[African histoplasmosis due to Histoplasma capsulatum var. duboisii: relationship with AIDS in recent Congolese cases]. / Histoplasmose africaine à Histoplasma capsulatum var. duboisii: liens avec le SIDA à propos de cas congolais récents.

Six new cases are described for African histoplasmosis, Histoplasma capsulatum var. duboisii, from Congo. The first was an HIV sero-negative child who has been monitored for the last three years. While under treatment with ketoconazole, amphotericin B, and finally itraconazole, the development of the infection was accompanied by purulent lesions, mainly cutaneous, but also superficial and deep lymphadenopathies. As a last option, itraconazole gave very satisfactory results both during the acute phase and during long-term treatment. However, eight months after treatment had ceased, there was a relapse and the long-term treatment had to be restarted. The other cases concerned HIV sero-positive patients with disseminated infections that had all been mistaken for tuberculosis. After diagnosis of the infection in two cases, the following two years of treatment could not prevent death. A fourth case, diagnosed in December 1994, is currently undergoing treatment. The fifth subject was lost after diagnosis during follow-up, but inquires made after the discovery of the patient's death strongly indicated acquired immunodeficiency as the cause. The last of these six cases, determined as HIV sero-negative, showed large bony lesions of the spinal column associated with a sore on the thorax. Thus, in a short period of time, three or four cases of African histoplasmosis occurred which were associated with HIV infection. Only seven identical observations have previously been reported in the literature. Therefore, we believe that this mycosis should now be included in the criteria for the diagnosis and definition of AIDS in the tropics.

PIP: In Congo, the parasitology-mycology laboratory in Brazzaville diagnosed six new cases of African histoplasmosis (Histoplasma capsulatum var. duboisii) in a 3-year period. Three cases had AIDS. Another case was strongly suspected of being HIV seropositive. The first case was a 4-year-old child from Brazzaville who had been monitored for more than 3 years. Health providers treated him first with ketoconazole, then amphotericin B, and finally itraconazole. The child's African histoplasmosis was characterized by purulent lesions, particularly cutaneous, but also superficial and deep lymphadenopathies. Itraconazole adequately treated the child's condition both during the acute phase and during long-term treatment. Eight months after the end of itraconazole treatment, the child suffered a relapse, resulting in re-administration of longterm treatment. The remaining African histoplasmosis cases had disseminated infections, which were initially suspected to be tuberculosis. After diagnosis, two cases died despite two years of treatment. The fourth case was diagnosed in December 1994 and is still receiving treatment. After diagnosis, the fifth case was lost to follow-up. Health providers later learned that AIDS was probably responsible for the patient's death. The sixth case did not have HIV infection. The 32-year-old man, a nurse in the central army hospital in Brazzaville, had large bony lesions of the spinal column associated with a sore on the thorax. The literature shows only seven other African histoplasmosis cases infected with HIV. These HIV-infected African histoplasmosis cases along with the seven cases in the literature suggest that African histoplasmosis should be included in the criteria for the diagnosis and definition of AIDS in tropical countries.

[Plasmodium falciparum index and level of parasitemia: diagnostic and prognostic value in the Congo]. / Indice plasmodique et parasitemie à Plasmodium falciparum: valeur diagnostique et pronostique au Congo.

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.

[Drug sensitivity of Plasmodium falciparum in vivo and in vitro in Brazzaville (Congo)]. / Chimiosensibilité in vivo et in vitro de Plasmodium falciparum à Brazzaville (Congo).

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.

[Malaria and febrile pathology of expatriates in Brazzaville in 1993]. / Le paludisme et la pathologie fébrile des expatriés à Brazzaville en 1993.

Between January 1 and December 31, 1993, malaria was found in 22.6% of unexplained fever cases among expatriates in Brazzaville, i.e. 0.5% of all consulting physicians at the Medico-Social Centre of the Coopération française. There are three possible explanations for the small proportion of paludism infection among expatriates: the low density of anopheles in the city centre, living conditions that restrict possible man-vector contacts and use of chemoprophylaxis. Considering the risks of self-treatment which are not insignificant, the authors on the importance of taking into account these facts when treating cases of fever among European residents in Brazzaville.

[Plasmodium prevalence and parasitic burden in blood donors of Brazzaville, Congo]. / Indices plasmodiques et charges parasitaires chez les donneurs de sang à Brazzaville, Congo.

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.

[Therapeutic trial with ivermectin in loiasis with medium and high microfilaremia]. / Essai thérapeutique de l'ivermectine au cours de la loase à moyenne et forte microfilarémie.

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.

[Comparative efficacy of chloroquine and amodiaquine (25 and 35 mg/kg) in school children infected with P. falciparum (Brazzaville, March 1990)]. / Efficacité comparée de la chloroquine et de l'amodiaquine (25 et 35 mg/kg) chez des écoliers porteurs de P. falciparum (Brazzaville, Mars 1990).

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.

[Plasmodium falciparum drug resistance in the Congo. Evaluation of surveys carried out from 1985 to 1989]. / La résistance médicamenteuse de Plasmodium falciparum au Congo. Bilan des enquêtes réalisées de 1985 à 1989.

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.

[Opportunistic parasitic diseases and mycoses in AIDS. Their frequencies in Brazzaville (Congo)]. / Parasitoses et mycoses opportunistes au cours du SIDA. Leurs fréquences à Brazzaville (Congo).

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.

PIP: Studies conducted with locally available means at the University Hospital in Brazzaville have provided data on opportunistic parasitic and mycotic disease in AIDS patients in the Congo. The diagnosis of AIDS was based on the World Health Organization clinical definition for Africa and on positive ELISA tests. Patients were prospectively studied in 1986-87. 12 cases of meningitic cryptococcosis were found in 139 patients studied, for a rate of almost 9% of AIDS cases. Prior to the AIDS epidemic only 2 cases were published in the Congo. 35.6% of 146 cases studied showed oral pharyngeal candidiasis on clinical examination. The frequency of esophageal and bronchopulmonary candidiasis could not be estimated with the means available. 118 AIDS patients had intestinal parasites, of whom 2/3 had chronic diarrhea. 9.3% were caused by Isospora belli and 4.2% by Cryptosporidiosis. Other intestinal flora were apparently affected by routinely administered antiparasite treatments. An estimate of 20% for cerebral toxoplasmosis was obtained by comparing serum toxoplasmosis antibody and cerebrospinal fluid rates for 75 patients. The rate of pneumocystis carinii pneumonia appears on indirect evidence to be under 10%. No cases of disseminated histoplasmosis or malignant strongyloidiasis were observed. The biggest differences between the patterns of opportunistic infection in industrialized countries and especially the US and in the Congo appear to be the lesser frequency in the Congo of pneumocystosis and the greater frequency of Isosporosis and cerebral toxoplasmosis.

[Drug resistance of Plasmodium falciparum in the Congo. 2. Comparative study in vivo of chloroquine and amodiaquine in Brazzaville schoolchildren (November 1986)]. / Chimio-résistance de Plasmodium falciparum au Congo. 2. Etude comparative in vivo de la chloroquine et de l'amodiaquine chez des écoliers brazzavillois (novembre 1986).

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.