Opportunistic tropical infections in immunosuppressed patients.

Autoimmune and autoinflammatory diseases are associated with severe morbidity, and represent an impactful health and economic burden worldwide. The treatment of these diseases can include a course with detrimental side effects. Immunosuppression increases the risk of opportunistic infections, but in some cases, the abrupt discontinuation of these medications can result in immune reconstitution inflammatory syndrome. Special attention must be directed to endemic tropical infections, such as leishmaniasis, Chagas disease, malaria, arbovirosis, yellow fever, leprosy, paracoccidioidomycosis, disseminated strongyloidiasis, and ectoparasitosis. These endemic diseases of developing countries can be considered as possible emerging diseases in developed regions partially because of environmental factors and migration. In the present article, we aim to review the evidence-based aspects of the most important opportunistic tropical infections in immunosuppressed patients. We also aim to review the important aspects of vaccination, chemical prophylaxis, and treatment for these infections in people with medication-induced immunosuppression.

Comportamiento de los estados reaccionales de la lepra en la proviencia Camagïeu. Cuba / No disponible

Se realizó un estudio observacional descriptivo prospectivo con el objetivo de caracterizar el comportamiento de los estados reaccionales de la lepra en la provincia Camagüey, en el período comprendido del 1ero de Abril del 2014 al 30 de Marzo de 2015. El universo de estudio estuvo constituido por todos los pacientes con diagnóstico de estados reaccionales. La mayoría de los pacientes se encontraban en las edades de 40 años y más, con predominio del sexo masculino. El eritema nudoso leproso se presentó con mayor frecuencia. La mitad de los enfermos presentó la reacción leprótica en el primer semestre de diagnosticada la enfermedad y las formas clínicas leves fueron las de mayor incidencia. La totalidad de los pacientes presentó malestar general. Las caries dentales y la faringo- amigdalitis estreptocóccica fueron las enfermedades asociadas más frecuentes. La afectación psicológica se presentó en más de la mitad de los enfermos. Las reacciones lepróticas fueron causa de discapacidad en más de la cuarta parte de los pacientes. La totalidad de ellos fue tratada según lo normado en el Programa Nacional de Control de la lepra en Cuba, y solo un enfermo presentó efecto adverso

A prospective, observational, descriptive study was carried out to characterize the behavior of leprosy reactive states in the province of Camagüey during the period from April 1, 2015 to March 30, 2016. The aim of the study was to evaluate all of the patients with a diagnosis of reactional states (leprosy reactions). The majority of the patients were in the ages of 40 years and above and the majority were male. Erythema nodosum leprosum was the most frequent episode. Half of the patients presented the leprosy reaction in the first semester after diagnosis of the disease and the mild clinical forms presented the highest incidence of reactions. All patients presented general malaise. Dental caries and streptococcal pharyngitis were the most common associated diseases. Psychological involvement occurred in more than half of the patients and leprosy reactions were the cause of disability in more than a quarter of patients. All of them were treated as recommended in the National Leprosy Control Program in Cuba, and only one patient had an adverse effect

[Nontuberculous mycobacterial infections of the lung]. / Atypische Mykobakteriose der Lunge.

Nontuberculous mycobacterium (NTM) species are mycobacterial species other than those belonging to the Mycobacterium tuberculosis complex and M. leprae. NTM are generally free-living organisms that are ubiquitous in the environment. Pulmonary disease, especially in older persons with and without underlying lung disease, is caused primarily by M. avium complex (MAC) and M. kansasii. The symptoms and signs of MAC lung disease are variable and not specific, but include cough, malaise, weakness, dyspnoea, chest discomfort and occasionally hemoptoe. Two major clinical presentations include disease in those with underlying lung disease, primarily white, middle-aged or elderly men - often alcoholics and/or smokers with underlying chronic obstructive lung disease, patients in whom MAC develops in areas of prior bronchiectasis, and patients with cystic fibrosis; and those without known underlying lung disease, including non-smoking women over age 50 who have interstitial patterns on chest radiography. M. kansasii infections are endemic in cities with infected tap water. Symptoms of the M. kansasii lung disease resemble to tuberculosis. M. abszessus is the most pathogenic rapid growing Mycobacterium which causes pulmonary infection. The American Thoracic Society and Infectious Disease Society of America's diagnostic criteria for nontuberculous mycobacterial pulmonary infections include both imaging studies consistent with pulmonary disease and recurrent isolation of mycobacteria from sputum or isolated from at least one bronchial wash in a symptomatic patient. For treatment of MAC lung disease we recommend depending on severity and susceptibility testing a three to four drug treatment with a macrolide, rifampicin and ethambutol and for M. kansasii a treatment with Isoniazid, rifampicin and ethambutol. Surgical management only plays a role in rare and special cases. Treatment should be continued until sputum cultures are consecutively negative for at least one year.

[Cutaneous and soft skin infections due to non-tuberculous mycobacteria]. / Infecciones cutáneas y de partes blandas por micobacterias no tuberculosas.

The frequency of isolation as well as the number of species of non-tuberculous mycobacteria (NTM) has increased in the last years. Nearly every pathogenic species of NTM may cause skin and soft tissue infections, but rapidly growing mycobacteria (Mycobacterium fortuitum, Mycobacterium chelonae and Mycobacterium abscessus), Mycobacterium marinum and Mycobacterium ulcerans are the most commonly involved. Many of these cutaneous mycobacteriosis, such as rapidly growing mycobacteria, M. marinum, Mycobacterium avium complex, Mycobacterium kansasii or Mycobacterium xenopi are world-wide distributed. In contrast, some others have a specific geographical distribution. This is the case of M. ulcerans, which causes a cutaneous diseases endemic of Central and West Africa (Buruli ulcer) and Australia (Bairnsdale ulcer), being the third mycobacterial infection after tuberculosis and leprosy. Cutaneous mycobacteriosis usually appear either after contact of traumatic or surgical wounds with water or other contaminated products, or, secondarily, as a consequence of a disseminated mycobacterial disease, especially among immunosuppressed patients. For an early diagnosis, it is necessary to maintain a high degree of suspicion in patients with chronic cutaneous diseases and a history of trauma, risk exposure and negative results of conventional microbiological studies. In general, individualized susceptibility testing is not recommended for most NTM infections, except for some species, and in case of therapeutic failure. Treatment includes a combination of different antimicrobial agents, but it must be taken into account that NTM are resistant to conventional antituberculous drugs. Severe cases or those with deep tissues involvement could also be tributary of surgical resection.

[A very current aspect of the fate of infectious diseases: tuberculosis, leprosy and opportunistic mycobacteria]. / Un aspect très actuel du destin des maladies infectieuses: la tuberculose, la lèpre, les mycobactéries opportunistes.

The human mycobacterial diseases, such as tuberculosis and leprosy, are chronic infectious diseases and have been present for a long period of time with human beings. Clearly tuberculosis and leprosy have been on the wane long before effective therapy was introduced, each of them having a natural epidemic evolution, with onset, peak and decline. Such decline was apparently accelerating in recent decades, due to individual and collective measures aiming at controlling the diseases, and it gives the hope of their possible elimination in the early XXIe century. If for leprosy recent data seems to indicate a realistic hope, such one has been destroyed for tuberculosis, since worldwide reemergence of cases occurs, which was associated with non application of control measures and occurrence of the HIV infection. Such coinfection leads to immunodeficiency that increases the risk of tuberculosis and the development of disseminated opportunistic mycobacterioses, mostly due to M. avium. An increased persevering action in the control measures and the development of new ways of research on mycobacterial infections are even more necessary if one will master such devastating plaques.

[Infection by the human immunodeficiency virus (HIV) in French Guyana. Dermato-venereologic problems]. / L'infection par le virus de l'immunodéficience humaine (VIH) en Guyane Française. Problèmes dermato-vénéréologiques.

Dermato-venereal manifestations in HIV infection and its severe evolution stage, AIDS, is of particular importance in tropical zones: We may be suspicious of the viral infection and consequently to request serologic tests to confirm it. We get an explanation of the virus transmission during heterosexual relations by the frequent occurrence and importance of the genital manifestations, leading to consider AIDS as a true sexually transmitted disease. Beside the classical opportunistic infections, the authors draw the attention to three types of manifestations: prurigo, already well known in Haïti and Africa capillary dystrophies, already reported in Haïti donovanosis that, because its epidemiological and etiopathological peculiarities, should be listed within the possible opportunistic infection if we take into consideration the regional pathological environment. In an other correction, syphilis, lepra and cutaneous leishmaniasis have to be carefully monitored, because they are capable to evaluate unexpectedly in some immunodepressive diathesis. Importance of dermato-venereal pathology in black people in tropical zone is explained by the weakness of cutaneous corneal stratum, immunologic disorders linked up to accumulated parasitic pathologies, socio-cultural life with a sexuality without complex.

PIP: Cutaneous manifestations of AIDS in the 1st 91 cases diagnosed in French Guiana between 1982-October 1987 included 40 cases of candidiasis, 29 of prurigo, 13 of herpes simplex, 5 of trichomoniasis, 7 of human papilloma virus, 3 of shingles, 3 of donovanoses, and 1 of Kaposi's sarcoma. There were also 7 cases of seborrheic dermatitis, 6 of capillary dystrophies, and 1 of leucoplasia. 26 of the 40 cases of candidiasis were buccal or buccopharyngeal and 14 were vaginal. Such infections are intense, chronic, and easy to diagnose. Local treatment with Nystatin or Amphotericin B in solution for buccal cases and with imidazole derivatives for vaginal cases should be supplemented with systemic medications such as ketoconazole. Most herpes simplex cases are type 2 genital infections which may be chronic and extensive. A perfusion of Aciclovir usually gives good results in 5 or 6 days. Shingles during AIDS often has nonthoracic localizations; involves itching, pain, and burning sensations; is recurrent, perhaps on the contralateral side; and may leave scars. Sensitivity to Aciclovir is less than for herpes simplex. Human papilloma virus lesions that are not too large are treated locally. Although tuberculosis is in 2nd place after candidiasis among opportunistic infections in AIDS patients in French Guiana. Only 2 cases of cutaneous tuberculosis were observed. 3 cases of Donovanosis due to Calymmatobacterium granulomatis were observed, with 2 cases with 1 couple. Chronic prurigo has been observed frequently in AIDS patients in Africa and Haiti. Along with asthenia, polyadenopathies, and shingles, it is often an early sign of AIDS. The pruritus becomes more and more intense and the only treatment providing some relief is local corticotherapy. The dermatovenereal signs of AIDS in tropical environments should raise suspicions of the disease in undiagnosed cases, and they also provide an explanation for the high rate of heterosexual transmission in individuals with various disorders involving genital lesions. Some dermatological disorders common in French Guiana have not been observed in AIDS patients to date.