[Paradoxical reactions and responses during antibiotic treatment for Mycobacterium ulcerans infection (Buruli ulcer). Four cases from French Guiana]. / Réponses et réactions paradoxales au cours du traitement médicamenteux de l'infection à Mycobacterium ulcerans (ulcère de Buruli). Quatre observations en Guyane française.

BACKGROUND: In recent years, first-line therapy for Mycobacterium ulcerans infection in French Guiana has consisted of antibiotics active against this organism. Two regimens are used comprising rifampicin associated with clarithromycin or amikacin. PATIENTS AND METHODS: We describe four patients presenting apparent worsening of their lesions during treatment: ulceration of a nodular lesion in a 32-year-old woman and worsening of an ulcerated lesion in three patients aged 16, 27 and 79 years. DISCUSSION: In these 4 patients, we concluded that the symptoms were caused by a paradoxical response or a reaction, a phenomenon already described in tuberculosis and leprosy. Such worsening is transient and must not be misinterpreted as failure to respond to treatment. The most plausible pathophysiological hypothesis involves the re-emergence of potentially necrotizing cellular immunity secondary to the loss of mycolactone, a necrotizing and immunosuppressive toxin produced by M. ulcerans, resulting from the action of the antibiotics.

Skin and treponemal diseases among Asian domestic house-helpers in northern Saudi Arabia.

BACKGROUND: Asian domestic house-helpers in Saudi Arabia come from a different socioeconomic setting with a different disease pattern from that of their host country. This study reports the incidence of skin and treponemal diseases in this group seen at a referral hospital in northern Saudi Arabia. METHODS: The study was based on the analysis of the dermatologic and serologic examinations of 1520 domestic house-helpers during resident permit issue, and a retrospective study of clinical records of house-helpers with skin disorders. RESULTS: Routine examination revealed significant skin disease in 374 (24.6%) individuals, and the disease was transmissible in 126 (8.3%). Treponemal infection (5, 0.3%) and leprosy (1, 0.07%) were seen. Hand dermatitis and chicken pox were the most common causes of hospital attendance. Psychologic skin disorders included three cases of neurotic excoriations, two cases of delusion of parasitosis, and a case of dermatitis artefacta. CONCLUSIONS: The prevalence of transmissible skin diseases in Asian domestic house-helpers is low compared with that in their home countries. Excluding individuals with stigmata of atopic dermatitis from employment as house-helpers, adequate counselling will reduce the incidence of hand dermatitis and psychologic skin disorders. There is a need for continuous surveillance to prevent the introduction of skin diseases not normally seen in the native population.

Prevalence of human T cell lymphotropic virus (HTLV) types I and II and human immunodeficiency virus type 1 infections among persons with Hansen's disease in New York City.

One-hundred seven consecutive patients attending a New York Hansen's disease clinic from November 1990 through June 1991 were tested for retroviruses. This cohort included 58 patients diagnosed with Hansen's disease after the onset of the AIDS epidemic, 54 of whom immigrated to the United States before diagnosis of Hansen's disease (median, 7 years). The overall rate (1.9%) of human T cell lymphotropic virus (HTLV) type I infection was low. Two (3.6%) of 55 Caribbean-born patients had polymerase chain reaction (PCR)-documented HTLV-I infection, but this incidence was not higher than expected in persons without Hansen's disease. No patient had PCR-documented evidence of either HTLV-II or human immunodeficiency virus (HIV) type 1 infection. The low rate of HIV-1 among those studied was likely related to an absence of classic HIV risk behavior because about half of the cohort could have incubated Mycobacterium leprae for a prolonged period while infected with HIV-1.

The effects of World Health Organization chemotherapy on imported leprosy in Auckland, New Zealand, 1983-90.

Between January 1983 and December 1990 in Auckland, New Zealand, 87 patients (28 paucibacillary disease (PBD) and 59 multibacillary disease (MBD)) commenced WHO multidrug therapy (MDT). All were immigrants from the Pacific Islands (65) or Asia (22). A total of 57 patients had already received non-WHO regimens, some continuously, but often intermittently, for many years; 30 patients received WHO MDT only. By December 1990, 50 had completed treatment, with 1 relapse and 1 late reaction, both in patients with PBD treated with WHO MDT only. There have been no relapses in those treated with WHO MDT after prior leprosy treatment. In those with MBD, type II leprosy reactions were less common (16%) in those treated only with WHO MDT than in those treated continuously before 1983 with older regimens (64%). Type I leprosy reactions occurred in about 20% of both these groups. The bacterial index fell faster in those who had had a prolonged prior treatment beginning WHO MDT than in those starting WHO MDT as their initial leprosy chemotherapy. Overall we found WHO MDT was well accepted and the compliance good, but 13 patients (15%) left Auckland before treatment was completed and 6 (7%) during follow up.

Leprosy in Kuwait: an epidemiological study of new cases.

The latency of infection in leprosy is long so that new cases may present several years after emigration from endemic areas. This is of concern to the health authorities in Kuwait, since there is a sizeable immigrant population. An epidemiological study of new cases was, therefore, conducted to assess the extent of the leprosy problem. A total of 121 (99 male, 22 female) consecutive new leprosy patients were diagnosed nationwide over a six-year period (1983-1988). Over 95% of the patients were foreign born, emphasizing that the problem in Kuwait is mainly a reflection of immigration patterns. There were 74 cases of Asio-Indian origin, 13 Oriental and 34 Arab (including two Kuwaiti). This represents a respective mean incidence of the disease in Kuwaitis and other nationalities of 0.49 and 18.92 per 100,000 per year. Polar lepromatous (LL) leprosy was the most frequent type in the Arab group (44.1%) and polar tuberculoid (TT) the most frequent in the Asio-Indian group (37.8%). LL and borderline lepromatous (BL) types of leprosy were significantly more frequent in patients over 45-years-old and in females (P less than 0.05), contributing to the higher rate of LL in the Arab cases. The mean lag time from symptoms onset to presentation to doctor was 9.4 (range 0-192) months, with lepromatous cases tending to present later than other types. The longest lag times occurred in Arab women with LL, suggesting that cultural influences may delay presentation of leprosy. The mean interval from presentation to diagnosis was 4.1 weeks. The mean latency from entry into Kuwait to diagnosis was 44.7 (range 0-180) months; which stresses the need for physicians to remain vigilant in considering leprosy, especially in any patient with dermatological, neurological or ophthalmic manifestations of disease.

Leprosy in the United States, 1971-1981.

In the period 1971-1981, 1,835 cases of leprosy were reported in the United States; only 10% of these cases were indigenous. Since 1977, the number of new cases reported each year has risen because of an increase in imported cases of disease, a situation reflecting the increased number of refugees and immigrants who have entered the United States from areas endemic for leprosy. Forty-five of the 50 states reported cases. In only 25% of the imported cases were the patients known to have had leprosy at the time of immigration; the remaining 75% were diagnosed in this country. The highest rate of disease onset for this latter group occurred within 12 months after entry into the United States, but cases continued to be reported 10 years after entry. Active refugee resettlement programs have widely distributed persons with leprosy, contacts of diseased persons, and persons from endemic areas throughout the 50 states, a situation necessitating the development of expertise by medical professionals and public health officials in the diagnosis, treatment, and long-term follow-up of patients with leprosy.