Bernard CARME

Abstract: Compared to the incidence in adults, cryptococcosis is rare among children. We report a case of neurocryptococcosis due to Cryptococcus gattii in a five-year-old girl without identified risk factors living in French Guiana. Neurological surgery in combination with long-term antifungal treatment with amphotericin B and 5-flucytosine successfully resolved the cryptococcal infection. Subsequent molecular characterization of the Cryptococcus isolate revealed that the infection was caused by a C. gattii genotype AFLP6B/VGIIb strain.

Abstract: The origin of Plasmodium falciparum in South America is controversial. Some studies suggest a recent introduction during the European colonizations and the transatlantic slave trade. Other evidence--archeological and genetic--suggests a much older origin. We collected and analyzed P. falciparum isolates from different regions of the world, encompassing the distribution range of the parasite, including populations from sub-Saharan Africa, the Middle East, Southeast Asia, and South America. Analyses of microsatellite and SNP polymorphisms show that the populations of P. falciparum in South America are subdivided in two main genetic clusters (northern and southern). Phylogenetic analyses, as well as Approximate Bayesian Computation methods suggest independent introductions of the two clusters from African sources. Our estimates of divergence time between the South American populations and their likely sources favor a likely introduction from Africa during the transatlantic slave trade.

Abstract: ABSTRACT: BACKGROUND: Dengue and malaria are two major arthropod-borne infections in tropical areas, but dual infections were only described for the first time in 2005. Reports of these concomitant infections are scarce and there is no evidence of more severe clinical and biological pictures than single infections. METHODS: To compare co-infections to dengue alone and malaria alone, a retrospective matched-pair study was conducted between 2004 and 2010 among patients admitted in the emergency department of Cayenne hospital, French Guiana. RESULTS: 104 dengue and malaria co-infection cases were identified during the study period and 208 individuals were matched in two comparison groups: dengue alone and malaria alone. In bivariate analysis, co-infection clinical picture was more severe than separated infections, in particular using the severe malaria WHO criteria. In multivariate analysis, independent factors associated with co-infection versus dengue were: masculine gender, CRP level > 50 mg/L, and thrombocytopaenia < 50 109/L, and low haematocrit <36% and independent factors significantly associated with co-infections versus malaria were red cells transfusion, low haematocrit < 36%, thrombocytopaenia < 50 109/L and low Plasmodium parasitic load < 0.001%. CONCLUSIONS: In the present study, dengue and malaria co-infection clinical picture seems to be more severe than single infections in French Guiana, with a greater risk of deep thrombocytopaenia and anaemia.

Abstract: 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.

Abstract: Leishmania species of the subgenus Viannia and especially Leishmania Viannia guyanensis are responsible for a large proportion of New World leishmaniasis cases. Since a recent publication on Leishmania Viannia braziliensis, the debate on the mode of reproduction of Leishmania parasites has been reopened. A predominant endogamic reproductive mode (mating with relatives), together with strong Wahlund effects (sampling of strains from heterogeneous subpopulations), was indeed evidenced. To determine whether this hypothesis can be generalized to other Leishmania Viannia species, we performed a population genetic study on 153 human strains of L. (V.) guyanensis from French Guiana based on 12 microsatellite loci. The results revealed important homozygosity and very modest linkage disequilibrium, which is in agreement with a high level of sexual recombination and substantial endogamy. These results also revealed a significant isolation by distance with relatively small neighbourhoods and hence substantial viscosity of Leishmania populations in French Guiana. These results are of epidemiological relevance and suggest a major role for natural hosts and/or vectors in parasite strain diffusion across the country as compared to human hosts.

Abstract: Malaria is a major health issue in French Guiana. Amerindian communities remain the most affected. A previous study in Camopi highlighted the predominant role of environmental factors in the occurrence of malaria. However, all parameters involved in the transmission were not clearly identified. A new survey was conducted in order to clarify the risk factors for the presence of malaria cases in Camopi.

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Abstract: Cryptococcosis is a common opportunistic systemic mycosis caused by members of the encapsulated yeast genus Cryptococcus. The aetiological agents of the disease are classified into two species, i.e., Cryptococcus neoformans (serotypes A, D, and AD) affecting mainly immunocompromised patients and Cryptococcus gattii (serotypes B and C) usually found in immunocompetent individuals. Limited data exist on Cryptococcus infections in French Guiana, the department with the highest HIV incidence in the French territories. A retrospective study between January 1998 and December 2008 was performed on all patients with cryptococcosis, admitted to hospitals in French Guiana. Epidemiological data, clinical forms and diagnosis methods were studied. Of the 43 patients with cryptococcosis, 29 (67.4%) had HIV infections. Among the HIV-negative patients, two (4.7%) presented identified risk factors for cryptococcosis. This study has shown a high frequency of patients with HTLV-1 positive serology (12.1%). C. neoformans var. grubii was recovered with a frequency of 77.3% and was mainly isolated from patients with AIDS (13/17), whereas C. gattii (22.7%) was strictly isolated from HIV-negative patients with no apparent risk factors. Despite a socio-economic environment closer to western countries, the overall epidemiology of cryptococcosis in French Guiana is more similar to that found in South America, particularly with reference to the serotypes of the causative yeasts. Indeed, French Guiana presents an especially high proportion of cases caused by C. gattii, which may explain the significant incidence of this disease, particularly in HIV-negative and immunocompetent patients.

Abstract: 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.

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Abstract: The pathogen ecology of Amazonian regions may lead to specific differences in the most frequent clinical presentations of acquired immunodeficiency syndrome (AIDS). A retrospective cohort study was thus conducted to describe the main AIDS-defining events in French Guiana. Disseminated histoplasmosis was the most frequent opportunistic infection (15.4/1000 person years).

Abstract: 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.

Abstract: ABSTRACT: BACKGROUND: Malaria remains a major health problem in French Guiana, with a mean of 3800 cases each year. A previous study in Camopi, an Amerindian village on the Oyapock River, highlighted the major contribution of environmental features to the incidence of malaria attacks. We propose a method for the objective selection of the best multivariate peridomestic landscape characterisation that maximises the chances of identifying relationships between environmental features and malaria incidence, statistically significant and meaningful from an epidemiological point of view. METHODS: A land-cover map, the hydrological network and the geolocalised inhabited houses were used to characterise the peridomestic landscape in eleven discoid buffers with radii of 50, 100, 200, 300, 400, 500, 600, 700, 800, 900 and 1000 metres. Buffer-based landscape characterisations were first compared in terms of their capacity to discriminate between sites within the geographic space and of their effective multidimensionality in variable space. The Akaike information criterion (AIC) was then used to select the landscape model best explaining the incidences of P. vivax and P. falciparum malaria. Finally, we calculated Pearson correlation coefficients for the relationships between environmental variables and malaria incidence, by species, for the more relevant buffers. RESULTS: The optimal buffers for environmental characterisation had radii of 100 m around houses for P. vivax and 400 m around houses for P. falciparum. The incidence of P. falciparum malaria seemed to be more strongly linked to environmental features than that of P. vivax malaria, within these buffers. The incidence of P. falciparum malaria in children was strongly correlated with proportions of bare soil (r = -0.69), land under high vegetation (r = 0.68) and primary forest (r = 0.54), landscape division (r = 0.48) and the number of inhabited houses (r = -0.60). The incidence of P. vivax malaria was associated only with landscape division (r = 0.49). CONCLUSIONS: The proposed methodology provides a simple and general framework for objective characterisation of the landscape to account for field observations. The use of this method enabled us to identify different optimal observation horizons around houses, depending on the Plasmodium species considered, and to demonstrate significant correlations between environmental features and the incidence of malaria.

Abstract: Information on the global risk factors of children mortality is crucial to guide global efforts to improve survival. Corruption has been previously shown to significantly impact on child mortality. However no recent quantification of its current impact is available.

Abstract: Malaria remains a serious problem in French Guiana, which is at potential risk for drought linked with the El Niño Event and where there could be a risk of malaria epidemic after the onset of an El Niño event.

Abstract: The epidemiological profiles of vector-borne diseases, such as malaria, are strongly associated with environmental conditions. An understanding of the effect of the climate on the occurrence of malaria may provide indirect insight into the anopheles mosquito vectors endemic to a particular region. The association between meteorological and hydrographical factors and the occurrence of malaria was studied in a village in French Guiana during an epidemic caused essentially by Plasmodium vivax.

Abstract: Clin Microbiol Infect ABSTRACT: 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.

Abstract: In order to determine whether HIV-associated disseminated histoplasmosis was a recent infection or a reactivation, time series of first episodes of disseminated histoplasmosis were analyzed. Climatic variables were associated with histoplasmosis incidence. This suggested an important proportion of cases were due to recent exposure, and therefore primary prophylaxis may be warranted in French Guiana.

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Abstract: In 2002, the French Food Safety Agency drew attention to the lack of information on the prevalence of human cryptosporidiosis in the country. Two years later, the ANOFEL Cryptosporidium National Network (ACNN) was set up to provide public health authorities with data on the incidence and epidemiology of human cryptosporidiosis in France. Constituted on a voluntary basis, ACNN includes 38 hospital parasitology laboratories (mainly in university hospitals). Each laboratory is engaged to notify new cases of confirmed human cryptosporidiosis, store specimens (e.g. stools, duodenal aspirates or biopsies) and related clinical and epidemiological data, using datasheet forms. From January 2006 to December 2009, 407 cryptosporidiosis cases were notified in France and 364 specimens were collected. Of the notified cases, 74 were children under four years of age, accounting for 18.2%. HIVinfected and immunocompetent patients represented 38.6% (n=157) and 28% (n=114) of cases, respectively. A marked seasonal pattern was observed each year, with increased number of cases in mid to late summer and the beginning of autumn. Genotyping of 345 isolates from 310 patients identified C. parvum in 168 (54.2%) cases, C. hominis in 113 (36.4%) and other species in 29 (9.4%), including C. felis (n=15), C. meleagridis (n=4), C. canis (n=4), Cryptosporidium chipmunk genotype (n=1), Cryptosporidium rabbit genotype (n=1) and new Cryptosporidium genotypes (n=4). These data represent the first multisite report of laboratory-confirmed cases of cryptosporidiosis in France.

Abstract: 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.

Abstract: When immunocompetent people become infected with the parasite Toxoplasma gondii, the disease is generally asymptomatic. However, transplacental transmission of T. gondii may lead to severe congenital infection including in utero abortion, foetal death, or neurological or ocular damage of the foetus. France has had a national programme to prevent congenital toxoplasmosis since 1978. However, although estimated seroprevalence in pregnant women has fallen from 84% in the 1960s to 44% in 2003, no reliable data have been available on the annual number of cases of congenital toxoplasmosis or the severity of infection. In 2006, the French National Institute for Public Health Surveillance (Institut de Veille Sanitaire) and the National Reference Centre for Toxoplasmosis recommended that a national laboratory-based surveillance system be used for the surveillance of the disease. In 2007, 31 laboratories reported at least one congenital case through the surveillance system, giving a total of 272 cases. A total of 11 terminations of pregnancy were reported (six abortions and five foetal deaths). Of the live-born cases, 206 were asymptomatic, 28 were symptomatic and seven had a severe form of the disease. As there were 818,700 births in France and French overseas departments in 2007, the overall prevalence of congenital toxoplasmosis observed that year was 3.3 (95% confidence interval (CI): 2.9 to 3.7) per 10,000 live births and the incidence rate of the disease at birth was 2.9 (95% CI: 2.5 to 3.2) per 10,000 live births; the estimated incidence rate of symptomatic congenital toxoplasmosis was 0.34 (95% CI: 0.2 to 0.5) cases per 10,000 live births.

Abstract: Leishmania (Viannia) guyanensis was for many years the only species commonly identified in French Guiana, but precise species identifications were quite rare. We describe a new restriction fragment length polymorphism-polymerase chain reaction technique using a 615-bp fragment of the RNA polymerase II gene and 2 restriction enzymes, TspRI and HgaI. Seven reference strains (Leishmania (Leishmania) amazonensis, Leishmania (Viannia) lainsoni, Leishmania (Viannia) braziliensis, L. (V.) guyanensis, Leishmania (Viannia) naiffi, Leishmania (Leishmania) major, Leishmania (Leishmania) infantum) and 112 clinical samples from positive lesions were used for the development of the technique. The rates of positive species identification were 85.7% for punch skin biopsy specimens, 93.1% for positive Giemsa-stained smears, and 100% for positive culture supernatants. In the framework of cutaneous leishmaniasis species surveillance for the 2006 to 2008 period, parasite identification was carried out for 199 samples from different patients. The prevalence of the various Leishmania spp. was 84.4% for L. (V.) guyanensis, 8.0% for L. (V.) braziliensis, 5.0% for L. (L.) amazonensis, and 2.6% for L. (V.) lainsoni. L. (V.) braziliensis seems to be locally an emerging pathogen.

Abstract: BACKGROUND: Malaria is a major public health problem in French Guiana, where Plasmodium vivax has become the dominant malaria species since 2000. As in others endemic areas, it is important to specify the pattern of vivax malaria relapses and to try to discriminate efficiently re-infections from relapses. METHODS: This study was conducted in children born between January 1, 2001 and December 31, 2008 in Camopi, an Amerindian village located in the Amazon forest (n = 325), using an open cohort design. Primary and secondary attack rates of P. vivax were calculated using survival analysis. With the difference between the primary and secondary rates, this study aimed to estimate indirectly P. vivax relapse rate and evaluate its time evolution. RESULTS: Of the 1042 malaria attacks recorded, 689 (66%) were due to P. vivax (without mixed infection). One hundred and fifty one children had their primary attack with P. vivax and 106 had their two first attacks with P. vivax. In the absence of primaquine treatment, it was shown that P. vivax relapses mainly occurred during the first three months after the first attack. Thirty percent of children never had a relapse, 42% had a relapse before the first month after primary attack, 59% before the second month and 63% before the third month. CONCLUSION: This study confirmed that the relapse pattern in Camopi was compatible with the pattern described for the P. vivax Chesson (tropical) strain. In addition, due to the relapse rate time evolution, a simple arbitrary classification rule could be constructed: before 90 days after the primary attack, the secondary attack is a relapse; after 90 days, it is a re-infection. Adapted management of malaria cases based on these results could be devised.

Abstract: 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.

Abstract: Toxoplasma gondii is highly virulent in New World monkeys, but despite numerous outbreaks observed in captive populations there are few reports of molecular characterization of strains. In this article, we describe two outbreaks of toxoplasmosis that occurred in 2001 and 2006 in an outdoor captive breeding colony of squirrel monkeys (Saimiri sciureus) kept by the Institut Pasteur in French Guiana. A microsatellite DNA analysis of the biological samples collected in the 2001 and 2006 outbreaks showed that two different Toxoplasma strains were involved. The 2001 strain exhibited a type II genotype whereas the 2006 strain showed a combination of type I, type III and atypical alleles. Infection could be related to oocysts contaminating water or food, or to ingestion of rats by monkeys. In 2006, a second episode was observed 3 weeks after the first, and was believed to be related to direct contamination by tachyzoites of bronchopulmonary origin from dying monkeys of the first event. During both outbreaks, a total of 50 monkeys died and none recovered spontaneously, confirming the virulence of both type II and non-type II Toxoplasma strains in New World monkeys.

Abstract: We report the genotyping analysis of Toxoplasma gondii isolates in samples collected from 88 immunocompromised patients, along with clinical and epidemiological data. Most of these samples were collected in France during the current decade by the Toxoplasma Biological Resource Center. Lack of specific anti-Toxoplasma treatment, pulmonary toxoplasmosis, and involvement of multiple organs were the 3 main risk factors associated with death for this patient group. Genotyping results with 6 microsatellite markers showed that type II isolates were predominant among patients who acquired toxoplasmic infection in Europe. Non-type II isolates included 13 different genotypes and were mainly collected from patients who acquired toxoplasmosis outside Europe. Type III was the second most common genotype recovered from patients, whereas type I was rare in our population. Three nonarchetypal genotypes were repeatedly recovered from different patients who acquired the infection in sub-Saharan Africa (genotypes Africa 1 and Africa 2) and in the French West Indies (genotype Caribbean 1). The distribution of genotypes (type II vs. non-type II) was not significantly different when patients were stratified by underlying cause of immunosuppression, site of infection, or outcome. We conclude that in immunocompromised patients, host factors are much more involved than parasite factors in patients' resistance or susceptibility to toxoplasmosis.

Abstract: From 1998 through 2006, 44 cases of severe primary toxoplasmosis were observed in French Guiana in immunocompetent adults. Toxoplasma gondii isolates exhibited an atypical multilocus genotype. Severe disease in humans may result from poor host adaptation to neotropical zoonotic strains of T. gondii circulating in a forest-based cycle.

Abstract: BACKGROUND: Reliable molecular typing tools are required for a better understanding of the molecular epidemiology of Plasmodium vivax. The genes msp3a and msp1_block5 are highly polymorphic and have been used as markers in many P. vivax population studies. These markers were used to assess the genetic diversity of P. vivax strains from French Guiana (South America) and to develop a molecular typing protocol. METHODS: A total of 120 blood samples from 109 patients (including 10 patients suffered from more than one malaria episode, samples were collected during each episode) with P. vivax infection were genotyped. All samples were analysed by msp3a PCR-RFLP and msp1_b5 gene sequencing was performed on 57 samples. Genotyping protocol applied to distinguish between new infection or relapse from heterologus hypnozoites and treatment failure or relapse from homologus hypnozoites was based on analysing first msp3a by PCR-RFLP and secondly, only if the genotypes of the two samples are identical, on sequencing the msp1_b5 gene. RESULTS: msp3a alleles of three sizes were amplified by PCR: types A, B and C. Eleven different genotypes were identified among the 109 samples analysed by msp3a PCR-RFLP. In 13.8% of cases, a mixed genotype infection was observed. The sequence of msp1_b5 gene revealed 22 unique genotypes and 12.3% of cases with mixed infection. In the 57 samples analysed by both methods, 45 genotypes were found and 21% were mixed. Among ten patients with two or three malaria episodes, the protocol allowed to identify five new infections or relapses from heterologous hypnozoites and six treatment failures of relapses from homologous hypnozoites. CONCLUSION: The study showed a high diversity of msp3a and msp1_b5 genetic markers among P. vivax strains in French Guiana with a low polyclonal infection rate. These results indicated that the P. vivax genotyping protocol presented has a good discrimination power and can be used in clinical drug trials or epidemiological studies.

Abstract: Dengue-malaria co-infection reports are scarce. Of 1,723 consecutive febrile patients in Cayenne Hospital, 238 had dengue (174 early dengue fever cases) and 393 had malaria (371 acute malaria); 17 had both. Diagnosis of 1 of these 2 infections should not rule out testing for the other infection.

Abstract: Should the Kalimbe (a traditional Amerindian loincloth) be banned, based on its association with an increased risk of malaria? Studies on malaria conducted on Amerindian children in the Oyapock region, French Guiana suggest that there is an argument for replacing the Kalimbe with a modern alternative. However, the wider issue of how the positive (risk reduction and related benefits) and negative effects (exacerbation of acculturation processes and associated consequences) should be assessed needs to be considered before suggesting a change in ancestral behaviour for medical purposes. A multidisciplinary approach is needed, together with caution and humility from epidemiologists.

Abstract: Two duplex real-time PCR assays were developed to diagnose three human parasites: Plasmodium falciparum, Plasmodium vivax and Plasmodium malariae. TaqMan duplex real-time PCR was evaluated in 263 blood samples of suspected malaria patients by comparing results against those obtained with microscopy and nested PCR. Compared with nested PCR, duplex real-time PCR assays showed 100% sensitivity and specificity. Duplex real-time PCR detected all mixtures of P. falciparum and P. vivax DNA, except at threshold detection limits for both parasites in which P. vivax was not amplified. Threshold detection limits of real-time PCR were 3.1, 0.3 and 0.8 parasites per microlitre of blood for P. falciparum, P. vivax and P. malariae, respectively. Duplex real-time PCR allows the detection of malarial cases, including mixed species infection, it simplifies analysis and reduces cost. Thus, this protocol may prove invaluable for use in the diagnosis of human infection, trial treatments and epidemiologic studies in which high-throughput analyses are often required.

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Abstract: 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.

Abstract: Febrile illness is a common cause of attendance at emergency departments. The purpose of this study was to describe infectious aetiologies of fever in a tropical setting. We prospectively included 1443 febrile patients, all French Guiana residents, who presented at Cayenne Hospital emergency department. This report will propose an overview of aetiologies of febrile illness in French Guiana, and tropical diseases such as malaria and arbovirus infections are discussed. Almost 30% of fevers remained unexplained. Further prospective multicentre studies are warranted to improve the diagnosis of overlooked pathogens in French Guiana. Such studies would lead to conclusions of specific interest in the travel medicine field.

Abstract: 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.

Abstract: OBJECTIVE: Histoplasma capsulatum var. capsulatum infection is a major AIDS-defining illness in French Guiana. Although it affects South and Central American countries, the number of published cases is low. We present the largest series of AIDS-related histoplasmosis. The aim of this work is to describe clinical features and to help optimize investigations in settings where antigen detection methods are not available. DESIGN: Two hundred cases of AIDS-related histoplasmosis, diagnosed in the hospitals of French Guiana, were included retrospectively between 1982 and 2007. RESULTS: At the time of diagnosis, 92% of patients did not receive highly active antiretroviral therapy. CD4 cell count was less than 100 cells/microl for 80% of them. Most patients had fever, lymphadenopathies, and pulmonary and digestive symptoms. Neurological signs and skin/mucosal locations were less common. Other opportunistic infections were associated in 36.6% of cases (mostly tuberculosis). In most of the patients, lactic dehydrogenase was at least four times the normal value, and there was a moderate increase of aspartate aminotransaminase but not alanine aminotransaminase levels. Bone marrow aspirations were useful, but cultures of liver and lymphadenopathy specimens were the most contributive. Following treatment initiation, 17.5% died within a month. Presumptive treatment was started before diagnostic confirmation in 14.3% of the cases. CONCLUSION: In high prevalence settings, histoplasmosis often revealed AIDS in severely immunodeficient and poorly followed patients. In the absence of a quick sensitive technique, skin smear and fungal tissue cultures are contributive. Nevertheless, given the diagnostic delays and the poor prognosis, presumptive treatment with amphotericin B-containing regimens should be recommended when clinical and epidemiological contexts are evocative.

Abstract: Field isolates of Toxoplasma gondii in Europe and North America have been grouped into three clonal lineages that display different virulence in mice. Whether the genetic structure of the parasite is related to clinical expression in humans has not yet been demonstrated. We developed an enzyme-linked immunosorbent assay which uses lineage-specific, polymorphic polypeptides derived from the dense granule antigens, GRA5 and GRA6. Our goal was to compare serotypical patterns observed in asymptomatic versus symptomatic (ocular disease and severe infection in human immunodeficiency virus (HIV)-positive patients) infections among patients from Europe and South America. Independent of the clinical presentation of the disease, serotypes differed according to geographical origin, with a homogeneous distribution of serotype II in Europe and of serotypes I and III in South America. We conclude that GRA5-GRA6 serotyping is an interesting tool to study serotype prevalence in populations but it is not an accurate marker of pathogenicity of Toxoplasma infection in humans.

Abstract: 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.

Abstract: BACKGROUND: Well-documented outbreaks of human toxoplasmosis infection are infrequently reported. Here, we describe a community outbreak of multivisceral toxoplasmosis that occurred in Patam, a Surinamese village near the French Guianan border. METHODS: From the end of December 2003 through the middle of January 2004, 5 adult patients in Patam, including 2 pregnant women, were initially hospitalized for multivisceral toxoplasmosis. A French-Surinamese epidemiological investigation was conducted in the village; inquiries and clinical examinations were performed, and blood and environmental samples were obtained. For all serologically confirmed cases of toxoplasmosis, molecular analysis and mouse inoculations were performed for diagnosis and genetic characterization of Toxoplasma gondii. RESULTS: The hospitalized patients, who did not have any immunodeficiencies, presented with an infectious disease with multivisceral involvement. Serological examination confirmed acute toxoplasmosis. One adult died, and a neonate and a fetus with congenital toxoplasmosis also died. During the investigation, 4 additional acute cases of toxoplasmosis were diagnosed among the 33 villagers. Only 3 inhabitants had serological evidence of previous T. gondii infection. In total, we reported 11 cases of toxoplasmosis: 8 multivisceral cases in immunocompetent adults, resulting in 1 death; 2 cases of lethal congenital toxoplasmosis in a neonate and a fetus; and 1 symptomatic case in a child. Molecular analysis demonstrated that identical isolates of only 1 atypical strain were responsible for at least 5 of the 11 cases of toxoplasmosis in the outbreak. No epidemiological sources could be linked to this severe community-wide outbreak of toxoplasmosis. CONCLUSION: This report is in agreement with the particular features of toxoplasmosis involving atypical strains that were recently described in French Guiana.

Abstract: Filariasis are vector-transmitted parasitoses, exclusively tropical, except for dirofilariosis. Their impact differs according to the type of filaria and the induced immune response. The diagnosis is made based on the presence of dermatological or lymphatic manifestations, acute or chronic, associated with usually extended stays in an endemic country. It can also be established following a laboratory examination revealing hypereosinophilia or correspond to the incidental finding of microfilariae (blood or skin). The visualization of the embryonic and/or adult parasite confirms the infection. For pathogenic filariasis with microfilaremiae, paradoxically, clinically positive subjects are often amicrofilaremic. In this case, the presence of antibodies and/or specific serum antigens confirms the diagnosis. On the contrary, asymptomatic microfilariaecarriers are common but there is no guarantee that they will remain asymptomatic. The etiological treatment of choice is based on a combination of ivermectin and albendazole. However, diethylcarbamazine, which was formerly used, is still indicated. Dracunculiasis has been almost eradicated and the elimination of lymphatic filariasis and onchocerciasis as public health problems can be contemplated in the medium term.

Abstract: Immune reconstitution disease (IRD) has been associated with many pathogens after the initiation of antiretroviral therapy for advanced HIV infection. A retrospective cohort study was conducted to determine whether cutaneous mycoses were also associated with IRD. After adjusting for various confounding factors, the recent initiation of HAART was found to be associated with an increased incidence of cutaneous mycoses when compared with untreated patients.

Abstract: Malaria is a major public health problem in French Guiana. This study was conducted in children <1-5 years of age in Camopi, an Amerindian village in eastern French Guiana. Medical, environmental, and behavioral predictive factors of malaria were studied using the Kaplan-Meier method and Cox modeling. Variables included were clearing vegetation around the home (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = 0.43-0.88 for 50-75% cleared and HR = 0.5, 95% CI = 0.31-0.81 for > 75% cleared) relative to homes surrounded by vegetation; distance of a home from a river (HR = 0.56, 95% CI = 0.37-0.85 for distances between 20 and 40 meters, HR = 0.72, 95% CI = 0.47-1.09 for distances between 40 and 80 meters, HR = 0.52, 95% CI = 0.28-0.94 for distances between 80 and 120 meters, and HR = 0.5, 95% CI = 0.30-0.86 for distances > 120 meters) relative to distances < 20 meters; the number of occupants in the home (HR = 1.54, 95% CI = 0.98-2.44 for 7 occupants, HR = 1.9, 95% CI = 1.29-2.81 for 8-11 occupants, and HR = 2.03, 95% CI = 1.27-3.23 for > 11 occupants); clothing (HR = 0.64, 95% CI = 0.46-0.90 for children wearing western-style clothes relative to those wearing the traditional kalimbe), and ethnicity (Wayampi children had a lower hazard of malaria relative to Emerillon children: HR = 0.55, 95% CI = 0.40-0.80). The environment near the home was strongly associated with malaria. This suggests that simple pragmatic protection measures would be useful in Camopi.

Abstract: Immune reconstitution after HAART initiation is often complicated by adverse clinical manifestations caused either by the unmasking of preexisting untreated opportunistic infections or the clinical deterioration of a known and treated opportunistic infection. The present study was conducted to determine whether the initiation of HAART was followed by an increase in the incidence of mucosal candidiases, a possible manifestation of immune reconstitution disease of the unmasking type.

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Abstract: 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.

Abstract: The purpose of this study was to show that individual malaria rapid diagnosis tests (MRDTs) could also be used to isolate Plasmodium DNA for genetic studies. We extracted and amplified Plasmodium DNA using two commercial MRDT kits. Phenol/chloroform extraction followed by a nested polymerse chain reaction (PCR) can be used to identify Plasmodium falciparum and Plasmodium vivax from MRDTs. The PCR on MRDT-isolated DNA was more sensitive than antigen capture by MRDT. Satisfactory results were also obtained if older MRDT tests were used, even after long periods of storage at ambient temperature, with no special preservation.

Abstract: Little information is available about the genetic variability of Leishmania populations and the possible correlations with ecoepidemiological features of leishmaniases. The present study was carried out in French Guiana, a country where cutaneous leishmaniases (CL) are endemic over the whole territory. The genetic polymorphism of a nuclear sequence encompassing the end of the ribosomal small subunit and the internal transcribed spacer 1 of 265 isolates from patients with CL was examined by restriction fragment length polymorphism analysis. Genotypes based on the fingerprinting phenetic integration were compared to epidemiological, clinical, and geographical data. In agreement with previous reports, five different Leishmania species were identified, but Leishmania (Viannia) guyanensis represented 95.8% of the samples. Two distinct L. (V.) guyanensis populations were found to originate in two ecologically characterized regions. Higher lesional parasite densities and the need for additional treatments were significantly linked to genotype group I. Parasites of genotype group II were more likely to cause chronic and disseminated cutaneous forms in patients. L. (V.) guyanensis was previously said not to be very polymorphic; however, the present analysis resulted in a significant degree of discrimination among L. (V.) guyanensis isolates from diverse ecological areas and with different clinical implications.

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Abstract: PURPOSE OF REVIEW: Histoplasmosis due to Histoplasma capsulatum var capsulatum is a frequent systemic fungal infection in the Americas. Diagnostic and therapeutic options differ between North and South America. Disseminated histoplasmosis is an AIDS-defining infection. Prognostic factors of potentially severe presentations must be evaluated in order to facilitate the initial therapeutic choice. RECENT FINDINGS: Patients with HIV with disseminated infections presenting with severe pulmonary and renal impairment have a poor prognosis. Cutaneous presentations are more frequent in HIV patients in South America than in North America. A murine model has shown that South American isolates have a greater virulence that North American isolates. These differences are due in part to diagnostic delays in resource-poor countries. SUMMARY: Direct examination of May-Grünwald-Giemsa-stained smears or tissues in suspected histoplasmosis is a simple means of confirming the diagnosis in resource-poor settings. Studies of prognostic factors should further refine indication criteria to guide first-line treatment choice between amphotericin B and itraconazole. The association of tuberculosis and histoplasmosis is frequent in HIV patients and presents diagnostic and therapeutic challenges that may be difficult to resolve in resource-poor settings. It is important that affordable generic drugs for treating histoplasmosis be made widely available in resource-poor countries.

Abstract: 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.

Abstract: 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.

Abstract: In French Guiana, at least five Leishmania species are known to be sympatically transmitted in sylvatic ecotopes. However, the previous surveys on the phlebotomine sand fly fauna were published 20 years ago. During that period, many ecological changes have occurred. Sand fly collections were conducted with CDC light traps in five stations representing the main ecotopes of French Guiana. A total of 817 sand flies belonging to 2 genera, 18 sub-genera, and 46 different species were identified. The species Lutzomyia umbratilis (16.6% of the collected specimens), Lu. infraspinosa (12.7%), Lu. ininii (8.0%), and Lu. flaviscutellata (6.1%) were the most common species. The stratification by height, activity period, and resting site preferences of the most abundant sand flies were analyzed. Population abundance and diversity were compared for each ecotope. The potential of certain sand fly species in leishmaniasis transmission is discussed.

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Abstract: At least 13 characterized Leishmania species are known to infect humans in South America. Five of these parasites are transmitted in the sylvatic ecotopes of the whole French Guianan territory and responsible for cutaneous leishmaniasis. For the diagnosis of cutaneous leishmaniasis, restriction fragment length polymorphism (RFLP) analyses have shown promising results. Thus, the end of the small subunit and internal transcribed spacer 1 of the rRNA genes were sequenced and targeted by PCR-RFLP analysis in the 10 main New World (NW) Leishmania species from the two subgenera. Then, the procedure was tested on 40 samples from patients with cutaneous leishmaniasis, and its results were compared with those of conventional methods. (i) The results of this simple genus-specific method were in agreement with those of previous isoenzyme analyses. (ii) This method distinguished the most medically relevant Leishmania species with only one enzyme (RsaI). (iii) This method could be performed directly on human biopsy specimens (sensitivity of 85.7%). Performing NW Leishmania species typing rapidly and easily in the field constitutes a very valuable improvement for detection of Leishmania spp. Revealing great diversity with several enzymes, this method could also be useful for taxonomic, ecological, and epidemiological studies in space and time.

Abstract: The first two cases of canine visceral leishmaniasis in French Guiana are described. One infected dog was most probably imported from France. A second dog was then infected with Leishmania infantum in French Guiana. These observations exemplify the intercontinental transportation theory for L. infantum.

Abstract: Studying the ecology of Leishmania parasites is essential for understanding and controlling the epidemiology of the diseases they cause. Despite their abundance and diversity in neotropical forests, few studies have been conducted to investigate the potential involvement of Chiroptera in the Leishmania pathogenic complexes. However, phlebotomine sand flies are known to colonize the same anthropized habitat, are attracted to bats, and are able to transmit trypanosomatids. Thus, 216 bats representing 29 species were sampled in the field in different primary and secondary forests of French Guiana where human cutaneous leishmaniases have been reported, together with 62 non-volant mammals. A series of 411 tissue samples representing 47 mammalian species were cultured and screened for the presence of Leishmania spp. by a genus-specific polymerase chain reaction. All 278 individuals surveyed were negative. Thus, bats do not appear to be involved in the Leishmania parasitic cycles in the Guyanas.

Abstract: To determine whether the initiation of highly active antiretroviral therapy (HAART) had any influence on the incidence of disseminated histoplasmosis, a retrospective cohort study was performed on 1551 patients followed for up to 12 years. After controlling for CD4 counts, age, and sex, patients taking HAART for 2 months or less were more likely to develop disseminated histoplasmosis than untreated patients (respectively, hazard ratio, 3.7 [95% confidence interval, 1.57-8.7]; P = 0.003). In contrast, after 6 months of HAART, treated patients were less likely to develop disseminated histoplasmosis than untreated patients (hazard ratio, 0.6 [95% confidence interval, 0.37-0.98], P = 0.04). This increased incidence suggests that the initiation of HAART and the subsequent immune reconstitution may reveal undiagnosed latent disseminated histoplasmosis.

Abstract: 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.

Abstract: 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.

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Abstract: 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.

Abstract: Cases of scrotal elephantiasis operated in the Brazzaville' hospital are naturally imputed to Wuchereria bancrofti, in spite of the absence of parasitological proof. This is due to the fact that data's diffused by WHO which are widely included in the literature, unfortunately present this filariasis as being endemic in the Republic of Congo. But it is impossible to identify what works are at the origin of this assertion during the 30 last years. What is certain, it is that no case of lymphatic filariasis was found at the time of the field surveys carried out on filariasis both in the Congo and in Gabon, country also presented as an endemic territory, at the end of the Seventies and during the Eighties. These works were unfortunately published in French. Since this time no publication related a fieldwork or a conclusive clinical observation has confirmed the presence of Wuchereria bancrofti in these two countries of Central Africa.

Abstract: A non-toxic and versatile protein salting-out DNA extraction method is here described for convenient and rapid extraction of nuclear DNA molecules from trypanosomatids. The procedure just involves four manipulations, does not require any organic solvent, and is performed in less than 1h in a single tube. DNA yields obtained were similar to those from commercial kits and phenol-chloroform procedures. Samples extracted by this method were suitable for PCR and subsequent analyses. The reduced manual labour involved was perceived as an important benefit in medical diagnosis routine use as well as for large-scale taxonomic and eco-epidemiological studies of trypanosomatids.

Abstract: The Oyapock region is the second largest malaria outbreak area in French Guiana after Maroni. This area that has been less extensively studied that Maroni is characterized by the presence of an exclusively American Indian population on the French bank and by a high incidence of Plasmodium vivax associated with Plasmodium falciparum. The purpose of this study was to determine the incidence of malaria attacks in Camopi, a population center in which most inhabitants live in 15 small villages located along the middle part of the Oyapock River on the Brazilian border. Study involved diagnosis of malaria attacks (ongoing fever or reported fever within 48 hours and presence of asexual Plasmodium parasites with no other apparent etiology) and accurate estimation of its incidence as well as evaluation of the American Indian population. Study was carried out over the two-year period between April 2000 and March 2002. The mean annual incidence of malaria was 486 per 1000. Incidence was comparable for the two Plasmodium species: 248 p. 1000 for P. falciparum versus 259 p. 1000 for P. vivax but was much higher in children than adults (402 p. 1000 versus 92 p. 1000). The incidence of P. falciparum varied during the year and from one year to the next. Mixed infection documented by microscopic evidence was uncommon. With an annual incidence of around 500 p 1.000, the Oyapock area of French Guiana must be considered as a malaria hot spot.

Abstract: 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.

Abstract: Abstract The larval stages of the fly Cochliomyia hominivorax are responsible for myiasis, which primarily affects wounds. We report the case of a bed-ridden patient with dementia who developed right nasal myiasis during his stay at Cayenne Hospital. Progression was favorable, but the nasal pyramid was partially destroyed. In zones where this fly is endemic, particular attention should be given to hospitalized patients with wounds and consciousness problems.

Abstract: This study includes malaria cases diagnosed by the Parasitology Unit of the Cayenne Hospital (French Guiana) using the same procedure from 1996 to 2003. We provide data for two main rural communities in slightly inland areas of eastern French Guiana (Cacao, Regina) and for Cayenne, the capital of this French department. The frequency of bouts of malaria has been increasing rapidly since mid-2001, in these regions that were virtually considered to be malaria-free. This substantial increase of malaria appears mainly to involve Plasmodium vivax and recent Brazilian immigrants. Other plausible explanations which could account for the observed trend are discussed.

Abstract: Some of the immunologic mechanisms involved in malaria physiopathology remain unclear. In animals, the spleen seems to play a key role in protecting the host against malaria. However, little is known about the effect of spleen dysfunction on human malaria. We report two severe cases of Plasmodium falciparum infection with unusual clinical and parasitologic features in two splenectomized men living in French Guiana. The peripheral blood of these cases showed hyperparasitemia, with a high proportion of mature parasites and leukocytes with malaria pigment. Despite appropriate treatment and adequate absorption, hyperparasitemia persisted. Parasite clearance was delayed and one patient died. Only the patient who died had the merozoite surface protein 1 allele B-K1 and the varD gene genotype, which is considered to be a probable parasite virulence factor. These uncommon cases differ from most of those described in the literature, illustrating the complexity of the mechanisms underlying the protective function of the spleen in human malaria.

Abstract: PURPOSE: To report nine cases of external ophthalmomyiasis caused by Dermatobia hominis. METHODS: Retrospective, non-comparative, interventional case series. Participants consisted of patients (n = 9) presenting at Cayenne Hospital between 1968 and 2003. The location and number of larvae, the larval stage, and the medical and surgical procedures applied were studied in each case. RESULTS: Seven patients had palpebral myiasis (including one with three larvae) and two had conjunctival myiasis. Every patient had palpebral oedema. The larval respiratory pore was located on the palpebral skin or free margin or on the conjunctiva. Movements were present within the lesion in at least three patients. Petroleum ointment or ivermectine solution was used in at least four patients to smother or kill the larvae. Extraction under local anaesthesia was possible in six patients, while three required general anaesthesia. CONCLUSION: Several larvae may be present in a patient. Topical ivermectine may help to kill the larvae before extraction is attempted.

Abstract: 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.

Abstract: BACKGROUND: Few data are available on cutaneous leishmaniasis caused by dermotropic species in human immunodeficiency virus (HIV)-infected patients. OBJECTIVES: To describe nine cases of cutaneous leishmaniasis in HIV+ patients and to compare their clinical features and their response to treatment with those of HIV- patients with the forms of leishmaniasis commonly found in French Guiana. METHODS: A case-control study was carried out between July 1994 and December 2000 in French Guiana. We compared the following variables in nine HIV-infected patients with leishmaniasis and 27 matched controls: clinical type of leishmaniasis, number of lesions, presence of lymphangitis and adenopathy, the rate of recovery after treatment, and recurrence or reinfection. RESULTS: Eight of the HIV-infected patients had localized cutaneous leishmaniasis and one had mucocutaneous leishmaniasis. All of the controls had localized cutaneous leishmaniasis. Leishmania guyanensis was the only species isolated from HIV-infected subjects. HIV-Leishmania coinfected patients had a higher rate of recurrence or reinfection (P < 0.02) and a lower rate of recovery after one treatment cycle with pentamidine (P < 0.02) than did HIV- subjects. The CD4+ lymphocyte counts exceeded 200 mm(-3) in all HIV+ patients at the time of the diagnosis with leishmaniasis. CONCLUSIONS: In French Guiana, cutaneous leishmaniasis in moderately immunosuppressed HIV-infected subjects (> 200 CD4+ T cells mm(-3)) is characterized by a higher rate of recurrence or reinfection and is more difficult to treat than that in HIV- subjects.

Abstract: A survey was carried out on 1487 individuals to assess the seroprevalence of Trypanosoma cruzi infection in French Guiana. The overall prevalence of T. cruzi specific IgG was 0.5%. In multivariate analysis, residence in areas where housing is favorable for the presence of triatomine bugs was the only factor associated with the presence of T. cruzi antibodies. These results have implications for public health since blood donors are not routinely screened for T. cruzi infection in French Guiana.

Abstract: The majority of Toxoplasma gondii strains from a variety of human and animal sources have been grouped into three highly clonal but closely related lineages. The low occurrence of nucleotide differences among the three predominant lineages and their unusual dimorphic allelic composition suggest that they have arisen from a recent common ancestry. Less than 1% of the previously studied strains contain unique genotypes and high divergence of DNA sequence, and therefore are considered 'exotic' or 'atypical' strains. The seemingly low genetic diversity in T. gondii may have been underestimated because most parasite strains in previous studies were collected from human patients and domestic animals in North America and Europe. To investigate the genetic diversity of T. gondii, we analysed parasite strains isolated from remote geographical regions by multilocus microsatellite sequencing and phylogenetic analysis. The genetic diversity indices, the molecular analysis of microsatellite genotypes and the constructed phylogram considered together suggest that the global T. gondii population is highly diversified and not characteristic of a clonal organism. The most parsimonious hypothesis is that T. gondii presents a complex population structure with a mix of clonal and sexual propagation as a function of the environmental conditions. The comparison between domestic strains data on one hand and wild strains data on the other hand is in favour of more frequent sexual recombinations in wild environment even though Toxoplasma subpopulation in human and domestic animals is largely clonal.

Abstract: Giemsa-stained blood smears are mainly used for microscopic examination to diagnose malaria. However, they may also be subjected to polymerase chain reaction (PCR) to confirm diagnosis or for retrospective studies requiring the analysis of old smears. We investigated the possibility of DNA contamination occurring during automated Giemsa staining or due to the failure to clean the oil-immersion objective during microscopic examination. We tested blood smears from uninfected, Plasmodium vivax-infected, and P. falciparum-infected patients. DNA contamination was observed after both staining and microscopy, although contamination was unpredictable during staining. These results are of utmost importance when smears are used for PCR.

Abstract: The resistance of Plasmodium falciparum to antimalarial drugs is one of the most worrisome problems in tropical medicine, but few clinical studies or observations have described confirmed cases of therapeutic failure. We report two cases of in vivo P. falciparum resistance (RIII response) to quinine in French Guiana, an Amazonian focal zone in which multi-resistant malaria is endemic. Both patients presented with uncomplicated malaria and were initially treated with intravenous quinine. Although absorption was normal, the treatment was not effective and the patients still had fever and significant parasitemia three days after the onset of treatment (day 3). The addition of intravenous tetracycline completely resolved the parasitemia within approximately 96 hours. These clinical reports confirm the necessity to combine quinine with tetracycline in this area, as recommended by the recent French regional antimalarial policy.

Abstract: This case control study was conducted among female blood donors in Guadeloupe. A total of 85 HTLV-1 positive subjects were matched by age (+/- 5 years) in a 1:3 ratio to 255 HTLV-1 negative controls. The mean age was 48.5 and 48.9 years respectively. Ethnic, environmental and socio-economic risk factors were studied. Four risk factors were found independently associated with HTLV-1 seropositivity: Strongyloides stercoralis antibodies (OR = 3.6, CI 1.8, 7.3), low socio-economic status (OR = 2.0 CI 1.0, 4.0), low educational level (OR = 2.0 CI 1.0, 4.0) and agricultural activity (OR = 2.8 CI 1.4, 5.6). This logistic regression analysis demonstrates the reality of the association between HTLV-1 carriers and Strongyloides stercoralis, and its association with socio-economic and environmental risk factors.

Abstract: We evaluated retrospectively the safety of mefloquine (25 mg/kg) for the curative treatment of uncomplicated Plasmodium falciparum malaria in 26 infants weighing <15 kg and managed during a 5-year period. Side effects were recorded in 30.8% of patients and consisted chiefly of mild and transient gastrointestinal symptoms. Mefloquine was safe in infants weighing <15 kg in our experience.

Abstract: We aimed to identify prognostic factors for AIDS-associated disseminated histoplasmosis. In a multivariate analysis, we found that dyspnea, a platelet count of <100,000 platelets/mm3, and lactate dehydrogenase levels of >2 times the upper limit of the normal range were significantly independently associated with the death of the patient during the first 30 days of antifungal treatment.

Abstract: A serologic survey for Toxoplasma gondii in 18 free-ranging forest mammal species (n = 456) in French Guiana was undertaken with a direct agglutination test. Serum antibody prevalence varied from 0-71%. The relationships between ecologic features of the species and seroprevalence were investigated. Terrestrial mammals were significantly more exposed to T. gondii than other mammals. This result is concordant with oral exposure to T. gondii related to ground dwelling behavior and/or carnivory.

Abstract: Only a limited number of treatments are available for use in young children with malaria. OBJECTIVES: The aim of this study was to evaluate the efficacy and tolerance of mefloquine treatment in children, especially in infants of less than 15 kg, in an endemic area of malaria (French Guiana). METHOD: This five-years (1996-2000) retrospective study included 61 children aged six months to 16 years who have been treated with mefloquine for acute P. falciparum malaria. Twenty-six of these children weighted less than 15 kg. The efficiency of the treatment was evaluated using clinical and parasitic data that had been validated according to the criteria of the World Health Organization (WHO). Tolerance was compared with the data in the medical literature. RESULTS: None of the 59 patients who were given the treatment correctly presented signs of early therapeutic failure as defined by the WHO. Apyrexia was obtained in 47.8 h on average (CI 95%: 39-57; median: 36 h). The mean time required to obtain negative parasitism was 90.8 h (CI 95%: 80-101; median: 96 h) among the 51 patients in whom this was measured. Mild side effects were observed in 27.8% of the cases affecting mainly the digestive system. No differences were observed regarding efficacy or tolerance for children who weighed less than 15 kg. CONCLUSION: Mefloquine represents an efficient treatment for acute uncomplicated P. falciparum malaria in children and is well tolerated even in infants.

Abstract: The emergence of dengue haemorrhagic fever is a public health problem in Latin America and the Caribbean. This study, carried out in French Guiana where malaria is endemic, evaluated the value and the limitations of a non-specific alert system including all patients admitted to the emergency department of Cayenne Hospital, between 1 January 1996 and June 2001. Four indices were studied on a weekly basis: the emergency malaria negative index (EMN), the EMN thrombocytopenia index (EMNT), the dengue suspected index: EMNT/EMN ratio; and the number of hospitalized patients with dengue fever according to the Department of Medical Information. These indices were retrospectively compared with data from the Arbovirus Reference Centre at the Pasteur Institute in French Guiana. Using the non-specific indices, we were able to identify four clear epidemics, two of which were shown to be linked to dengue. Variations in the incidence of malaria had no marked effect on this alert system. We propose that this simple, cheap, sensitive and reactive alert system be used to improve the serological and virological monitoring of dengue and to facilitate adequate and timely vector control measures. It could be used in all regions at risk of dengue and malaria.

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Abstract: BACKGROUND: The purpose of this study was to describe child deliveries in French Guyana and describe changes in perinatal mortality in different population groups between 1992 and 1999. MATERIAL AND METHODS: All deliveries in health centers and maternity wards in French Guyana between January 1, 1992 and December 31, 1999 were included in the study. Social, demographic, and clinical data were collected at the time of delivery. Infants with a birth weight of 500 g or term 22 weeks were included. RESULTS: From 1992 to 1995, the number of deliveries in health centers declined 5.7% and the number in public maternity wards increased 69.7%. The same trend was observed in 1998 - 1999 (2.4% and 85.7% respectively), an expression of the policy of antenatal referral implemented by the network of childbirth professionals. Perinatal mortality decreased significantly between 1995 and 1998 from 35.4 to 15.2 for the Creole population (p=0.06), from 46 to 16.5 for the Black-Marron Surinam population (p<0.0007), and from 36 to 10.2 for the Black-Marron French population (p<0.009). This drop in mortality in high-risk population groups may have contributed to the overall decline in perinatal mortality observed over the study period. The rate of preterm birth remained stable (at 13.5%) and the proportion of low-weight infants increased only slightly (12.8% to 13.7%). Mortality among preterm infants declined considerably, undoubtedly because of improved neonatal intensive care. CONCLUSION: Despite significant improvement, the perinatal mortality in French Guyana (18.9 in 1999) remains almost three times that in metropolitan France (7.4 in 1999). The mothers are young (17% aged less than 20 years) and the proportion of primiparous and grand multiparous mothers is high. With the absence or insufficiency of prenatal care, the problem of perinatal mortality remains a public health priority and challenge in French Guyana.

Abstract: The only islands in the Caribbean that still have endemic malaria are Haiti and the Dominican Republic. Cases of imported malaria occur on the other islands, particularly Martinique and Guadeloupe, due to the movement of people to and from endemic regions that are geographically and/or culturally close. The re-emergence of transmission cannot be ruled out due to the local persistence of the potential vectors, the anopheles mosquitoes. This retrospective study, over a ten year-period (1991-2000), included all of the cases of malaria confirmed by blood tests at Pointe-à-Pitre University Hospital. This hospital is the main healthcare facility in Guadeloupe. Fifty-nine bouts of malaria occurred in 56 patients. The annual incidence was estimated at 2 to 2.5 cases per 100,000 inhabitants. Plasmodium falciparum largely predominated, accounting for over 80% of cases. The only pernicious case observed resulted in the death of the patient. In all cases the patient had recently travelled to an endemic region, except in one case, caused by P ovale which has never been endemic in the Caribbean. African countries accounted for 43% of cases. No Asian or Pacific strains were identified. In all cases, anti-malarial drugs were not taken, taken incorrectly or were inappropriate. All of the cases of malaria reported in Guadeloupe in the last decade were imported and this region cannot be considered to be at risk of malaria infection. However, long-term epidemiological monitoring is necessary, together with specific entomological monitoring.

Abstract: OBJECTIVES: The aim of this study was to evaluate the efficacy and tolerance of mefloquine treatment in children, especially in infants of less than 15 kg, in an endemic area of malaria (French Guiana). METHOD: This 5-years (1996-2000) retrospective study included 61 children aged 6 months to 16 years who had been treated with mefloquine for acute Plasmodium falciparum malaria. Twenty-six of these children weighted less than 15 kg. The efficiency of the treatment was evaluated using clinical and parasitic data that had been validated according to the criteria of the World Health Organization (WHO). Tolerance was compared with the data in the medical literature. RESULTS: None of the 59 patients who were given the treatment correctly presented signs of early therapeutic failure as defined by the WHO. Apyrexia was obtained in 48 h on average (CI 95%: 39-57; median: 36 h). The mean time required to obtain negative parasitism was 91 h (CI 95%: 80-101; median: 96 h) among the 51 patients in whom this was measured. Mild side effects were observed in 27.8% of the cases affecting mainly the digestive system. No differences were observed regarding efficacy or tolerance for children who weighed less than 15 kg. CONCLUSION: Mefloquine represents an efficient treatment for acute uncomplicated P. falciparum malaria in children and is well-tolerated even in infants.

Abstract: This report describes the results of epidemiological surveillance of cutaneous leishmaniasis in French military personnel in French Guiana. Data was collected regarding microscopic diagnosis, clinical manifestations, and lesion location as well as compliance with vector control measures. Year-to-year variations in the incidence in the general population have been attributed to changes in climatic conditions. Monitoring incidence and density curves, correlation of findings with local epidemiological data, and analysis of the most recent epidemic in 1998/99 (326 cases, attack rate 3.2% men years) highlight the importance of behavioral factors. The proportion of total cases involving military personnel varied widely from 20 to 85%. Investigation consistently showed that failure to apply elementary protective measures against sandfly bites was the most determinant factor in this proportion. Strict compliance with these measures appears to reduce the risk of infection considerably.

Abstract: The aim of this study was to determine the frequency of Toxoplasma infection in wild mammals, particularly noncarnivorous species, and to identify possible sources of infection for humans. A serological study was conducted that included 310 animals representing 10 species of terrestrial mammals from the same region (primary tropical rain forest inhabited by humans). Toxoplasmosis was diagnosed using a direct agglutination test using formalin-treated Toxoplasma gondii. The prevalence of antibodies for toxoplasmosis differed greatly between species and ranged from 0% to 62%. The seroprevalence of toxoplasmosis was zero or very low for tree-dwelling animals, which included sloth, porcupine, and howler monkey. Conversely, the prevalence of infection was 46-62% among granivores, insectivores, and burrowing animals, such as peccary, paca, and armadillo. We conclude that wild mammals in French Guiana constitute a reservoir of T. gondii parasites. Given the absence of domestic cats from the forest, noncarnivorous species may be infected by the ingestion of oocysts that are eliminated into the soil or water in the stools of wild cats and then dispersed.

Abstract: The most common presentation of symptomatic postnatally acquired toxoplasmosis in immunocompetent patients is painless cervical adenopathy. Acute visceral manifestations are associated in rare cases. We report 16 cases of severe primary toxoplasmosis diagnosed in French Guiana during a 6.5-year period. All of the subjects were immunocompetent adults hospitalized with clinical presentations consisting of a marked, nonspecific infectious syndrome accompanied by an altered general status with at least one visceral localization, mainly pulmonary involvement (14 cases). Acute toxoplasmosis was diagnosed according to the results of serological tests suggestive of recent primary infection and the absence of an alternative etiology. Recovery was rapid following specific antitoxoplasmosis treatment. Thirteen of the 16 patients had consumed game in the 2 weeks before the onset of the symptoms, and in eight cases the game was considered to have been undercooked. Toxoplasma strains, which were virulent in mice, were isolated from three patients. Microsatellite analysis showed that all of these isolates exhibited an atypical multilocus genotype, with one allele found only for isolates of this region.

Abstract: In French Guiana, marked seasonal fluctuations have been observed in the numbers of individuals who present with cutaneous leishmaniasis (CL). To investigate the seasonal trends further, the clinical characteristics and responses to treatment of 455 cases of CL, who presented over a 3-year period (1995-1998), were compared against data on the weather for the calendar month of presentation (month 0) and for the month before presentation (month-1). Several statistically significant associations were observed. The number of sunlight hours in month -1 was lower for the treatment successes than for the treatment failures [adjusted odds ratio (AOR) for successful treatment=0.28; 95% confidence interval (CI)=0.13-0.6; P=0.001] and for those with long incubation periods than for those with relatively short incubation periods (multiple-regression coefficient=-0.003; P=0.002). However, the radiation intensity for month-1 was higher for the treatment successes than for the treatment failures (AOR=2.1; CI=1.1-3.8; P=0.02). Relatively high numbers of hours of sunlight on month-1 were associated with relatively high numbers of parasites on the skin smears (AOR=1.03; CI=1.01-1.04; P<0.001). Relatively high numbers of hours of sunlight during month 0 were associated with lymphangitis (AOR=0.4; CI=0.19-0.8; P=0.01). These results indicate that meteorological parameters may influence the evolution of CL, at least in French Guiana.

Abstract: BACKGROUND: Oral or cutaneous acquired immunodeficiency syndrome (AIDS)-related histoplasmosis is a rare presentation of disseminated histoplasmosis. OBJECTIVE: To describe this clinical presentation and to compare it with other forms of AIDS-related disseminated histoplasmosis. METHODS: A cross-sectional study of patients with AIDS-related disseminated histoplasmosis was performed. CD4 counts and survival were compared between patients with oral or cutaneous histoplasmosis and patients with nonmucocutaneous disseminated histoplasmosis. RESULTS: The mean CD4 lymphocyte count was lower in patients with mucocutaneous lesions than in patients with nonmucocutaneous disseminated histoplasmosis (29 vs. 72/mm3, P = 0.002). The proportion of survivors 1 month after diagnosis did not differ significantly between the two groups (13/21 vs. 32/45, P = 0.4). At 6 months, the proportion of survivors was significantly lower for patients with mucocutaneous lesions (6/21 vs. 22/39, P = 0.03). CONCLUSIONS: These results suggest that mucocutaneous lesions occur at a later stage of human immunodeficiency virus infection, but are not, in themselves, associated with a higher level of mortality. The excess mortality at 6 months reflects deaths from other complications of severe immunodepression. This study confirms the polymorphism of mucocutaneous lesions, emphasizing the need for systematic testing for Histoplasma in all cases of mucocutaneous lesions in AIDS patients.

Abstract: Intestinal parasitism and its epidemiological characteristics were studied in an isolated Amerindian population from Upper Oyapock (French Guiana) that has retained its traditional social and cultural specificities. This population consisted of 138 Wayampi Indians, 68 adults and 70 children (below the age of 15 years), with a sex ratio (M/F) of 0.86, spread over the four villages of the community of Trois Sauts, corresponding to more than two thirds of the population recorded as inhabiting the sector in the last census (375 inhabitants). Fecal examination combined the direct examination of fresh feces with the quantitative techniques of Kato-Katz method, Baermann and MIF staining. Overall, 92% of the subjects were found to have intestinal parasites, 85% if only direct examination of fresh stools was taken into account. Fourteen species of human parasite were identified: seven protozoa and seven helminths. We observed in particular 1) a high frequency of hookworm infection due to Necator americanus. Over 50% of subjects were affected, with a range of 25% to 75% according to the village, but with only moderate parasite loads; 2) a high level of parasitism by E. histolytica/E. dispar (17%), Stongyloides stercoralis (16%) and Hymenolepis nana (18%); 3) a lower level of parasitism by Ascaris lumbricoides and very low levels (almost absent) of Trichiuris trichiura; 4) the absence of Schistosoma and fluke eggs. With the exception of H. nana, which was more frequent in children than in adults, there was no significant difference in the level of parasitism according to sex and age. Although the Wayampi of French Guiana are French citizens and consequently have quite high incomes and ready access to clinics and medicines, intestinal parasites are far from under control in this population. A lack of fecal hygiene and the habit of walking barefoot are widespread in the unchanging Amazonian environment and contribute to this phenomenon.

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Abstract: The cure 'rates' achieved using intramuscular pentamidine isethionate (two injections of 4 mg/kg separated by an interval of 48 h) were investigated in French Guiana, in 198 consecutive patients with cutaneous leishmaniasis caused by Leishmania braziliensis guyanensis. One aim was to see if initial clinical presentation could be used to predict treatment failure. The cure rate after one course of pentamidine isethionate was 87% and almost all (80%) of the treatment failures responded to an identical second course. Although many of the patients complained of adverse effects, most commonly of pain at the injection site (54%), none of these effects was severe. Although frequently associated with discomfort, the two-injection course, giving a total of 8 mg pentamidine isethionate/kg, appears to be an effective treatment for cutaneous leishmaniasis in French Guiana. The observation of satellite papules on presentation was associated with a significantly increased risk of failure of the first course of treatment (P = 0.01), with an odds ratio (and 95% confidence interval) estimated at 3.5 (1.3-11.1), after adjusting for other clinical presentations and lesion size and number. The presence of satellite papules perhaps indicates that the patient's immune system is unable to control the progression of the parasite. Patients with more than three lesions were also less likely to be cured after one course of pentamidine than those with fewer lesions (P = 0.01).

Abstract: The authors report four cases of acute chagasic myocarditis which had been diagnosed and treated in Cayenne, French Guiana, in the past 6 years. This French territory, which has the highest standard of living in South America, should be considered an area of risk for sporadic Chagas disease with epidemiologic features similar to those of the disease found in dense Amazon forest areas. Appropriate measures must be taken to screen and promptly manage Chagas disease in the French Guiana population.

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Abstract: MALARIA: This review summarises current knowledge of the epidemiological situation regarding parasitoses in French Guiana. Malaria is the most prevalent infection. The most common species is Plasmodium falciparum which is responsible for three quarters of all bouts of malaria. Plasmodium vivax is mostly present in endemic areas inhabited by Amerindian communities. Plasmodium malariae is rarer. CHAGAS' DISEASE, LEISHMAMIASIS AND TOXOPLASMOSIS: Four acute cases of cardiac Chagas' disease were observed between 1994 and 1996. These cases serve as a warning concerning the possible emergence of this type of parasitosis among the poor in Latin America. Cutaneous leishmaniasis is still highly endemic, with an incidence of about 2 cases per 1,000 inhabitants, which has remained essentially unchanged for 15 years. The identification of severe primary toxoplasmosis in immunocompetent individuals in recent years seems to be associated with an as yet poorly known, natural, Amazonian cycle. INTESTINAL PARASITOSES: Improvements in living conditions, hygiene and treatments are such that intestinal parasitoses, other than anguilluliasis, are no longer a major problem in the urban or coastal areas. The situation is very different in the central areas of the country and in the Amerindian and black half-cast communities, with high prevalences of ankylostomiasis (hookworm disease), anguilluliasis and amoebal disease (Entamoeba histolytica/E. dispar). OTHERS: Lymphatic filariasis is no longer endemic; tropical schistosomiasis and distomiasis have never been endemic. Parasitic pests (cutaneous larva migrans and insect or dust-mite ectoparasites) are more spectacular than severe, and constitute a classic "exotic" component of the spectrum of diseases in French Guiana.

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Abstract: 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.

Abstract: Among over 40 mammal species threatened by the filling of a hydroelectric dam reservoir in French Guiana, three species of primates have been translocated, comprising 124 red howler monkeys, six white-faced sakis, and 95 golden-handed tamarins. Health status of the animals was evaluated by direct physical examination and by hematological, biochemical, virological, and parasitological surveys of collected blood. The physical condition of the howlers was slightly worse toward the end of the capture period, but that of sakis and tamarins remained satisfactory. Several ectoparasites (ticks, larvae of dipterous insects, fleas, and lice) were collected, and various wounds, apparently nondebilitating, were recorded in howlers. Hematological and biochemical profiles determined for the three species revealed a slight anemia in howlers. Entamoeba, Strongyloides, and Trypanoxyurus were common in fecal samples of howlers. A survey of blood smears from the three species revealed infection by several types of microfilaria, Trypanosoma rangeli-like and Plasmodium brasilianum in all three, and Trypanosoma cruzi-like in howlers. These infections had no significant impact on the health status or the hematological profiles. Serologic investigations revealed occasional reactions against Toxoplasma gondii, a strong anti-Plasmodium response in the two Cebidae species, and a weaker one in tamarins. Attempts to isolate arbovirus failed, but antibody responses to Mayaro and yellow fever viruses were strong, especially in the howlers. A strong correlation between age and serological status led to a better understanding of the epidemic cycles. Our survey indicates French Guianan primates are reservoirs for several anthropozoonoses, including malaria, Chagas disease, and arboviruses.

Abstract: PURPOSE: Histoplasmosis due to Histoplasma capsulatum is a granulomatous fungic infection which appears opportunistic and disseminated in immunocompromised patients, especially among HIV patients in whom it can lead to death. Histoplasmosis is endemic in numerous areas worldwide, but in Europe most of the cases reported are imported. We describe the clinical features and the available diagnosis methods issued from our experience in French Guyana. METHODS: Contamination occurs by inhalation of spores contained in dust. Most endemic areas are located on the American continent, including the French West Indies, where the incidence of histoplasmosis among HIV patients in French Guyana varies from 1.2 to 2.2% per year. In non-immunocompromised patients, histoplasmosis is asymptomatic most of the time. In HIV patients, the disseminated form is common and may occur many years after exposure to the fungus. RESULTS: Non-specific symptoms, similar to those of either tuberculosis or other opportunistic infections, may reveal disseminated histoplasmosis in patients with AIDS. Early treatment (amphotericin B or itraconazole) is effective; however, it should be followed by a lifelong antifungic treatment (itraconazole) to prevent relapse. CONCLUSION: The infection should be suspected in any febrile HIV-infected patient with CD4 blood cell count < 200/mm3, if he/she ever travelled in an endemic zone. Direct examination of smear relating to clinical symptoms help guide diagnosis, while culture will confirm it after at least 4 weeks. Efficient serologic techniques for HIV-infected patients are not available in Europe.

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Abstract: A retrospective study was carried out in the General Hospital of Cayenne, the main city in French Guiana, where malaria is endemic and dengue fever constitutes a permanent threat. The aim of this study was to test an alert system for epidemic outbreaks of dengue fever. Patients attending the emergency ward and for whom a search of Plasmodium was prescribed were included. In 90% of cases, patients were febrile, presenting clinical symptoms compatible with malaria or dengue fever-like syndrome. The period of survey covered 39 months (January 1996 to March 1999). Three indices were studied; two non specific: EMN (Emergency Malaria Negative--UPN in French): number of negative malaria blood tests for patients having consulted the emergency ward; EMNT (Emergency Malaria Negative Thrombopenia--UPNT in French): UPN with platelets < 150.000; and one more specific; number of hospitalised dengue fever cases according to data from a hospital programme on medical systems information. EMN weekly follow-ups led to three epidemic alerts, two of which turned out to be crucial for dengue. Accounting for thrombopenia (EMNT) reinforced the specificity. This simple and reactive alert system should incite increased serological and virological surveillance and contribute to precocious antivectorial control measures in districts where several dengue fever cases are suspected.

Abstract: OBJECTIVE: The purpose of this study was to investigate the effect of HTLVI infection on survival in AIDS patients in French Guiana. PATIENTS AND METHODS: A cohort of 151 adult patients with AIDS were followed from January 1992 through June 1996. Kaplan-Meier survival curves were established. Using the Cox model, multivariate analysis was performed to examine different factors affecting survival. RESULTS: The incidence of HTLVI infection in this cohort was 11.9% and 57.6% of the patients died during the study period. Multivariate analysis disclosed that older age at diagnosis of AIDS (over 45 years) and low CD4 count (< 100/mm3) were predictors of poor survival. HIV-HTLVI co-infection was strongly correlated with reduced survival (p = 0.02; RR = 2.2; CI = 1.1-4.5). CONCLUSION: In our region, all patients with HIV infection should be screened for HTLVI infection. In case of co-infection, early care should included adapted antiretroviral regimens.

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Abstract: Each year an estimated 4900 cases of primary Toxoplasma infection occur in pregnant women in France, a country with a high prevalence. Since 1992 all pregnant women at risk of Toxoplasma infection have been required to undergo monthly serological testing. This case-control study, the first of its kind in France, was undertaken to identify risk factors for Toxoplasma infection during pregnancy, with a view to improving primary prevention among non-immune pregnant women. A total of 80 pregnant women who seroconverted to Toxoplasma were matched with 80 pregnant women who had repeatedly negative tests. The women were interviewed by telephone, using a standardized questionnaire, to determine socio-demographic characteristics, exposure to possible risk factors and the type of information on prevention received during pregnancy. The risk factors for Toxoplasma infection included in a multivariate analysis were poor hand hygiene (OR = 9.9; 95%CI: 0.8-125), consumption of undercooked beef (OR = 5.5; 95%CI: 1.1-27), having a pet cat (OR =4.5; 95%CI: 1.0-19.9), frequent consumption of raw vegetables outside the home (OR = 3.1; 95%,CI: 1.2-7.7) and consumption of undercooked lamb (OR = 3.1; 95%CI: 0.85-14). Receipt of documentary advice on prevention was associated with a lower risk of infection. Prevention campaigns among pregnant women in France could be improved and should focus on eating habits, hand hygiene and cats.

Abstract: In 1996, malaria involving Plasmodium vivax, Plasmodium falciparum, and, to a lesser extent, Plasmodium malariae was endemic in 21 countries in the Americas. The Amazon river basin and bordering areas including the Guyanas were the most affected zones. Until the mid 1970s, endemic malaria appeared to be under control. However in the ensuing 15 year period, the situation deteriorated drastically. Although trends varied depending on location, aggregate indexes indicated a twofold increase with recrudescence in previously settled areas and emergence in newly populated zones. Since 1990, the situation has worsened further in some areas where increased incidences have been associated with a high levels of drug-resistant Plasmodium falciparum. However this species remains in minority except in the Guyanas where the highest annual incidences (100 to 500 cases per 1000) and the most drug-resistant Plasmodium have been reported. The causes underlying this deterioration are numerous and complex. In regions naturally prone to transmission of the disease, outbreaks have been intensified by unrestrained settlement. The resulting deforestation has created new breeding areas for Anopheles darlingi, the main vector of malaria in the Americas. Migration of poor populations to newly opened farming and mining areas has created highly exposed areas for malaria infection. Implementation of adequate medical care and prevention measures has been hindered by a lack of money and sociopolitical unrest. Climatic phenomenon related the El Nino have also been favorable to the return of malaria to the region. Except with regard to financial resources and political unrest, the same risk factors for malaria are present in French Guiana.

Abstract: BACKGROUND: Histioplasmosis is a usually asymptomatic fungal infection. In the immunocompetent patient, it leads to chronic disseminated infection. Mucosal involvement is common and can provide the diagnosis. CASE REPORT: A metropolitan Frenchman with a history of alcoholism and smoking and living in Guyana consulted for lingual and tonsil erosion. Squamous cell carcinoma was suspected but not confirmed at pathology. The patient had a bi-apical infiltration on the chest x-ray and was treated empirically for tuberculosis. The diagnosis of histoplasmosis was reached when rare Histoplasma capsulatum were evidenced from a buccal swab. Itraconazole led to cure in 6 months. DISCUSSION: This case illustrates the importance of mucosal signs in the diagnosis of disseminated histoplasmosis in immunocompetent subjects. Histoplasmosis is rarely the cause of active infection in immunocompetent subjects. In these patients, the fungal infection generally progresses to chronic dissemination. Mucosal signs are frequent in this form but are rare in case of cutaneous histoplasmosis. Itraconazole (200 mg/d) is indicated for 6 months.

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Abstract: A simplified Plasmodium falciparum in vivo test was carried out in Brazzaville (Congo) in April 1996. Chloroquine was prescribed at 25 mg/kg for 3 days in asymptomatic Brazzavillian school children who presented parasitemia > 800 P. falciparum trophozoïtes and lived in a highly endemic district. A massive decrease of parasitemia was observed on day 2. The percentage of resistance (presence of P. falciparum trophozoïte on day 7 in a thick blood film) was 43.5, 28 and 21 respectively (IC: 95%: 29-57, 15-41 & 10-34) at the threshold of 6, 50 and 100 parasites/microliter. In positive children on day 7 the reduction of parasitemia was > 95% and no case of R3 resistance was detected. A comparison with previous studies carried out in 1985, 1986, 1990 and 1993 in the same school using the same methodology proves the long-lasting stabilization of chloroquino-resistance for this semi-immune indigenous population.

Abstract: A case of balantidial dysentery is reported in a patient infected with the HIV in French Guiana. This case is the first described in medical literature. The patient presented also a disseminated histoplasmosis. Immunosuppression probably favoured the evolution of asymptomatic carriage to clinical dysentery. This clinical case did not present any complications. Treatment with doxycycline had to be carried out for 20 days in order to obtain a clinical and parasitological cure.

Abstract: To determine if mild adverse events attributed to mefloquine (MQ) and chloroquine + proguanil (CQ-PRO) were experienced with the same frequency, we carried out a study in two groups of French native adult short-term visitors to Africa originating from Amiens. CQ (100 mg daily) + PRO (200 mg daily) prophylaxis was prescribed for all patients travelling to Senegal and those for Kenya when MQ was contraindicated, including all the patients with an history of any neuropsychiatric events, even mild (group 1). MQ (250 mg weekly) was prescribed for the others subjects (group 2). The self-reported questionnaire has been sent by mail to 534 travellers between one to three months after the end of their travels for obtaining information about travel conditions and health problems, mainly those attributed to anti-malarial drugs taken for chemoprophylaxis. We have received 377 available responses (71%): 183 in group 1 and 194 in group 2. There are no significant differences for age, sex, exposition and measures of protection against mosquito bites, concomitant drug use, mean duration of chemoprophylaxis. The compliance during the travel is excellent in each group. CP was interrupted prematurely (< 15 days after returning) in 13.8% of the case with MQ against 4.2% only with CQ-PRO (OR = 3.7; CI 95% = 1.5-9.1). The rates of overall side effects attributed to malaria chemoprophylaxis are respectively: 15.8% for MQ against 12.4% for CQ-PRO (difference not significant). However non-serious neuropsychiatric adverse events (dizziness, headache, mood change and sleep disturbance) are more frequent with MQ: 11.5% against 2.1% with CQ-PRO (OR = 6.2; CI 95% = 2.2-17.2). Although all side effects were transient and judged to be mild to moderate by the subjects themselves, these results back up the fact that mefloquine should be used with caution.

Abstract: To compare the compliance with and tolerance of mefloquine (MQ) and chloroquine + proguanil (CQ-PRO) chemoprophylaxis, we conducted a study using a self-reported questionnaire in 2 groups of native French adult visitors to Senegal or Kenya. CQ (100 mg daily) + PRO (200 mg daily) prophylaxis was prescribed for all patients travelling to Senegal and for those going to Kenya when MQ was contraindicated; MQ (250 mg weekly) was prescribed for the other subjects. There were no significant differences in age, sex, exposition and measures of protection against mosquito bites, concomitant drug use or mean duration of chemoprophylaxis between the 2 groups, and compliance during travel was excellent in both. Chemoprophylaxis was more frequently interrupted prematurely in the MQ group. The rates of overall side-effects attributed to malaria chemoprophylaxis were 16% for MQ against 12% CQ-PRO (not significant). However, nonserious neuropsychiatric adverse events are more frequent with MQ: 11.5% compared to 2% with CQ-PRO. MQ should be used with caution.

Abstract: The main trends and the significant points concerning the evolution of seroprevalence, seroconversion's rate and knowledge's level of preventive measures against toxoplasmosis in pregnant women in France are : a progressive decrease of immunisation's ratio with regional variation (national mean is estimated at 54 % in 1995); diversity of factors having a potential influence on the contamination, the trends of most of them tend to decrease the contamination but the exact impact is difficult to appreciate; stability of seroconversion's rate since 15 years 4 to 5 p.1000 of the whole pregnancy for nine months exposition period; ways of contamination are still the same; few informations about knowledge's level concerning preventives measures and performances of educative action.

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Abstract: In vitro Plasmodium falciparum drug sensitivity was investigated in 115 brazzavillians children, between 1 year and 10 years of age. On the basis of clinical aspects, four groups were constituted: Group 1: 39 asymptomatic school children, Group 2: 16 children with uncomplicated malaria, Group 3: 40 with severe but not pernicious malaria and Group 4: 20 with pernicious malaria. The drugs tested were chloroquine (CQ), quinine (QN) and mefloquine (MQ). The sensitivity level was assessed by a 48-hour in vitro maturation test involving the uptake of tritiated hypoxanthine, the initial blood level of parasite being > or = 0.1% in all cases. For QN and MQ, the median IC50 values showed no significant difference related to clinical status, age or parasitaemia levels. For CQ, the proportion of resistant strains and the 50 inhibitory concentration (IC50) values were greater in the cases of children hospitalised for malaria but there were no differences related to clinical severity of these hospitalised children nor, within each group, to the age or parasitaemia levels. The percentage of subjects with an IC50 value greater than the 90 percentile of the IC50 of the asymptomatic group, which we propose as the severity index related to chemoresistance, was 15% for uncomplicated malaria, 38% for severe but non-pernicious forms and 35% for pernicious malaria. The IC50 for QN was significantly higher in CQ-resistant strains and there was a positive correlation for CQ vs QN and for QN vs MQ.

Abstract: We report the second Congolese case of subcutaneous entomophthoramycasis, a rare tropical disease expressed as cellulitis. Despite characteristic clinical features, the diagnosis for this twelve-year old child was confirmed four years after the beginning of the disease. Dramatic clinical improvement was observed within the first month of treatment with ketoconazole.

Abstract: Parasitological data of various malarial studies performed in the Congo where Plasmodium falciparum malaria is holo-endemic in rural and suburban zones, between 1988 and 1991, were analyzed with the intention of establishing diagnosis and prognosis value of Plasmodium falciparum parasitaemia in areas with high perennial transmission. In such an area congolese school-children (6-10 years old) had 88% P. falciparum index, this is the same percentage as that for children hospitalized with a pernicious attack. However, the parasite load is distributed differently; parasitaemia is greater than 6,000 asexual form of P. falciparum/microliters (afPf/microL) in only 4.6% of cases in the former group versus 67% in the second group. A threshold of 10,000 afPf/microliters, above which the Plasmodium infection triggers a febrile attack in semi-immune children, is confirmed in school children in a rural context where the factor of taking antimalarial drugs within the preceding days is negligible; three out of four children with levels above this threshold are febrile versus 4.1% (7 out of 170) with lower blood parasite levels. Some adults were also asymptomatic carriers but much less frequently and with lower mean parasitaemia levels. The parasite load mirrors the clinical severity although this concept can be misleading as an individual prognostic criterion and for hospital studies carried out in areas where multiple drug administration before hospitalisation is common. For the studies recently performed in Brazzaville, the 5% threshold level of parasitized red cells, the WHO severity criterion, was never reached in asymptomatic subject or in cases of simple attack; it was reached in one out of two cases of pernicious attack.

Abstract: Various projects were launched in 1993 to monitor the chemosensitivity of Plasmodium falciparum in Congo. Resistance of 34 strains in Brazzaville to chloroquine, quinine and mefloquine and of 35 to halofantrine was investigated in an in vitro survey using an isotopic micro test. The resistance rates were 61.8, 14.7, 3.0 and 0.0% respectively. Thus, the chemoresistance which first appeared in 1990 is confirmed and is stable in the population. This finding was further confirmed by a parallel in vitro analysis of sensitivity to chloroquine in Brazzaville. A chloroquine monitoring network is now being established throughout the country based on simplified WHO tests of 100 asymptomatic schoolchildren conducted every six months. The first results in 1993, from three Southern regions indicate that parasites are found in 20 to 60% of cases seven days after a standard 3 day treatment with 25 mg/kg, according to the region. The results of in vitro and in vivo tests are very variable. Indeed, the value of such results for these tests for national monitoring is questionable: a more reliable system of identifying true therapeutic failures would be better suited.

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Abstract: Current epidemiologic and clinical research on cerebral malaria is directed towards prognostic criteria and neurologic sequelae. However, the assessment of risk factors related to the environment and the socioeconomic standard of the family is of practical as well as theoretical interest. A prospective survey was carried out in March 1990 in Brazzaville, Congo by interviewing subjects in two groups: 1) 600 households representative of the Brazzaville population and 2) 84 households with a child who had been hospitalized for cerebral malaria between January 1, 1988 and June 30, 1989 (i.e., 9-27 months prior to the interview). The mothers' knowledge and attitudes with regard to the prevention and treatment of malaria in children were assessed, as was the socioeconomic standards of the households. The group in which at least one child had been hospitalized for cerebral malaria had a lower socioeconomic standard than the control group. Other differences in this group included a greater number of offspring and a higher average number of decreased children, less chemoprophylaxis, antimalarials available less often in the household, less early treatment of fever at home, and drugs bought more often at the market. There was no significant difference between the groups with regard to using the correct dosage of chloroquine, ownership of a mosquito net, or the use of insecticides or repellents.

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Abstract: This study was carried out on 170 children admitted to the University Hospital of Brazzaville (Congo) for cerebral malaria between January 1, 1988 and June 30, 1989. The selection criteria were 1) unarousable coma, cerebrospinal fluid without microorganisms or a marked cellular reaction, and the absence of other causes, and 2) that the children lived in Brazzaville. The case fatality rate was 15%. In 75% of the cases, death occurred within the first 48 hr. The prognosis worsened with the stage of the coma and a younger age. At discharge from the hospital, 9% of the cases presented with sequelae. The postcerebral malaria mortality was high; indeed, death occurred in six (7%) of 90 children discharged from the hospital whose parents were contacted between nine and 27 months later. Two deaths were directly related to neurologic sequelae. Among the 58 children examined under satisfactory conditions between nine and 27 months (mean 16.9 months) after discharge, 50% (3 of 6) still presented with attenuated forms of the sequelae observed immediately after the episode of cerebral malaria (cortical blindness had regressed completely, unlike ataxia and loss of balance). Disorders that may have been related to the episode of cerebral malaria were observed in 31% of these 58 cases.

Abstract: The prevalence of skin depigmentation in the pretibial region is closely correlated in the adult Congolese population with conventional indices (microfilarial index, mean microfilarial density, cyst index) for the evaluation of endemic onchocerciasis. Individuals over 15 years of age in endemic villages who had a microfilarial index of 80-90%, had a cystic index of 60-70% and a pretibial depigmentation index about 20% (30-40% for individuals aged > 50 years). Thus, in Africa, this new evaluation index offers a simple, noninvasive, quick and cheap way to identify areas where the level of endemic onchocerciasis is probably high and which are likely to benefit from an anti-onchocerciasis campaign.

Abstract: By the year 2000, 40% of the population of sub-Saharan Africa (western and middle Africa) will live in urban areas. It is obvious that urbanization reduces the transmission of malaria and make treatment easier. However, excessive optimism is inappropriate in regions where malaria transmission remains intense and where it is unfortunately illusory to hope for any major or geographically extensive reduction in transmission outside urban and suburban areas. In this context, the benefit of a reduction in malarial morbidity could be compromised by the increased risk of severe forms in town-dwellers, who now have little or no immunity, when they venture into the surrounding rural zone. The prevention of malaria during trips to endemic areas has become a reality for sub-Saharan African town-dwellers. We have to conceive and propose specific protective measures. This version of the advice to travellers about malaria, intended for use in Africa, is fairly similar, in theory, to the advice we give in Europe to travellers going to tropical areas: 1) at most, chemoprophylaxis throughout the exposure period plus 2 or 4 weeks after their return; 2) in all cases, protection against anopheles (take and travel with an impregnated mosquito net) and: 3) above all, the systematic and rapid treatment of any suspected attack of malaria (take and travel with a medicine pack containing antimalarials). If it seems vain to hope to be able to apply these measures in the current socio-economic situation in sub-Saharan African, they are nonetheless justified.

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Abstract: The modalities of prevention and treatment of malaria in expatriates residing in Brazzaville, capital of the Congo, have been studied in March 1989, April 1990 and April 1992. These surveys of the type Behavior, Attitude, Practice have been carried out in the Ecole Française where the same questionnaire has been distributed among the primary school children to complete by their parents. Only the data pertaining to Europeans, Lebanese, and North-Americans are presented. The proportion of French expatriates is 80%. A progressive decrease is noticed in the regular taking of chemoprophylaxis: the percentage varies between 86 and 43% according ot the duration of residence in 1989, to between 57 and 16% in 1992. Chloroquine alone remains the most widely used product, especially in long term expatriates. The association chloroquine-proguanil is mentioned only by a quarter or respondents. Apparently efficient, it is especially taken by people exposed for less than 4 years. Amodiaquine, although contra-indicated for prevention purposes, is cited in 1992 by 9% of subjects taking regular chemoprophylaxis; other products are only exceptionally used. In curative treatment, which generally is presumptive, halofantrine is since 1990 the most widely used drug, especially in children. In contrast, a relative disclaimer is noted for the amino-4-quinolines, due to resistance, but also and with no justification, for the association sulfadoxine-pyrimethamine and, to a lesser degree, for quinine. The occurrence of attacks considered to be malarial and their frequency, remained stable during the period of study.(ABSTRACT TRUNCATED AT 250 WORDS)

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Abstract: To assess the frequency of malaria-infected blood donations in Brazzaville (Congo) thick films from all blood donors (n = 12,375, minimum per month: 857, maximum per month: 1,295; sex ratio: 9.6) at the Brazzaville University Hospital were examined quantitatively for Plasmodium (screening threshold: 20/microliters of blood) over one year (1989). The overall prevalence rate for all species of Plasmodium was 8.5%. It varied according with age but not with sex. P. falciparum predominated (92%), followed by P. malariae (7%) and P. ovale (3%). For P. falciparum: 1--the prevalence rate was 7.8% but varied over the year from 4.8% in August (6.2% for the dry season on the whole) to 11.5% in March (9.6% for the rainy season); 2--the parasitic load, also variable according to the season, was over 600/microliters in 24% of the cases (i.e. 1.9% of all donations) and over 6,000/microliters in 15 cases (i.e. 1.6% of the cases). In conclusion the proportion of blood donations infected with P. falciparum (with a parasitic load > or = 20/microliters) varied in Brazzaville from 6% in the dry season to 10% in the rainy season.

Abstract: This study was conducted in all four hospitals of Brazzaville, the capital of the Congo in order to assess the trend in malaria morbidity, the frequency of cerebral malaria and the related mortality between 1983 and 1989 in Brazzaville children. For the period 1983 to 1987 the study was retrospective, based on records. For the period 1988 and 1989 a prospective study was carried out in the two main hospitals in which a system for reporting cases of cerebral malaria was set up. This was completed by a retrospective analysis of data similar to that carried for the previous years. The population of Brazzaville children aged between 0 and 14 years and the distribution by district were estimated from the 1984 official census taking the annual demographic growth to be 5%. The results show a marked increase in hospitalizations for malaria, noticeable since 1985, and which now account for about 50% of the overall non-surgical hospitalizations. The number of cases of cerebral malaria and related deaths have probably increased. However, these severe forms of malaria were relatively rare. Indeed, in 1988 and 1989, for the 0-4, 5-9 and 10-14 year age groups, the annual incidence rates of cerebral malaria were estimated at respectively 240, 61 and 13 per 100,000 and the related mortality rates at respectively 58, 5 and 1 per 100,000. No obvious relationship was found between the intensity of malaria transmission, which varied considerably according to the district, and the level of mortality from cerebral malaria.

Abstract: This survey was carried out on a cohort of children born between 1st January 1981 and 30th June 1987 in the maternity department of the hospital in Linzolo, a village situated 25 km south-west of Brazzaville, the capital of the Congo. The mothers of the children resided in the suburbs of Brazzaville at the time of delivery. In this region, the rate of transmission of Plasmodium falciparum malaria is high without marked seasonable variations. The mothers and children were traced in the second quarter of 1989 in order to assess the rates and, where possible, the causes of mortality. Information on 75% of the recorded births (2424 children) was obtained directly by interviewing the mothers in the home. Between 1981 and 1988, the infant mortality rate varied overall between 33 and 52 per thousand, and in the 1-2 year age group, between 7 and 25 per thousand (1981 to 1987). The number of deaths attributable to malaria was relatively low although resistance to amino-4-quinolone is well established since 1985. During this period, no particular trend was observed in the mortality at 0-2 years, or at 0-5 years.

Abstract: Current practices for the prevention and treatment of malaria in children and in pregnant women in the Brazzaville Region (Congo) were studied in 1989 and 1990. Information was obtained by interviewing a total of 1152 subjects. Overall, chemoprophylaxis was used less than was the systematic treatment of fever. Fever was treated before seeking medical advice in over 50% of the cases. Two-thirds of those interviewed reported that they slept under mosquito nets. Families with lower socio-economic standards were less likely to use chemoprophylaxis, to have antimalarials in the home, and to own mosquito nets; and they were more likely to prefer injections and to purchase drugs in the local markets.

Abstract: We report the first Congolese case of African histoplasmosis in a patient with AIDS which represents the third case to be described in the literature. This contrasts with the now frequent occurrence of Histoplasma capsulatum histoplasmosis in HIV-infected subjects in North America; the difference is likely to be due to differences in exposure to the fungus rather than to differences in behaviour of the fungus or in the epidemiology of HIV.

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Abstract: Three observations of sanke-bite that occurred in the Congo are reported: the bite of an aglyph colubridae (Philothamnus nitidus loveridgee) that was severe; the bite of an Atheris s.p. with moderate symptoms; the bite of a Naja melanoleuca remained totally asymptomatic.

Abstract: Five cases of encephalitis following treatment with diethylcarbamazine (DEC) were observed in Congolese patients with Loa loa filariasis. Two cases had a fatal outcome and one resulted in severe sequelae. The notable fact was that this complication occurred in three patients hospitalized before treatment began, with whom particularly strict therapeutic precautions were taken, i.e., initial dose less than 10 mg of DEC, very gradual dose increases, and associated anti-allergic treatment. This type of drug-induced complication may not be that uncommon in highly endemic regions. It occurs primarily, but not exclusively, in subjects presenting with a high microfilarial load. The relationship between the occurrence of encephalitis and the decrease in microfilaremia is evident. The pathophysiological mechanisms are discussed in the light of these observations and the few other comments on this subject published in the literature.

Abstract: Forty-five bronchoalveolar lavages (BAL) were performed in Brazzaville in AIDS patients who did not expectorate acid- and alcohol-resistant bacilli (AARB). All patients presented with respiratory symptoms (cough, dyspnoea or chest pain), and all but 6 of them had abnormal radiography of the chest. Four cases of pneumocystosis were diagnosed (9%); 3 of these patients had interstitial pneumonia and dyspnoea. No AARB was found at microscopic examination of BAL which showed Pneumocyctis carinii; no culture on Löwehstein's medium could be made. The authors consider that the low prevalence of pneumocystosis in Africa, compared with industrial countries, is due to a smaller dissemination of the parasite in Africa rather than to immunodepression which is known to be more pronounced in AIDS patients from industrial countries.

Abstract: The efficacy of 4 therapeutic schedules was compared in March and April 1990 in Brazzaville school children, aged between 6 and 8 years, with parasitaemia of at least 1,000 trophozoites of Plasmodium falciparum per mm3. It was possible to interpret 125 simplified in vivo tests. The results showed that the activity of amodiaquine is still relatively satisfactory. The activity of chloroquine was slightly lower with the schedule of 25 mg/kg but was good at 35 mg/kg. Although these results were obtained in children who were mostly asymptomatic, they show that the use of amino-4-quinolines is still justified, at least in the initial treatment of uncomplicated malaria in semi-immune congolese subjects.

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Abstract: The efficacy of quinine prescribed to children from Brazzaville hospitalized for acute malaria (temperature over 38 degrees C, P. falciparum parasitaemia over 10,000/mm3, no other obvious disease; the reason for hospitalisation often being digestive or neurological disorders) was assessed. Quinine was administered by perfusion: 25 mg/kg/day for at least 3 days. Associated treatment (sulfadoxine-pyrimethamine combination in 80% of the cases) was given at day 3. Blood was taken at day 0, and before discharge (usually between days 3 and 5). Thick Blood Smears (TBS) were examined for a volume of blood corresponding to 300 leucocytes. Antimalarials had been taken in 60% of the cases (chloroquine in 67% of the cases, quinine in 10%). Antimalarials were not assayed in the sera. In 68 cases of non pernicious malaria, no obvious cases of resistance were observed. TBF were negative in 49 out of 52 cases at day 3, and 11 out of 12 at day 4 and in five out of five cases at day 5. In 96 cases of pernicious malaria, only one case was suspected of being resistant, with a weakly positive TBS at day 7. 13 children died but all in the first three days without suspicion of resistance. Apyrexia was observed before day 4 in 89% of the cases; only one case of fever at day 7. TBS were negative before day 4 in 97% of the cases. So, at the dosage of 25 mg/kg, quinine was found to be very effective in the Congo in 1989 against both pernicious and non pernicious malaria.

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Abstract: The drug sensitivity of 184 Plasmodium falciparum isolates was studied in vitro in three areas of the Congo in January 1987. Results show that parasites resistant to chloroquine but not to quinine or mefloquine were prevalent in the three investigated regions, but the drug response pattern varied widely. In Brazzaville, after the outburst of chloroquine resistance in 1985, prevalence of chloroquine resistant isolates seemed to have stabilized around 60%. The phenomenon more recently reached the North where about 30% isolates could be considered as drug resistant. As in Cameroon, wide variations in the prevalence and the level of resistance were observed within a very limited area emphasizing the role of drug pressure in market places where chloroquine is easily available.

Abstract: The therapeutic, preventive and curative, habits concerning malaria of expatriates living in Brazzaville, Congo, were investigated on two occasions. In March 1989 and April 1990, a questionnaire was handed out to the pupils of the French school to be filled in by their parents. Three quarters of the expatriates are Europeans, and 85 percent of these are French. In this country where the chemoresistance of Plasmodium falciparum has been established since 1985, chemoprophylaxis was regularly performed by expatriates during their first years of residence to diminish later on; in 1989 it was still practised by more than 50 percent of adults who had been living in the tropics for more than 10 years, but in 1990 this proportion had fallen to 35 percent. Chemoprophylaxis is provided by chloroquine in 3 out of 4 persons and by amodiaquine in 1 out of 5. Mefloquine and the chloroquine-proguanil combination are still rarely prescribed as preventive treatments. About 50 percent of the expatriates have had at least on attack of malaria in the previous 2 years, with or without chemoprophylaxis and irrespective of the measures taken to avoid mosquito bites. Mosquito nets, never sprayed with insecticides, are little used, but air-conditioning at night is favoured by 80 percent of the population studied. Curative treatment was distinctly altered between 1989 and 1990, with a rapidly increasing use of mefloquine or halofantrine after confirmation of the diagnosis or as presumptive therapy.

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Abstract: The clinical manifestations observed in 102 malaria patients (parasitaemia of over 8,000 Plasmodium falciparum/mm3) hospitalized in 1989 in Brazzaville (Congo) were analyzed after ruling out the cases of pernicious malaria. The clinical picture was fever, stomach upset with headache and musculo-articular pain as in classical cases. In children these manifestations were frequently associated with convulsions. Diarrhoea was not uncommon in young children. Vomiting was frequent in both children and adults. Splenomegaly and hepatomegaly were closely related to age. In these subjects, chemoprophylaxis was rare in children, practically non-existent in those aged over 5 years. However, presumptive treatment and self medication was usual regardless of age.

Abstract: Treatment with ivermectin at the dosage of 200 microgram/kg in 28 Congolese loiasis patients led to an important decrease of the microfilaremia on day 7, with a reduction of about 90% of the initial parasite load. However, no negativation was observed and, moreover, the parasitemia did not change from day 7 to day 14. Tolerance was quite good, but weak to moderate reactions, linked to the lysis of the microfilariae, were observed in one third of the patients with a microfilaremia greater or equal to 2,500/mm3.

Abstract: Five cases of calcification of the breast due to filariasis in Congolese women are reported. The cases were discovered during mammographies carried out for suspect carcinoma (4 cases) and benign tumor (1 case). The geographic origin of the patients, a past history of subconjunctival filarial migration in 2 individuals, the bilateral localization, and, above all, the radiographic appearance and size of the calcifications, suggested that the images were due to Loa loa.

Abstract: Our study group, which was composed of over 2,500 subjects, aged between 0 and 65 years, came from different regions of Congo. The samples obtained were examined for the presence of IgG and IgM against Toxoplasma gondii. IgG were detected in about 33% of children over 9 years and in about 40% of adults. A study of IgM confirmed the early contact of children with the parasite (11% of positive samples for children between 4 and 9) and that of young women (5 to 7% positivity for subjects between 15 and 30). In spite of local variations, the extremely humid climate did not allow us to detect a difference based on the origin of the samples as furthermore there seems to be an ethnic factor involved. Among the different types of professions in our sample only farmers appear to be less frequently positive. Diet, as well as contact with animals do not seem to have an influence.

Abstract: Surveys on drug sensitivity of Plasmodium falciparum carried out between 1985 and 1989 included 7-day in vitro tests and in vivo tests. 485 in vivo tests were carried out in eight surveys conducted in Brazzaville and in several inland regions. The subjects were congolese children aged between 3 months and 15 years old. They were recruited in hospital, mother-child clinics or at school. The drugs studied were chloroquine, amodiaquine and the sulfadoxine-pyrimethamine combination. 182 strains were tested in vitro in two surveys (December 1985 and January 1987); amino-4-quinolines, quinine and mefloquine were studied. Although resistance to amino-4-quinolines is a recent occurrence, by 1985 it had spread widely in the indigenous population in the Centre and South of the country. Resistance has since increased gradually, especially for chloroquine which undergoes specific surveillance. The situation is less serious in the North, a less densely populated region which is still enclosed. In an in vivo comparative study with chloroquine conducted in Brazzaville in November 1986, amodiaquine was found to be only slightly more effective at a similar dosage. At that time, certain isolated observations already seem to imply that the sulfadoxine-pyrimethamine combination was also affected by resistance. This was not corroborated in an in vivo study carried out in 1989 on 40 children presenting with a malarial attack. Although the sensitivity to quinine may probably be decreased. This drug cannot yet be considered as being truly affected by resistance. The activity of mefloquine, the use of which is still limited, was satisfactory in 1987 in two different regions of the country.

Abstract: The functional symptomatology of loiasis was studied in 101 Congolese subjects living in a village in a highly endemic area. 27.7% of them were carriers of Loa loa microfilariae. 5.9% were infected with Mansonella perstans. No subjects were found to have dermal microfilariae. In anamnesis, 51.5% of them reported episodes of Calabar swellings, 69.3% history of eyeworm and 10.9% episodes of subcutaneous migration of worms during the last 12 months. Pruritus and secondary dermal lesions were frequently demonstrated in 64.4% and 56.4% of the individuals respectively. Asymptomatic amicrofilaraemic subjects only accounted for 11.9% of the adult population. The study of the life-time risk of eyeworm, also conducted in the Pygmy and Bantu populations of another village, was shown to be useful in epidemiological evaluations.

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Abstract: A study of Mansonella perstans filariasis conducted in the Chaillu mountains, Southern Congo, showed that 108 of 134 Pygmies (80.6%) and 79 of 302 Bantus (26.2%) presented with microfilaraemia. The mean microfilarial densities were also significantly higher in the Pygmies (1213 ml-1 of blood) than in the Bantus (136 ml-1). Ninety eight per cent of the Culicoides taken which had bitten man in the daytime were C. grahamii, and 0.8% of these were infected with filarial larvae. Two other species of Culicoides (C. kumbaensis and C. rutshuruensis) might also play a role in the transmission of M. perstans.

Abstract: Analysis of 25 surveys carried out in the Congo between 1978 and 1987 (covering nine of the ten administrative regions), during which 6,215 subjects were examined, showed that onchocerciasis is endemic in the southern part of the country. Two main foci meeting at the southern exit of Brazzaville (Pool region) were identified. One focus in the Djoué basin. The other is the zone along the Congo river stretching from below Brazzaville south west to the Zaire border. Two secondary foci were noted, one in the region of the Bouenza and the other west of the Mayombe mountains. Surveys carried out in the north of the country and in the west did not reveal any onchocerciasis. However, certain areas of primary forest in these regions were found to be endemic for Mansonella streptocerca. Simulium damnosum s.l. in the sole vector of onchocerciasis. In both the Pool foci, and in the Mayombe focus, prevalences assessed from microfilarial and cyst counts were high but the mean microfilarial densities were relatively low. In certain villages over 90% of the population aged over 14 years may present with microfilariae and nearly 70% may present cysts.

Abstract: In a multiclinic trial in Brazzaville, Congo, 14 patients with late-stage Trypanosoma brucei gambiense trypanosomiasis were treated with eflornithine. All cases had previously been treated with one or several courses of melarsoprol. Eflornithine treatment consisted of 400 mg/kg/day intravenously for 14 days followed by 300 mg/kg/day orally for 21 days. After treatment all patients had a disappearance of trypanosomes from cerebrospinal fluid (CSF), a normalization of CSF WBC count, and, where present prior to study, a clear, rapid and lasting amelioration of neurological signs. Neither clinical nor biological adverse effects necessitated modifying or discontinuing treatment. These encouraging results in melarsoprol-refractory cases demonstrate, despite certain logistical problems, the interest of eflornithine in the treatment of human African trypanosomiasis.

Abstract: The diagnosis of malaria attack in regions for highly endemic P. falciparum is difficult. It is more so since the wide use of antimalarials by the infected populations and the spread of drug resistance. A positive test is not evidence for a malarial attack since in certain schools, in both rural regions and in some districts of big towns, over 3/4 of the children attending school are carriers of Plasmodium. On the other hand, true attacks, even severe forms, can occur without evidence of parasitaemia. The parasitic load is thus an important factor but the following must be taken into consideration: age, level of immunity, the extent of transmission and whether if is continuous or not, self medication and the initial systematic treatments, the possibility of drug resistance, ... The difficulties are illustrated by data collected in the Congo.

Abstract: 1934 Bantus and 379 Pygmies were investigated for Loa loa and Mansonella perstans filariasis in 7 villages in the Chaillu forest of the Congo. Bantus were more frequently infected with L. loa than Pygmies (18.9% of microfilariae carriers compared with 10.6%). In individuals over 30 years of age, males were more frequently infected than females. Microfilarial densities increased until the age of 20 years and then remained stable. Parasite load was not significantly different in the two ethnic groups. For mansonelliasis, the microfilarial rate was higher in the Pygmies (67.5% compared with 22.0%) and males of the 2 groups were more frequently infected than females. Microfilarial load was also higher in Pygmies than in Bantus (mean microfilarial densities (MfD 50) 13 and 2 respectively). In the Pygmy group, MfD 50 for M. perstans increased with age whereas it remained stable in the Bantus. 53.8% of the 249 questioned persons had experienced worm migration under the conjunctiva. Both ethnic groups were equally exposed to the vectors of L. loa and reasons for the difference in prevalence of microfilaria carriers are discussed. For mansonelliasis increased contact with vectors may explain the higher degree of infestation observed in Pygmies. Other filariases were infrequent in (Mansonella streptocerca), or absent from (Onchocerca volvulus and Wuchereria bancrofti), the study area.

Abstract: Two cases of very high hypereosinophilia (28,160 and 11,232/mm3) observed in congolese patients are presented. Although microfilaraemia was not detectable, loiasis was diagnosed, given the clinical manifestations, epidemiological data, history of sub-conjunctival migration of the adult worm (in one case), spectacular recovery (clinical and biological) after treatment with diethylcarbamazine. This "allergic form" of filariasis is often considered unusual in indigenous subjects.

Abstract: Clinical and biological evaluations were carried out on 84 Congolese patients with parasitologically confirmed Loa loa filariasis (without concurrent infection with other filariae) and on 98 controls without filariasis. On the patients, 72 presented with microfilaremia; another 12 with negative blood tests were seen towards the end of an episode of subconjunctival migration of the adult worm. The incidence and severity of the clinical signs depended upon the method of recruitment. The 3 most common signs were pruritus and edema (both occurring in successive acute episodes affecting mainly the hands and forearms) and subconjunctival migration of adult filariae. Papulovesicular eruptions were located mainly on the arms. Headaches and arthralgia were noted more frequently than in the controls. No relation was found between the ABO blood groups and loiasis. Eosinophilia (higher in patients with symptoms) and raised serum IgE levels were found in nearly all patients and were strongly marked in approximately 66%. A positive correlation was observed between these 2 parameters. Fluorescent antibody levels (adult filaria Dipetalonema viteae antigen) were comparatively low in patients with microfilaremia.

Abstract: About the two first cases of rhinoentomophthoromycosis (Conidiobolus coronatus) observed in Congo, the spectacular efficiency of ketoconazole must be pointed out: the second patient who has been treated from the beginning, recovered in two months. This evolution is to be compared with the therapeutic difficulties which had occurred before this antimycotic drug was used, as illustrated by the first patient who had to be hospitalized for almost one year and half and to suffer twice from an upper lip necrosis. However, that patient regained a decent facies due to a treatment with ketoconazole which had been postponed for a long time, and added to an hepatitis, and to plastic surgery.

Abstract: The authors report a case of a dead adult Loa loa filarial worm, in a subconjunctival position, but well recognisable. This manifestation, with no notable functional consequence, had never been previously reported.

Abstract: To determine the frequency of opportunistic parasitic and mycotic diseases in adult AIDS patients in the Congo, a study was conducted at l'Hôpital Universitaire de Brazzaville in 1986 and 1987. Diagnosis of AIDS was made using the WHO clinical definition for Africa (Bangui, 1985) and HIV seropositivity Pasteur Elisa test. Oral pharyngeal candidiasis occurred in 36% of cases. Intestinal parasitic profile found in 118 patients, 2/3 of whom were associated with chronic diarrhoea showed clearly relative frequency of isosporiasis (Isospora belli): 9.3% and rarity of crystosporidiosis: 4.2%. 12 meningitic cryptococcosis cases out of 139 patients was confirmed (8.6%); for cerebral toxoplasmosis, it was by comparing the serum toxoplasmosis antibody and cerebrospinal fluid rates on 75 patients that an estimation of 20% was reached. Pneumocytis carinii pneumonia seems to be rare, lower than 10%. No case of disseminated histoplasmosis and malignant strongyloidiasis was observed.

Abstract: The current incidence of pernicious attacks and of mortality due to malaria were studied in Brazzaville. The results of this study, which concerned all the medical units of the town, were analysed in terms of previous studies on the epidemiology of malaria transmission in the various districts of the town. It was estimated that the annual incidence of pernicious attacks in children in Brazzaville is 1.15 per thousand between 0 and 4 years, 0.25 per thousand between 5 and 9 years and 0.05 per thousand between 10 and 14 years. The annual mortality due to malaria was estimated at 0.43 per thousand between 0 and 4 years and 0.08 per thousand between 5 and 9 years. These values are about 30 times lower than those expected from the results of previous studies of the mortality due to malaria in intertropical Africa. Whereas considerable differences in intensity of malaria transmission exist in the different districts of Brazzaville, the incidence of pernicious attacks and the resulting mortality are remarkably unvarying whatever the level of transmission. In particular, similar results were observed for the sector Mfilou-Ngamaba-Ngangouoni, where malaria is holoendemic with over 100 infective bites per person per year and a parasite rate of 80.95% in schoolchildren, and the central sector of Poto-Poto-Ouenze-Moungali, where malaria is hypoendemic with less than one infective bite per person every three years and a parasite rate of less than 4% in schoolchildren. These results are discussed in terms of previous observations in urban and surrounding rural areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract: This study was conducted in Brazzaville, the capital of Congo, for the purpose of assessing the resistance to chloroquine and amodiaquine of Plasmodium falciparum. 64 in vivo tests using the WHO protocol--trial period 7 days after administration over 3 days of a dose of 25 mg/kg (N = 31 for chloroquine, 33 for amodiaquine)--were performed in schoolchildren aged 6 to 7 years, with parasite counts of at least 1,000 trophozoites/mm3. The respective percent resistance was found to be 38.7% (9.7% at the RII level, 29% at the RI level) for chloroquine and 21.2% (3% at the RII levels, 18.2% at the RI level) for amodiaquine. Based on these percentages and levels of resistance, and on changes in parasite counts, amodiaquine does not appear to be more efficacious. The emergence and rapid simultaneous spreading of resistance to these two drugs are discussed.

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