Histoplasma capsulatum causing sinusitis: a case report in French Guiana and review of the literature.

BACKGROUND: American histoplasmosis is a mycosis caused by Histoplasma capsulatum. A variety of clinical features of histoplasmosis have been commonly described ranging from asymptomatic infections to severe pulmonary infections. In immunocompromised individuals, progressive disseminated forms are frequent, leading to fatal outcome if untreated. However, H. capsulatum sinusitis is unusual with a few cases documented over the last three decades and may be underdiagnosed or confused with other fungal aetiologies, especially outside endemic regions. CASE PRESENTATION: In this study, we report an atypical case of Histoplasma capsulatum sinus fungus ball-like in a patient with Acquired Immunodeficiency Syndrome due to Human Immunodeficiency Virus complicated by a disseminated histoplasmosis with a death ending. Diagnosis relied on CT-Scan imaging and on both direct examination of H. capsulatum yeast forms (Gomory methenamine Grocott) in the sinus specimen (aspirate, biopsy) and on positivity of the culture further confirmed by qPCR. CONCLUSIONS: Since last few decades, among the eight reviewed patients, H. capsulatum sinusitis occurred mostly in HIV-immunocompromised patients and for three cases as a sinusitis with disseminated histoplasmosis. Even if this is a rare clinical presentation, its diagnosis is crucial as it could represent an early expression of an Histoplasma capsulatum exposure that can evolve into a disseminated fatal infection when immunity decreases.

[Paracoccidioidomycosis of the external ear]. / Paracoccidioïdomycose localisée au pavillon d'une oreille.

BACKGROUND: Paracoccidioidomycosis is a systemic fungal infection common in Latin America. Cutaneous involvement is frequent and usually affects multiple sites, being most frequently associated with lesions of the oropharyngeal mucosa. The cutaneous form on its own is rare. PATIENTS AND METHODS: We report a case of paracoccidioidomycosis isolated from the ear of a 43-year-old immunocompetent man. The lesion consisted of a partially ulcerated plaque on the auricle of the left ear. Direct examination, histopathological examination and PCR revealed the presence in the skin lesion of yeasts identified as Paracoccidioides brasiliensis. DISCUSSION: The sites of paracoccidioidomycosis on the ear can be confused with other tropical diseases frequently found in the Amazon region such as leishmaniasis, leprosy and lobomycosis. The absence of any other cutaneous sites in this case raised the question of whether the lesion was of primary or secondary origin.

Acute toxoplasmoses in immunocompetent patients hospitalized in an intensive care unit in French Guiana.

Atypical Toxoplasma gondii strains, unrelated to archetypal clonal lineages (I, II, III), have been reported more frequently over the last decade in areas other than Europe and North America. A newly described form of toxoplasmosis, 'Amazonian toxoplasmosis' (AT), has been reported since 2002 in French Guiana. It is characterized by severe cases and atypical strains linked to a neotropical forest-based cycle. We report on the cases of AT that required intensive care management. We performed a prospective observational study on hospitalized adults in the Intensive Care Unit (ICU) from 2002 to 2008. Clinical and laboratory data, microbiological findings and outcomes were recorded. Data, including the ICU simplified acute physiology score and the pneumonia severity index, were calculated. Epidemiological risk factors for AT were assessed through questionnaires. Eleven non-immunodeficient patients were admitted to the ICU in Cayenne for life-threatening pneumonia associated with disseminated toxoplasmosis. Mechanical ventilation was necessary in seven patients, four of whom required immediate orotracheal intubation. Cardiac and ophthalmological abnormalities were found in five and four patients, respectively. One patient died from multiple organ failure. The genetic characterization of Toxoplasma DNA using six microsatellite markers revealed unique and atypical genotypes in eight patients. All patients presented epidemiological risk factors for AT. In French Guiana, significant T. gondii-related infectious syndrome associated with the lungs, a high level of LDH activity and the reported risk factors for AT was strongly suggestive of disseminated toxoplasmosis with a possible trend toward life-threatening pneumonia.

Fatal histoplasmosis in a non-HIV patient in French Guiana.

Histoplasmosis is an endemic fungal infection that causes no symptoms or minor self-limited illnesses in most cases. Severe forms are commonly reported in patients with immunodeficiency disorders; histoplasmosis is considered to be an opportunistic infection in patients with AIDS. We report a case of disseminated histoplasmosis in a patient with no induced active suppression of the immune response. The infection was fulminant, and antifungal treatment was delayed because of a misdiagnosis of tuberculosis.

Eumycetoma caused by Diaporthe phaseolorum (Phomopsis phaseoli): a case report and a mini-review of Diaporthe/Phomopsis spp invasive infections in humans.

Diaporthe phaseolorum (syn. Phomopsis phaseoli) is a frequent fungal parasite of plants, present on all continents around the world. It has rarely been involved in human diseases. We report a case of eumycetoma with osteomyelitis of the forefoot caused by this fungus and diagnosed by molecular biology. The patient had positive HTLV-1 serology and was a farmer from French Guiana who walked barefoot. He was successfully treated with long-term oral itraconazole (400 mg/day). A review of the literature underlines the essential roles of plants and host immunosuppression in this infection and the favourable outcome with a triazole antifungal treatment.

Human impact on genetic diversity of Toxoplasma gondii: example of the anthropized environment from French Guiana.

In French Guiana, severe cases of toxoplasmosis in immunocompetent patients are associated with atypical strains of Toxoplasma gondii linked to a wild neotropical rainforest cycle and a higher genetic diversity than usually observed for T. gondii isolates from anthropized environment. This raises the question of the impact of anthropization of the natural environment, on genetic diversity and on the population structure of T. gondii. However, few data are available on strains circulating in the anthropized areas from French Guiana. Seropositive animals originating mainly from anthropized sub-urban areas and punctually from wild environment in French Guiana were analyzed for T. gondii isolation and genotyping. Thirty-three strains were obtained by bioassay in mice and compared with 18 previously reported isolates chiefly originating from the Amazon rainforest. The genotyping analysis performed with 15 microsatellite markers located on 12 different chromosomes revealed a lower genetic diversity in the anthropized environment. Results were analyzed in terms of population structure by clustering methods, Neighbor-joining trees reconstruction based on genetic distances, F(ST,) Mantel's tests and linkage disequilibrium. They clearly showed a genetic differentiation between strains associated to the anthropized environment and those associated to the wild, but with some inbreeding between them. The majority of strains from the anthropized environment were clustered into additional lineages of T. gondii that are common in the Caribbean. In conclusion the two environmental populations "wild" and "anthropized" were genetically well differentiated. The anthropization of the environment seems to be accompanied with a decreased diversity of T. gondii associated with a greater structure of the populations. We detected potential interpenetration and genetic exchanges between these two environmental populations. As a higher pathogenicity in human of "wild" genotypes has been described, the interpenetration of both environments leads to hybridization between strains that may be at risk for human health.

Unravelling the relationships between Anopheles darlingi (Diptera: Culicidae) densities, environmental factors and malaria incidence: understanding the variable patterns of malarial transmission in French Guiana (South America).

Anopheles darlingi, one of the main malaria vectors in the Neotropics, is widely distributed in French Guiana, where malaria remains a major public-health problem. Elucidation of the relationships between the population dynamics of An. darlingi and local environmental factors would appear to be an essential factor in the epidemiology of human malaria in French Guiana and the design of effective vector-control strategies. In a recent investigation, longitudinal entomological surveys were carried out for 2-4 years in one village in each of three distinct endemic areas of French Guiana. Anopheles darlingi was always the anopheline mosquito that was most frequently caught on human bait, although its relative abundance (as a proportion of all the anophelines collected) and human biting rate (in bites/person-year) differed with the study site. Seasonality in the abundance of human-landing An. darlingi (with peaks at the end of the rainy season) was observed in only two of the three study sites. Just three An. darlingi were found positive for Plasmodium (either P. falciparum or P. vivax) circumsporozoite protein, giving entomological inoculation rates of 0·0-8·7 infectious bites/person-year. Curiously, no infected An. darlingi were collected in the village with the highest incidence of human malaria. Relationships between malaria incidence, An. darlingi densities, rainfall and water levels in the nearest rivers were found to be variable and apparently dependent on land-cover specificities that reflected the diversity and availability of habitats suitable for the development and reproduction of An. darlingi.

Mapping of lymphatic filariasis: "to be (in English) or not to be".

Despite lack of supporting evidence from epidemiologic studies and/or confirmed case reports over the last 30 years, maps in non-specialist works on tropical medicine as well as in documents from specialized organizations (e.g. WHO) systematically include Congo and Gabon, two French-speaking countries, within the zone of endemic filariasis due to Wuchereria bancrofti. One certainty is that no cases were found in field studies carried out in these countries in the late 1970s and 1980s but unfortunately published only in French. Studies that we carried out in the Congo between 1982 and 1987 as part of the National Project on Onchocerciasis and Other Filarioses confirmed the presence of four types of human filariasis: onchocerciasis, loaiasis filarioses caused by Mansonella perstans and M. streptocerca. However, there were no confirmed cases of lymphatic filariosis (bancroftosis). Hopefully the WHO program aimed at the elimination of lymphatic filariasis as a public health problem will provide up-to-date data on the distribution and endemicity of filariasis in Central Africa. Achievement of this objective will depend not only on carrying out new field studies but also on taking into account past studies published in languages other than Shakespeare's.

[Update on the epidemiology of malaria in French Guiana]. / Situation epidémiologique du paludisme en Guyane.

The last study describing the epidemiology of malaria in French Guiana was published 20 years ago. Yet French Guiana in the Americas along with Mayotte in the Indian Ocean is the only French territory with persisting endemic malaria. The purpose of this study is to provide an update based on official malaria surveillance data as well as on information from hospital records and various field surveys that have been carried out in recent years. Due to recurrent problems in collecting thorough, continuous, and consistent data, exact determination of incidence by plasmodium species has always been difficult in French Guiana. These problems include not only the remote location of endemic areas and intense unpredictable migration patterns but also poor data collection methods that do not always ensure consistency and homogeneity. Another factor hindering thorough collection of conventional epidemiological data is the requirement for rapid effective treatment in remote regions. The overall incidence of malaria in French Guiana appears to have remained stable since the beginning of the decade with an average of 3,920 case reports per year for an incidence rate of 20 per thousand, noting that three fourths of the 206,000 inhabitants of French Guiana live outside of endemic areas. Overall involvement of P. falciparum and P. vivax appears to be equal with P. malariae accounting for only 2.6% of cases. Trends in recent years indicate an increase in the number of cases involving P. vivax especially in the eastern zones, i.e. in the Oyapock focus where annual incidences in children have reached up to 500 per thousand and in the whole region located between Saint Georges and Cayenne. Conversely a decrease in endemic levels has been observed in western areas, especially for P. falciparum in the upper and middle focuses of the Maroni. Most zones now causing problems are located near migration points, particularly in relation with clandestine gold panning activities. In the coastal strip where the three main cities with most of the population are located, most reported cases are imported but local cases may occur. In general local transmission in these areas has been promptly controlled but trends indicate that incidence of these events may be rising. Anopheles darlingi is still recognized as the main vector but its role in transmission is less obvious in eastern areas where increasing evidence suggests that other species may contribute to maintaining endemic levels. These findings indicate that the extensive resources deployed in this French territory (public financing, health care network, public awareness campaigns, and training of health care personnel in diagnosis and treatment of malaria) have helped reduce the number of severe cases in an unfavorable epidemiological setting.

[Mucocutaneous leishmaniasis due to Leishmania guyanensis: a case report in an HIV-infected patient]. / Leishmaniose cutanéo-muqueuse à Leishmania guyanensis: une observation chez un patient infecté par le VIH.

In French Guiana cutaneous leishmaniasis occurs mainly in the localized form with L. guyanensis accounting for more than 90% of cases. Mucocutaneous leishmaniasis is uncommon (less than 2% of cases) with L. braziliensis accounting for all previously reported cases. The purpose of this report is to describe a case of mucocutaneous leishmaniasis due to L. guyanensis that led to diagnosis of HIV infection in a patient living in French Guiana.

Atypical Toxoplasma gondii strain from a free-living jaguar (Panthera onca) in French Guiana.

Like domestic cats, wild felids are involved in the complete infective cycle of Toxoplasma gondii because they can host in their gastrointestinal tract sexually mature parasites and shed infective oocysts in their feces. We report, to our knowledge, the first isolation and molecular characterization of a T. gondii strain from the heart tissue of a free-living jaguar (Panthera onca) in French Guiana. Sequencing at six polymorphic markers indicated that the jaguar isolate had an atypical genotype, including an allele at TgM-A previously found only in isolates from South America, and an allele at GRA6, which was previously reported only in Californian sea otter isolates. These findings are consistent with the recent description of atypical T. gondii strains involved in severe toxoplasmoses in immunocompetent patients in French Guiana that seemed to be linked to a neotropical forest-based cycle involving wild cats and their prey.

[Cutaneous leishmaniases in French Guiana]. / Les leishmanioses cutanées en Guyane française.

Cutaneous leishmaniases are endemic over the entire territory of French Guiana. At least 5 distinct Leishmania species coexist in the sylvatic ecotopes of this French territory. The present paper checks the advances in the ecological research field during the past 5 years. The current epidemiological situation and trends are detailed successively Links between the recrudescence of leishmaniases and gold-mining are highlighted. The potential adaptation of the pathogenic complexes to the newly anthropized habitats is also described.

[Pathological fracture revealing an osseous histoplasmosis. A case report on a 60-year patient]. / Fracture pathologique révélant une histoplasmose osseuse. A propos d'une observation chez une patiente de 60 ans.

The authors report a new case of African Histoplasmosis in a 60-year-old patient. It was an humeral localization revealing a pathological fracture which grew into an extension of osteolysis and a cutaneous fistulization likely to be a malignant bone tumor. The case has been diagnosed by surgical biopsy and histological analysis. Its antifungal treatment in progress resulted in the drainage of the out-flow that should permit the bone reconstruction by graft. The authors stress on the need to focus on this affection whenever, in a tropical area, one is faced with any chronic bone fistula that cannot positively be cured in spite of sound medical cares.

[Intestinal parasitosis in French West Indies: endemic evolution from 1991 to 2003 in the University Hospital of Pointe-a-Pitre, Guadeloupe]. / Diagnostic des parasitoses intestinales au CHU de la Guadeloupe: evolution de 1991 a 2003.

Guadeloupe is one of the French West Indies, where, until 1960, intestinal parasitic infections were endemic. In the microbiological laboratory of the university hospital of the island, we carried out a retrospective study of the 17,660 stool examinations received from 1991 to 2003. All the stool specimens were examined using at least a wet mount preparation and a concentration method (Bailenger). Specific techniques such as Ziehl-Neelsen modified acid fast stain, chromotrope staining procedure or Baermann's technique were used when indicated. A parasite considered as really pathogenic is detected in only 5.6% of the cases of the 17,660 stool examinations. The intestinal protozoa count for 10.8% of them, G. intestinalis (60%) is the most common, followed by Cryptosporidium sp (26%) and Isospora belli in AIDS patients while Entamoeba histolytica/dispar rarely appears (2.3%). Among the parasitic intestinal helminths, Strongyloïdes stercoralis is seen as the most prevalent (82%) whereas hookworms and Trichuris trichuria count respectively for 9.8% and 5.6%. Schistosoma mansoni appears as an exception. This epidemiological change for intestinal parasitic infections results from the improvement of socio-economic and sanitary way of living of the population. However the persistence of the strongyloidiasis constitutes the outstanding fact in a area of strong prevalence of the HTLV1 infection.

Comparison between one and two injections of pentamidine isethionate, at 7 mg/kg in each injection, in the treatment of cutaneous leishmaniasis in French Guiana.

In a retrospective study set in French Guiana, the efficacy and tolerance of the intramuscular treatment of cutaneous leishmaniasis (CL) with a single injection of pentamidine isethionate, at 7 mg/kg, were compared with those observed, earlier, using two such injections (given 48 h apart). Although 83.6% of the 281 patients given two injections each were cured, the single-injection protocol was generally as effective, curing 78.8% of 137 patients. The single-injection protocol was also associated with fewer adverse effects than the two-injection. In the treatment of "difficult" cases (those with satellite papules or relatively high numbers of amastigotes in their lesions), however, the two-injection protocol appeared significantly more effective than the single-injection. In French Guiana, therefore, patients with CL should be given one injection with pentamidine isethionate and only be given a second, 48 h later, if they have satellite papules and/or relatively high numbers of amastigotes in their lesions.

[Toxoplasmosis in French Guiana. Atypical (neo-)tropical features of a cosmopolitan parasitosis]. / La toxoplasmose en Guyane française: particularités (néo)tropicales d'une parasitose cosmopolite.

Toxoplasmosis, a typical cosmopolitan parasitosis, is a major health problem in French Guiana. Three factors account for this situation, i.e., (1) severity of toxoplasmosis in patients with HIV infection that is particularly prevalent in the area, (2) high risk of congenital transmission as shown by the steadily increasing prevalence of seropositivity in function of age in most of the Guianese population and (3) recent identification of severe primary toxoplasmosis infection in immunocompetent patients. In AIDS patients, the epidemiologic aspects of toxoplasmosis are correlated to the special features of the HIV-positive population in French Guiana and its clinical expression, mainly in the form of cerebral toxoplasmosis, does not suggest involvement of a particularly virulent strain of Toxoplasma. Similarly congenital toxoplasmosis does not present special tropical features other than problems associated with prevention, diagnosis and follow-up in poor and/or remote settings. These features are fully compatible with the classic domestic cat cycle of Toxoplasma gondii. However severe forms of primary infection, particularly in immunocompetent adults, appear to be associated with atypical features. These forms appear to be correlated with a forest-based cycle involving wild cats, which are still numerous in French Guiana, and their prey. Ingestion of undercooked wildcat prey, which is also a delicacy for man, can also be a source of contamination as can be consumption of untreated river water infected with oocysts excreted by felines. Observation of higher toxoplasmosis seroprevalence in wild noncarnivorous mammals that live by foraging on the ground in uninhabited forest zones suggests that infection can also be due to ingestion of oocysts eliminated into the soil. Since there are no domestic cats in the area, it must be assumed that these oocysts are shed by wild felines. More convincing proof can be seen in the fact that T. gondi strains presenting polymorphism, similarities and atypical genetic features can be found both in this animal reservoir, particularly in jaguars, and in patients presenting the more severe form of toxoplasmosis. In addition to the purely scientific interest of confirming the existence of the forest-based cycle, knowledge of this atypical form of toxoplasmosis that is probably not confined to French Guiana or to the Amazon region has obvious practical medical implications not only for diagnosis but also for therapy and prevention.

[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.