Hepatitis B and hepatitis D virus infections in the Central African Republic, twenty-five years after a fulminant hepatitis outbreak, indicate continuing spread in asymptomatic young adults

Hepatitis delta virus (HDV) increases morbidity in Hepatitis B virus (HBV)-infected patients. In the mid-eighties, an outbreak of HDV fulminant hepatitis (FH) in the Central African Republic (CAR) killed 88% of patients hospitalized in Bangui. We evaluated infections with HBV and HDV among students and pregnant women, 25 years after the fulminant hepatitis (FH) outbreak to determine (i) the prevalence of HBV and HDV infection in this population, (ii) the clinical risk factors for HBV and/or HDV infections, and (iii) to characterize and compare the strains from the FH outbreak in the 1980s to the 2010 HBV–HDV strains. We performed a cross sectional study with historical comparison on FH-stored samples (n = 179) from 159 patients and dried blood-spots from volunteer students and pregnant women groups (n = 2172). We analyzed risk factors potentially associated with HBV and HDV. Previous HBV infection (presence of anti-HBc) occurred in 345/1290 students (26.7%) and 186/870 pregnant women (21.4%)(p = 0.005), including 110 students (8.8%) and 71 pregnant women (8.2%), who were also HBsAg-positive (p = 0.824). HDV infection occurred more frequently in pregnant women (n = 13; 18.8%) than students (n = 6; 5.4%) (p = 0.010). Infection in childhood was probably the main HBV risk factor. The risk factors for HDV infection were age (p = 0.040), transfusion (p = 0.039), and a tendency for tattooing (p = 0.055) and absence of condom use (p = 0.049). HBV-E and HDV-1 were highly prevalent during both the FH outbreak and the 2010 screening project. For historical samples, due to storage conditions and despite several attempts, we could only obtain partial HDV amplification representing 25% of the full-length genome. The HDV-1 mid-eighties FH-strains did not form a specific clade and were affiliated to two different HDV-1 African subgenotypes, one of which also includes the 2010 HDV-1 strains. In the Central African Republic, these findings indicate a high prevalence of previous and current HBV-E and HDV-1 infections both in the mid-eighties fulminant hepatitis outbreak and among asymptomatic young adults in 2010, and reinforce the need for universal HBV vaccination and the prevention of HDV transmission among HBsAg-positive patients through blood or sexual routes.

In the Central African Republic (CAR), due to 20 years of conflict, the health system has been disorganized. This could contribute to maintenance of high transmission levels of Hepatitis B Virus (HBV) and its satellite Hepatitis Delta Virus (HDV). This work studies the evolution of both infections 25 years after a fulminant hepatitis (FH) outbreak occurring in the mid-1980s associated with HDV superinfection. In young asymptomatic adults, the results show that both HBV and HDV were still actively circulating in CAR in 2010. Indeed, more than one third of HBV-infected individuals were chronic HBV carriers. Furthermore, HDV infection could be spreading among 10% of them through blood and sexual transmission. The past FH outbreak and contemporary infections were both associated with heterogeneous HDV-1 strains, combined with HBV-E. Vaccination against HBV was uncommon among pregnant women and students, even among medical students. The study constitutes warning signals to help CAR health-care reconstruction and underlines the importance of HBV vaccination. The high level of HBV infection creates a background for HDV superinfection. Neonatal HBV vaccination is needed, together with vaccination of unprotected populations. Awareness of health authorities as well as the general public would help reduce HBV and HDV infections.

Neurocysticercosis: a major aetiological factor of late-onset epilepsy in Madagascar

To assess the impact of cysticercosis on public health in Madagascar, we compared patients > 15 years with late-onset epilepsy to non-epileptic controls in a matched case-control study. The association between epilepsy and cysticercosis was studied by enzyme-linked immunoelectrotransfer blot (EITB) assay for antibodies specific to Taenia solium. The EITB assay was performed on 104 pairs of sera specimens and on 95 pairs of cerebrospinal fluid (CSF) specimens. Depending on whether we consider the results obtained from sera or from CSF, we obtain for the population attributable risk percent of cysticercosis in late-onset epilepsy two slightly different estimates: 22.3% and 17.6%. Therefore cysticercosis is a major aetiological factor of late-onset epilepsy in Madagascar. In the control group, the frequency of positive results, especially in CSF specimens (7.4%), confirms the existence of asymptomatic cases of neurocysticercosis.

Serial transmission of spongiocytic hepatitis to woodchucks (possible association with a specific delta strain)

BACKGROUND/AIMS

Outbreaks of severe hepatitis have been reported from Africa and South America. Description of the cases has shown the histological hallmark to be the presence of ballooning hepatocytes with fat drops surrounding the nucleus (spongiocytes or morula cells).

METHODS

Experimental reproduction of this syndrome for the verification of a possible role of a specific HDV strain was performed by the inoculation of serum and liver extracts from African patients (Bangui-Central African Republic), who died with this syndrome, into American woodchuck carriers of WHV (WC 231,144), the results of which were then compared with animals inoculated with a reference wild HDV strain (WC 300,173,154), and those which received material from a European fulminant HDV case (WC 88,93).

RESULTS

Following the initial inoculation, the animals receiving African inocula had a delayed anti-HDV seroconversion, high mortality and showed the presence of spongiocytes, while the other animals had a classical evolution of HDV superinfection in woodchucks. Furthermore, the African inocula caused less inhibition of WHV replication, as well as a predominant cytoplasmic expression of HDAg, in contrast to the animals which received the other inocula. The second passage experiments gave similar results.

CONCLUSIONS

We conclude that this peculiar form of HDV fulminant hepatitis can be experimentally reproduced and might be specifically related to a more pathogenic strain.

Discovery of a novel point mutation changing the HDAg expression of a hepatitis delta virus isolate from Central African Republic

None of the mutations so far discovered in several hepatitis delta virus (HDV) isolates appears to determine important changes in HDV specific protein (HDAg) expression, except for a putative mutation at nucleotide 1012 converting an amber stop codon (TAG) to a codon for tryptophan (TGG). Here we present the characterization of an HDV obtained from the liver of a woodchuck inoculated with sera from fulminant HDV patients in Central African Republic (CAR). By restriction enzyme analysis and sequencing of HDAg-coding region cDNA clones, we found that this HDV isolate bears a novel mutation (T to A) at nucleotide 1013 which converts the amber stop codon (TAG) to a codon for lysine (AAG). Comparison of these nucleotide sequences with those available from American, Japanese, Taiwanese, French, Italian and Nauru isolates showed a variability of 1.7 to 21.5% and 1.9 to 28.7% at the nucleic acid and amino acid levels, respectively. The HDAg-encoding sequence of the CAR isolate is closely related to that of the Italian HDV isolate. The in vitro expression of this HDV isolate resulted in a unique HDAg species (28K) which was identical with that characterized in vivo.

Fulminant hepatitis with microvesicular steatosis (a histologic comparison of cases occurring in Brazil--Labrea hepatitis--and in central Africa--Bangui hepatitis)

A similar histopathologic picture of fatal hepatitis associated with widespread acute fatty changes in hepatocytes and single-cell necrosis was seen in epidemic cases occurring in two distinct equatorial areas having high prevalences of HBV and HDV infections. The cases were previously considered to be two different entities; Labrea hepatitis in Brazil, and Bangui hepatitis in the Central African Republic. However, the histopathologic findings suggest that they are pathogenetically and etiologically related to HBV and HDV infections, probably modified by some as yet unknown factor(s) present in equatorial forest zones.

[Idiopathic chylopericardium. Apropos of a new case. Review of the literature]

The authors report a new case of primary chylopericardium in an asymptomatic 26 year old male. In view of the negativity of the complementary etiological investigations a surgical subxiphoid window was performed and this confirmed the diagnosis. After failure of isolated evacuatory drainage, the patient was cured by pericardectomy. The anatomo-clinical, biochemical and diagnostic features of this condition are described based on a review of the other cases of primary chylopericardium reported in the literature. Surgical pericardectomy seems to be the only effective long term treatment.

[The treatment of imported Plasmodium falciparum malaria with halofantrine. Apropos of 59 case reports (corrected and republished article orginally printed in Med Trop (Mars) 1990 Jan-Mar;50(1):113-7)]

59 cases of Plasmodium falciparum malaria fever occurring in non-immune Caucasian subjects having got a correct chemoprophylaxis by chloroquine were treated by halofantrine (HALFAN). They were given 1500 mg divided in 3 doses of 500 mg every 6 hours from D1 to D8. All them were back from a malarial highly endemic zone with chloroquine resistance. Analysis of the main biological and clinical efficiency parameters displayed very satisfactory results: disappearances of fever (mean 22 H) and parasitemia (mean 36 H) are short. After two months of monitoring, no malaria recrudescence was noted. With an efficacy of 10 p.c. associated to a noticeable clinical and biological tolerance Halofantrine is a first-class treatment of chloroquine resistant malaria fever.

[malnutrition and human immunodeficiency virus (HIV) in Bagui (Central Africa). Study and 2-year follow-up of a cohort of 175 malnourished children and 101 mothers]

In Bangui (Central African Republic) a survey started in 1986 for 2 years. 175 undernourished children and the mothers were surveyed. In this target group, a high seroprevalence to HIV was determined (12 p.c. of the undernourished children and 25 p.c. for the mothers.) It was also possible to put into light the predictive signs of HIV1 infection in the undernourished people, to follow them up clinically and to determine the sociocultural profile of the undernourished child's mother. In fact, unmarried woman, incidentally prostitute. This is a group at risk that has to be privileged within the control of HIV infection.

[Pseudotumoral naso-sinusal aspergillosis stabilized by itraconazole]

A 25 year-old non-immunocompromised African man showed a sino-orbital aspergillosis involving mostly the sphenoïd sinus, presenting as a growing tumour. Histopathologic study of the specimen biopsy revealed granulomata with intracellular septum branching hyphae. The electrosyneresis demonstrated serum antibodies to Aspergillus flavus. Initial treatment consisted of only surgical debridement in association of standard antifungal therapy (miconazole). After 14 months, a recurrence of the aspergillosis was stopped by the administration of itraconazole, an oral triazole antifungal. This treatment was performed during a period of 12 months and marked clinical improvement was observed. No adverse effects were noted. Itraconazole may be useful in therapy for extra-pulmonary aspergillosis when standard therapy has failed.

[Clinical aspects of human immunodeficiency virus (HIV) infection in Central Africa: 6 years' experience at a hospital in an endemic area]

In Bangui (Central African Republic), where seroprevalence of HIV is 11% in the adult population, AIDS presents some clinical aspects different from the ones known in the west; the clinical experience reported in this paper is based on 504 cases infested by HIV group 4; diagnosis is very often made thanks to the clinical score recommended by World Health Organization (predictive value of 66%). Predominant manifestations (14%) are: asthenia (100%), emaciation (100%), fever (88%), diarrhea (42%), pulmonary attacks (37%), adenopathies, cutaneous manifestations (35%), neurological manifestations (14%). Some affections call for HIV infection with a significant predictive value: herpes zoster (96%), Kaposi's symptom (68%), mouth candidiasis (71%), pulmonary tuberculosis (56%: as far as some others are concerned, HIV has to be suspected: infant denutrition, acute infections, neurological disorders. Development is severe: 45% of the patients examined died in the 4 months coming after diagnosis. Epidemiology speaking, they are young patients (mean age 27.4 years), neither addicted nor "doped", heterosexual with multiple partners, with female prostitution occasionally; sex ratio is 0.95. Recognized transmission by transfusion is the exception (2/504). The transmission due to vaccination or injection is rare and difficult to evaluate. Only radical alteration of sexual behaviour will modify HIV dissemination.

Clinical and histopathological aspects of Kaposi's sarcoma in Africa: relationship with HIV serology

From 1983 to 1987, 45 Kaposi's sarcomas (KS) were diagnosed at the University Hospital in Bangui; 37 cases were easily classified as either endemic or AIDS-related KS on clinical grounds and HIV serology. Moreover, probably due to the stage at which patients consulted and lesions were sampled, noticeable histopathological differences were observed between the two clinical presentations. But for 8/45 which we classified as "borderline KS", strong discrepancies occurred between clinical aspects, patient evolution, HIV serology and histopathology. In two cases, HIV-positive patients had typical endemic non-evolutive KS and have survived 15 and 36 months.

[Tuberculosis in infection with the human immunodeficiency virus (HIV) in Bangui (Central African Republic)]

Tuberculosis in Central African Republic is an endemic disease. Its prevalence is 3.87 p. 1.000. The relationship between tuberculosis and HIV infection has been observed on 39 out of 72 cases in the National Hospital of Bangui from September 1986 to June 1987. Tuberculosis is often acute and a severe disease with cervical adenopathies. 13 out of 39 patients died. In spite of cutaneous anergy, some cases (7/39) recovered with antituberculosis therapy.

[Mycoses in AIDS in the Central African Republic]

Among the 155 cases of A.I.D.S. observed by the authors in Bangui (C.A.R.) from April 1985 to February 1986, 49 patients (31.6%) were carriers of mycosis. 42 candidosis, 5 cryptococcosis, 2 aspergillosis were found; the authors describe the clinical aspects, the localizations and the methods of diagnosis.

[Kaposi's sarcoma in Burundi and the Central African Republic in the framework of acquired immunodeficiency syndrome (AIDS)]

The authors carried out in 1985 a survey in two French speaking States in Central Africa, namely Burundi and Central African Republic (C.A.R.), in order to study the links between Kaposi sarcoma (K.S.) and A.I.D.S. In Burundi the prospective study conducted in Bujumbura, lead to collect in one year 25 cases of K.S. out of them 24 linked to A.I.D.S. No group at risk has been identified. The 24 K.S. linked to A.I.D.S. present a stage IV (cutaneous and visceral form) in 21 cases. 20 of them got an associated affection, 5 being tuberculosis bacteriologically confirmed. All of them present a cellular immunity deficiency. Evolution was fatal in 22 cases out of 24, average presumption of survival was 10 months. In C.A.R., retrospective survey conducted in Bangui made possible to find out 24 cases in 4 years, of which 20 having had a L.A.V. antibodies research, were considered. 9 of them were linked to A.I.D.S. No group at risk. 7 patients presented a sporadic form, 6 an African endemic form, 7 an epidemic form with associated infection. Out of 9 LAV positive patients, 5 deceased. Out of 11 LAV negative patients, 3 deceased with a A.I.D.S. clinical aspect. This survey carried out in Burundi and in C.A.R. demonstrates that K.S. is significantly in increase in these two countries. In Burundi it is significantly linked to A.I.D.S. In C.A.R., classical African K.S. do exist (sporadic, endemic), as well as K.S. linked to A.I.D.S., as underlined recently in Bayley's publications in Zambia. Since A.I.D.S. has been detected, it does exist an outbreak and a new clinical form of K.S. in Central Africa.

[Clinical aspects of AIDS in the Central African Republic]

AIDS is known in Central African Republic since 1983: 64 recognized cases have been registered. AIDS is of endemic aspect presenting the main following signs: lost of weight (100%), degeneration of the health status (80%), lymphadenopathy (46%), pneumopathy (44%), diarrhea (40%), candidiasis (21%), Kaposi's disease (16%), purpura (8%), pruritus (8%), Cutaneous anergy to tuberculin or to the 7 antigens (Merieux test) is constant. LAV serology was positive in 61 cases. The number of helper T. cells is less than 400/mm3, and OKT4/OKT8 ratio is less than 0.50. The concerned population is heterosexual with a sexual hyperactivity.

[Prevalence of hepatitis B surface antigen and determination of its subtypes in the Central African Republic]

To contribute to the epidemiology of hepatitis B, the authors report the results of a survey made in Bangui. This survey was performed on patients hospitalized in the department of medicine of the University Hospital. Some of the patients had a clinically typical hepatitis. HBsAg prevalence was 15.4%. The subtypes detected were: ay (8%), ayw2 (4%), ayw4 (88%). Those data are compared with other data obtained through medical publications in Central Africa.

[Bacteriological and clinical aspects of Salmonella typhi infections in the Central African Republic. Evaluation of a 3-year study in Bangui]

Authors have isolated and identified 229 strains from patients with typhoid syndrome . The bacteriology of each strain was studied. We have observed the extension of A (subtype Dakar) lysotype to Central Africa from West Africa. All the strains are resistant for G penicillin. Clinical features are quite the same as in mild countries, with a high incidence in children. The typhoid fever is frequent and precocious in CAR, where prophylaxis by vaccination is not usual.