Imported loiasis in France: a retrospective analysis of 167 cases with comparison between sub-Saharan and non sub-Saharan African patients.

BACKGROUND: Imported loiasis is a rare cause of consultation at the return of stay in central Africa, which often poses difficult diagnostic and therapeutic questions to practitioners especially those who are unaccustomed to tropical medicine. These difficulties can lead to risks for the patients especially if inappropriate treatment is given. Large series of imported loiasis are scarce. METHODS: We retrospectively studied the data including outcome in patients diagnosed with imported loiasis between 1993 and 2013 in the Paris area on the basis of a parasitological diagnosis (microfilaremia > 1/ml and/or serologic tests). We compared sub-Saharan and non sub-Saharan African patients. RESULTS: Of the 177 identified cases, 167 could be analysed. Sex ratio was 1, mean age 41 years and 83% were sub-Saharan Africans. Cameroon was the main country of exposure (62%). Incubation time may be long (up to 18 months). Of the 167 cases, 57% presented with characteristic symptoms (Calabar swellings, creeping dermatitis, eyeworm) whereas 43% were diagnosed fortuitously. Microfilaremia was evidenced in 105 patients (63%), and specific antibodies in 53%. Compared to sub-Saharan Africans, other patients were presenting less frequently with eyeworm migration and microfilaremia whereas they had higher eosinophilia and positive serology. Prevalence of Calabar swellings was not significantly different between the two groups. Cure rates were 52% with ivermectin alone, and 77% with ivermectin followed by diethylcarbamazine. No severe adverse event was reported. CONCLUSIONS: Presentation of imported loiasis varies according to ethnicity. A systematic screening should be recommended in patients with potential exposure in endemic country. Treatment with ivermectin followed by diethylcarbamazine could be a valuable option.

[Remain alert for Covid-19 in Mayotte]. / La Covid-19 à Mayotte : toujours en « rouge ¼.

The Covid-19 epidemic has reached the island of Mayotte, a french overseas department on march 2020. Since that date, and until the beginning of September, 3 374 cases have been diagnosed, including 75 cases in intensive care unit which progressed to death in 40 cases. Screening and barrier measures are difficult to control in this country.

[A NEW PANDEMIC: ZIKA VIRUS INFECTION]. / Une nouvelle pandémie: la fièvre due au virus Zika.

Zika virus is a flavivirus isolated in non human primates in 1647, then in humans 1954 (Uganda). It emerged on Micronesia (island af Yap) in 2007, then in French Polynesia in 2013-2014, in South America (mostly in Brazil and Colombia) in 2015 and in French West Indies in 2016. It is transmitted by the bite of Aedes mosquitoes. Zika virus infection is symptomatic in only 20% of cases and clinical presentation is associated with mild illness. But several neurological complications are reported (as Guillain-Barré syndrome: 48 cases in French Polynesia) and congenital malformations (microcephaly). Laboratory diagnosis is based on virus isolation by PCR. There is no specific treatment or vaccine available against the Zika virs. Prevention is based on measures of protection from mosquitoes bites.

[Ebola hemorrhagic fever: its extension reflects the African sanitary disaster]. / Fièvre hémorragique Ebola: son extension témoigne du désastre sanitaire africain.

Ebola virus, described in 1976 in Zaire, causes severe hemorrhagic fever with a high mortality rate in humans and nonhuman primates. Epidemics occurred since this time to nowadays in Sudan, Gabon, Congo and currently in Guinea, Liberia, Sierra-Leone, Nigeria and Senegal. Specific treatment and vaccine are not available. So, to prevent the virus transmission with live and dead patients, we must use strict individual and collective measures which are not always understood by local populations and make contact tracing; it is the only way to curb the epidemic.

[MERS-CoV: a new virus from Saudi Arabia]. / MERS-CoV: un nouveau virus venant d'Arabie.

Since about a year, a new pulmonary pathology occurred in Saudi Arabia and some cases are imported in Europa. This disease is due to a coronavirus named MERS-CoV (Middle East Respiratory Syndome Coronavirus). The main symptoms are fever, pulmonary and digestive troubles, with a risk of nosocomial transmission and a mortality of about 42%. The reservoir is probably the dromedary camel and the bat is the vector. There is no specific treatment or vaccine.

Atovaquone-proguanil in the treatment of imported uncomplicated Plasmodium falciparum malaria: a prospective observational study of 553 cases.

BACKGROUND: Each year, thousands of cases of uncomplicated malaria are imported into Europe by travellers. Atovaquone-proguanil (AP) has been one of the first-line regimens used in France for uncomplicated malaria for almost ten years. While AP's efficacy and tolerance were evaluated in several trials, its use in "real life" conditions has never been described. This study aimed to describe outcome and tolerance after AP treatment in a large cohort of travellers returning from endemic areas. METHODS: Between September 2002 and January 2007, uncomplicated malaria treated in nine French travel clinics with AP were followed for 30 days after AP initiation. Clinical and biological data were collected at admission and during the follow-up. RESULTS: A total of 553 patients were included. Eighty-eight percent of them were born in Africa, and 61.8% were infected in West Africa, whereas 0.5% were infected in Asia. Migrants visiting friends and relatives (VFR) constituted 77.9% of the patients, the remainder (32.1%) were backpackers. Three-hundred and sixty-four patients (66%) fulfilled follow-up at day 7 and 265 (48%) completed the study at day 30. Three patients had treatment failure. One-hundred and seventy-seven adverse drug reactions (ADR) were reported during the follow-up; 115 (77%) of them were digestive ADR. Backpackers were more likely to experiment digestive ADR compared to VFR (OR = 3.8; CI 95% [1.8-8.2]). Twenty patients had to be switched to another regimen due to ADR. CONCLUSION: This study seems to be the largest in terms of number of imported uncomplicated malaria cases treated by AP. The high rate of reported digestive ADR is striking and should be taken into account in the follow-up of patients since it could affect their adherence to the treatment. Beside AP, artemisinin combination therapy (ACT) is now recommended as first-line regimen. A comparison of AP and ACT, in terms of efficacy and tolerance, would be useful.

Longitudinal study assessing the return of chloroquine susceptibility of Plasmodium falciparum in isolates from travellers returning from West and Central Africa, 2000-2011.

BACKGROUND: Chloroquine (CQ) was the main malaria therapy worldwide from the 1940s until the 1990s. Following the emergence of CQ-resistant Plasmodium falciparum, most African countries discontinued the use of CQ, and now promote artemisinin-based combination therapy as the first-line treatment. This change was generally initiated during the last decade in West and Central Africa. The aim of this study is to describe the changes in CQ susceptibility in this African region, using travellers returning from this region as a sentinel system. METHODS: The study was conducted by the Malaria National Reference Centre, France. The database collated the pfcrtK76T molecular marker for CQ susceptibility and the in vitro response to CQ of parasites from travellers' isolates returning from Senegal, Mali, Ivory Coast or Cameroon. As a proxy of drug pressure, data regarding CQ intake in febrile children were collated for the study period. Logistic regression models were used to detect trends in the proportions of CQ resistant isolates. RESULTS: A total of 2874 parasite isolates were genotyped between 2000-2011. The prevalence of the pfcrt76T mutant genotype significantly decreased for Senegal (from 78% to 47%), Ivory Coast (from 63% to 37%), Cameroon (from 90% to 59%) and remained stable for Mali. The geometric mean of the 50% inhibitory concentration (IC50) of CQ in vitro susceptibility and the proportion of resistant isolates (defining resistance as an IC50 value > 100 nM) significantly decreased for Senegal (from 86 nM (59%) to 39 nM (25%)), Mali (from 84 nM (50%) to 51 nM (31%)), Ivory Coast (from 75 nM (59%) to 29 nM (16%)) and Cameroon (from 181 nM (75%) to 51 nM (37%)). Both analyses (molecular and in vitro susceptibility) were performed for the 2004-2011 period, after the four countries had officially discontinued CQ and showed an accelerated decline of the resistant isolates for the four countries. Meanwhile, CQ use among children significantly deceased in this region (fixed effects slope = -0.3, p < 10-3). CONCLUSIONS: An increase in CQ susceptibility following official withdrawal of the drug was observed in travellers returning from West and Central African countries. The same trends were observed for molecular and in vitro analysis between 2004-2011 and they correlated to the decrease of the drug pressure.

[Current status of leprosy]. / Aspects actuels de la lèpre.

Leprosy, known since antiquity, is a world infectious disease due to Mycobacterium leprae. The transmission is probably via nasal droplets. The clinical range, from tuberculoid to lepromatous leprosy is a result of variation in the cell-mediated immune response, with a chronic inflammation in skin and peripheral nerves. Diagnosis of leprosy is clinical with anesthetic skin lesion and skin smears detect acid fast bacilli. Besides the classification of patients due to the Ridley scale which is clinically useful, WHO proposed is a simple field classification based on the number of skin patches (paucibacillary or multibacillary). Despite an effective multidrug therapy, leprosy has not been eliminated and remains an important health problem.

[Use of bitumen in medicine throughout the ages]. / Usage du bitume en médecine au cours des âages.

Bitumen, which results of the storage of organic material and of the decomposition in process of time, was used since ancient times for cosmetic, art and the caulk of boats. So, mummies were treated by bitumen to improve their preservation. But bitumen was held to be useful to cure varying pulmonary, digestive, ENT troubles and even to set fractures. Besides, bitumen was used to realize the first photograph. In Iran, bitumen is yet used to improve the quality of the skin, but mixed with to limit its toxicity.

[Angiostrongylosis or eosinophilic meningitis]. / Angiostrongyloïdose ou méningite à éosinophiles.

Eosinophilic meningitis, or angiostrongyliasis, is a common disease in Asia, in the Caribbean and in the Pacific islands. It is caused by a rat lungworm Angiostrongylus cantonensis. Infection occurs by consumption of raw or undercooked snails. Diagnosis is based on epidemiological criteria, clinical manifestations, elevated count of eosinophils in the cerebrospinal fluid and serological tests. Treatment is symptomatic and supportive.

[Tungiasis, an uncommon ectoparisitic disease]. / La tungose: une ectoparasitose mal connue.

Tungiasis is an infestation of the skin due to the sand flea chigger (or Tunga penetrans). After penetration under the nails of the feet, this ectoparasite enlarged and the lesion becomes painful. Diagnosis is made on the past history (travel in tropical areas) and the inspection. Treatment consists of extraction the insect entire, and administration of topical antiseptic lotion.

Critical care management and outcome of severe Pneumocystis pneumonia in patients with and without HIV infection.

BACKGROUND: Little is known about the most severe forms of Pneumocystis jiroveci pneumonia (PCP) in HIV-negative as compared with HIV-positive patients. Improved knowledge about the differential characteristics and management modalities could guide treatment based on HIV status. METHODS: We retrospectively compared 72 patients (73 cases, 46 HIV-positive) admitted for PCP from 1993 to 2006 in the intensive care unit (ICU) of a university hospital. RESULTS: The yearly incidence of ICU admissions for PCP in HIV-negative patients increased from 1993 (0%) to 2006 (6.5%). At admission, all but one non-HIV patient were receiving corticosteroids. Twenty-three (85%) HIV-negative patients were receiving an additional immunosuppressive treatment. At admission, HIV-negative patients were significantly older than HIV-positive patients (64 [18 to 82] versus 37 [28 to 56] years old) and had a significantly higher Simplified Acute Physiology Score (SAPS) II (38 [13 to 90] versus 27 [11 to 112]) but had a similar PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio (160 [61 to 322] versus 183 [38 to 380] mm Hg). Ventilatory support was required in a similar proportion of HIV-negative and HIV-positive cases (78% versus 61%), with a similar proportion of first-line non-invasive ventilation (NIV) (67% versus 54%). NIV failed in 71% of HIV-negative and in 13% of HIV-positive patients (p < 0.01). Mortality was significantly higher in HIV-negative than HIV-positive cases (48% versus 17%). The HIV-negative status (odds ratio 3.73, 95% confidence interval 1.10 to 12.60) and SAPS II (odds ratio 1.07, 95% confidence interval 1.02 to 1.12) were independently associated with mortality at multivariate analysis. CONCLUSION: The yearly incidence of ICU admissions for PCP in HIV-negative patients in our unit increased from 1993 to 2006. The course of the disease and the outcome were worse in HIV-negative patients. NIV often failed in HIV-negative cases, suggesting that NIV must be watched closely in this population.

[Aspergillosis]. / Aspergillose.

Aspergillosis, due to moulds belonging to the genus Aspergillus, occurs in patients with residual lung cavities. The clinical manifestations are determined by the host immune response, ranging from a local inflammatory response to the systemic dissemination. Haemoptysis is the most common symptom. The chest X-ray reveals a round mass with a radio-lucent crescent of air. The antifungal treatments are successful.

[Tropical sprue]. / Sprue tropicale.

Tropical sprue associates prolonged diarrhea, a malabsorption syndrome, and nutritional deficiency in patients who live in or have visited tropical areas. Pathogenesis is still unknown but an infectious cause is suspected. Macrocytic anemia and hypoalbuminemia are present, together with progressive villus atrophy of the small intestine. Treatment with tetracycline, folic acid and proper nutritional support generally results in full recovery.

[Parasitic diarrhea]. / Diarrhées parasitaires.

After a trip to tropical areas, diarrhea is frequent and is most often due to a parasite. Amebiasis is the principal cause of acute diarrhea. The other intestinal parasites cause chronic diarrhea, including in temperate countries; these include Giardia, Cryptosporidium, and Microsporidium species in immunocompromised patients. Helminthic diseases, either cosmopolitan (Ascaris, Enterobius, and Taenia) or tropical (hookworms, Strongyloides, and Schistosoma), cause diarrhea with blood hypereosinophilia. Diagnosis is based on the examination of stool. Treatment is rapid, effective and well tolerated, while prophylaxis is often difficult to explain to the populations concerned.

[Management of blood eosinophilia in an outpatient clinic for tropical diseases]. / Prise en charge des hyperéosinophilies sanguines dans une consultation de maladies tropicales.

OBJECTIVE: We assessed the frequency of parasitic diseases and the efficacy of presumptive treatment when no cause was found. MATERIALS AND METHODS: This prospective study took place in the Tropical Disease department of Bicêtre Hospital over a two-year period and included patients with eosinophil counts exceeding 500/mm(3). RESULTS: The study included 117 patients with blood eosinophilia. A parasitic infection was identified for 48 (41%), and appropriate treatment resulted in a return to normal eosinophil counts for all of them. No parasite was identified in 45 patients (38.5%), but parasitic disease was suspected on the basis of clinical or epidemiologic evidence. These patients received presumptive treatment with antiparasitic drugs (ivermectin, albendazole and praziquantel, alone or in combination). Of the 30 patients in this group not lost to follow-up, eosinophil counts returned to normal for 20. Finally, a cause other than parasitosis was suspected for 15 of the 117 patients (13%): 9 (7.5%) of them were lost to follow-up. DISCUSSION: Parasites remain the leading cause of blood eosinophilia. Because the sensitivity of additional testing for these parasites is low and these antiparasitic drugs are safe (except for patients with loiasis), presumptive treatment appears appropriate.

[Zoonotic worms from carnivorous pets: risk assessment and prevention]. / Les helminthes transmissibles des carnivores domestiques à l'homme : évaluation des risques et stratégies de prévention.

A wide range of parasites can infect carnivorous pets. Some are more significant than others, owing to their prevalence, their pathogenicity for animal hosts, or their capacity to cause human disease. This article focuses on roundworms (Toxocara spp.) and tapeworms (Echinococcus spp.), which are emerging public health hazards in France. When humans ingest infective Toxocara eggs, the eggs hatch and release larvae that can migrate anywhere in the body, causing a disease called visceral larva migrans. Common target organs are the eyes, brain, liver, and lungs, with a risk of permanent visual, neurological and other tissue damage. Epidemiological studies have identified geophagy and pet dogs (particularly puppies) as the principal risk factors for human toxocarosis. Childrens' play habits and their attraction to pets put them at a higher risk for infection than adults. Eggs of the dog tapeworm Echinococcus granulosus hatch and release embryos that migrate to various organs and form voluminous cysts, causing a disease called cystic echinococcosis. Human alveolar echinococcosis is caused by the larval stage of the fox tapeworm Echinococcus multilocularis, which usually develops in the liver. Larval growth is slow, resulting in an asymptomatic phase of several years before diagnosis. Left untreated, the condition may be lethal. In central and eastern European areas where Echinococcus multilocularis is endemic, dogs that have access to rodents should be considered as potential hazards for humans. Rational measures for preventing animal and human infection include pet owner education and regular deworming of dogs and cats. Education of pet owners should focus on prevention, and will include personal hygiene, clearing up pet feces regularly to reduce environmental contamination, and minimizing exposure of children to potentially contaminated environments. Because puppies, kittens, pregnant and nursing animals and hunting dogs are at the highest risk of roundworm or tapeworm infection--and are therefore responsible for most environmental contamination and human disease--antihelminthic treatments are most effective when they are initiated early and target these animal populations. Various guidelines for the treatment and control of parasitic infections in carnivorous pets have been proposed in the United States (by the Centers for Disease Control and Prevention, and the Companion Animal Parasitology Council) and in Europe (by the European Scientific Counsel Companion Animal Parasitology). In France a non profit organization (CEPHA, Comité d'Experts en Parasitologie Humaine et Animale) was recently created to participate in the prevention of parasitic zoonoses associated with companion animals.