[Update on Dermatobia hominis: South American furuncular myiasis]. / Le point sur Dermatobia hominis: myiase "furonculeuse" d'Amérique du Sud.

Furuncular myiasis is an infestation of the skin caused by Dermatobia hominis larvae known as "ver macaque" in French Guyana, "berne" in Brazil, "torsalo" in Colombia, or "human botfly" in English-language literature. It has identical features in man and domestic mammals. The primary lesion consists of a boil-like inflammatory papule with a central punctum exuding a serosanguinous discharge. The respiratory sinus of the D. hominis larvae may be visible through the punctum. Myiasis secondary to D. hominis accounts for 10% of imported tropical dermatosis observed in Paris. Diagnosis of furuncular myiasis should be considered in any patient with a history of travel or residence in an endemic area. Treatment depends mainly on mechanical removal that may be facilitated by injection of lidocaine into the lesion or prior application of a 1% solution of ivermectin.

[Cutaneous-mucosal paracoccidio-domycosis: the first case diagnosed in French Guiana]. / Paracoccidioïdomycose cutanéo-muqueuse: premier cas diagnostiqué en Guyane Française.

INTRODUCTION: Paracoccidio-domycosisis a deep mycosis due to a dimorphic fungus:Paracoccidioides brasiliensis. The principle endemic country is Brazil. We describe the first case of paracoccidio-domycosis, in its cutaneous-mucosal form, diagnosed in French Guiana. OBSERVATION: A 20 year-old Brazilian man, having mover to French Guiana a few months earlier, presented with multiple disseminated cutaneous lesions, predominating on the face, and composed of multiple nodules and two ulcerations. The clinical examination also revealed voluminous superficial lymph nodes and ulcerations of the pharynx and larynx. Direct examination, anatomopathology and culture of cutaneous biopsies revealed specific images of Paracoccidioides brasiliensis. HIV serology was negative. Treatment combining cotrimoxazole and itraconazole eliminated the lesions in one month. DISCUSSION: Because the patient had just moved to Guiana, this observation probably corresponded to an imported disease. The principle differential diagnosis was leishmaniosis.

Comparative prevalence, incidence and short-term prognosis of cervical squamous intraepithelial lesions amongst HIV-positive and HIV-negative women.

OBJECTIVE: To investigate the impact of HIV infection on the prevalence, incidence and short-term prognosis of squamous intraepithelial lesions (SIL), in a prospective study with 1-year follow-up. METHODS: Between 1993 and 1995, 271 HIV-positive and 171 HIV-negative women at high risk of HIV infection were recruited, 365 (82.6%) of whom completed the 1-year follow-up. The women underwent a Papanicolaou smear test at inclusion and at 6 and 12 months. Human papillomavirus (HPV) was detected at inclusion by Southern blot and PCR. RESULTS: The SIL prevalence ranged from 7.5% for HIV-negative to 31.3% for HIV-positive women with CD4 cell counts < 500 x 10(6)/l (P < 0.001). Other factors associated independently and significantly with SIL prevalence were HPV-16, 18, 33 and related types, HPV-31, -35, -39 and related types, lifetime number of partners, younger age, past history of SIL and lack of past cervical screening. The SIL incidence ranged from 4.9% in HIV-negative women to 27% in HIV-positive women with CD4 cells < 500 x 10(6)/l (P < 0.001). Progression from low- to high-grade SIL during follow-up was detected in 38.1% of HIV-positive women with CD4 cells < or = 500 x 10(6)/l but in no HIV-negative nor HIV-positive women with CD4 cells > 500 x 10(6)/l. HPV-16, 18, 33 and related types were also associated with higher incidence of SIL and progression from low- to high-grade SIL. CONCLUSION: HIV-induced immunodeficiency is associated with high prevalence, incidence and persistence/progression of SIL. A pejorative influence of HIV infection without marked immunodeficiency is less clear. HIV-positive women with SIL may thus benefit from early treatment when a useful immune response is still present.

Virus excretion in the cervicovaginal secretions of pregnant and nonpregnant HIV-infected women.

In order to estimate the prevalence of viral excretion in cervicovaginal secretions, we made a cross-sectional study of 55 HIV-infected women. The patient population was diverse, including pregnant and nonpregnant women in different disease stages from three centers. Virus replication was found in the cell-free supernatant from 12 of 55 cervicovaginal samples (21.8%) by coculture on the CD4-positive cell line CEM-C113. In addition, cell-associated virus was detected in five of a subgroup of 22 samples testing negatively on cell-free supernatant. The prevalence of HIV in the cell-free supernatant was not related to disease stage, zidovudine therapy, transmission group, or history of sexually transmitted diseases. Excretion of HIV was significantly higher in our population of pregnant women (eight of 21, 38%) compared with an unmatched group of nonpregnant women (four of 34, 11.8%; p = 0.04). These results provide evidence of cell-free virus shedding as well as the presence of cell-associated virus in the genital secretions of HIV-infected women.

Disseminated cutaneous leishmaniasis due to Leishmania guyanensis: case of a patient with 425 lesions.

Disseminated cutaneous leishmaniasis is characterized by the presence of a large (> or =10) number of lesions at several anatomic sites (head, limbs, and trunk). Most of the lesions are small, papular, and appear simultaneously with or secondarily to one or several ulcerated lesions of localized cutaneous leishmaniasis. We report the first case of disseminated cutaneous leishmaniasis in French Guiana. It concerns a 24-year-old woman who tested negative for human immunodeficiency virus (HIV). The disease began with three lesions that became ulcerated. One week later, multiple papulo-nodular lesions appeared. We counted a total of 425 lesions. Leishmania were observed in the lesions. The species involved was L. guyanensis, which has never been described in a case of disseminated cutaneous leishmaniasis. The patient was rapidly cured by a single course of pentamidine. Disseminated cutaneous leishmaniasis should be distinguished from other types of leishmaniasis with multiple lesions. These include anergic diffuse cutaneous leishmaniasis, post-kala-azar leishmaniasis, and leishmaniasis associated with HIV infection.

Epidemiological aspects of human cutaneous leishmaniasis in French Guiana.

A follow-up study of 219 patients infected with parasitologically confirmed cutaneous leishmaniasis in French Guiana was made between 1981 and 1987. Cutaneous leishmaniasis appeared to be common in young male adults entering the forest for professional activities (84.2% of the cases). The lesions were generally of the classical ulcerative type. They were limited to the skin and preferentially located on the legs and forearms (20.7% and 19.8% respectively). Most of the cases (86.6%) represented primary infections, but 6.8% had a recurrent lesion at the site of an old, previously cured lesion.

Delayed culture of Leishmania in skin biopsies.

Between January 1997 and October 1998, 16 skin biopsies collected from 13 patients with cutaneous leishmaniasis in French Guiana were inoculated in culture medium after travel for 3-17 days from the place of biopsy to the culture laboratory in France. Each biopsy fragment was introduced near the flame of a Bunsen burner into the transport medium (RPMI medium supplemented with 10% fetal calf serum) which was maintained at ambient temperature during postal delivery to France. In France the biopsies were ground in sterile saline before being inoculated into NNN culture tubes. The cultures were incubated at 25 degrees C and subcultured every week until the 5th week. The cultures were positive in 9 cases, remained negative in 4, and were contaminated in 3 cases. Positive results were obtained at all seasons and for 3 different Leishmania species. The study indicates that delayed culture can yield useful results from biopsies taken in field conditions.

Killer cells in human cutaneous leishmaniasis.

In French Guiana, American cutaneous leishmaniasis is localized in the skin. The host response appears to be effective since few extra- or intracellular organisms can be found in tissue lesions, and we never observed any cutaneous dissemination or visceral involvement. However, this response is not fully effective since lesions may last for months. By using immunoperoxidase techniques and monoclonal antibodies directed against various cell populations, we examined the local immune response in skin biopsies. We found a high percentage of cells with the K/NK phenotype, a variable but usually high percentage of cells with the T cell phenotype bearing TAC receptors, and moderate numbers of monocytes and B cells. These results suggest that K/NK cells could play a role in the local control of parasite dissemination.

Cell-matrix patterns in the cutaneous lesion of chromomycosis.

Chromomycosis is a chronic fungal infection characterized by dermal fibrosis with persisting fungi in situ, generally leading to a verrucous skin lesion. The absence of good clinical results under specific treatment suggests irreversibility of the fibrotic lesion. Frozen and paraffin-embedded skin biopsies of eleven patients with chromomycosis due to Phialophora pedrosoi were studied by immunohistochemistry and electron microscopy. Distinct cell-matrix patterns were found in different tissue localizations: neutrophilic abscesses with oedema and necrotic keratinocytes in the epidermis; dense connective matrix around inflammatory infiltrates, mainly composed of macrophages and giant cells, and organized granuloma in the dermis. Active fibroblasts and mast cells were constantly observed. The inability of fibrotic tissue to be remodelled seems correlated to the nature and the organization of the matrix components but, the factors triggering the initial fibrogenic events remain to be characterized.

Seasonal fluctuations of incubation, healing delays, and clinical presentation of cutaneous leishmaniasis in French Guiana.

An investigation was conducted to determine whether seasonal variations affected the development of cutaneous leishmaniasis. Data from 499 cases treated between July 1994 and December 1998 were analyzed. The interval between infection and consultation and between treatment and clinical cure varied significantly between cases with an incubation period during the dry season compared with the rainy season (P < 0.001). When the incubation period occurred during the dry season, the standard pentamidine isethionate treatment seemed to be less effective (i.e.. the odds ratio for failure was 1.9 [1.1-3.4], P = 0.01). The presence of lymphangitis was more frequent during the dry season (i.e., the odds ratio was 0.26 [0.15-0.45], P < 0.001). These results suggested that the observed seasonal variations were due to variations in the host/parasite balance. Converging indirect elements that suggest a role for variations in solar ultraviolet radiation are discussed.

[Prurigo in tropical area. Importance of its association with HIV infection]. / Le prurigo en milieu tropical. Importance de son association avec l'infection à VIH.

The term prurigo applies to a classic chronic skin disease of children (P. strophulus) which is becoming found very seldom in developed countries, but remains extraordinarily prevalent in tropical areas. This striking geographical distribution relies on its ectoparasitic origin. Some peculiar aspects of prurigo, observed in French Guyana (South America), are reported. The original point is a new aspect of adult acquired prurigo, associated with HIV infection, which appears to be one of the features characteristic of tropical AIDS. This HIV associated prurigo (HAP) is the revelating event, in as high as 20% of HIV infected people, significatively those with less than 200 CD4 cells. HAP appears as a marker of HIV infection with poor sensitivity, but much higher specificity (92%), with no correlation with acquisition's risk factors. Just like infantile prurigo, HAP can be considered an arthropod bite reaction which seems to be enhanced in HIV infected people living in tropical environment.

[Diagnosis of Mycobacterium ulcerans infection by PCR: report of 3 cases observed in French Guiana]. / Diagnostic par PCR de l'infection due à Mycobacterium ulcerans: à propos de trois cas observés en Guyane Française.

Mycobacterium ulcerans infection is the third most important mycobacterial infection in the world. It has been described in many different countries including French Guiana. The diagnosis of M. ulcerans infection by culture is often difficult because culture is hard to perform in endemic areas and their sensitivity is not reliable. As a result the diagnosis of this infection is often delayed. However, molecular methods are now available to diagnose rapidly infections by M. ulcerans and distinguish it from other mycobacteria. We report three cases of skin infection due to M. ulcerans observed in French Guiana. Diagnosis was initially made by polymerase chain reaction and was confirmed later by culture (in two patients) and inoculation to mice (in one patient). A faster diagnosis of M. ulcerans infection should lead to a better prognosis of this infection.

[A case of coinfection by Balantidium coli and HIV in French Guiana]. / Un cas de co-infection par Balantidium coli et VIH en Guyane Française.

A case of balantidial dysentery is reported in a patient infected with the HIV in French Guiana. This case is the first described in medical literature. The patient presented also a disseminated histoplasmosis. Immunosuppression probably favoured the evolution of asymptomatic carriage to clinical dysentery. This clinical case did not present any complications. Treatment with doxycycline had to be carried out for 20 days in order to obtain a clinical and parasitological cure.

[Local administration of ivermectin for the treatment of Cochliomyia hominivorax's myiasis]. / Traitement des myiases dues à Cochliomyia hominivorax par application locale d'ivermectine.

Myiasis with Cochliomyia homonivorax induce sensitive and nauseating cutaneous ulcerations. The usual treatment is limited to the mechanical extraction of the larvae. The authors have made a report on the treatment of C. hominivorax by local application of ivermectin. The use of this molecule paralyses and then kills the larvae. This allows rapid alleviation of pain and makes the extraction of the larvae easier.

[Effectiveness of 20% salicylated vaseline in the treatment of profuse tungiasis. Report of 8 cases in French Guiana]. / Efficacité de la vaseline salicylée à 20% dans le traitement des tungoses profuses. A propos de huit observations en Guyane Française.

The treatment of tungiasis involves the mechanic extraction of the gravid females of Tunga penetrans. We have observed on 8 patients profuse tungiasis diagnosed in the centre hospitalier de Cayenne. We have carried out different types of treatment, including the occlusive application of 20% of salicylated vaseline during 12 or 24 hours. This procedure causes the death of the parasites and facilitates their extraction.

[Leishmania (Viannia) braziliensis Vianna, 1911 in French Guiana. Clinical, therapeutic and epidemiological considerations in the ninth human diagnosed case]. / Leishmania (Viannia) braziliensis Vianna, 1911 en Guyane française. Considérations cliniques, thérapeutiques et épidémiologiques à propos du neuvième cas humain diagnostiqué.

The authors report the ninth case of cutaneous Leishmaniasis without mucosal involvement due to Leishmania (Viannia) braziliensis (isoenzymatic profile related to zymodeme MON-44) diagnosed in a legionnaire who recently arrived in French Guiana. The skin lesion as a single ulcerated nodule of the dorsum of the left ringfinger was cured after two courses of four intramuscular injections of pentamidine isothionate (total posology of pentamidine-base: 16.6 mg/kg). The transmission occurred during nocturnal trekking in forest and swamps just behind the coastal belt at Degrad Saramaka (7 km South of Kourou). In French Guiana, the good level of medical care and the early treatment of the majority of the cases of Leishmaniasis may explain the rarity of mucosal lesions. Since the clinical aspect of the lesion is not sufficient to prejudge the identity of the causative species, it is necessary to perform cultivation of Leishmania for iso-enzymatic identification. The adaptation of pentamidine doses and long term follow up of patients infected by L. (V.) braziliensis could be defined more precisely.

[Disseminated histoplasmosis: 2 cases in patients with human immunodeficiency virus infection in French Guiana]. / Histoplasmose disséminée: deux cas chez des patients infectés par le virus de l'immunodéficience humaine (VIH) en Guyane française.

The authors report two cases of disseminated histoplasmosis occurring in HIV-infected patients living in French Guiana. The first case was an acute disseminated histoplasmosis with a rapid fatal evolution. The second case was diagnosed on a mucosal localisation, and improved under itraconazole therapy. These two cases show the diversity of the clinical course of this opportunistic infection. The authors focus on the difficulty of the diagnosis and the need for direct microscopic examination to identify histoplasma and to enable a swift therapeutic intervention.

[Histoplasmosis due to Histoplasma capsulatum capsulatum and HIV infection]. / Histoplasmose à Histoplasma capsulatum capsulatum et infection à VIH.

PURPOSE: Histoplasmosis due to Histoplasma capsulatum is a granulomatous fungic infection which appears opportunistic and disseminated in immunocompromised patients, especially among HIV patients in whom it can lead to death. Histoplasmosis is endemic in numerous areas worldwide, but in Europe most of the cases reported are imported. We describe the clinical features and the available diagnosis methods issued from our experience in French Guyana. METHODS: Contamination occurs by inhalation of spores contained in dust. Most endemic areas are located on the American continent, including the French West Indies, where the incidence of histoplasmosis among HIV patients in French Guyana varies from 1.2 to 2.2% per year. In non-immunocompromised patients, histoplasmosis is asymptomatic most of the time. In HIV patients, the disseminated form is common and may occur many years after exposure to the fungus. RESULTS: Non-specific symptoms, similar to those of either tuberculosis or other opportunistic infections, may reveal disseminated histoplasmosis in patients with AIDS. Early treatment (amphotericin B or itraconazole) is effective; however, it should be followed by a lifelong antifungic treatment (itraconazole) to prevent relapse. CONCLUSION: The infection should be suspected in any febrile HIV-infected patient with CD4 blood cell count < 200/mm3, if he/she ever travelled in an endemic zone. Direct examination of smear relating to clinical symptoms help guide diagnosis, while culture will confirm it after at least 4 weeks. Efficient serologic techniques for HIV-infected patients are not available in Europe.