Migration in French Guiana: Implications in health and infectious diseases.

In French Guiana, more than a third of the population, and nearly half of the adults, are of foreign origin. This immigration is explained by the French standard of living, which is attractive to nationals of surrounding countries. Infectious diseases remain in the top 10 causes of premature death, often in the most precarious populations. In this context we aimed to synthesize the state of the knowledge regarding immigration and infectious diseases in French Guiana and the general implications that follow this diagnosis. For HIV, although the majority of patients are of foreign origin, estimates of the presumed date of infection based on CD4 erosion modelling and from molecular analyses suggest that the majority of transmissions in foreign-born individuals occur in French Guiana and that the Guiana shield has been a crossroad between Latin America and the Caribbean. Among key populations bridging these regions illegal gold miners are very mobile and have the greatest proportion B Caribbean HIV viruses. Gold miners have been a key vulnerable population for falciparum malaria and other tropical diseases such as leishmaniasis, leprosy, or leptospirosis. The complex history of migrations in French Guiana and on the Guiana Shield is also reflected in the fingerprinting of mycobacterium tuberculosis and the high incidence of tuberculosis in French Guiana, notably in immigrants, reflects the incidences in the countries of origin of patients. The high burden of infectious diseases in immigrants in French Guiana is first and foremost a reflection of the precarious living conditions within French Guiana and suggests that community-based proactive interventions are crucial to reduce transmission, morbidity, and mortality from infectious diseases.

[Overview of infectious and non-infectious diseases in French Guiana in 2022]. / Panorama des pathologies infectieuses et non infectieuses de Guyane en 2022.

Source of many myths, French Guiana represents an exceptional territory due to the richness of its biodiversity and the variety of its communities. The only European territory in Amazonia, surrounded by the Brazilian giant and the little-known Suriname, Ariane 6 rockets are launched from Kourou while 50% of the population lives below the poverty line. This paradoxical situation is a source of health problems specific to this territory, whether they be infectious diseases with unknown germs, intoxications or chronic pathologies.Some infectious diseases such as Q fever, toxoplasmosis, cryptococcosis or HIV infection are in common with temperate countries, but present specificities leading to sometimes different management and medical reasoning. In addition to these pathologies, many tropical diseases are present in an endemic and / or epidemic mode such as malaria, leishmaniasis, Chagas disease, histoplasmosis or dengue. Besides, Amazonian dermatology is extremely varied, ranging from rare but serious pathologies (Buruli ulcer, leprosy) to others which are frequent and benign such as agouti lice (mites of the family Trombiculidae) or papillonitis. Envenomations by wild fauna are not rare, and deserve an appropriate management of the incriminated taxon. Obstetrical, cardiovascular and metabolic cosmopolitan pathologies sometimes take on a particular dimension in French Guiana that must be taken into account in the management of patients. Finally, different types of intoxication are to be known by practitioners, especially due to heavy metals.European-level resources offer diagnostic and therapeutic possibilities that do not exist in the surrounding countries and regions, thus allowing the management of diseases that are not well known elsewhere.Thanks to these same European-level resources, research in Guyana occupies a key place within the Amazon region, despite a smaller population than in the surrounding countries. Thus, certain pathologies such as histoplasmosis of the immunocompromised patient, Amazonian toxoplasmosis or Q fever are hardly described in neighboring countries, probably due to under-diagnosis linked to more limited resources. French Guiana plays a leading role in the study of these diseases.The objective of this overview is to guide health care providers coming to or practicing in French Guiana in their daily practice, but also practitioners taking care of people returning from French Guiana.

Leprosy in French Guiana, 2015 to 2021: Dynamics of a Persistent Public Health Problem.

A resurgence of leprosy as a public health problem in French Guiana was reported over the period 2007 to 2014, particularly among Brazilians gold miners. Prolonged multidrug therapy and reversal reactions represent a therapeutic challenge. The objective of this study was to assess the evolution of leprosy in this European overseas territory. All patients with leprosy confirmed in histopathology between 1 January 2015 and 31 December 2021 were included. A total of 86 patients were included, including 64 new cases and 22 previously diagnosed cases. Sixty patients (70%) were male, 6 cases were paediatric. Brazilian gold miners represented 44.1% of reported occupations (15/34). Maroons represented the second community (13 patients, 15%). Multibacillary and paucibacillary forms were found in 53 (71%) and 22 (29%) patients, respectively. The annual prevalence never exceeded the threshold of 1/10,000. The mean incidence and prevalence were significantly lower than during the period 2007 to 2014 (p < 0.0001). Reversal reactions were found in 29 patients and almost always required a long course of steroids. Infliximab allowed a reduction in the length of treatment with steroids in 2/2 cases. In conclusion, the prevalence of leprosy has decreased significantly in French Guiana, but remains driven by the population of illegal gold miners. Anti-tumour necrosis factor (anti-TNF) drugs represent a promising option in the management of reversal reactions.

Epidemiology of infection by pulmonary non-tuberculous mycobacteria in French Guiana 2008-2018.

INTRODUCTION: Unlike diseases caused by Mycobacterium tuberculosis, M. leprae and M. ulcerans, the epidemiology of pulmonary non-tuberculous mycobacteria (PNTM) has not received due attention in French Guiana. The main objective of the current study was to define the incidence of these PNTM infections: NTM pulmonary diseases (NTM-PD) and casual PNTM isolation (responsible of latent infection or simple colonization). The secondary objectives were to determine species diversity and geographic distribution of these atypical mycobacteria. METHODS: A retrospective observational study (2008-2018) of French Guiana patients with at least one PNTM positive respiratory sample in culture was conducted. Patients were then classified into two groups: casual PNTM isolation or pulmonary disease (NTM-PD), according to clinical, radiological and microbiological criteria defined by the American Thoracic Society / Infectious Disease Society of America (ATS / IDSA) in 2007. RESULTS: 178 patients were included, out of which 147 had casual PNTM isolation and 31 had NTM-PD. Estimated annual incidence rate of respiratory isolates was 6.17 / 100,000 inhabitants per year while that of NTM-PD was 1.07 / 100,000 inhabitants per year. Among the 178 patients, M. avium complex (MAC) was the most frequently isolated pathogen (38%), followed by M. fortuitum then M. abscessus (19% and 6% of cases respectively), the latter two mycobacteria being mainly found in the coastal center region. Concerning NTM-PD, two species were mainly involved: MAC (81%) and M. abscessus (16%). DISCUSSION/CONCLUSION: This is the first study on the epidemiology of PNTM infections in French Guiana. PNTM's incidence looks similar to other contries and metropolitan France and NTM-PD is mostly due to MAC and M.abscessus. Although French Guiana is the French territory with the highest tuberculosis incidence, NTM should not be overlooked.

Spectrum of skin diseases in Maroon villages of the Maroni area, French Guiana.

BACKGROUND: Due to their genetic characteristics and their high exposure to infectious diseases, Maroons are likely to suffer from a specific spectrum of skin diseases. However, skin disorders have never been explored in this population. We aimed to describe all skin diseases in Maroon villages of the Maroni region in French Guiana. METHODS: This retrospective study concerned all patients who consulted in the remote health centers of Apatou, Grand-Santi, Papaichton, and Maripasoula between October 5, 2017, and June 30, 2020. We included all patients registered with a skin disorder (International Classification of Diseases) in the medical database. We excluded patients whose diagnosis was invalidated after cross-checking by a dermatologist. RESULTS: A total of 4741 patients presented at least one skin disease, for 6058 different disorders. Nonsexually transmitted infections represented 71.6% of all diagnoses, followed by inflammatory diseases (9.8%) and bites/envenomations (4.6%). The three most frequent conditions were scabies, abscesses, and impetigo. Besides scabies, neglected tropical diseases (NTDs) were still prevalent as we reported 13 cases of leprosy and 63 cutaneous leishmaniasis. Atopic dermatitis (AD) represented only 2.5% of our diagnoses. CONCLUSIONS: With the exception of AD, which was less frequent among Maroons, these results are similar to those previously reported in Amerindians. Therefore, a common exposure to rainforest pathogens seems to induce a common spectrum of skin diseases dominated by infections. The high prevalence of NTDs requires specific public health actions.

Leprosy as immune reconstitution inflammatory syndrome in patients living with HIV: Description of French Guiana's cases over 20 years and systematic review of the literature.

BACKGROUND: HIV infection is highly prevalent in French Guiana, a territory where leprosy is also endemic. Since the introduction of Highly Active Antiretroviral Treatment (HAART) in the management of HIV, leprosy has been reported as part of the immune reconstitution inflammatory syndrome (IRIS). METHODOLOGY/PRINCIPAL FINDINGS: We aimed to present a general description of these forms of leprosy as IRIS, highlighting clinical and therapeutic specificities. A retrospective study was conducted in French Guiana, including patients living with HIV (PLHIV) with advanced infection (CD4 < 200/mm3) and developing leprosy or a leprosy reaction within six months of HAART initiation, from 2000 to 2020. Clinical, histological and biological data were collected for all these patients. Six patients were reported in French Guiana. A systematic review of the literature was conducted, and its results were added to an overall analysis. Overall, seventy-three PLHIV were included. They were mainly men (74%), aged 22-54 years (median 36 years), mainly from Brazil (46.5%) and India (32.8%). Most leprosy cases (56.2%) were borderline tuberculoid (BT). Leprosy reactions were frequent (74%), mainly type 1 reaction (T1R) (68.5%), sometimes intense with ulceration of skin lesions (22%). Neuritis was observed in 30.1% of patients. The outcome was always favorable under multidrug therapy (MDT), continuation of HAART and additional corticosteroid therapy in case of neuritis or ulceration. There was no relapse. CONCLUSION: Leprosy as IRIS in PLHIV mainly presents as a BT leprosy in a T1R state, sometimes with ulcerated skin lesions. Response to MDT is usually good. Systemic corticosteroids are necessary and efficient in case of neuritis.

An atypical keloid in a Brazilian man.

Case report from French Guiana of an atypical keloid in a Brazilian man: Lobomycosis. Lobomycosis is a rare fungal skin infection, endemic to the Amazon basin. Its clinical manifestations are slow-growing keloid-like nodules, with a granulomatous reaction on histopathology. The etiological agent, Lacazia loboi, has never been isolated in the environment or cultured in a laboratory. Diagnosis is based on the typical appearance on microscopy. Treatment is disappointing, with a high recurrence rate. We report a new case in French Guiana and review the literature. Only 10 cases have been reported outside of the endemic area, 2 involving no travel; the mean time to diagnosis was 21 years. Phylogenetic analysis has recently proved that lobomycosis in dolphins is caused by a fungus more closely related to Paracoccidioides brasiliensis than to L. loboi (two very closely related species). Molecular diagnosis is possible in a few centers. Climate change may result in spreading lobomycosis to currently disease-free areas of the world.

Mycobacterium ulcerans infection (Buruli ulcer) in French Guiana, South America, 1969-2013: an epidemiological study.

BACKGROUND: Mycobacterium ulcerans infection is the third most common mycobacterial disease in the world after tuberculosis and leprosy. To date, transmission pathways from its environmental reservoir to humans are still unknown. In South America, French Guiana has the highest reported number of M ulcerans infections across the continent. This empirical study aimed to characterise the epidemiology of M ulcerans infection in French Guiana between 1969 and 2013. METHODS: Data were collected prospectively mainly by two dermatologists at Cayenne Hospital's dermatology department between Jan 1, 1969, and Dec 31, 2013, for age, date of diagnosis, sex, residence, location of the lesion, type of lesion, associated symptoms, and diagnostic method (smear, culture, PCR, or histology) for all confirmed and suspected cases of M ulcerans. We obtained population data from censuses. We calculated mean M ulcerans infection incidences, presented as the number of cases per 100 000 person-years. FINDINGS: 245 patients with M ulcerans infections were reported at Cayenne Hospital's dermatology department during the study period. M ulcerans infection incidence decreased over time, from 6·07 infections per 100 000 person-years (95% CI 4·46-7·67) in 1969-83 to 4·77 infections per 100 000 person-years (3·75-5·79) in 1984-98 and to 3·49 infections per 100 000 person-years (2·83-4·16) in 1999-2013. The proportion of children with infections also declined with time, from 42 (76%) of 55 patients in 1969-83 to 26 (31%) of 84 in 1984-98 and to 22 (21%) of 106 in 1999-2013. Most cases occurred in coastal areas surrounded by marshy savannah (incidence of 21·08 per 100 000 person-years in Sinnamary and 21·18 per 100 000 person-years in Mana). Lesions mainly affected limbs (lower limbs 161 [66%] patients; upper limbs 60 [24%] patients). We diagnosed no bone infections. INTERPRETATION: The decrease of M ulcerans infection incidence and the proportion of children with infections over a 45 year period in this ultra-peripheral French territory might have been mostly driven by improving living conditions, prophylactic recommendations, and access to health care. FUNDING: Agence Nationale de la Recherche.

[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.

Increased incidence of leprosy following HAART initiation: a manifestation of the immune reconstitution disease.

A retrospective cohort study was conducted to determine whether the incidence of leprosy varied with the duration of antiretroviral therapy (ART). Between 1992 and 2006, seven cases of leprosy were observed. The incidence of leprosy in untreated patients was 0.7 per 1000 person-years, 13 per 1000 person-years in persons receiving HAART for more than 3 months and 0.9 per 1000 person-years for persons receiving HAART for more than 3 months. The adjusted hazard ratio was 18.5 (95% confidence interval, 1.6-217) with P = 0.02. In tropical areas where HAART is increasingly available, physicians should be aware of the possibility of incident leprosy shortly after HAART initiation.

[Dermatologic manifestations associated with immune reconstitution syndrome in HIV+ patients starting HAART: a retrospective study in French Guiana]. / Manifestations dermatologiques associées au syndrome de restauration immunitaire du patient VIH+ débutant un traitement antirétroviral: etude rétrospective en Guyane française.

Immune reconstitution syndrome (IRIS) is an unusual inflammatory reaction to an opportunistic infection in an HIV-positive patient. This syndrome occurs when immunity is restored in the first months of an effective highly active antiretroviral treatment (HAART). First, we described all patients with a cutaneous form of IRIS. Then, between 1992 and 2004 we conducted a retrospective cohort study comparing Herpes Zoster and Herpes Simplex infections among untreated patients, patients treated by HAART for < or = six months, and patients treated for > six months. We observed three cases of atypical leprosy and three original observations: two of these were fistulisation of lymph node histoplasmosis and tuberculosis, the third one reports the recurrence of a treated cutaneous leishmaniasis. Multivariate analysis showed that, after controlling for age, sex and CD4 counts, patients receiving HAART for < or = six months were more likely to develop Herpes Zoster or herpes simplex infections (p < 0.005). Herpes Simplex and Herpes Zoster infections are the two most frequent dermatological manifestations in our tropical setting. Although mycobacterial infections are more rarely observed than in visceral IRIS, the increased incidence of leprosy may be quite significant when the availability of HAART spreads to developing countries.

American cutaneous leishmaniasis, lepromatous leprosy, and pulmonary tuberculosis coinfection with downregulation of the T-helper 1 cell response.

Cutaneous leishmaniasis, leprosy, and tuberculosis are caused by intracellular pathogens whose development depends on impaired cell-mediated immunity. We report an exceptional triple association of American cutaneous leishmaniasis, lepromatous leprosy, and pulmonary tuberculosis in a man with no recognized immunodeficiency. Normal immunological assessment of the interferon-gamma pathway does not support the hypothesis of a genetic defect in any of the genes involved in the T helper (Th)-1 cytokine cascade in this patient. Unresponsiveness to interleukin (IL)-12 of his T cells after stimulation with Leishmania guyanensis, Mycobacterium bovis bacille Calmette-Guérin, and Mycobacterium leprae antigens suggested the inability to mount an appropriate Th cell response to upregulate the IL-12 receptor expression.

[Bullous erythema nodosum leprosum. A case report in French Guiana]. / Erythème noueux lépreux bulleux. Une observation en Guyane française.

BACKGROUND: Polar and borderline lepromatosis leprosy can be complicated by type 2 reactional states, including erythema nodosum leprosum. CASE REPORT: A 36-year-old man was treated for lepromatous leprosum. He consulted for recurrent erythema nodosum leprosum. Certain nodular lesions were bullous. Histopathology demonstrated major dermal edema causing bullous blisters. Treatment with thalidomide led to rapid regression. DISCUSSION: The bullous form of erythema nodosum leprosum is rarely described in the literature. It raises the diffential diagnosis with other bullous dermatoses, particularly Sweet's syndrome.

[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.

[Supervised bimonthly quadruple chemotherapy in 72 paucibacillary leprosy patients in French Guyana]. / Quadruple chimiothérapie bimensuelle supervisée chez 72 paucibacillaires en Guyane française.

In French Guyana we have treated 72 paucibacillary leprosy with an association of Rifadine + Lamprene + Trecator + Disulone given twice monthly under supervision during 6 months. Results have been satisfying and side effects rare. The sequential character of treatment shows a substantial advantage on the operational side but may appear to be favorable to bacterial resistance.

[24 cases of donovanosis in French Guiana]. / Etude de 24 cas de donovanose en Guyane française.

24 cases of Donovanosis (Granuloma inguinale) have been observed at the Dermatology Clinic of the Centre Hospitalier of Cayenne (French Guyana) between 1970 and 1980, representing a high rate for a 60,000 population. All the patients were coloured people. The disease is more important in the cutaneous parts of the ano-genital areas, than on the mucous parts. The "carcinoid" aspects of some histopathological exams must be considered with the bacteriological research and the very soft clinical aspects. It is often caused by intrarectal sexual contacts whether homo- or heterosexual. The high rate of Donovanosis within the homosexual population is a good argument for an intestinal localisation of the germ Calymnatobacterium granulomatis. All the cases diagnosed show an individual susceptibility to this disease. A deficit of cellular immunity as found in lepromatous leprosy seems a very attractive hypothesis. The treatment with 4 g of streptomycin by day during 5 days or more is considered as the best actually.