[Malaria in France: Mainland and territories]. / Le paludisme en France : métropole et outre-mer.

Malaria, which was eliminated first from Metropolitan France (mainland and Corsica), then in the French West Indies and the Reunion Island during the 20(th) century, remains endemic in two French territories: French Guiana and the Indian Ocean Mayotte island. Despite differences in the dominating plasmodial species and epidemiological patterns, these two territories have achieved marked quantitative improvements (in the reported number of cases and severe cases) thanks to efforts undertaken over the past decade. The situation, however, remains a concern from a qualitative standpoint with the emergence of resistance to antimalarial drugs and logistical and administrative issues which hinder access to treatment. Although malaria was eradicated in Metropolitan France half a century ago, competent vectors remain present in part or all of these territories and can give rise to limited outbreaks.

[Delayed home screening of leprosy; experience of the screening team in Mayotte]. / Dépistage actif intra-domiciliaire différé de la lèpre : expérience de l'equipe de dépistage sur l'île de mayotte.

Mayotte, a French territory island located in the Indian Ocean near Madagascar, remains a leprosy endemic area. In 2006, leprosy was still a problem of public health with a prevalence of 3.94 per 10,000 inhabitants. There is practically no formal consensus about active screening (AS) on an index case. According to teams and their related staffs, the AS concerns intradomicilary contact individuals (IDC) restrictively or extended to extra-domicilary social and professional contacts. Date, number and frequency of these investigations depend on each team. Between 1997 and 2003, there was no AS planned in Mayotte, but all index case individuals have been encouraged to propose a screening to their relatives through specific campaign information and education. This procedure allowed to identify 10 new cases of leprosy infection among the IDC. Concurrently 12 IDC cases have been diagnosed by health workers. In 2003, we performed a postponed AS within IDC of every Mahorais case registered by passive detection between 1997 and 2003. 325 IDC have been examined and 15 new cases have been detected. All these new cases showed early leprosy features: 14 were paucibacillary forms, among which 9 cases with an isolated cutaneous lesion (7 had an infracentimetric lesion). One patient had multibacillary disease although he presented with an isolated skin lesion which developed within the 6 previous months. None presented with disability. Our results suggest that passive detection even reinforced by repeated individual information and education about leprosy is neither appropriate nor effective. The postponed AS seems to favour an increased self-esteem and a better involvement of the index patient in sanitary education together with the screening of his relatives. In the Mayotte background, the postponed AS has not been associated with a significant delay for diagnosis. Although WHO recommandations are to abandon immediate AS of IDC and to promote self-screening for leprosy our study suggests an intermediate position, namely delayed active screening for an enhanced effective detection.

[Combination of three cutaneous diseases in Mayotte]. / Une triple atteinte dermatologique a Mayotte.

This report describes the case of a young woman from Mayotte (Comoros Islands) who presented a combination of three cutaneous diseases, i.e. pityriasis versicolor, scabies, and multibacillary leprosy. Symptoms of leprosy were concealed by those of the other two diseases. After multidrug therapy for leprosy, the patient developed erythema nodosum leprosum that was successfully treated using pentoxifylline. Combination of cutaneous diseases can alter usual presentations and lead to misdiagnosis. It is important to take into account possible disease combination to establish proper diagnosis and prescribe effective treatment.

[Pentoxifylline in the treatment of erythema nodosum leprosum: results of an open study]. / Efficacité de la pentoxifylline dans le traitement de l'érythème noueux lépreux: résultats d'une étude ouverte.

Erythema nodosum leprosum (ENL) is a well-known immunological serious complication affecting lepromatous multibacillary leprosy patients. For a long time, ENL has been regarded as an immune complex-mediated disease or Arthus phenomenon. Recently, it has been reported that ENL was associated with high serum tumor necrosis factor-alpha (TNFa) levels, suggesting that this cytokine could also play a central role in the manifestations of ENL. Thalidomide (TH) and systemic steroids (S), both TNFa production inhibitors, are the two current effective drugs for the management of ENL. However, TH is rarely available in leprosy endemic countries, and its teratogenicity and neurotoxicity strongly limit its use. Moreover, the morbidity of S and the frequent steroid-dependence of ENL also create real therapeutic problems. Recently, the efficacy of pentoxifylline (PTX), which also inhibits in vitro and in vivo production of TNFa, has been suggested for ENL treatment. We report our experience on its use for the treatment of 15 leprosy patients suffering from a first ENL. attack. (11 cases), a chronic steroid-dependent ENL (3 cases) or chronic steroid- and thalidomide-dependent ENL (1 case). PTX has been given at 800 mg t.i.d, (2 cases) or 400 mg t.i.d. (13 cases) doses. The patients received PTX at the initiating dosage until complete clinical cure. At the end of ENL attacks, PTX was either abruptly stopped or tapered down over the next 4 months. In ten of 11 patients who developed ENL for the first time, the systemic symptoms and neuritic pains disappeared within one week; at three weeks, half of the patients were cured and the other half had striking clinical improvement; complete cure was obtained within 7 to 35 days (mean: 27 days). A relapse occurred within 2-3 months in the 5 patients, in which PTX was abruptly stopped. In contrast, no relapse occurred in the patients who benefited from decreasing doses of PTX. Recurrent ENL episodes also responded well to PTX. The 3 patients who had chronic steroid-dependent ENL failed to show any improvement after 3 to 6 weeks of PTX. In contrast, steroid therapy could be stopped in the steroid- and thalidomide-dependent patient. Our results confirm the action of PTX if it is slowly tapered down (4 months seem sufficient) and not abruptly to avoid relapses. As it is safe use, PTX could constitute the first line of ENL attack treatment.

[Hansen's disease in the territorial collective of Mayotte (Indian Ocean); retrospective study from 1990-1998]. / La maladie de Hansen dans la collectivité territoriale de Mayotte (Océan Indien): etude rétrospective de 1990 à 1998.

Mayotte French island of the Comoro Islands in the Indian Ocean, is located in a leprosy endemic area including the other islands of the archipelago and Madagascar island. As the last Hansen's disease epidemiological study in the island have been reported in 1982, we achieved a new valuation by a retrospective study on the 1990-1998 period. Our investigation showed that the disease was still endemic with a prevalence of 32/100,000 population in 1998 and an high annual new case detection rate (14 to 31/100,000 population). The profile of the newly detected cases was the same that reported at the world level (prédominance of males, less than 45-years old adults and paucibacillary forms) with two exceptions: the high percentage of children below 15 years of age (28.2%) and of family cases (25.3%). Moreover, 12.6% of the new cases exhibited disabilities grade 2 at the time of the diagnosis. These features emphasize the need for an enhanced leprosy control in this island which has a well-developed medical assistance.