[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.

[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.

Intralesional regulatory T-cell suppressive function during human acute and chronic cutaneous leishmaniasis due to Leishmania guyanensis.

The levels of regulatory T cells (Treg cells), analyzed by Foxp3 mRNA expression, were determined in lesions from patients with acute cutaneous leishmaniasis (ACL) and chronic cutaneous leishmaniasis (CCL). We demonstrated that Treg cells preferentially accumulate in lesions from ACL patients during the early phase of infection (lesion duration of less than 1 month). In addition, levels of Foxp3 mRNA transcripts were significantly higher in specimens from patients with CCL than in those from patients with ACL, suggesting a critical role of intralesional Treg cells in CCL. Intralesional Treg cells from both ACL and CCL patients were shown to have suppressive functions in vitro, since they inhibited the gamma interferon (IFN-gamma) produced by CD4(+) CD25(-) T cells purified from peripheral blood mononuclear cells from the same patient in response to Leishmania guyanensis stimulation. Intralesional 2,3-indoleamine dioxygenase (IDO) mRNA expression was associated with that of Foxp3, suggesting a role for IDO in the suppressive activity of intralesional Treg cells. In addition, a role, albeit minor, of interleukin-10 (IL-10) was also demonstrated, since neutralization of IL-10 produced by intralesional T cells increased IFN-gamma production by effector cells in an in vitro suppressive assay. These results confirm the role of intralesional Treg cells in the immunopathogenesis of human Leishmania infection, particularly in CCL patients.

[Leprosy in French Guyana: a retrospective study from 1997 to 2006]. / La lèpre en Guyane française: étude rétrospective de 1997 à 2006.

French Guyana borders Brazil with the second highest number of cases of leprosy in the world. The purpose of this retrospective study of leprosy cases diagnosed in Guyana between January 1997 and December 2006 was to calculate the incidence of the disease and to identify any special clinical and epidemiological features. A total of 90 new cases were recorded during the study period for a mean incidence of 0.53 cases/10,000 inhabitants/year. Since this incidence is below the 1/10,000 threshold defined by the World Health Organization, leprosy is no longer considered as a major public health issue in French Guyana. However it must be noted that while the number of "native leprosy" cases has declined, the number of Brazilian cases has increased (p<0.01). Brazilian leprosy has different epidemiological features, i.e., dominance of multibacillary forms and high incidence in gold panning and western regions of the country where the incidence is over 1/10,000 inhabitants/year.

[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.

[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.

[Disseminated histoplasmosis: an atypical ulcerous form in an HIV-infected patient]. / Histoplasmose disséminée: forme ulcéreuse atypique chez un malade infecté par le VIH.

INTRODUCTION: Histoplasma capsulatum var capsulatum is a dimorphic fungi predominating on the American continent. It is responsible for disseminated histoplasmosis associated with AIDS. The presentation in the form of cutaneous ulceration is uncommon and misleading. OBSERVATION: A 25 year-old man presented with 3 ulcerations, of 2 to 4 cm in diameter, localized on the lower lip and knees. The patient exhibited fever, alteration in his general status of health and a pulmonary interstitial syndrome. He was seropositive for the human immunodeficiency syndrome (HIV). His lymphocyte CD4+ level was of 1/mm3. Diagnosis of histoplasmosis was established by direct examination and culture of the cutaneous ulcerations and bronchoalveolar washing fluid. DISCUSSION: The clinical aspect of cutaneous localizations of disseminated histoplasmosis is usually multiple, disseminated, papular or nodular-type lesions. Ulcerations represent less than 20% of the cases described. In our patient, the aspect of the lesions at first evoked cutaneous leishmaniosis. Direct mycological examination followed by culture confirmed the final diagnosis.

[Cutaneous-mucosal paracoccidio-domycosis: the first case diagnosed in French Guiana]. / Paracoccidioïdomycose cutanéo-muqueuse: premier cas diagnostiqué en Guyane Française.

INTRODUCTION: Paracoccidio-domycosisis a deep mycosis due to a dimorphic fungus:Paracoccidioides brasiliensis. The principle endemic country is Brazil. We describe the first case of paracoccidio-domycosis, in its cutaneous-mucosal form, diagnosed in French Guiana. OBSERVATION: A 20 year-old Brazilian man, having mover to French Guiana a few months earlier, presented with multiple disseminated cutaneous lesions, predominating on the face, and composed of multiple nodules and two ulcerations. The clinical examination also revealed voluminous superficial lymph nodes and ulcerations of the pharynx and larynx. Direct examination, anatomopathology and culture of cutaneous biopsies revealed specific images of Paracoccidioides brasiliensis. HIV serology was negative. Treatment combining cotrimoxazole and itraconazole eliminated the lesions in one month. DISCUSSION: Because the patient had just moved to Guiana, this observation probably corresponded to an imported disease. The principle differential diagnosis was leishmaniosis.

[Oculocutaneous albinism in French overseas territories (Reunion, French Guyana, Martinique) and Mayotte. Study of 21 cases in 16 families]. / L'albinisme oculocutané dans les départements français d'Outre-Mer (Réunion, Guyane, Martinique) et à Mayotte: à propos de 21 observations dans 16 familles.

The dual purpose of this study was to determine the genotype of patients with oculocutaneous albinism type 1 and 2 based on analysis of tyrosinase and P gene mutations and to attempt to establish a correlation between phenotype and genotype. This study included a total of 21 Caucasian, Indian and Black African patients from La Reunion, la Martinique, French Guyana and Mayotte. PCR-sequencing of genomic DNA was performed to detect tyrosinase gene mutations and PCR-separation of PCR products by agarose gel electrophoresis was performed to detect 2.7kb deletion allele of the P gene. Tyrosinase gene mutations were identified in two cases, i.e., on eheterozygous guanine "g" deletion (c.572 delG) with a frameshift (Gly191fs) resulting in apremature termination signal at codon 225 in a Caucasian patient from La Reunion and one homozygous missense mutation, Glycine419Arginine, in an Indian patient from La Reunion. The 2.7-kb deletion allele of the P gene was detected in three Black African patients, i.e. two in the homozygous state in siblings from Mayotte and one in the heterozygous state in a girl from la Martinique. The latter patient whose mother was from la Martinique inherited the mutation from her father who was from Cameroon. This study shows that characterization of tyrosinase and P gene mutations in albinos patients is crucial to (a) differentiate subjects with oculocutaneous albinism types 1 and 2 and establish a correlation between phenotype and genotype, (b) identify healthy heterozygous carriers among the patient's immediate family (parents and siblings) and (c) allow prenatal diagnosis during subsequent pregnancies in couples who have already engendered albino children with severe visual phenotype and documented mutation(s).

Disseminated cutaneous leishmaniasis due to Leishmania guyanensis: case of a patient with 425 lesions.

Disseminated cutaneous leishmaniasis is characterized by the presence of a large (> or =10) number of lesions at several anatomic sites (head, limbs, and trunk). Most of the lesions are small, papular, and appear simultaneously with or secondarily to one or several ulcerated lesions of localized cutaneous leishmaniasis. We report the first case of disseminated cutaneous leishmaniasis in French Guiana. It concerns a 24-year-old woman who tested negative for human immunodeficiency virus (HIV). The disease began with three lesions that became ulcerated. One week later, multiple papulo-nodular lesions appeared. We counted a total of 425 lesions. Leishmania were observed in the lesions. The species involved was L. guyanensis, which has never been described in a case of disseminated cutaneous leishmaniasis. The patient was rapidly cured by a single course of pentamidine. Disseminated cutaneous leishmaniasis should be distinguished from other types of leishmaniasis with multiple lesions. These include anergic diffuse cutaneous leishmaniasis, post-kala-azar leishmaniasis, and leishmaniasis associated with HIV infection.

Cell-matrix patterns in the cutaneous lesion of chromomycosis.

Chromomycosis is a chronic fungal infection characterized by dermal fibrosis with persisting fungi in situ, generally leading to a verrucous skin lesion. The absence of good clinical results under specific treatment suggests irreversibility of the fibrotic lesion. Frozen and paraffin-embedded skin biopsies of eleven patients with chromomycosis due to Phialophora pedrosoi were studied by immunohistochemistry and electron microscopy. Distinct cell-matrix patterns were found in different tissue localizations: neutrophilic abscesses with oedema and necrotic keratinocytes in the epidermis; dense connective matrix around inflammatory infiltrates, mainly composed of macrophages and giant cells, and organized granuloma in the dermis. Active fibroblasts and mast cells were constantly observed. The inability of fibrotic tissue to be remodelled seems correlated to the nature and the organization of the matrix components but, the factors triggering the initial fibrogenic events remain to be characterized.

Seasonal fluctuations of incubation, healing delays, and clinical presentation of cutaneous leishmaniasis in French Guiana.

An investigation was conducted to determine whether seasonal variations affected the development of cutaneous leishmaniasis. Data from 499 cases treated between July 1994 and December 1998 were analyzed. The interval between infection and consultation and between treatment and clinical cure varied significantly between cases with an incubation period during the dry season compared with the rainy season (P < 0.001). When the incubation period occurred during the dry season, the standard pentamidine isethionate treatment seemed to be less effective (i.e.. the odds ratio for failure was 1.9 [1.1-3.4], P = 0.01). The presence of lymphangitis was more frequent during the dry season (i.e., the odds ratio was 0.26 [0.15-0.45], P < 0.001). These results suggested that the observed seasonal variations were due to variations in the host/parasite balance. Converging indirect elements that suggest a role for variations in solar ultraviolet radiation are discussed.

[Prurigo in tropical area. Importance of its association with HIV infection]. / Le prurigo en milieu tropical. Importance de son association avec l'infection à VIH.

The term prurigo applies to a classic chronic skin disease of children (P. strophulus) which is becoming found very seldom in developed countries, but remains extraordinarily prevalent in tropical areas. This striking geographical distribution relies on its ectoparasitic origin. Some peculiar aspects of prurigo, observed in French Guyana (South America), are reported. The original point is a new aspect of adult acquired prurigo, associated with HIV infection, which appears to be one of the features characteristic of tropical AIDS. This HIV associated prurigo (HAP) is the revelating event, in as high as 20% of HIV infected people, significatively those with less than 200 CD4 cells. HAP appears as a marker of HIV infection with poor sensitivity, but much higher specificity (92%), with no correlation with acquisition's risk factors. Just like infantile prurigo, HAP can be considered an arthropod bite reaction which seems to be enhanced in HIV infected people living in tropical environment.

[Diagnosis of Mycobacterium ulcerans infection by PCR: report of 3 cases observed in French Guiana]. / Diagnostic par PCR de l'infection due à Mycobacterium ulcerans: à propos de trois cas observés en Guyane Française.

Mycobacterium ulcerans infection is the third most important mycobacterial infection in the world. It has been described in many different countries including French Guiana. The diagnosis of M. ulcerans infection by culture is often difficult because culture is hard to perform in endemic areas and their sensitivity is not reliable. As a result the diagnosis of this infection is often delayed. However, molecular methods are now available to diagnose rapidly infections by M. ulcerans and distinguish it from other mycobacteria. We report three cases of skin infection due to M. ulcerans observed in French Guiana. Diagnosis was initially made by polymerase chain reaction and was confirmed later by culture (in two patients) and inoculation to mice (in one patient). A faster diagnosis of M. ulcerans infection should lead to a better prognosis of this infection.

[Local administration of ivermectin for the treatment of Cochliomyia hominivorax's myiasis]. / Traitement des myiases dues à Cochliomyia hominivorax par application locale d'ivermectine.

Myiasis with Cochliomyia homonivorax induce sensitive and nauseating cutaneous ulcerations. The usual treatment is limited to the mechanical extraction of the larvae. The authors have made a report on the treatment of C. hominivorax by local application of ivermectin. The use of this molecule paralyses and then kills the larvae. This allows rapid alleviation of pain and makes the extraction of the larvae easier.

[Effectiveness of 20% salicylated vaseline in the treatment of profuse tungiasis. Report of 8 cases in French Guiana]. / Efficacité de la vaseline salicylée à 20% dans le traitement des tungoses profuses. A propos de huit observations en Guyane Française.

The treatment of tungiasis involves the mechanic extraction of the gravid females of Tunga penetrans. We have observed on 8 patients profuse tungiasis diagnosed in the centre hospitalier de Cayenne. We have carried out different types of treatment, including the occlusive application of 20% of salicylated vaseline during 12 or 24 hours. This procedure causes the death of the parasites and facilitates their extraction.

[Leishmania (Viannia) braziliensis Vianna, 1911 in French Guiana. Clinical, therapeutic and epidemiological considerations in the ninth human diagnosed case]. / Leishmania (Viannia) braziliensis Vianna, 1911 en Guyane française. Considérations cliniques, thérapeutiques et épidémiologiques à propos du neuvième cas humain diagnostiqué.

The authors report the ninth case of cutaneous Leishmaniasis without mucosal involvement due to Leishmania (Viannia) braziliensis (isoenzymatic profile related to zymodeme MON-44) diagnosed in a legionnaire who recently arrived in French Guiana. The skin lesion as a single ulcerated nodule of the dorsum of the left ringfinger was cured after two courses of four intramuscular injections of pentamidine isothionate (total posology of pentamidine-base: 16.6 mg/kg). The transmission occurred during nocturnal trekking in forest and swamps just behind the coastal belt at Degrad Saramaka (7 km South of Kourou). In French Guiana, the good level of medical care and the early treatment of the majority of the cases of Leishmaniasis may explain the rarity of mucosal lesions. Since the clinical aspect of the lesion is not sufficient to prejudge the identity of the causative species, it is necessary to perform cultivation of Leishmania for iso-enzymatic identification. The adaptation of pentamidine doses and long term follow up of patients infected by L. (V.) braziliensis could be defined more precisely.

[Disseminated histoplasmosis: 2 cases in patients with human immunodeficiency virus infection in French Guiana]. / Histoplasmose disséminée: deux cas chez des patients infectés par le virus de l'immunodéficience humaine (VIH) en Guyane française.

The authors report two cases of disseminated histoplasmosis occurring in HIV-infected patients living in French Guiana. The first case was an acute disseminated histoplasmosis with a rapid fatal evolution. The second case was diagnosed on a mucosal localisation, and improved under itraconazole therapy. These two cases show the diversity of the clinical course of this opportunistic infection. The authors focus on the difficulty of the diagnosis and the need for direct microscopic examination to identify histoplasma and to enable a swift therapeutic intervention.