Descriptive and comparative analysis of mucocutaneous manifestations in patients with dengue fever: A prospective study.

BACKGROUND: Dengue is an arbovirosis affecting nearly 4 billion people worldwide. Since 2018, dengue has been re-emerging in Reunion Island. The incidence of mucocutaneous manifestations varies according to the studies and is generally called 'rash'. OBJECTIVES: To assess the prevalence of different mucocutaneous symptoms and describe the characteristics of patients developing these symptoms and the clinical signs associated with severe dengue. METHODS: A prospective study was conducted in 2019 at the University Hospital of La Réunion, in patients presenting a positive PCR for dengue. Descriptive analyses were performed. All cases in the prospective study were examined by a dermatologist. RESULTS: A total of 163 cases were included. The prevalence of mucocutaneous signs was 80.4%. A pruritus was reported in 33.7% cases, an erythematous rash in 29.4% and a mouth involvement including lip, tongue, cheek, angular cheilitis, pharyngitis, mouth ulcer and gingivitis in 31.3%. Most of symptoms appeared in the first days, but some of them could disappear only after the 3rd week. Mucocutaneous signs were not associated with a severe dengue fever (p = 0.54), but ecchymotic purpura was (p = 0.037). In multivariate analysis, skin involvement was associated with flu-like syndrome (headache, pharyngitis, rachis pain) and patient required rehydration but not invasive reanimation. CONCLUSION: This work confirms the high prevalence of skin symptoms in dengue disease, but also their wide diversity. The mucocutaneous involvement of dengue fever appears to be accompanied by a pronounced flu-like syndrome in people without severity, but careful examination to identify ecchymotic purpura or sign of dehydration in the mucous membranes would better identify cases that may worsen.

Evaluation of a school-based sun safety education program in Reunion Island, 2016-2017.

BACKGROUND: Sun exposure, especially during childhood, is the main environmental risk factor for skin cancers. This study evaluated the impact of the school-based sun safety education program "Living with the Sun" on the knowledge and behavior of primary school children regarding sun safety in Reunion Island. METHODS: This multicenter, comparative intervention study was conducted in selected primary schools of Reunion during the 2016-2017 school year. The intervention consisted of an in-class slide-show presentation on sun safety, a teaching guide, and school trips during which children were offered sunscreen and were requested to wear sunglasses, a T-shirt, and a cap. The children completed a questionnaire before and after the intervention. The percentage of children wearing a cap in school playgrounds at the end of the school year was compared between paired intervention and control schools. RESULTS: Seven hundred children from 7 Reunionese schools completed the questionnaire before and after the intervention. There was a statistically significant improvement in children's knowledge of sun safety, with differences between schools, teachers, school levels, and questionnaire responses. The percentage of children wearing a cap at the end of the school year was significantly higher in intervention schools compared to control schools. CONCLUSIONS: Children's knowledge and behavior regarding sun safety improved significantly as a result of the intervention.

Hydration and clinical warning signs of dengue fever in primary care: An observational prospective study.

OBJECTIVES: Dengue fever is an arbovirosis expanding worldwide, for which hydration has been reported to reduce the risk of hospitalization. Our objective was to estimate the volume of hydration in Reunionese patients with dengue. METHODS: A prospective observational study included patients presenting with a 'dengue-like' syndrome in ambulatory care. General practitioners recruited patients during consultation, and beverage consumption over the previous 24 hours was reported at two different times. Warning signs were defined according to the 2009 WHO guidelines. RESULTS: GPs included 174 patients from April to July 2019. Average oral hydration volume was 1863 mL and 1944 mL, at the 1st and 2nd medical consultations, respectively. Water was the most wide consumed liquid. Drinking at least 5 glasses of liquid was significantly associated with fewer clinical warning signs at the 1st medical consultation (p = 0.044). CONCLUSIONS: Sufficient hydration volume could prevent dengue warning signs. Further studies with standardized measurement of hydration would be needed.

Cerebellar syndrome associated with legionellosis: A case report and literature review.

INTRODUCTION: Legionnaire's disease is a community-acquired pneumonia caused by the Gram-negative bacterium Legionella pneumophila. This disease is often associated with neurological symptoms, the clinical presentation of which can be very varied. CASE REPORT: We report a 47-year-old female patient who developed Legionnaires' disease with cerebellar symptoms (ataxia, dysarthria and hypermetria). Laboratory tests revealed a biological inflammatory syndrome. The cerebrospinal fluid was sterile. Urinary antigen test and serology were positive for L. pneumophila. An interstitial syndrome of the right upper lobe was detected on chest computed tomography (CT) scan. Brain imaging (magnetic resonance imaging and CT angiography) showed no abnormalities. The outcome was favourable after treatment with spiramycin, levofloxacin and corticosteroids. DISCUSSION: Few cases only (n=110) of Legionnaires' disease with cerebellar symptoms have been reported in the literature. The pathogenic mechanism behind neurological dysfunction in patients with Legionnaires' disease is unknown. Neurological symptoms improve with antibiotic therapy and corticosteroids. Extra-pulmonary forms of Legionnaires' disease are frequent, with neurological symptoms being the most common symptoms. Cerebellar dysfunction may be underestimated and requires appropriate management with antibiotic therapy and corticosteroid therapy. Recommendations for the management of Legionnaire's disease with severe extra-pulmonary symptoms are needed.

Epidemiology of cutaneous malignant melanoma in Reunion Island.

INTRODUCTION: The incidence of cutaneous malignant melanoma (CMM) is increasing worldwide. The aim of this study was to evaluate the epidemiology of CMM in Reunion Island, a French overseas department whose population is characterized by high ethnic diversity and high exposure to ultraviolet radiation. METHODS: This cross-sectional study examined all cases of in situ CMM and invasive CMM diagnosed between 1 January and 31 December 2015 in the Reunionese population. RESULTS: One hundred and three new cases of CMM were recorded in Reunion Island in 2015: 33 cases of in situ CMM and 70 cases of invasive CMM. The sex ratio of men to women was 1.3 and 80% of patients had a fair skin phototype (Fitzpatrick skin phototype≤III). Age-standardized incidence rates of invasive CMM for all skin phototypes combined were 6.7/100,000 person-years (PY) in women and 5.3/100,000 PY in men. Crude incidence rates of invasive CMM for fair skin phototypes were estimated to be over 21/100,000 PY in women and over 25/100,000 PY in men. CONCLUSIONS: In Reunion Island, the incidence of CMM in the population with fair skin phototype is very high. Primary and secondary prevention measures should be reinforced and tailored to the local context.

Prevalence and risk factors for gonococcal infection in Reunion Island.

OBJECTIVE: To determine the prevalence and risk factors for gonococcal infection, and the resistance profile of Neisseria gonorrhoeae (NG) in Reunion Island. PATIENTS AND METHODS: All patients who visited the four sexually transmitted infection (STI) clinics of Reunion Island between January 2017 and December 2018 were screened by multiplex polymerase chain reaction. Data on patient characteristics were collected using a self-administered questionnaire (reason for screening, marital status, risk-taking behaviors, place of birth, employment status, type of health care coverage, sexual orientation, number of sexual partners, occurrence of extra-marital relationships, history of STIs, and symptomatology. Precarity was defined as being unemployed and/or receiving universal health insurance). RESULTS: The prevalence of NG (n=4289) in the screened population was 2.8% (95% CI [2.3-3.3]). Minors were especially at-risk (4.4% (95% CI [2.6-7])) and especially girls (5.6% (95% CI [3.2-8.9])). The prevalence observed in the homosexual population was 4.0% [2.6-5.9]. Gonococcal infection was asymptomatic in 56 (69%) patients. For all infection sites, the main risk factors were male minors (P=0.019), individuals living in conditions of precarity (P=0.023), individuals co-infected with chlamydia (P<0.001) or syphilis (P<0.001), and individuals of foreign origin (P=0.006). No NG strain was resistant to ceftriaxone. Strains were resistant to penicillin G, ciprofloxacin, and azithromycin in 22% (20/91), 38% (35/91), and 1% (1/91) of cases, respectively. CONCLUSION: The prevalence of NG in patients visiting STI clinics in Reunion Island is particularly high among minors. Prevention programs targeting this population should be reinforced and screening should be facilitated in school settings.

High prevalence of syphilis in women, minors and precarious patients: a cross-sectional study in a Reunion Island sexually transmitted infection clinic, 2017-2020.

BACKGROUND: Syphilis is a sexually transmitted infection (STI) with a global prevalence estimated at 0.5% in 2012. Syphilis has been on the rise among men who have sex with men (MSM) in high-income countries and remains at endemic levels in low- and middle-income countries. This trend, however, has not been observed in Reunion Island. OBJECTIVES: To determine the prevalence, clinical characteristics and risk factors of syphilis in at-risk patients visiting the South Reunion STI clinic in Reunion Island. METHODS: This monocentric cross-sectional study included all patients who visited our STI clinic between 2017 and 2020. Syphilis serology was performed on all included patients, and data were collected using a standardized self-administered questionnaire. RESULTS: Over the 3-year study period, 2593 patients were enrolled. The prevalence of syphilis was 7.52% (n = 195, 95% CI, 6.50-8.65%) in the overall study population, 11.76% (n = 18, 95% CI, 6.97-18.59%) in minors (aged under 18 years) and 36.36% (n = 16, 95% CI, 21-59%) in pregnant women. The risk factors identified in multivariate analysis were being female [adjusted Prevalence Ratio (aPR) 1.85, 95% CI, 1.10-3.11], being MSM (aPR 2.87, 95% CI, 1.71-4.80), being aged under 18 years (aPR 3.54, 95% CI, 1.90-6.57), living in precarious conditions [aPR 3.12, 95% CI, 2.11-4.62] and being born in Reunion Island (aPR 2.43, 95% CI, 1.42-4.13). The clinical presentation was heterogeneous (plaques and papules, chancre, atypical ulcerations, multiple ulcerations, condyloma lata, etc.). CONCLUSIONS: These findings suggest a high prevalence of syphilis in at-risk patients visiting our STI clinic. Unlike the situation in other high-income countries, the people most at risk of syphilis in Reunion Island are local-born residents, minors, women and precarious patients. This is a source of concern, especially given the risk of resurgence of congenital syphilis on the island.

Minors are the most affected by Chlamydia trachomatis in Reunion Island: A cross-sectional study, 2017-2018.

OBJECTIVES: To determine the prevalence of Chlamydia trachomatis (CT) in the population screened at sexually transmitted infection (STI) clinics on Reunion Island and to identify risk factors for CT infection. PATIENTS AND METHODS: This cross-sectional multicenter study was conducted in 2017-2018. Data were obtained from self-administered questionnaires and multiplex PCR tests. RESULTS: The overall prevalence of CT in the screened population was 8.6% (95% CI 7.7-9.5%). The prevalence of urogenital CT was highest in women under 18 (13.2%, 95% CI 9.3-18.1%) and in men who have sex with men under 18 (13.3%, 95% CI 1.6-48.2%). Risk factors associated with CT infection in multivariate analysis were: female gender, being born in Reunion Island, having had a large number of sexual partners in the past year, and being co-infected with another STI. CONCLUSIONS: The prevalence of CT in the screened population is higher in Reunion Island than in mainland France, especially in minors. Prevention campaigns targeting minors should be strengthened.

Azithromycin resistance in Treponema pallidum in Reunion Island: A cross-sectional study.

OBJECTIVE: Since the beginning of the 21st century, Reunion Island has experienced a syphilis epidemic. Infected patients are mostly heterosexual, with a high proportion of women, suggesting that congenital syphilis is present on the island. To determine whether azithromycin can be used for mass treatment of syphilis on Reunion Island, we assessed the prevalence of macrolide resistance in Treponema pallidum (TP). METHODS: This monocentric cross-sectional study was conducted at the Reunion Island University Hospital. Samples were collected from lesions suggestive of primary or secondary syphilis. Samples positive for TP by multiplex polymerase chain reaction (PCR) were sent to the French National Reference Centre (NRC) for further analysis. Nested PCR-tpp47 was performed on these samples for detection of TP-DNA; 23s rRNA was amplified by PCR in confirmed positive samples. The Restriction Fragment Length Polymorphism (RFLP) technique was performed on samples with amplified 23s rRNA for detection of the A2058G mutation. RESULTS: A total of 129 samples were collected from 119 patients. Of these, 18 tested positive for TP using multiplex PCR and were sent to the NRC. Fifteen (83.3%) of the 18 samples were confirmed positive by nested PCR-tpp47, and 23s rRNA was amplified in only 7 (38.9%) samples. Azithromycin resistance was detected in all TP strains with amplified 23s rRNA. CONCLUSION: Amplification of 23s rRNA was successful in only 7 TP strains, all of which displayed resistance to macrolides. Keeping in mind the small sample size of our study, this suggests that azithromycin should not be used for mass treatment of syphilis in Reunion Island.

Prevalence of urogenital, anal, and pharyngeal infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium: a cross-sectional study in Reunion island.

BACKGROUND: Recommendations for sexually transmitted infection (STI) screening vary significantly across countries. This study evaluated the prevalence of urogenital and extragenital infections with Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Mycoplasma genitalium (MG) in patients visiting a French STI clinic in the Indian Ocean region to determine whether current STI screening practices should be updated. METHODS: This cross-sectional study examined all patients who visited the STI clinic between 2014 and 2015. Triplex polymerase chain reaction screening for CT, NG, and MG was performed on urine, vaginal, pharyngeal, and anal specimens (FTD Urethritis Basic Kit, Fast Track Diagnostics, Luxembourg). RESULTS: Of the 851 patients enrolled in the study, 367 were women (367/851, 43.2%) and 484 were men (484/851, 56.0%). Overall, 826 urogenital specimens (826/851, 97.1%), 606 pharyngeal specimens (606/851, 71.2%), and 127 anal specimens (127/851, 14.9%) were taken from enrolled patients. The prevalence of urogenital CT and MG was high in women ≤25 years (19/186, 10.21%; 5/186, 2.69%) and in men who have sex with women ≤30 years (16/212, 7.54%; 5/212, 2.36%). Among patients with urogenital CT infection, 13.7% (7/51) had urethritis. All patients with urogenital MG infection were asymptomatic. Men who have sex with men had a high prevalence of pharyngeal CT (2/45, 4.44%) and NG (3/44, 6.81%) and a high prevalence of anal CT (2/27, 7.41%), NG (2/27, 7.40%), and MG (1/27, 3.70%). After excluding patients with concomitant urogenital infection, extragenital infections with at least 1 of the 3 pathogens were found in 20 swabs (20/91, 21.9%) taken from 16 patients (16/81, 19.7%), all of them asymptomatic. CONCLUSIONS: Routine multisite screening for CT, NG, and MG should be performed to mitigate the transmission of STIs in high-risk sexually active populations.

[Prevalence and Risk Factors of Chlamydia Trachomatis Infection Among Women Consulting at the Sexually Transmitted Infection Centre in la Reunion: A Cross-Sectional Study]. / Prévalence et Déterminants de L'infection à Chlamydia Trachomatis chez les Femmes Consultant en Centres de Dépistage à la Réunion: Une Étude Transversale.

Introduction: Chlamydia trachomatis (CT) infection is the commonest bacterial sexually transmitted infection (STI) in the world. Often asymptomatic, it can lead to significant complications in women. In France, since 2003, systematic screening for CT in STI center has been recommended for women aged less than 25 year. The main objective of this study was to determine CT prevalence in patients attending STI centers in Reunion Island. The second objective was to explore the determinants of this infection. Method: A cross-sectional survey using an anonymous questionnaire was conducted among women attending STI center in two hospitals in western and southern Reunion Island during one year. All women who had performed a CT PCR, based on vaginal self-swabs, were included. Results: Among the 620 patients tested, the prevalence of infection was 6.6% (95% CI [4.7-8.6]). By age group, the highest prevalence was between 12 and 17 years with 14.3% positive tests compared to 7.5% and 3.9% respectively in 18-24 and 25-67 year age group (p = 0.003). The risk factors for CT were a young age (p = 0.02), a first sexual intercourse between 11 and 14 years old (p = 0.01), lack of previous STI screening history (p = 0.02), and the following motives for seeking screening: "partner unfaithfulness" (p = 0.01) and "infected partner" (p = 0.02). Conclusion: This study highlights the high prevalence of CT among Reunionese minors. A more systematic screening and a reinforcement of STI awareness among young people in Reunion Island seem to be essential.

Emergence of murine typhus in La Réunion, France, 2012-2017.

OBJECTIVE: Murine typhus (MT) is an acute zoonosis caused by Rickettsia typhi, a flea-borne rickettsiosis. The first autochthonous case was reported in 2012. Once autochthonous transmission of Rickettsia typhi was proven, we performed a prospective study to describe and raise awareness of this often-misdiagnosed disease among physicians. PATIENTS AND METHODS: We performed a prospective observational study of MT cases in La Réunion from 2012 to 2017. MT cases were defined as clinically compatible illnesses with a specific positive serology and/or PCR. RESULTS: Sixty-one confirmed cases were collected. The main clinical features were prolonged fever (90%), asthenia (87%), and headaches (79%). The main biological abnormalities were elevated liver enzymes (84%) and thrombopenia (75%). Renal function was normal in 90% of cases; it was an important feature because leptospirosis is a frequent cause of acute renal failure. A seasonal factor was observed with 79% of cases reported in the warm season and most of them in the west and south of the island (i.e., the dry areas). CONCLUSION: MT is an emerging disease in La Réunion, and local conditions could lead to an endemic situation. Cases of acute undifferentiated fever with headaches should guide to the diagnosis of MT especially in the warm season and dry areas. Leptospirosis is an alternative diagnosis, which differs from MT by its epidemiological characteristics and by the associated frequent renal dysfunction.