Dapsone for thrombocytopenic purpura related to human immunodeficiency virus infection.

PURPOSE: The purpose of this study was to determine the effect of dapsone on platelet count in patients with human immunodeficiency virus (HIV)-related autoimmune thrombocytopenia. PATIENTS AND METHODS: Eleven patients with HIV-related thrombocytopenia received dapsone (50 to 125 mg/day) for 2 to 43 months. Patients with the acquired immunodeficiency syndrome were not enrolled. RESULTS: Of the 11 patients, six developed platelet counts above 50 X 10(9)/L and did not require any other specific therapy. No significant side effects were observed. CONCLUSION: We conclude that dapsone may be effective in some patients with HIV-related thrombocytopenia.

[Pulmonary manifestations of malaria]. / Les manifestations pulmonaires du paludisme.

Pulmonary edema is a classic and severe manifestation of falciparum malaria. To evaluate the predictive factors of this severe complication, we studied epidemiological, clinical and biological data of 136 patients with acute malaria. Two groups were individualized according to the presence (group I = 53 patients) or the absence (group II = 83 patients) of pulmonary manifestations. Pulmonary signs incidence was not correlated with impairement consciousness, creatinemia, hypoglycemia, and coagulation abnormalities. However, age, tobacco abused, delay in starting treatment, oliguria, decreased protidemia were significantly increased. These factors, associated with severe malaria, expose to a more important risk of pulmonary edema, often induced by reanimation management.

[Cytokines and malaria. A study of TNF-alpha, IL1-beta, IL6 and IL2R in 28 patients]. / Cytokines et paludisme. Etude du TNF alpha, de l'IL1 bêta, de l'IL6 et du RIL2s chez 28 malades.

Authors have studied TNF alpha, IL1 bêta, IL6 and RIL2s in 28 malaria illness patients. Increased levels of TNF, IL1 bêta and RIL2s in serum, are observed on admission to hospital. These cytokine levels are decreased, eight days later, after patients are treated. In discussion, TNF levels as a prognosis component is evocated.

[Malaria in the republic of São Tomé and Principe. Epidemiologic evaluation and chemoresistance of P. falciparum]. / Le paludisme en république de São Tomé et Principe. Evaluation épidémiologique et chimiorésistance de P. falciparum.

The authors report the results of a valuation of paludometric indices during mai 1990 in Democratic São Tomé e Príncipe Republic (RDSTP). These investigations (parasitic index and spleen index) suggest that malaria is mesoendemic in these area. Plasmodium susceptibility to chloroquine at posology of 25 mg/kg per os was evaluated (WHO standard 7 days field test). Among 58 children, ranging from 5 to 11 years old, resistance at level R I was observed in 9% of cases, at level R II in 14%. Among 10 strains of P. falciparum, 9 were chloroquine resistant in vitro. 2 strains were also less sensible to quinine.

[Falciparum malaria in French residents in Yaounde]. / Le paludisme a Plasmodium falciparum chez les Français résidants a Yaoundé.

In South Cameroon, malaria is a disquieting problem. It represented 2.6% of consultants and concerned each year 10% among French residents. We have included 310 cases of Falciparum malaria between January 1, 1990 and December 31, 1990. There were 207 adults and 103 children with a mean age of 26 years. The duration of the stay was over one year in 137 cases and lower than 1 year in 183 patients. The chemoprophylaxis was correct in 194 patients according to the dose and duration. Forty-nine patients followed a combination of chloroquine and proguanil. Malaria attack was observed in 272 patients. Among them, there were 95 children. A severe malaria occurred in 38 cases. Mean parasitemia was of 0.24% (range: 0.002-7.5%). Therapy regimen was quinine: 36 cases, halofantrine: 266 cases, amodiaquine: 7 cases and association MFP (Fansimef) in 12 patients. The study shows the importance of malaria in an endemic area among expatriates despite the observance of chemoprophylactics regimens including proguanil.

[Bone localizations disclosing Hodgkin's disease. Apropos of 11 cases]. / Localisations osseuses révélatrices de la maladie de Hodgkin. A propos de 11 observations.

The authors report 11 cases of Hodgkin's disease in which the first sign was due to bone involvement. Such observations are rare and raise diagnosis delays (Means: 5, 6 months in this series). Modern medical imaging techniques (scintigraphy, CT scan, magnetic resonance imaging) are very useful to an earlier diagnosis which will be better confirmed by lymph node biopsy given the poor information yielded by osseous cytology and/or histology. The elective localisation in bones belonging to the axial skeleton seems to support the hypothesis of a contiguous osseous involvement from lymphoïd organs in contact with bones. Evolution with chemotherapy and radiotherapy is very similar to that observed in patients without bone involvement.

[Pulmonary strongyloidiasis complicated by E. coli meningitis in a HIV-1 and HTLV-1 positive patient]. / Anguillulose pulmonaire compliquée d'une méningite à E. coli chez un patient VIH1 et HTLV1 positif.

INTRODUCTION: Disseminated strongyloidiasis occurs in immunodepressed patients, notably those infected by retroviruses. OBSERVATION: A pulmonary strongyloidiasis, complicated by an Escherichia coli meningitis, occurred in a patient exhibiting seropositivity HIV1 for the past year. The status of cell immunity, with 354 lymphocytes T CD4+/mm3, could not explain this severe complication. This led to the diagnosis of an HTLV1 infection. The strongyloidiasis was treated with two cycles of ivermectine, which cured the patient. COMMENTS: In HIV-infected patients exhibiting severe strongyloidiasis, research for an HTLV co-infection is recommended.

[Salmonella enteritidis splenic abscess complicating a Plasmodium falciparum malaria attack]. / Abcès splénique à Salmonella enteritidis compliquant un accès palustre à Plasmodium falciparum.

INTRODUCTION: Salmonella splenic abscesses are rare and usually occur on pre-existing lesions. OBSERVATION: A Moorish 16 year-old woman from Senegal presented with a S. enteritidis abscess without any factor other than an attack of P. falciparum malaria. Treatment associated quinine salts, antibiotherapy and splenectomy. COMMENTS: P. falciparum malaria attacks not only induce humoral and then cellular immunodepression but are also at the origin of infarction or splenic hematoma that may enhance bacterial infection and the development of abscesses. Splenectomy or percutaneous drainage associated with antibiotherapy is the usual treatment for splenic abscesses. Prognosis remains severe (13 to 16% mortality).

[Digestive disorders in histoplasmosis. Report of a case of ulcerous enterocolitis caused by Histoplasma capsulatum (author's transl)]. / Les manifestations digestives des histoplasmoses. A propos d'un cas d'entérocolite ulcéreuse à Histoplasma capsulatum.

Report of a new American histoplasmosis caused by Histoplasma capsulatum in a young adult Haitian, and review of the digestive disorders as reported in the previous medical papers. In the present case, the first localization detected was a granulomatous hepatitis which lead to the disclosure of an ulcerous entercolitis. Tuberculosis and Crohn disease were first suspected, but their treatment induced a worse turn of the patient's condition and compelled to a laparotomy, which shown ulcerous entercolitis with associated lymph-nodes. Per operative pathological examination gave evidence of Histoplasma capsulatum yeasts. Treatment, first with miconazole and later on with amphotericin B could not prevent the death of the patient affected by a deficiency of cell mediated immunity. Disseminated histoplasmosis is rare: 1 out of 5,000 cases of American histoplasmosis-digestive disorders are generally detected by surgery or post-mortem examination. They occur in 20 p. 100 of the cases envolving the whole digestive tract from mouth to anus, giving mucous ulcerations, difficult to detect by X ray. Endoscopic control with biopsies has therefore a great value. In Histoplasma duboisii, histoplasmosis digestive disorders are very unusual and localized to intestine. They may be detected by surgery, or by endoscopies. In the reported case, in spite of the geographical origin of the patient, the diagnosis of American histoplasmosis was not retained because of the negativity of the immunological tests and of the biopsies performed before surgery. An afterward checking of these biopsy specimens gave evidence of a few yeasts. Special dyeing technique may have made the diagnosis somewhat earlier; this is important because new non toxic imidazole drugs seem to be active against these yeasts.

[Prevalence of infection by the human immunodeficiency virus (HIV) in a target population in the Republic of Djibouti]. / Prévalence de l'infection par le virus de l'immunodéficience humaine (VIH) dans une population-cible en République de Djibouti.

The Prophylaxis Center of the Republic of Djibouti reports a prevalence investigation about AIDS seropositivity from January to May 1991 at risk people: the "street" prostitutes and "bar" prostitutes in Djibouti town. This serological investigation confirmed by WESTERN-BLOT technique shows the quick-growing of AIDS seropositivity in Djibouti.

[Pleuropulmonary manifestations of salmonellosis]. / Les manifestations pleuropulmonaires des salmonelloses.

Salmonella infections are widespread particularly in tropical zones. Each year, 12.5 million cases of typhoid fever are reported with an incidence of 540 cases for every 100,000 inhabitants in developing countries versus 0.2 cases in industrialized countries. Pleuropulmonary manifestations constitute the most common extra-intestinal manifestation of salmonella infection. Counts are usually carried out in the digestive tract. Respiratory tract manifestations result from blood-borne diffusion from mesenteric lymph nodes, but gastroenteritis goes unnoticed in 2 of 3 cases. Predisposing factors are frequent including cancer, previous graft placement and immunosuppressant therapy, sickle cell disease, alcohol abuse, and pre-existing pulmonary disease. Clinical manifestations are usually acute but subacute forms cannot be ruled out. Cough is a common symptom observed in 25% of patients with typhoid fever. Pneumonia is uncommon overall (1%) but occurs in 50% of patients with pleural effusion, empyema, lung abscess, or bronchopleural fistula. A few cases of adult respiratory distress syndrome have been described in the literature. Recognition is important since these manifestations may signal previously unsuspected underlying pulmonary disease. Treatment requires appropriate antimicrobial therapy and close surveillance to prevent recurrence or complications.

[Current aspects of malaria in expatriates in the Central African Republic]. / Aspects actuels du paludisme chez l'expatrié en République de Centrafrique.

This survey was carried out on 35 cases of malaria, having occurred during a period of 4 months in a population of expatriates living in a zone III of chloroquino-resistance. So, the authors can recall actual frequency of non-typical forms of this endemia. They underline the sensitivity of orange acridine test and its interest in the biological diagnosis of the forms offering a low parasitemia. The survey demonstrates once again the limits of the recommended chemoprophylaxis and the remarkable efficiency of halofantrine, while suspecting a possible coming up of a resistance.

[Concurrent mycetoma and chromomycosis: case report from Senegal]. / Association d'un eumycétome et d'une chromomycose: une observation au Sénégal.

A 68-year-old cattle farmer from northern Senegal sought medical attention for tumefaction that had been progressing on the right foot and leg for 20 years. Physical examination of the right extremity revealed very firm tumefaction involving the foot and whole leg associated with numerous nodules. Bone radiographs and CT-scan of the foot and leg disclosed extensive osteolytic involvement. A specimen of squamous tissue from the top of nodules showed the presence of fumagoid cells characteristic of chromomycosis. Histologic examination after skin biopsy demonstrated fungal myocetoma. Due to the extent of involvement surgical and antifungal treatment was proposed but the patient refused to undergo surgery. Only one previous case of concurrent chromomycosis and mycetoma has been described. However the previous case involved actinomycetoma. The rarity of this combination of diseases despite their common contamination mode is due to different geographical distribution with mycetoma being found in the Sahelian region and chromomycosis in the humid equatorial region.

[Medical treatment of lymphatic filariasis]. / Le traitement medical des filarioses lymphatiques.

Lymphatic filariasis remains in 1991 a major health problem. Ivermectine revolutionizes their treatment and, by suppressing microfilaremia, provides a new method of helping to control the vector-borne transmission of lymphatic filariasis.

[HTLV1 and coinfections]. / HTLV1 et coinfections.

After reminding the epidemiology of the HTLV1 infection the authors sum up the actually recommended diagnosis procedure. --Case finding by ELISA, confirmation by WESTERN-BLOT and/or RIPA (anti-gag and anti-env specificities), or even PCR which makes specific diagnosis of HTLV1/2. --Or if possible directly by PCR which has helped some authors to find provirus in seronegative people. Coinfections caused by HIV and by Strongyloides are the best documented. As a rule, HTLV1 seems to have rather a worsening effect on evolutiveness and on seriousness of the clinical picture caused by mixed infections, than the contrary (possibly for lack of experience and owing to slow evolution of HTLV1 pathology). Several mechanisms have been proposed concerning coinfections with HTLV1 and HIV (in vitro studies). --Immortalization of CD4 lymphocytes infected with HTLV1 by stimulating both IL2 and its receptor, and by activating lymphocytes with translocation of the replicating factor NF k B in the nucleus, on a promoting sequence of HIV-LTR by stimulating its replication. --The product of HTLV1 tax gene would also have a transactivating effect on the provirus HIV-LTR replication. And finally infection with HTLV1 may facilitate HIV by inducing CD4, molecule expression in non-expressing cells. In Strongyloides modulating effects of HTLV1 on the immune response would facilitate and predispose Strongyloides stercoralis multiplication. As far as other coinfections are concerned (caused by viruses, by parasites: such as malaria, filariasis, trypanosomiasis or by bacteria), epidemiological convergence (risk factors, and geographic distribution) on the one hand, and immunological dysregulation induced by the other, on the other hand, would be of varying importance. In conclusion, these data ask more questions than they answer. But it seems to be established that detection of HIV and Strongyloides should performed in every case HTLV1 carries and vice versa.

[Does emergency tropical medicine exist? The physician's point of view]. / Existe t-il des urgences médicales tropicales? Le point de vue du medecin.

The existence of tropical medical emergencies is a recurrent issue that joins the debate over the definition of tropical medicine. Is it medicine practiced in warmer climates, medicine practiced with poor diagnostic and therapeutic facilities or medicine involving only tropical diseases? Presentation of a few case reports provides a better response to this question than a long speech. The first case involves a 57-year-old man presenting a complicated attack of Plasmodium falciparum malaria and severe respiratory distress. The second case involves a pregnant AIDS patient presenting multifocal miliary tuberculosis associated with renal abscess and bacteremia. The third case involves a 34-year-old soldier hospitalized for right hilar pneumonia in whom work-up demonstrated co-infection by HIV 1 and 2, thick drop tests revealed uncomplicated Plasmodium falciparum malaria, and cytobacterial examination of sputum samples identified Salmonella enteritidis and acid-alcohol resistant germs. The fourth case involves a 60-year man hospitalized for febrile collapse in whom work-up revealed amebic pericarditis. These four case reports illustrate the main features of tropical medical emergencies: adult patients (frequently young), associated deficiencies or immunocompromise (HIV infection/AIDS), severe or complicated tropical disease, severe advanced stage disease because of inability to pay for care, multiple pathology, poor diagnostic/therapeutic facilities, and high mortality.

[Intracranial subdural hematoma during spinal anesthesia]. / Hematome sous-dural intracranien au decours d'une rachianesthesie.

Spinal anesthesia (SA) is frequently used in tropical zones. Intracranial subdural hematoma is an uncommon complication of SA. The purpose of this report was to describe a case of intracranial subdural hematoma observed during SA performed for cesarean section in a 22-year-old women in Senegal. After one month of persistent intense headache, diagnosis was confirmed by computerized tomography. The hematoma was successfully treated by drainage under general anesthesia. Intracranial subdural hematoma has been attributed to cerebrospinal fluid hypotension due to leakage through the dural puncture site. Diagnosis, which may be difficult in Africa, should be suspected in patients with persistent headaches after SA. Confirmation requires computerized tomography of the brain. Prevention of this complication depends on the use of fine beveled-tipped puncture needle which are rarely available in the African setting.

[Extensive bone marrow necrosis as presenting manifestation of sickle cell disease in Africa]. / Necrose médullaire etendue en Afrique révélant une drépanocytose homozygote.

Extensive bone marrow necrosis is a rare but severe complication of sickle cell disease. A formerly healthy man was admitted for bone pain, fever, and jaundice with severe aregenerative anemia. Bone marrow aspiration and biopsy showed extensive bone marrow necrosis while hemoglobin electrophoresis demonstrated homozygotic sickle cell disease. Despite early onset of septic arthritis of the right shoulder, outcome after blood transfusion and nonspecific treatment was favorable. Six months later, hemoglobin level remained stable up to 97 g/L. This first African case report illustrates typical features and good prognosis of extensive bone marrow necrosis in sickle cell disease. Extensive bone marrow necrosis is a highly unusual presenting manifestation of sickle cell in an adult.

[Mechanism of action of antimalarials. Value of combined atovaquone/proguanil]. / Les modes d'action des antipaludiques. Interet de l'association atovaquone-proguanil.

Determining the mode of action of different antimalarial drugs at the cellular level is essential to optimizing their use and to understanding the mechanisms underlying plasmodial resistance. The main targets for antimalarial drugs in Plasmodium falciparum have been the food vacuole and mitochondrial system. A new target is recently discovered organelle named the apicoplast. The apicoplast is the site of a number of metabolic pathways crucial to the survival of the parasite. It may also be involved in DNA replication and transcription. Antimalarial drugs are classified into three groups according to site of action, i.e., drugs that act on the food vacuole, drugs that block metabolic synthesis and oxidative processes, and drugs that interfere with membrane processes. Knowledge of these sites of action has enabled identification of new drugs with the most promising potential for development. Current antimalarial strategies prioritize combination therapies such as atovaquone/proguanil or artemether/lumefantrine and prolonged treatments to limit the risk of inducing drug resistant Plasmodium.

[Cerebromeningeal listeriosis associated with a cytolytic hepatitis. First case report in Senegal]. / Listériose cérébro-méningée associée à une hépatite cytolytique. A propos de la première observation sénégalaise.

Hepatitis due to Listeria monocytogenes is uncommon in adults. This report describes the first case observed in Senegal. The patient was a 73-year old man presenting listeria-related hepatitis presumably secondary to low-grade meningeal encephalitis. Treatment using ampicillin was unsuccessful and the patient died four days after hospitalization. The authors note that the incidence of adult listeriosis has risen constantly for the past twenty years in relation with alcohol abuse, cirrhosis, diabetes, kidney insufficiency, cancer, AIDS, and organ transplantation. However no predisposing factors were observed in the present case.