[Cervical adenitis caused by Mycobacterium kansasii: advantage of the INNO-LiPA V2 test in diagnosis of nontuberculous mycobacterial diseases]

Mycobacterium kansasii is one of the main mycobacterial species. Among the numerous subtypes, I and II subtypes are the only pathogens ones. A 56 years old woman has been under observation during her hospitalization for a cervical adenitis check-up; these one having been evolving for 2 months, without inflammatory syndrome. The failures of various antibiotics treatments lead one to withdraw some cervical ganglions whose histopathologic aspect reminds tuberculosis. These adenitis being isolated. An INH, rifampin, and ethambutol associated treatment is set up. After 2 weeks, the different cultures enable to isolated numerous photochromogenic colonies; a positive result is obtained with M. kansasii probe (Accuprobe). The identification is confirmed in 24 hours time with another molecular hybridation test (INNO-LiPA V2); the various specific probes of the different M. kansasii subtypes show it's not a I or II subtype (subtype IV by sequence analysis). This observation underlines the advantage and rapidity of the new diagnosis methods for nontuberculous mycobacterial diseases.

[Extensive bone marrow necrosis as presenting manifestation of sickle cell disease in Africa]

Extensive bone marrow necrosis is a rare but severe complication of sickle cell disease. A formerly healthy man was admitted for bone pain, fever, and jaundice with severe aregenerative anemia. Bone marrow aspiration and biopsy showed extensive bone marrow necrosis while hemoglobin electrophoresis demonstrated homozygotic sickle cell disease. Despite early onset of septic arthritis of the right shoulder, outcome after blood transfusion and nonspecific treatment was favorable. Six months later, hemoglobin level remained stable up to 97 g/L. This first African case report illustrates typical features and good prognosis of extensive bone marrow necrosis in sickle cell disease. Extensive bone marrow necrosis is a highly unusual presenting manifestation of sickle cell in an adult.

[Management of American cutaneous leishmaniasis. Outcome apropos of 326 cases treated with high-dose pentamidine isethionate]

The purpose of this retrospective analysis was to evaluate the outcome of pentamidine isethionate treatment (4 mg/kg of Pentamidine by the intramuscular route on Days 1 and 3) of cutaneous leishmaniasis in 326 cases that occurred during an outbreak among French military personnel in French Guyana from 1998 to 1999. A great difference was found between the 205 patients treated in French Guyana (series G) and 32 patients treated at the Laveran Military Hospital in Marseille, France (series L). Failure rate, i.e. 25% in series L versus 5% in series G, was significantly correlated with the delay to treatment which was much longer in series L. Extensive rhabdomyolysis was observed in all cases tested: this side-effect has not been reported. Based on these findings and a review of the literature on pentamidine isethionate, the authors recommend prompt treatment using lower doses. Other treatment alternatives for American cutaneous leishmaniasis are also presented including two of the latest developments in the field, i.e., oral treatment using miltefosine and topical treatment using agents such as paromomycine.

[Heyde syndrome]

OBJECTIVE

Heyde's syndrome associates aortic stenosis and digestive hemorrhage secondary to intestinal angiodysplasia.

OBSERVATION

A 61 year-old man presented with anemia due to martial deficiency and melena, the endoscopic examination of which was negative. The existence of a tight aortic stenosis, suspected on auscultation, suggested the diagnosis of Heyde's syndrome. Angiodysplasia is revealed during oriented enteroscopy. Following valve replacement, the need for transfusion disappeared, together with the anemia.

DISCUSSION

Although some epidemiological studies deny the existence of this syndrome, the observation of authentic cases of resolution of digestive bleeding following surgical replacement of an aortic valve, such as ours, is an argument in favor of the reality of Heyde's syndrome.

[Does emergency tropical medicine exist? The physician's point of view]

The existence of tropical medical emergencies is a recurrent issue that joins the debate over the definition of tropical medicine. Is it medicine practiced in warmer climates, medicine practiced with poor diagnostic and therapeutic facilities or medicine involving only tropical diseases? Presentation of a few case reports provides a better response to this question than a long speech. The first case involves a 57-year-old man presenting a complicated attack of Plasmodium falciparum malaria and severe respiratory distress. The second case involves a pregnant AIDS patient presenting multifocal miliary tuberculosis associated with renal abscess and bacteremia. The third case involves a 34-year-old soldier hospitalized for right hilar pneumonia in whom work-up demonstrated co-infection by HIV 1 and 2, thick drop tests revealed uncomplicated Plasmodium falciparum malaria, and cytobacterial examination of sputum samples identified Salmonella enteritidis and acid-alcohol resistant germs. The fourth case involves a 60-year man hospitalized for febrile collapse in whom work-up revealed amebic pericarditis. These four case reports illustrate the main features of tropical medical emergencies: adult patients (frequently young), associated deficiencies or immunocompromise (HIV infection/AIDS), severe or complicated tropical disease, severe advanced stage disease because of inability to pay for care, multiple pathology, poor diagnostic/therapeutic facilities, and high mortality.

[Diagnostic and treatment of hypereosinophilia upon return from the tropics: 102 patients]

Management of blood eosinophilia in travelers returning from the tropics is controversial. In this prospective study, 102 asymptomatic tropical travelers underwent investigation and treatment for hypereosinophilia. In contrast with direct tests for parasitic infection which were positive in only 15% of cases, immunological tests were suggestive of helminthic infection is 77%. The most common diagnoses were toxocarosis (49%), strongyloidiasis (30%), and filariasis (19%). Anti-parasite treatment was undertaken based on laboratory findings (12 cases) or on presumptive diagnosis using two-agent therapy (ivermectin and praziquantel) in 13 cases or three-agent therapy (ivermectin, praziquantel, flubendazole) in 77 cases. As a result of treatment, eosinophil count returned to normal in 61% of cases and decreased in 30%. These findings suggest that presumptive treatment of blood eosinophilia can be undertaken in tropical travelers using three anti-parasitic drugs: ivermectin (1 x 0.4 mg/kg), flubendazole (2 x 100 mg per day for 3 days), and praziquantel (1 x 40 mg). As a precaution before using ivermectin, tests should be performed to detect loiasis which can lead to adverse reactions.