[Stab wounds of the hand and forearm due to Kuluna in Kinshasa (Democratic Republic of Congo): types of injuries and treatment]. / Plaies de la main et de l'avant-bras par arme blanche dues au phénomene Kuluna à Kinshasa (République Démocratique du Congo): types de lésions et traitement.

Democratic Republic of Congo (DRC), a particular form of juvenile delinquency and insecurity intensifies in the city of Kinshasa. This is the phenomenon Kuluna. It is organized gangs equipped with machetes and other weapons. The main objective of this study is to know the phenomenon Kuluna and describe the upper limb injuries caused by machetes, while insisting on the specifics of the management of these lesions in our communities. This retrospective descriptive study examines 14 cases of wounds of the hand and forearm due to stab phenomenon Kuluna, in Kinshasa. It covers the period from 1 November 2010 to 1 November 2013. Among the 14 patients with lesions in the hand and forearm admitted and treated at the Unit of Plastic Reconstructive and Aesthetic Surgery, Hand Surgery and Burns, University Clinics of Kinshasa to attacks due to the phenomenon Kuluna. We have 11 men and 3 women. The average age was 33, 5 years (extremes of 21 and 56 years). The right upper limb is reached that the left upper limb, respectively 12 patients and 2 patients. The lesions are localized to the wrist in the majority of cases (10 patients) in the palm of hand and in 3 patients in the fingers in 1 patient. The palmar surface is reached (10 cases) and the dorsal (4 cases). Zone 5 of the International Classification of flexor and Zone 8 topographic classification extensors at hand are the predilection sites of lesions respectively the palmar surface (6 out of 10) and the dorsal (2 case 4). The median nerve at the wrist is cut in half the cases. On bone lesions localized to the forearm, we observed a high incidence of fracture of the ulna (62.5%). The treatment begins with the stabilization of bone pieces, gestures revascularization and nerve sutures and suture tendon and finally skin coverage. Rehabilitation was mandatory, she supervises the actions of repair and it continues until the recovery of function.

[Buruli ulcer in the health districts of the Democratic Republic of Congo from 1950 to 2013: literature review and new distribution map]. / Ulcère de Buruli dans les zones de santé en République démocratique du Congo, de 1950 à 2013 : revue documentaire et nouvelle carte de distribution.

This paper describes the current distribution of cases of Buruli ulcer (BU) by highlighting health districts that are endemic and suspected to be endemic, based on the studies, surveys, and activity reports published from 1950 to 2013. We define as endemic any health district with BU patients positive by PCR, whether or not positive on a Ziehl-Neelsen (ZN) test, culture or histologic sample. A district is defined as suspected to be endemic when it is a historical BU area, has BU clinical cases and/or patients with positive ZN, but negative PCR. Of the 515 health districts in the DRC, 17 were found to be endemic (3%) and 26 suspected to be endemic (5%). In most cases, former focal areas, described before 1974, remain currently active. New focal points were found along the Kwango River in the province of Bandundu. We also discovered the extension of former BU focal areas to neighboring health districts in the provinces of Bas-Congo, Bandundu, and Maniema. The need for diagnostic confirmation by PCR appears to be a requirement and a priority, not only in all former historical focal areas but also in the health districts newly suspected to be endemic.

[Mycobacterium ulcerans disease (Buruli ulcer) in Gabon: 2005-2011]. / L'infection à Mycobacterium ulcerans (ulcère de Buruli) au Gabon de 2005 à 2011.

The first cases of Buruli ulcer (BU) in Gabon were described in the 1960s. Between 2005 and 2011, 301 clinically suspected cases of BU were found in all nine provinces of Gabon, and their lesions sampled for microbiological confirmation. Polymerase chain reaction (PCR) found 120 (39.9%) of these lesions positive and 181 (60.1%) negative for Mycobacterium ulcerans. The confirmed cases came mainly from the province of Moyen-Ogooué, particularly from localities along the Ogooué River (n=117; 52.5% of the samples in this province were PCR-positive). The detection rates per 100,000 inhabitants in this province ranged from 94.7 cases in 2005 to 28 in 2007, after an absence of active case-finding in 2006. The final three PCR-positive cases were found in the province of Estuaire. The characteristics of the confirmed BU patients (that is, PCR-positive) were identical to those described in other African countries: most patients were younger than 15 years old, and most lesions were found on both the upper and lower limbs. The group of suspected cases (PCR-negative) differed from the PCR-positive group for patient age (most patients were aged 15 to 49 years), lesion location (more frequently on the lower limbs), and ulceration (more frequent in the suspected cases). Some PCR-negative patients probably had other diseases; this underlines the importance of the differential diagnosis of BU. The cure rate of PCR(-)confirmed cases in our study was 88%; treatment was the antibiotic combination recommended by the World Health Organization (WHO). Our study demonstrates that BU is endemic in Gabon and is a public health problem there. Patients consult late with often extensive lesions. Awareness campaigns should be pursued to ensure earlier treatment of patients. The influence of HIV on BU in Gabon also deserves particular attention.

The TDR Tuberculosis Strain Bank: a resource for basic science, tool development and diagnostic services.

BACKGROUND: The Special Programme for Research and Training in Tropical Diseases recently launched a Mycobacterium tuberculosis strain bank (TDR-TB Strain Bank). OBJECTIVE: To describe the TDR-TB Strain Bank, the characterisation of strains, bank management and the procedure for releasing materials. RESULTS: The TDR-TB Strain Bank consists of 229 clinical M. tuberculosis isolates (single-colony derived cultures) plus five mycobacterial reference strains for purposes of identification. These are available as freeze-dried, viable strains or as heat-inactivated bacterial suspensions, quality controlled for purity, viability and authenticity. Isolates originated from diverse geographical settings and were selected for their resistance profiles against first- and second-line drugs. Low and high levels of resistance were determined by the minimum inhibitory concentrations of isoniazid, rifampicin, ethambutol, streptomycin, ofloxacin, kanamycin, capreomycin, ethionamide and para-aminosalicylic acid. Sequencing for drug resistance mutations was performed on the relevant sections of the rpoB, katG, inhA, embB, rpsL, rrs, gyrA and gyrB genes. Typing using lineage-defining loci of mycobacterial interspersed repetitive unit-variable number tandem repeats indicated that the most important genetic lineages were represented. CONCLUSIONS: The TDR-TB Strain Bank is a high quality bioresource for basic science, supporting the development of new diagnostics and drug-resistant detection tools and providing reference materials for laboratory quality management programmes.

Thin-layer agar for detection of resistance to rifampicin, ofloxacin and kanamycin in Mycobacterium tuberculosis isolates.

BACKGROUND: In low-income countries there is a great need for economical methods for testing the susceptibility of Mycobacterium tuberculosis to antibiotics. OBJECTIVE: To evaluate the thin-layer agar (TLA) for rapid detection of resistance to rifampicin (RMP), ofloxacin (OFX) and kanamycin (KM) in M. tuberculosis clinical isolates and to determine the sensitivity, specificity and time to positivity compared to the gold standard method. METHODS: One hundred and forty-seven clinical isolates of M. tuberculosis were studied. For the TLA method, a quadrant Petri plate containing 7H11 agar with RMP, OFX and KM was used. Results were compared to the Bactec MGIT960 for RMP and the proportion method for OFX and KM. RESULTS: The sensitivity and specificity for RMP and OFX were 100% and for KM they were 100% and 98.7%, respectively. The use of a TLA quadrant plate enables the rapid detection of resistance to the three anti-tuberculosis drugs RMP, OFX and KM in a median of 10 days. CONCLUSION: TLA was an accurate method for the detection of resistance in the three drugs studied. This faster method is simple to perform, providing an alternative method when more sophisticated techniques are not available in low-resource settings.

Differences in virulence and immune response induced in a murine model by isolates of Mycobacterium ulcerans from different geographic areas.

Buruli ulcer (BU) is the third most common mycobacterial disease in immunocompetent hosts. BU is caused by Mycobacterium ulcerans, which produces skin ulcers and necrosis at the site of infection. The principal virulence factor of M. ulcerans is a polyketide-derived macrolide named mycolactone, which has cytotoxic and immunosuppressive activities. We determined the severity of inflammation, histopathology and bacillary loads in the subcutaneous footpad tissue of BALB/c mice infected with 11 different M. ulcerans isolates from diverse geographical areas. Strains from Africa (Benin, Ghana, Ivory Coast) induced the highest inflammation, necrosis and bacillary loads, whereas the strains collected from Australia, Asia (Japan, Malaysia, New Guinea), Europe (France) and America (Mexico) induced mild inflammation. Subsequently, animals were infected with the strain that exhibited the highest (Benin) or lowest (Mexico) level of virulence in order to analyse the local immune response generated. The Mexican strain, which does not produce mycolactone, induced a predominantly T helper type 1 (Th1) cytokine profile with constant high expression of the anti-microbial peptides beta defensins 3 and 4, in co-existence with low expression of the anti-inflammatory cytokines interleukin (IL)-10, IL-4 and transforming growth factor (TGF)-beta. The highly virulent strain from Benin which produces mycolactone A/B induced the opposite pattern. Thus, different local immune responses were found depending on the infecting M. ulcerans strain.

First molecular epidemiological study of tuberculosis in Benin.

OBJECTIVES: To assess the diversity of Mycobacterium tuberculosis strains in Cotonou, Benin, and the risk factors associated with clustering. METHODS: We analysed one sputum sample from 194 consecutive new pulmonary tuberculosis (TB) cases using two genotyping methods: spoligotyping and the 12 loci mycobacterial interspersed repetitive unit-variable number of tandem repeats (MIRU-VNTR). The data obtained were compared to the SpolDB4.0 database. RESULTS: We have found that spoligotype 61, highly predominant in West Africa, was also the most prevalent strain in Cotonou. We observed that the Beijing family represented 10.3% of strains and was associated with resistance to streptomycin. We also confirmed that combining spoligotyping and MIRU-VNTR provided a higher discriminatory power than the two techniques used individually. CONCLUSION: Spoligotype 61 and Beijing genotype are the most prevalent genotypes of M. tuberculosis in Cotonou.

[Follow-up of the first case of Mycobacterium ulcerans infection documented by PCR, genotyping and culture in the Republic of Congo-Brazzaville]. / Suivi du premier cas d'infection à Mycobacterium ulcerans confirmé par culture, PCR et génotypage République du Congo-Brazzaville.

This article presents follow-up data from the first patient in whom Mycobacterium ulcerans infection (MUI) was documented by PCR, genotyping and culture in the Republic of Congo-Brazzaville. Findings show the importance of regular clinical and microbiological evaluation for the disseminated form of the disease. The patient was probably infected in Pointe Noire where MUI has been described but never documented. Culture of specimens collected before antibiotic treatment showed that the bacterium was sensitive to the antibiotics being administered (streptomycin and rifampin) and was identical to isolates from Atlantic-coast regions of West Africa where MUI is endemic. The patient was treated with streptomycin and rifampin for 12 weeks in association with surgery. During treatment clinical examination was performed every day and microbiological analysis every two weeks. The duration of follow-up from the end of specific antibiotic treatment was 26 months. Medical treatment failed to prevent bone involvement and fistulae that were treated by surgery. However medical treatment may have limited dissemination of the disease. Serial microbiological evaluation was useful to detect bone involvement in this patient, but persistent positive gene amplification is not a proof of active disease. This study confirms that MUI is still endemic in the region of Pointe Noire. This finding underlines the need to optimize epidemiologic surveillance, laboratory diagnostic capabilities, and therapeutic management in the Republic of Congo-Brazzaville.

Bulk staining of smears: no demonstrated risk of bacilli transfer from a positive to a negative smear.

Despite a theoretical risk of transfer of bacilli from a positive to a negative smear, bulk staining is routinely performed in many laboratories. To assess this risk in our laboratory, two smears were made from each sputum specimen and stained with auramine: one smear was stained on a rack and the second using the bulk method. Smears were read blind using a fluorescence microscope. A total of 811 sputum specimens were analysed. No acid-fast bacilli transfer was observed even when staining solution jars had not been renewed for 3 days. Bulk staining is rapid and cheap, and could be used in laboratories with a high workload in low-resource settings.

High levels of resistance to second-line anti-tuberculosis drugs among prisoners with pulmonary tuberculosis in Georgia.

SETTING: Penitentiary system of Georgia. OBJECTIVE: To determine the prevalence of resistance to second-line drugs among prisoners with pulmonary tuberculosis (PTB). DESIGN: Retrospective evaluation of resistance to second-line drugs in tuberculosis (TB) patients treated from 2001 to 2003. RESULTS: The overall observed prevalence of multidrug-resistant TB (MDR-TB) was 14.4% (39/270). The lowest resistance was found for ofloxacin (OFX), which was 2.2% (6/270) overall and 5.1% (2/39) among MDR patients. Isolates from four non-MDR patients who had never received anti-tuberculosis treatment were found to be resistant to OFX. Resistance to kanamycin and capreomycin occurred simultaneously only among MDR patients and was observed in 17/39 cases (43.6%). High rates of resistance to > or =2 second-line drugs (18/39, 46.2%) and > or =3 second-line drugs (10/39, 25.6%) were observed among all MDR-TB patients, reaching respectively 59.3% and 29.6% among previously treated MDR-TB cases. Only one patient was found to be resistant to four second-line drugs. No extensively drug-resistant TB (XDR-TB) according to the latest definition was detected. CONCLUSION: Our findings reveal a serious threat to the TB control efforts in the study population.

Low levels of second-line drug resistance among multidrug-resistant Mycobacterium tuberculosis isolates from Rwanda.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) has become a therapeutic problem in many parts of the world, necessitating the inclusion of second-line anti-tuberculosis drugs in specific treatment regimens. METHODS: We studied the susceptibility of 69 MDR Mycobacterium tuberculosis isolates from Rwanda to second-line drugs by the BACTEC 460 method. RESULTS: The results showed that 62 (89.9%) were resistant to rifabutin while a low rate (4.3%) of resistance was registered for ofloxacin; there was one case (1.4%) of resistance each for para-aminosalicylic acid, kanamycin, ethionamide, and clarithromycin. CONCLUSIONS: This information is important for devising an appropriate treatment regimen for MDR-TB patients in order to stop the spread of MDR strains and contain the acquisition of additional drug resistance in Rwanda.

[Primary resistance of Mycobacterium tuberculosis to anti-tuberculosis drugs in Kinshasa, (DRC)]. / Résistance primaire de Mycobacterium tuberculosis aux anti-tuberculeux à Kinshasa, République Démocratique du Congo.

In a descriptive cross-sectional study carried out in Kinshasa between July 2003 and January 2004, we determined the prevalence of the primary resistance of M. tuberculosis to first-line anti-tuberculosis drugs. The antibiogram was performed with the proportion method on 301 isolats from patients who all had a first episode of pulmonary tuberculosis with positive microscopy (TPM+) and who had not received any anti-tuberculosis treatment before. The primary resistance rate reached 43.5%; it reached 31.6% in 1990. The multi-drug-resistance rate (MDR-TB) notified as resistant to both rifamicine and isoniazide rose to 5.3%. This rate of primary resistance is among the highest in Africa. The emergence of the resistant strains and specially the multi-drug-resistant strains (MDR-TB) in Kinshasa requires a regular assessment of these phenomena which threaten seriously the implementation of the national tuberculosis control programme.

Anti-tuberculosis drug resistance among new and previously treated pulmonary tuberculosis patients in Cotonou, Benin.

OBJECTIVES: To assess the current anti-tuberculosis drug resistance situation in Cotonou, at the largest anti-tuberculosis centre of Benin. METHODS: A total of 470 isolates of Mycobacterium tuberculosis complex from pulmonary tuberculosis (TB) patients were analysed: 244 from new cases and 226 from previously treated cases. Drug susceptibility testing of isolates against first-line drugs was performed using the proportion method. RESULTS: Primary multidrug resistance (MDR) depends on the patients' origin: MDR in new cases is relatively high (1.6%) when all patients are considered, but low (0.5%) and comparable to 1994 national survey results when only patients residing in Benin are considered. MDR in previously treated patients (11.1%) remains comparable to the study performed in Benin in 1994. No relation was found between human immunodeficiency virus co-infection and anti-tuberculosis drug resistance. CONCLUSION: This study shows the great importance of correct patient identification in epidemiological surveys, where results may vary according to the population(s) studied.

[Study of names and folklore associated with Mycobacterium ulcerans infection in various endemic countries in Africa]. / Etude des appellations et des représentations attachées à l'infection à Mycobacterium ulcerans dans différents pays endémiques d'Afrique.

The purpose of this article is to present names used for Mycobacterium ulcerans infection (Buruli ulcer) and explain their meanings in various African languages. Representations associated with the disease were also studied. The study approach involved qualitative analysis of information from interviews and literature. Interviews were conducted with the directors of various programs and management centers. Findings from 9 African countries where Buruli ulcer is known to be endemic, i.e., Benin, Cameroon, Congo-Brazzaville, Côte d'Ivoire, Ghana, Uganda, Democratic Republic of Congo, Southern Sudan and Togo, showed that the names used for the disease could be classified into three categories based on the geographical origin of infection, the features of the observed lesions, and aspects of ost often associated with belief in witch-craft, i.e., bad luck, fetishes, and curses. Representation of the disease in different African languages were similar and appear to demonstrate a good understanding of the disease in the countries where Buruli ulcer is prevalent. The impact of the representations of the disease on therapeutic choices and itineraries is also discussed.

Survival of Mycobacterium ulcerans at 37 degrees C.

Bone infection and metastatic spread in cases of Buruli ulcer imply that Mycobacterium ulcerans is able to survive and multiply at 37 degrees C. This study investigated the survival at 37 degrees C of M. ulcerans isolates from diverse geographical and clinical sources. Although the viability of all isolates decreased after a few days at 37 degrees C, viable bacilli remained after 13 days at 37 degrees C in most instances. African isolates of M. ulcerans were more thermotolerant than isolates from temperate regions. Isolates from skin and bone lesions of the same patients showed no difference in thermotolerance.

Molecular investigation of recurrent tuberculosis in patients from Rwanda.

SETTING: Pulmonary tuberculosis (TB) patients enrolled in four provinces of Rwanda. OBJECTIVE: To determine the cause of recurrent TB. DESIGN: Serial Mycobacterium tuberculosis isolates obtained from patients with recurrent TB from January 2002 to September 2005 were genotyped by spoligotyping and mycobacterial interspersed repetitive unit-variable number of tandem repeat (MIRU-VNTR) typing. Drug resistance was determined by phenotypic susceptibility testing and sequencing of rpoB, katG, inhA and embB genes. RESULTS: Among 710 culture-positive TB patients enrolled in the study, initial drug susceptibility testing results were available for 638. Sixty-nine of these had multidrug-resistant (MDR) TB and 569 were non-MDR-TB. Among the MDR-TB patients, 22 had follow-up isolates after cure (n = 12) or chronic infection (n = 10). The DNA patterns of sequential isolates from 4 of the 12 previously cured MDR-TB patients were different, indicating re-infection. DNA patterns of isolates from the remaining 8 previously cured and 10 chronic MDR-TB patients were identical, suggesting reactivation and treatment failure, respectively. Among the non-MDR-TB patients, disease recurrence was observed in one case; this was determined to be due to reactivation after initial mixed infection. CONCLUSION: These results document a high treatment failure/reactivation rate for MDR-TB and suggest that re-infection within 2 years may not be a common cause of recurrent TB in this setting.

[Primary and acquired resistance to antituberculous drugs in strains of Mycobacterium tuberculosis isolated in Rwanda]. / Résistance primaire et acquise aux antituberculeux des souches de Mycobacterium tuberculosis isolées au Rwanda.

This study was undertaken within the framework of a surveillance project on the resistance of Mycobacterium tuberculosis to first-line antituberculosis drugs in four provinces of Rwanda with a high prevalence of tuberculosis (TB). The purpose was to determine the prevalence of primary and acquired resistance of M. tuberculosis to major antituberculosis drugs. A cohort of patients (n=710) with pulmonary TB documented by positive microscopic examinations of exhaustive samples was recruited at 7 treatment centers. Sputum samples were cultured on Löwenstein-Jensen and Coletsos media. Sensitivity to antituberculosis drugs was tested using a BACTEC 460 radiometric system. M. tuberculosis was isolated in 644 of the 710 patients (90.7%). A total of 296 out of 573 tested for HIV infection (51.7%) were positive. Primary resistance to one, two, three or four antituberculosis drugs was observed in 3.5%, 2.9%, 1.4% and 5.7% respectively. The prevalence of acquired resistance to antituberculosis drugs was 11.2%. Primary monoresistance to streptomycin was the most prevalent (2.3%) followed by resistance to ethambutol (1%). The combined rate of multiresistance was 11.6% with 7% involving new cases and 25.5% involving retreatment. This study showed that the rates of primary and acquired resistance to first-line antituberculosis drugs were high and that TB was associated with HIV infection. The National TB Control Program must implement measures to coordinate diagnosis and management of TB and HIV infection.

Evaluation of the resazurin assay for the detection of multidrug-resistant Mycobacterium tuberculosis in Madagascar.

SETTING: Multidrug-resistant (MDR) tuberculosis (TB) can jeopardise the success of national TB control programmes. Rapid, simple drug susceptibility tests applicable in developing countries would allow earlier treatment of patients with MDR infections. OBJECTIVE: To test the feasibility and performance of the resazurin microtitre assay (REMA) as an indirect test for detecting isoniazid (INH) and rifampicin (RMP) resistance of Mycobacterium tuberculosis strains in Madagascar. DESIGN: Study comparing the sensitivity and specificity of the REMA plate test with the Löwenstein-Jensen proportion method for determining the resistance of M. tuberculosis strains to INH and RMP. RESULTS: The sensitivity and specificity of the resazurin test were studied in 77 strains and were respectively 95% and 97.3% for the detection of INH resistance, and 95% and 100% for the detection of RMP resistance. The sensitivity and specificity for the identification of MDR strains were respectively 89% and 100%. CONCLUSION: The resazurin test is sensitive and specific enough for the detection of INH- and RMP-resistant strains. It is also easy to use, rapid and inexpensive, making it suitable for developing countries. Its usefulness for national drug resistance surveys should be assessed.

Identification of a new variable number tandem repeat locus in Mycobacterium ulcerans for potential strain discrimination among African isolates.

Intra-species discrimination in the highly clonal pathogen Mycobacterium ulcerans was studied in a diverse collection of isolates by PCR amplification of a short sequence repeat locus containing heterogeneous arrays of tri-nucleotide repeats with an ACC consensus pattern. Post-amplification analysis indicated excellent typeability and identified five M. ulcerans alleles, including a unique Angolan type differentiated for the first time among a genetically conserved cluster of African isolates. These results are consistent with previously investigated independent markers, and provide an additional locus for variable number tandem repeat-based typing of M. ulcerans.