Plasmodium falciparum Recrudescence Two Years after Treatment of an Uncomplicated Infection without Return to an Area Where Malaria Is Endemic.

We report evidence, confirmed by the lack of travel activity outside of France and genetic diversity analysis using polymorphic microsatellite markers, that Plasmodium falciparum malaria infection effectively treated with an artemisinin-based combination can remain dormant and relapse during pregnancy at least 2 years after treatment.

Severe delayed autoimmune haemolytic anaemia following artesunate administration in severe malaria: a case report.

BACKGROUND: Parenteral artesunate is recommended as first-line therapy for severe and complicated malaria. Although its efficacy has been proven, long-term safety profile is still under evaluation. Several cases of delayed haemolytic anaemia occurred after initial clinical improvement and resolution of parasitaemia in non-immune travellers and children living in endemic areas. Reports have generated concern that this phenomenon might be related to the treatment itself, either by direct toxicity or immune-related mechanism. This is a report of the first case of autoimmune haemolytic anaemia following treatment of severe malaria initially managed with parenteral artesunate with strong indication for drug-immune related mechanism. CASE: A 17-year old Ivoirian female travelling in France presented with fever, headache and abdominal pain seven days after her arrival. Physical examination was indicative of septic shock while blood analysis showed normal haemoglobin level, but profound thrombocytopaenia and hyperlactataemia. Blood smear analysis showed Plasmodium falciparum infection with a parasitaemia of 0.8%. Severe malaria was diagnosed according to the WHO criteria. The patient was initially managed with artemether/lumefantrine combination and then parenteral artesunate for 48 hours. Empiric antibiotic course was also initiated with ceftriaxone, metronidazole, gentamycin, and then piperacillin and ciprofloxacin. At day 14, haemoglobin dropped to 4.6 g/dL with biologic features indicative of haemolysis (LDH 658 U/L, haptoglobin<0.15 g/L). At that time, parasitaemia was negative and other infections or hereditary disorders were excluded, while Coombs' direct antiglobulin test was positive for IgG and C3d. Antinuclear antibodies were absent. Further investigations evidenced drug-induced antibodies related to artesunate. It was concluded a drug-mediated autoimmune haemolytic anaemia. A corticosteroids regimen was initiated at 1 mg/kg/day. Outcome was favourable and corticosteroids were progressively tapered during two months. At present the patient's condition remains stable without recurrence of haemolytic anaemia. CONCLUSION: This is the first case of delayed haemolytic anaemia related to artesunate with a strong indication for drug-immune related mechanism. Further research is warranted to better characterize this plausible cause of post-treatment haemolysis following parenteral artesunate administration in severe malaria patients.

Pulmonary tuberculosis and management of contact patients in a Department of Nephrology and Kidney Transplantation.

OBJECTIVES: To describe the investigation, follow-up, management, and outcomes in a cohort of chronic kidney disease (CKD) and kidney transplant recipients (KTR) exposed to a case of pulmonary tuberculosis (TB). METHODS: Contacts were investigated following a concentric circles approach and followed-up according to their level of priority. In those with evidence of latent TB infection, treatment decision was based on the level of exposure, individual vulnerability, as well as the results of an interferon-gamma release assay. RESULTS: A total of 130 patients with CKD and 180 KTR were identified as contacts and followed-up over a 2-year period. Few vulnerable high-priority contacts received anti-TB treatment, including the two (100%) highly exposed patients in circle 1, 11/78 (14.1%) CKD patients and 4/142 (2.8%) KTR in circle 2, and 10/52 (19.2%) CKD patients and 2/36 (5.6%) KTR in circle 3; all had a positive interferon-gamma release assay result. No incident cases of TB disease occurred. CONCLUSIONS: These findings suggest that latent TB treatment, as recommended in European guidelines, might be reasonably avoided in vulnerable high-priority contacts of circle 2, with a negative interferon-gamma release assay and in countries with low prevalence of TB.

Quinine-resistant malaria in traveler returning from Senegal, 2007.

We describe clinical and parasitologic features of in vivo and in vitro Plasmodium falciparum resistance to quinine in a nonimmune traveler who returned to France from Senegal in 2007 with severe imported malaria. Clinical quinine failure was associated with a 50% inhibitory concentration of 829 nmol/L. Increased vigilance is required during treatment follow-up.

Destructive arthritis in a patient with chikungunya virus infection with persistent specific IgM antibodies.

BACKGROUND: Chikungunya fever is an emerging arboviral disease characterized by an algo-eruptive syndrome, inflammatory polyarthralgias, or tenosynovitis that can last for months to years. Up to now, the pathophysiology of the chronic stage is poorly understood. CASE PRESENTATION: We report the first case of CHIKV infection with chronic associated rheumatism in a patient who developed progressive erosive arthritis with expression of inflammatory mediators and persistence of specific IgM antibodies over 24 months following infection. CONCLUSIONS: Understanding the specific features of chikungunya virus as well as how the virus interacts with its host are essential for the prevention, treatment or cure of chikungunya disease.

An imported case of Chikungunya fever from Madagascar: use of the sentinel traveller for detecting emerging arboviral infections in tropical and European countries.

A major Chikungunya virus (CHIKV) epidemic affected the South-Western Indian Ocean islands in 2005. This major outbreak raised concerns about the possibility of the emergence of CHIKV infections in Europe as an autochthonous CHIKV outbreak occurred in the Ravenna region of Italy during the summer of 2007 and was linked to a viraemic index case originating in Kerala, India. This report highlights the need for surveillance in countries where such emerging infections could be introduced by returning travellers.

Evaluation of FRET real-time PCR assay for rapid detection and differentiation of Plasmodium species in returning travellers and migrants.

BACKGROUND: A simple real-time PCR assay using one set of primer and probe for rapid, sensitive and quantitative detection of Plasmodium species, with simultaneous differentiation of Plasmodium falciparum from the three other Plasmodium species (Plasmodium vivax, Plasmodium ovale and Plasmodium malariae) in febrile returning travellers and migrants was developed and evaluated. METHODS: Consensus primers were used to amplify a species-specific region of the multicopy 18S rRNA gene, and fluorescence resonance energy transfer hybridization probes were used for detection in a LightCycler platform (Roche). The anchor probe sequence was designed to be perfect matches to the 18S rRNA gene of the fourth Plasmodium species, while the acceptor probe sequence was designed for P. falciparum over a region containing one mismatched, which allowed differentiation of the three other Plasmodium species. The performance characteristics of the real-time PCR assay were compared with those of conventional PCR and microscopy-based diagnosis from 119 individuals with a suspected clinical diagnostic of imported malaria. RESULTS: Blood samples with parasite densities less than 0.01% were all detected, and analytical sensitivity was 0.5 parasite per PCR reaction. The melt curve means Tms (standard deviation) in clinical isolates were 60.5 degrees C (0.6 degrees C) for P. falciparum infection and 64.6 degrees C (1.8 degrees C) for non-P. falciparum species. These Tms values of the P. falciparum or non-P. falciparum species did not vary with the geographic origin of the parasite. The real-time PCR results correlated with conventional PCR using both genus-specific (Kappa coefficient: 0.95, 95% confidence interval: 0.9 - 1) or P. falciparum-specific (0.91, 0.8 - 1) primers, or with the microscopy results (0.70, 0.6 - 0.8). The real-time assay was 100% sensitive and specific for differentiation of P. falciparum to non-P. falciparum species, compared with conventional PCR or microscopy. The real-time PCR assay can also detect individuals with mixed infections (P. falciparum and non-P. falciparum sp.) in the same sample. CONCLUSION: This real-time PCR assay with melting curve analysis is rapid, and specific for the detection and differentiation of P. falciparum to other Plasmodium species. The suitability for routine use of this assay in clinical diagnostic laboratories is discussed.

Reimbursement of malaria chemoprophylaxis for travellers from Europe to Sub-Saharan Africa: Cost-effectiveness analysis from the perspective of the French national health insurance system.

Among Western countries, France has the highest incidence of imported malaria cases, mostly from travellers visiting Sub-Saharan Africa (SSA). Despite related high costs of imported malaria assumed by the public French national health insurance system (FHS), the latter does not reimburse travellers for malaria chemoprophylaxis (MC). This study aims to analyzes, from the FHS perspective, the cost-effectiveness of a 65% reimbursement of MC costs (MC 65%) for French resident travellers, under the assumption that this reimbursement would lead to increased recourse to MC. For that purpose, a decision tree model was developed with variables obtained from the literature, including incidence of malaria among travellers in the absence of MC, probabilities of recourse to MC, MC effectiveness and costs and medical expenses for a case of imported malaria. Data analysis of 1,434,675 travellers to SSA in 2005 estimated, for MC 65% vs. MC 0%, incidence of malaria cases to be 3836 malaria cases (21 deaths)/year vs. 6321 cases (34 deaths)/year, respectively, and cost of Euro 47,071,687/year vs. Euro 17,416,955/year. Incremental cost of MC 65% related to MC 0% was Euro 11,933 per malaria case prevented and Euro 2,281,133 per malaria-related death prevented. Results generated by this model, which can be adapted for other European countries, should be an incentive for the FHS to favourably consider MC 65% for French residents travelling to SSA.

Ectopic cutaneous schistosomiasis-perigenital infiltrative granulomata in a 34-year-old French pregnant woman.

Schistosomiasis, an infection with the three anthropophilic species of Schistosoma, is endemic throughout wide areas of the tropics and subtropics with an estimated rate of over 200 million people infected worldwide. Whereas symptoms and signs of vesical and gastrointestinal forms of the infection are recognized readily, cutaneous manifestations are still a challenging diagnosis particularly in Western countries. A case is described of a 34-year-old Caucasian pregnant woman who presented to our department and was diagnosed with a cutaneous schistosomiasis involvement of the perianal region. Shistosoma haematobium was shown to be present in the lesion by histopathology and was considered to be the causative organism of the disease. Treatment with a course of oral praziquantel in a dose of 40mg/kg allowed resolution of the symptoms.

Cluster of eosinophilic meningitis attributable to Angiostrongylus cantonensis infection in French policemen troop returning from the Pacific Islands.

BACKGROUND: Outbreaks of eosinophilic meningitis are reported rarely, even in regions of endemic infestation with the roundworm Angiostrongylus cantonensis, such as the Pacific Basin. We report a cluster of eosinophilic meningitis presumably attributable to A. cantonensis among French policemen returning from French Polynesia. METHODS: A retrospective cohort study among French policemen who had stayed in Tahiti was conducted using a clinical definition of eosinophilic meningitis that included severe headache within 30 days after return and eosinophilia, and who consumed locally exotic ethnic dishes with uncooked freshwater prawns. RESULTS: Five persons met the case definition for eosinophilic meningitis. Corticosteroid therapy associated with antihelminthic regimen led to improvement of symptoms in one patient. Other patients were treated with albendazole alone. All patients recovered. CONCLUSION: Among travellers at risk, the presence of severe headache and eosinophilia combined with a consistent exposure history to exotic food should alert to the possibility of A. cantonensis infestation. Travellers should be aware of the risk of infection associated with eating exotic ethnic dishes.

Dual infection by chikungunya virus and other imported infectious agent in a traveller returning from India.

Chikungunya virus infection is a vector-borne self-limiting disease. Recent outbreaks in the Indian Ocean islands have drawn attention to the condition. Nevertheless, only a few reports of co-infection with other communicable agents have been reported. The case described now is of a traveller returning from India with concomitant documented chikungunya virus infection associated with systemic amoebiasis. This report highlights the multifaceted pathology that can be encountered with tropical infections.

Furuncular myiasis for the Western dermatologist: treatment in outpatient consultation.

BACKGROUND: Furuncular myiasis is likely to be seen by Western dermatologists because of the increasing number of international travelers but remains unfamiliar to most of them, who tend to refer these patients to hospitals. Different treatments have been proposed, but many of them are not achievable in outpatient consultation. METHODS: We reported three typical cases of furuncular myiasis, according to each species involved, and proposed diagnostic and therapeutic guidelines for dermatologists in outpatient consultation. RESULTS: One patient, complaining of an inflammatory nodule of the leg with a central punctum, was diagnosed with Dermatobia hominis infection, after a forest walk in French Guiana. One woman returned from Senegal with a nodule of the left buttock. She had been infected by a Cordylobia anthropophaga larva after drying her underwear under a mango tree. One woman living in Cameroon presented with scalp nodules, pain, fatigue, and facial edema. She had been infected by more than 40 larvae of Cordylobia rodhaini after drying her sheets under a mango tree. Manual extraction ensured complete healing in the three patients. We used neither doppler ultrasound nor occlusive dressing. Diagnosis was immediately made thanks to the typical clinical stories. CONCLUSIONS: The diagnosis of furuncular myiasis requires only clinical skills and basic knowledge of life cycles. The treatment varies slightly depending on the species involved but is achievable in outpatient consultation and does not require occlusive dressing.

Expatriates in high-UV index and tropical countries: sun exposure and protection behavior in 9,416 French adults.

BACKGROUND: Overexposure to sunlight during long stays in tropical countries can reveal short- and long-term harmful effects on the skin of Caucasian residents, especially for fair-skinned subjects. The aim of this study was to describe sun exposure and sun protection behaviors during lifetime among French adults who declared having experienced at least one expatriation period in tropical or high-sun index areas for a duration of more than three consecutive months. METHODS: A self-reported questionnaire on sun exposure behavior was addressed two times, in 1997 and 2001, to the 12,741 French adult volunteers enrolled in the SU.VI.MAX cohort. A total of 8,084 subjects answered to the first survey and 1,332 additional responders answered to the second. Among the 9,416 individuals, 1,594 (652 women and 942 men) corresponded to expatriates and the remaining 7,822 to nonexpatriates (4,972 women and 2,850 men). A descriptive analysis of sun exposure and sun protection behaviors during lifetime of expatriates and nonexpatriates was performed by gender. RESULTS: Among women, 39% of expatriates belonged to the 50 to 60 class of age at inclusion, versus 33% in nonexpatriates (72 and 55% in men, respectively). In women, expatriates declared more frequently having during lifetime exposed voluntarily their skin to the sun, practiced tanning between 11 a.m. and 4 p.m., less gradually exposed their skin, experienced intensive sun exposure, and exposed their skin during nautical sports and practiced naturism. In men, expatriates declared more frequently having experienced intensive sun exposure and exposed their skin during outdoor occupations and during nautical and mountain sports. CONCLUSIONS: Although expatriates are aware of travel health advices concerning the countries where they planned to stay, they are usually poorly informed about sun exposure risk factors. Such individuals who planned to expatriate in countries with a high ultraviolet index should benefit from a visit to a travel clinic including specific health care information for risk related to sun exposure, ie, skin cancers and photoaging.

Travellers to high UV-index countries: sun-exposure behaviour in 7822 French adults.

BACKGROUND: Travel health information includes warning on sun exposure, particularly for fair-skinned individuals travelling to tropical countries. METHOD: A self-completed questionnaire on sun exposure behaviour was sent to the 12,741 French adults enrolled in the SU.VI.MAX cohort. Among the 7822 participants, 196 (110 women and 86 men) declared at least one visit to a high UV-index country over the past year for more than 1 month, subsequently referred to as long-term travellers. The remaining 7626 participants (non-travellers) accounted for 4862 women and 2764 men. RESULTS: Women travellers declared more frequently skin exposure to the sun over the past year, practised tanning in high UV-index areas more than 2h daily, experienced intensive sun exposure than non-travellers. Moreover, they asserted that basking in the sun is very important. Comparable results were found in men. The use of sun protection products was similar in travellers and non-travellers, but women tended to use sunscreen products more often, more regularly and with a higher sun protection factor (SPF) than men. CONCLUSIONS: Specific health education campaigns and pre-travel advice aiming to reduce sun exposure and to improve protective measures against ultraviolet (UV) radiation should be addressed to travellers to countries with high UV-index.

Haemoglobinuria in a 38-year-old French expatriate man living in Cameroon following artemisinin-based antimalarial treatment.

Massive haemoglobinuria is encountered rarely during the course of malaria. It is usually considered a diagnostic criterion for severe malaria, together with anaemia, acute renal failure and jaundice. Haemoglobinuria can also present among expatriates travelling to endemic areas following repeated exposure to quinoline or arylaminoalcohol drugs. A case is described of haemoglobinuria developing in a 38-year-old French expatriate diagnosed concurrently with numerous tropical infections, and treated on presumptive basis with an antimalarial regimen containing artemisinin derivatives. Haemoglobinuria resolved spontaneously within a few days. Although this case does not definitely indicate a causal link between haemoglobinuria and artemisinin derivatives, the risk of such infrequent side-effects should be taken into account in pharmacovigilance monitoring. Moreover, the patient illustrates the multifaceted pathology that can be encountered with tropical infections.

Prevalence of pulmonary tuberculosis among prison inmates: A cross-sectional survey at the Correctional and Detention Facility of Abidjan, Côte d'Ivoire.

BACKGROUND: In Côte d'Ivoire, a TB prison program has been developed since 1999. This program includes offering TB screening to prisoners who show up with TB symptoms at the infirmary. Our objective was to estimate the prevalence of pulmonary TB among inmates at the Correctional and Detention Facility of Abidjan, the largest prison of Côte d'Ivoire, 16 years after this TB program was implemented. METHODS: Between March and September 2015, inmates, were screened for pulmonary TB using systematic direct smear microscopy, culture and chest X-ray. All participants were also proposed HIV testing. TB was defined as either confirmed (positive culture), probable (positive microscopy and/or chest X-ray findings suggestive of TB) or possible (signs or symptoms suggestive of TB, no X-Ray or microbiological evidence). Factors associated with confirmed tuberculosis were analysed using multivariable logistic regression. RESULTS: Among the 943 inmates screened, 88 (9.3%) met the TB case definition, including 19 (2.0%) with confirmed TB, 40 (4.2%) with probable TB and 29 (3.1%) with possible TB. Of the 19 isolated TB strains, 10 (53%) were TB drug resistant, including 7 (37%) with multi-resistance. Of the 10 patients with TB resistant strain, only one had a past history of TB treatment. HIV prevalence was 3.1% overall, and 9.6%among TB cases. Factors associated with confirmed TB were age ≥30 years (Odds Ratio 3.8; 95% CI 1.1-13.3), prolonged cough (Odds Ratio 3.6; 95% CI 1.3-9.5) and fever (Odds Ratio 2.7; 95% CI 1.0-7.5). CONCLUSION: In the country largest prison, pulmonary TB is still 10 (confirmed) to 44 times (confirmed, probable or possible) as frequent as in the Côte d'Ivoire general population, despite a long-time running symptom-based program of TB detection. Decreasing TB prevalence and limiting the risk of MDR may require the implementation of annual in-cell TB screening campaigns that systematically target all prison inmates.

Extensive cutaneous larva migrans with folliculitis mimicking multimetameric herpes zoster presentation in an adult traveler returning from Thailand.

Hookworm-related cutaneous larva migrans (CLM) is a frequent cutaneous disease among travelers returning from the tropics. It can be misdiagnosed or treated incorrectly. We present a 42-year-old French patient who contracted the disease during a holiday in Thailand and who experienced an extensive CLM syndrome with a less frequent abdominal localization and a pseudo-multimetameric homolateral topography. The condition was late diagnosed and secondarily efficiently cured by a unique administration of ivermectin. Simple anamnestic information--often revealing beach activities--and clinical aspect of the creeping eruption allow to prevent diagnosis delay and to avoid aggressive or inadequate intervention.

Primary dengue fever associated with hemophagocytic syndrome: a report of three imported cases, Bordeaux, France.

The dengue virus is responsible for a wide range of symptoms that can be classified into two distinct syndromes: classical dengue fever and severe dengue fever. Among the complicating forms, hemophagocytic syndrome (HPS) has been previously reported in case series of patients with secondary dengue fever outside of endemic settings. Of note, the occurrence of HPS has not yet been included among the criteria for defining severe dengue fever. We herein present three patients with HPS related to confirmed primary dengue virus infection. Clinicians should therefore consider hemophagocytosis as a complication during severe dengue infection in naïve patients.