[Cutaneous leishmaniasis due to Leishmania major involving the bone marrow in an AIDS patient in Burkina Faso]. / Leishmaniose cutanée à Leishmania major avec atteinte de la moelle osseuse chez un malade infecté par le VIH au Burkina Faso.

BACKGROUND: Leishmaniasis covers three well-individualized clinical variants, each due to individual species found in different geographic areas. Herein we report the first case of cutaneous leishmaniasis due to Leishmania major involving bone marrow in an AIDS patient in Burkina Faso. CASE REPORT: A 38-year-old HIV-positive man presented with generalized, copper-coloured, painless, infiltrated, itching, papulonodular lesions present over the previous 10 months. Skin biopsy confirmed the diagnosis of diffuse cutaneous leishmaniasis. The bone-marrow smear showed numerous leishmania. The culture was positive and L. major was identified. The patient was being treated with antiretroviral medication and a pentavalent antimonial compound. The disease progression consisted of attacks and remissions separated by an average of three weeks. DISCUSSION: L. major is the Leishmania species identified in Burkina Faso. It is responsible for typical cutaneous leishmaniasis but particular clinical forms have been described in immunodeficient patients, especially with diffuse cutaneous involvement. The spread of L. major infection to bone marrow could represent a public health problem in our country, where the HIV epidemic is still not under control, and particular vigilance is thus called for.

[Vulvar complications of urogenital schistosomiasis: study of 8 cases in Ségou, Mali]. / Complications vulvaires de la schistosomose uro-génitale: étude de 8 cas à Ségou, Mali.

We present a retrospective study of eight cases of vulvar bilharziasis who attended our institution for dermatological visit from 1998 to 2001. The mean age was 11 years old (range: 7 to 13). The clinical examination found wart like or ulcerated nodules, papules and/or diffuse infiltration. All the lesions were located on the left side of the vulvae (labium) and/or the groin. S. haematobium was the only causative agent identified in all specimens. The exclusive left side location of the lesions reported here has never been mentioned in the previous studies. The physiopathology of this finding is possibly linked to factors similar to those explaining the Cockett syndrome. Further examinations, including ultrasonography of the pelvis in larger series, are needed to learn more about the mechanism of this clinical entity.

[Liposomal amphotericin B treatment of cutaneous leishmaniasis contracted in Djibouti and resistant to meglumine antimoniate]. / Traitement par amphotéricine B liposomale d'une leishmaniose cutanée contractée à Djibouti et résistante à l'antimoniate de méglumine.

Pentavalent antimony (PA) compounds remain the main therapeutic agents of cutaneous leishmaniasis (CL). CL infection resistant to PA is difficult to cure, limited by severe side effects and requiring a long course treatment of parenteral administration of recommended second line drugs. We report a case of CL unresponsive to meglumine antimoniate contracted in Djibouti, successfully treated with a short course treatment of AmBisome. In this case the subject had a recurrent thick crusted erythematous lesion on his left elbow associated with spreading micropapula on arms and thorax. The diagnosis of CL was confirmed by direct examination and genomic amplification by PCR of skin samples, cultures were negative. A short course treatment of parenteral AmBisome (18 mg/kg) has lead to clinical cure with no side effects and no relapse. In our hospital, the high cost of medication was counterbalanced by easiest administration, reduction of hospitalization duration, absence of adverse events and a gain of comfort. For this patient, a short course treatment of AmBisome proved to be a suitable alternative to traditional drugs used in CL resistant to PA.

[Noma in HIV-infected adults]. / Noma chez des adultes infectés par le VIH.

INTRODUCTION: Noma is a necrotic stomatitis, frequent in undernourished children in tropical countries. Its occurrence in adults is extremely rare and has recently been described during AIDS. We report two new cases. OBSERVATIONS: The first patient, a 37 year-old farmer, consulted for a mutilating ulcer of the commissure of the right lip. The second patient, a 25 year-old woman, consulted for an ulcerating and necrotic tumefaction of the left cheek. Anamnesis reconstructed the chronology of the lesions and a cutaneous biopsy revealed non-specific ulcers. The status of health of both patients was poor and they both exhibited positive HIV serology. DISCUSSION: The diagnosis of noma is easy and based on clinical manifestations. The characteristic aspect is that of a mutilating ulcer of the face with conventional progression: tumefaction, followed by ulceration and finally elimination necrosis. This disease predominates in children. Its discovery in adults is a sign of poor prognosis because it may reveal an HIV infection at the AIDS stage. CONCLUSION: It is important to draw the attention of practitioners on the interest of performing HIV serology when confronted with an adult exhibiting a noma, and to evoke a noma when confronted with a tumefaction of the face rapidly progressing towards necrosis.

[Mycobacterium ulcerans infection: epidemiological, clinical and therapeutical aspects]. / Infection par Mycobacterium ulcerans: aspects épidémiologiques, cliniques et thérapeutiques.

Mycobacterium ulcerans causing Buruli ulcer is an environmental mycobacteria responsible for an infectious necrotizing panniculitis. The epidemiology of this disabling disease is strongly linked to the aquatic ecosystem. Occuring mainly in children, it is an emergent public health threat in many humid rural tropical areas. Human contamination probably follows a direct percutaneous route from humid environment, but some insects may play a role in transmission. The clinical features develop in three phases: pre-ulcer, ulcer with unstick margins, healing leading to functional sequelae. Treatment relies on antibiotics in order to sterilize the infectious focus, together with the surgical repair of lost skin and joint deformities, as well as early physiotherapy. Despite uncertainties of in vivo efficacy of antibiotics, it seems logical to administer chemotherapy with both Rifampicin and Aminoglycosid or Fluroquinolon and Aminoglycosid. Surgical treatment depends on the size of the ulcer, as well as available techniques and skills on the field. Wide excision and graft are often recommended, however limited excision followed by small islet grafts may be successful.

Human cutaneous leishmaniasis caused by Leishmania naiffi is wide-spread in South America.

Four human cases of localized cutaneous leishmaniasis caused by Leishmania naiffi are reported. Two of the cases were infected in French Guiana, one in French Guiana or Martinique, and the other in Ecuador or Peru. The geographical distribution of L. naiffi is clearly larger than that initially reported. Three zymodemes were represented by the four isolates, confirming that there is intraspecific polymorphism in L. naiffi.

[Cutaneous-splanchnic neurofibromatosis]. / Neurofibromatose segmentaire cutanéo-splanchnique.

BACKGROUND: Segmental neurofibromatosis (NF V) is ten times less frequent than Recklinghausen disease. Would the risk of visceral involvement in this uncommon form of neurofibromatosis warrant systematic imaging procedures? CASE REPORT: A 31-year-old man consulted for a voluminous plexiform neurofibroma in the left lumbar area. More ventrally, on the left side, there was also a café au lait spot. There were no Lisch nodules. The chest and abdominopelvic computed tomography and magnetic resonance imaging showed intramuscular tumoral extension, two neurofibromas in the 9th intercostal space and a voluminous 5-cm tumor situated in the left adrenal area. After resection pathology examination of the surgical specimen confirmed the diagnosis of ganglioneuroma. DISCUSSION: In this patient, all the neurofibromas and the café of lait spot developed in the territories of the left T10 and adjacent spinal roots. This was also true for the ganglioneuroma which developed on the deep sympathetic ramus to the adrenal gland which originates essentially from roots T8 to T11. This would place this case in the second subgroup of NF V in Roth's classification. Only six other cases have been reported in the literature. Such deep localizations are very likely to be underestimated, raising the problem of their detection and the correct protocol to follow asymptomatic forms, especially to detect disease progression to malignant degeneration which has a poor prognosis. Patients with a NF V should receive genetic counselling with a search for a family history, other signs of neurofibromatosis and Lisch nodules. In young patients, the risk of deep asymptomatic spread underlines the importance of regional computed tomographic or magnetic resonance explorations.

[Cutaneous vasculitis disclosing cat-scratch disease]. / Vasculite cutanée révélatrice d'une maladie des griffes du chat.

BACKGROUND: We describe a case of cat-scratch disease ingnaugurated by vascular purpura and discuss the role of the causal agent, Bartonella henselae. CASE REPORT: A 49-year-old woman presented vascular purpura without fever. Skin biopsy demonstrated leukocytoclasic vasculitis. She owned a cat and a had a scratch scar on the back of her left hand. A few days later, two inflammatory epitrochlear lymph nodes suppurated. Catscratch disease was confirmed by serology and PRC analysis of pus aspirated from the nodes. The purpura resolved spontaneously in three weeks. Left axillary adenopathy developed and suppurated. In spite of four antibiotics, the nodes subsided only ten months later, leaving scars. DISCUSSION: Two arguments favor Bartonella henselae as the causal agent in this cutaneous vasculitis. The simultaneous onset of the two diseases and the absence of another cause of vasculitis. This patient did not have Bartonella henselae endocarditis which could have explained this vasculitis. Only one case of hypersensitivity vasculitis has been described during cat-scratch disease. The exceptional feature of this association is perhaps the result of the unawareness of moderate or asymptomatic cat-scratch disease. Bartonella henselae was possibility caused hypersensitivity vasculitis.

[Sun and skin and eye protection]. / Soleil et photoprotection cutanée et oculaire.

Overexposure to sunlight during travel can have harmful short- and long-term effects on the eyes and skin. Cutaneous effects include premature aging, actinic keratosis, and cancer. The eye is highly sensitive to invisible radiation, especially ultraviolet rays which can damage the crystalline lens and cornea. Retinal lesions usually involve the macula on which rays of the visible spectrum come to focus. Various natural and artificial methods can be used for sun protection. Limiting sun exposure is advisable for all. Sunscreens should be used to attenuate the effects of sun and not to prolong exposure. Fair-skinned subjects, especially those with numerous nevi, must use total sunscreen preparations starting from birth. Eye protection is necessary for everyone but especially young children, aphakic subjects, and patients presenting congenital or acquired retinal lesions. Dark lenses with a category 2 protection rating according to European Economic Community standards are recommended in tropical areas.

[Incontinentia pigmenti]. / Incontinentia pigmenti.

Incontinentia pigmenti (IP) is a hereditary syndrome characterized by specific skin lesions occurring mostly during the neonatal period (96% of the cases before 6 weeks of age). These skin lesions have four steps of evolution: inflammatory or erythemato-bullous stage (very often associated with peripheral blood hyper-eosinophilia), proliferative or verruco-lichenoid stage, pigmentary or terminal stage characterized by "fountain" or "firework" features (with a picture of pigmentary incontinence at histological examination), sometimes there is a fourth stage referred to as "involutive". Ocular and neurological involvement is the main determinant in the prognosis. Eye lesions include corneal flecks, cataracts, uveitis or optical atrophy with retrolental fribroplasia. The neurological involvement includes pyramidal syndrome, cerebral ataxia, microcephalia, and mental retardation. The disease has mainly an X-linked dominant transmission and is usually lethal for males. Rare cases are observed in boys, some being associated with Klinefelter syndrome. Research is ongoing to identify the IP gene on the X chromosome. In the family form of IP, the gene has been located on chromosome Xq28, which allows prenatal diagnosis using trophoblast biopsy.

[Conjugal mycosis fungoides]. / Mycosis fongoïde conjugal.

INTRODUCTION: The pathophysiology of mycosis fungoides remains uncertain but HTLV I or a similar virus could be involved. We observed a couple who developed mycosis fungoides suggesting the infectious hypothesis might indeed be valid. CASE REPORT: A 70-year-old man who had often travelled in foreign countries developed parapsoriasis en plaques, lymphomatoid papulosis and mycosis fungoides successively over a thirty year period. Several years after the first manifestation of mycosis fungoides, his wife also developed a single plaque of mycosis fungoides. The diagnosis was confirmed on pathology slides and immunohistochemistry tests as well as on the basis of T-receptor gene rearrangement in both patients. Search for HTLV I was negative using serology tests and PCR on circulating lymphocytes. COMMENTS: The epidemiological situation in our observation (several trips in foreign countries and the delayed development of mycosis fungoides in the wife) favours the hypothesis of an infectious mechanism. Search for HTLV I was unsuccessful with classical virology methods. Certain recent work suggests a virus similar but different from the HTLV I virus could be involved in the pathogenesis of mycosis fungoides.

[Mycobacterium ulcerans cutaneous infections: Buruli ulcers]. / Les infections cutanées à Mycobacterium ulcerans: ulcères de Buruli.

Mycobacterium ulcerans skin infection or Buruli ulcers are common in children in many rural tropical areas. The usual clinical appearance is a deep, rapidly developing chronic ulcer associated with necrosis of subcutaneous fat. Patients are usually seen at an advanced stage. Bacteriologic identification is not always possible because the pathogen, Mycobacterium ulcerans, is an atypical mycobacteria that is difficult to isolate and grows slowly in culture. Medium although of little assistance in tropical regions, the histological features are highly characteristic and can allow diagnosis in areas in which the disease is rare and unsuspected. The pathogenic effects of Mycobacterium ulcerans are due to the production of a necrotizing exotoxin with an immunosuppressive action. Treatment using antituberculosis and antileprosy drugs has been disappointing. Surgery is usually required and causes extensive sequels in many cases, the best technique being an excision/graft procedure. Many epidemiologic characteristics of Buruli ulcers which are andemic in regions with and aquatic ecosystem are still unclear including the mode of infection, transmission and reservoir. Recent outbreaks, particularly in west Africa, may be related to changes in the natural environment.

[Dermatological aspects of AIDS in western Africa. Apropos of 140 cases]. / Aspects dermatologiques du SIDA en Afrique de l'Ouest. A propos de 140 observations.

This clinical survey, carried out during a 3 years period in the Dermatological Department of Bouake Hospital (Ivory Coast) analyses the skin and mucous membranes troubles caused by AIDS among adults. It is the first of that kind in Western Africa. 140 patients were concerned, showing carious dermatological troubles, 25 of them were counted. Few tropical skin diseases have their clinical picture altered by immunodeficiency. However, the Buruli ulcer may be described, which has in this condition a particularly development. We have underlined the particularities of some ubiquitous diseases, either because they appear on black skin (seborrheic dermatitis, Kaposi's sarcoma, prurigo, woolly hair syndrome, ichtyosis) or because they were neglected, or because they take an extensive form (chronic herpes, profuse condyloma). At the end of the survey, we are proposing a classification of the dermatological troubles, according to their features which might suggest AIDS. On this account, erythroderma, scattered forms of Mycobacterium ulcerans infection, and noma, find a place among the troubles suggesting adult AIDS in sub-saharian Africa.

[Therapeutic approach in Mycobacterium ulcerans infections]. / Approche thérapeutique des infections à Mycobacterium ulcerans.

In Côte d'Ivoire, 88 patients of a series of 124 cases with Buruli ulcer have been able to be treated and supervised. All of them have received local cares and various antibiotics, and 23 have been treated by islet skin graft. Among the numerous antibiotics used, only Streptomycin seems to be accompanied by an acceptable failure rate. The islet-graft presents the advantage of the technical simplicity, of the good tolerance face the infection and of a good successful rate, which permits to shorten the evolution of this disabling affection. It seems to be the best adapted procedure taking into account available medical means in most of tropical countries.