are uncommon in infectious diseases. A multidisciplinary management is necessary. A conservative treatment should be considered in selected, closely monitored patients.

[Disseminated tuberculosis of unusual locations]. / Tuberculose floride avec localisations rares.

We report a case of disseminated tuberculosis involving the middle ear, the central nervous system, the spine and the lung. The tuberculous epidural abscess and otomastoiditis don't have any specific imaging features. But their coexistence with an other tuberculous involvement might suggest their tuberculous nature. The epidural abscess may result from direct extension from otomastoiditis.

[Disseminated Histoplasma duboisii histoplasmosis in a female inhabitant of the Ivory Coast]. / Histoplasmose disséminée à Histoplasma duboisii chez une Ivoirienne.

The authors describe a disseminated multivisceral form of african histoplasmosis due to H. duboisii in a 45 years old black woman. Clinical examination shows characteristic lesions of skin, bones and lymph glands. Lymphography reveals lesions of deep lymph glands and laparascopy lesions of liver and spleen. First untimely stopped, treatment was started again with ketoconazole. 20 months later, the course of the disease is, as for as we can appreciate it, favourable.

[Serum HRP-2 antigens and imported Plasmodium falciparum malaria: comparison of ParaSight-F and ICT malaria P.f]. / Antigénémie HRP-2 et paludisme d'importation à Plasmodium falciparum: comparaison du ParaSight-F et de l'ICT malaria P.f.

Serum levels of HRP-2 antigens against Plasmodium falciparum in 568 venous blood samples collected at two general hospitals were evaluated using the ParaSight-F (Becton-Dickinson) alone (568/568 samples) or in combination (156/568 samples) with the new ICT-Malaria P.f. (ICT-diagnostic). Comparison with the reference method (thin and thick blood smears assessed by two experienced parasitologists) showed that both tests were highly sensitive (93% and 96% respectively) and specific (98% and 98% respectively). The positive predictive values of the two tests were equal (96%) and the negative predicative values were close (96% and 98% respectively). Although both tests provided results within 10 minutes and required no special equipment for interpretation, the ICT-Malaria P.f. test seemed simpler and easier to use than the ParaSight-F test. The ParaSight-F test alone was used to monitor serum antigen levels after treatment in 24 patients. Antigen levels remained positive for at least three days after disappearance of circulating parasites (range: 3 to 28 days). Evaluation of serum levels of HRP-2 antigens can be useful for emergency diagnosis, especially in patients with low circulating parasite levels. The ICT-Malaria P.f. test seems especially suited for in-field use.

[Smallpox and bioterrorism]. / La variole et le bioterrorisme.

The variola virus was the first biological agent to be used as a military weapon. It is considered as one of the main agents that could potentially be used in the context of bioterrorism. Smallpox was declared eradicated in 1980. So, in case of a confirmed or suspected case of smallpox, a deliberate, intentional origin must be considered. The early diagnosis of the first case is essential for initiating an epidemiological alert. All physicians should be well informed of the epidemiological, clinical, diagnostic, and therapeutic aspects of smallpox.

[Infectious hazards in military personnel in operations.]. / Les risques infectieux chez les militaires en opération.

Military personnel in operations have always paid a high toll to infections, particularly epidemics. Currently, 40 000 servicemen serve overseas in various missions and operations of various durations in various countries. Infectious hazards persist in spite of the implementation of preventive measures. They are primarily due to poor sanitation, promiscuous living conditions, and the operational situation : bacterial diarrhea, amoebiasis, viral hepatitis A and E are relatively frequent. Others are due to the tropical environment ; malaria remains a concern due to its chemoresistance ; bilharziosis can also cause small epidemics, cutaneous leishmaniasis is not rare in Guyana. Exceptional but serious infections are observed. Infectious hazards associated with warfare are reviewed : biological warfare, infections of wounded, burnt and irradiated soldiers.

[Pulmonary anthrax]. / Le charbon pulmonaire.

Anthrax is a zoonotic disease caused by Bacillus anthracis. Skin disease is the most common form in humans. Pulmonary anthrax related to the inhalation of airborne germs develops after a silent incubation period of several days and followed by acute respiratory distress. Diagnosis is a difficult task and generally based on demonstration of Bacillus anthracis on direct examination. Despite the sensitivity of B. anthracis to penicillin, treatment is rarely successful.

[Diagnosis of cerebro-meningeal infections after travel abroad]. / Diagnostic des infections cérébro-méningées au retour d'un voyage outre-mer.

Cerebromeningitis after travel abroad is often acute and febrile and is a serious event. The most frequent and severe cause is pernicious malaria due to Plasmodium falciparum; diagnosis is rapid by thick blood film and thin blood smear; it requires specific emergency treatment. Many other aetologies exist but they are rare; they must nonetheless be considered, keeping in mind that cosmopolitan infections can be favoured by travel conditions.