[Delayed home screening of leprosy; experience of the screening team in 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.

[Leprosy and immune reconstitution syndrome in AIDS]

The immune reconstitution syndrome (IRS) has been typical of changes in the clinical presentations of opportunistic infections in AIDS patients since the introduction of HAART. Leprosy has joined the growing list of opportunistic infections associated with IRS.

[Review: update on erythema nodosum leprosum]

Erythema nodosum leprosum (ENL) is an immunological reaction corresponding to vascularitis due to circulating immune complexes usually occurring during treatment of lepromatous leprosy. The precise mechanism underlying ENL are unclear but involvement of tumor necrosis factor alpha (TNFalpha) is suspected. Based on this suspicion pentoxifylline has been used instead of conventional treatments such as corticosteroids and thalidomide.

[Leprosy disclosed by polyarthritis]

BACKGROUND

We report a case of leprosy observed in a French woman who had lived in Africa 30 years earlier. The clinical presentation was misleading, suggesting connective tissue disease.

CASE REPORT

A 69-year-old woman was hospitalized in April 1996 for inflammatory joint disease. The first manifestations had developed three years earlier and the patient had been on systemic corticosteroid therapy associated with anti-malarials since 1993. The clinical presentation progressively included neurological and skin manifestations. Histology examination gave the diagnosis of lepromatous leprosy. Three-drug anti-leprosy treatment in one oral dose was initiated.

DISCUSSION

Chronic Mycobacterium leprae infection usually leads to overt leprosy with neurological and cutaneous involvement. Rheumatological forms are less common and found almost exclusively during leprous reactions. The association of inflammatory join pain with neurological and skin manifestations wrongly suggested vasculitis. In addition, the general corticosteroid therapy certainly was implicated in disease activation and progression to a purely lepromatous form.

[Skin diseases disclosing human immunodeficiency virus infection in Mali]

INTRODUCTION

Several skin diseases are associated with human immunodeficiency virus (HIV) infection. In Africa, due to the difficult access to medical care and complementary examinations, certain diseases are of particular importance. In the present work, we report the skin manifestations observed in a dermatology unit of a large city in Africa over a 3 year period and which were the revealing signs of HIV infection.

PATIENTS AND METHODS

All adult subjects (>15 years) with a positive HIV serology (confirmed by Western blot) that had been revealed by a skin disease seen at the Marchoux Institute at Bamako between June 1991 and September 1994 were included in the study.

RESULTS

Two hundred sixty-three skin diseases revealed 233 cases of HIV infection. Diseases observed were: zoster (n = 71), seborrheic dermatitis (n = 43), Kaposi's sarcoma (n = 34), prurigo (n = 31), sexually transmitted diseases (n = 27), extensive dermatophytosis (n = 12), psoriasis (n = 12), molluscum contagiosum (n = 8), acquired ichthyosis (n = 3), cutaneous leishmaniasis (n = 2) and other skin diseases (n = 10). More than one disease were associated in 28 patients. Certain particular features were noted (superinfection of zoster, papular margin in dermatophytosis).

DISCUSSION

In Africa, certain skin diseases often reveal HIV infection and some diseases have a high positive predictive value for HIV infection (zoster, seborrheic dermatitis, prurigo, Kaposi's sarcoma, extensive dermatophytotis). For prognosis, frequently associated diseases are signs of AIDS (Kaposi's disease, prurigo, molluscum contagiosum).

[Bullous IgA linear dermatosis of children in Mali]

INTRODUCTION

Bullous IgA linear dermatosis is relatively frequent in children in Africa. The aim of this study was to evaluate the frequency of this disease among autoimmune bullous diseases in children in Mali.

PATIENTS AND METHODS

Children with chronic bullous disease seen at the Marchoux Institute in Bamako and for whom direct immunofluorescence of the perilesional skin demonstrated immunoglobulin and/or complement deposits were included in the study population.

RESULTS

Twelve children were included. Direct immunofluorescence showed linear IgA deposit along the dermo-epidermal junction in 10, once with a pemphigoid aspect and once with a pemphigus aspect. The skin lesions in the children with linear IgA deposits were stereotypic: disseminated bullae, rosettes (9 out of 10), involving the external genital organs (10/10), the limbs, the face and the trunk. Histology showed subepidermal bullae (10/10), with neutrophil papillar abscesses (9/10). Indirect immunofluorescence of the cleaved skin NaCl in 5 patients showed that the cleavage always lied at the roof of the cleavage. All the children responded to dapsone (1 to 2.5 mg/kg/d) which gave complete (7/10), or incomplete remission. Local corticosteroids were used in 2 patients and general corticosteroids in 1.

DISCUSSION

This confirms the frequency of bullous IgA linear dermatosis in Africa, in contrast with uncommon dermatitis herpetiformis. Diagnosis is facilitated with immunofluorescence. The low cost of this test makes it a useful diagnostic tool in these countries.

The proportion of medical consultations motivated by skin diseases in the health centers of Bamako (Republic of Mali)

BACKGROUND

Skin diseases have recently been identified as a public health problem in developing countries. However, most studies on skin diseases in developing countries, have been conducted in specialized dermatologic centers. Data on the proportion of consultations motivated by skin diseases in nonspecialized health centers in developing countries are scarce. In order to appreciate the request for dermatologic care of the population of a developing African country, we attempted to measure this proportion in health centers of Bamako, the capital of Mali.

METHODS

Eight out-patient health centers were randomly selected in Bamako, and the medical registers for the first 6 months of 1993 were consulted.

RESULTS

Out of a total of 14,058 consultations given, 1639 (11.7%) were motivated by skin diseases. The main diagnoses registered were pyoderma (42.2% of all the dermatologic diagnoses), eczema (15.5%), scabies (8.5%), and fungal infections (7.9%).

CONCLUSIONS

The high proportion of ambulatory consultations in health centers in Bamako motivated by skin diseases suggests that they are an important health problem for the population of this city. Public health policies should be implemented in order to manage this problem.

Effect of HIV infection on leprosy: a three-year survey in Bamako, Mali

From February 1992 until June 1994, all patients with histologically proven leprosy examined at the Leprology Unit of the Institut Marchoux in Bamako, Mali, were screened for HIV serology. In total, 740 leprosy patients have been tested; 553 known, previously treated leprosy cases and 187 new cases, mainly self-reporting and referred cases. The global seroprevalence in the sample was 1.5% (11/740), and increased from 1.3% in 1992 to 3.1% in 1994. HIV seroprevalence was higher in paucibacillary (PB) than in multibacillary (MB) cases (3.8% versus 0.8%, p < 0.05), and was slightly higher in new cases than in known, already treated cases (2.1% versus 1.3%), although not significantly. Among the 553 known, already treated leprosy patients, 1 out of 7 HIV-seropositive patients relapsed, as opposed to 34 out of 546 HIV-seronegative cases (14.2% versus 6.2%, p = 0.36). Among the new cases, none of the 37 patients with reaction and/or neuritis was HIV positive. In known, treated leprosy cases, there was no difference in the frequency of reactions and/or neuritis between HIV-positive and HIV-negative cases. Migration in a neighboring country appeared to be a risk factor for HIV seropositivity in our sample (chi 2 = 4.5, p = 0.04). In order to estimate the association of HIV with leprosy as compared to the general population, a control group of blood donors was set up, matched for age and sex. There was, however, no difference in HIV seroprevalence between the control group (9/735, 1.2%) and the leprosy group (1.5%). Although leprosy patients recruited for this study constitute a highly selected sample, it appears that HIV infection has little effect on leprosy, particularly on the PB/MB ratio, leprosy reactions and neuritis, but there is a suggestion the HIV infection might be associated with increased frequency of relapse.

Determination of the minimal effective dosages of ofloxacin and sparfloxacin against M. leprae in the mouse foot pad system

The minimal effective dosages (MEDs) of ofloxacin (OFLO) and sparfloxacin (SPFX) against 10 isolates of Mycobacterium leprae were measured in the mouse foot pad system. The drugs were administered either by gavage or by incorporation into the mouse diet in a range of concentrations. The results demonstrated that the MEDs of OFLO were 4 to 5 times higher than those of SPFX, thus confirming that, on a weight-to-weight basis, the anti-M. leprae activity of SPFX was significantly greater than that of OFLO. The MEDs of OFLO/SPFX measured by gavage were 20 times lower than those measured by incorporating the drug into the mouse diet.

[Anatomopathologic study of five cases of leprosy in HIV seropositive patients]

In an effort to establish whether the human immunodeficiency virus (HIV) modifies the histological image of lepromatous skin lesion, a comparative study was conducted in 1994 at the Marchoux Institute in Bamako, Mali, on persons newly suffering from leprosy who had been tested seropositive and seronegative for the HIV virus. These new leprosy patients had never been treated and could be grouped as follows: 5 HIV-positive (1 TT, 1 BT, 1 BL, 2 LL) and 10 controls testing HIV-negative, selected according to the following criteria: each seropositive leprosy subject was matched with two seronegative controls having the same clinical features, same stage under the Ridley classification system, same age and sex. No discordance between the clinical classifications and the histological features in the subjects testing HIV-positive has been observed. They display features similar to those testing negative, with the presence of histiocytes, in particular epithelioid cells and giant cells in normal proportion depending on the form of leprosy. The only remarkable difference was a greater incidence of oedema in the subjects testing seropositive, compared with patients testing seronegative. In conclusion, HIV infection does not appear to cause major modifications in cellular response to Mycobacterium leprae, and no changes should be made in leprosy control programmes.

Mycetomas in Mali: causative agents and geographic distribution

Although Mali is situated in the African zone endemic for mycetomas, no report has been published on the characteristics of the disease in this country. We report a series of 54 cases observed in Bamako. The causative agents were Madurella mycetomatis in 20 patients, Leptosphaeria sp. in one patients, Actinomadura madurae in 12 patients, A. pelletieri in 15 patients, and Streptomyces somaliensis in three patients. In this series, the observed geographic distribution of the causative agents was in agreement with data on the causative agents and their geographic distribution in neighboring countries, and with those suggesting a relationship between the type of infectious agent and the annual rainfall.

Pemphigus in Mali: a study of 30 cases

Pemphigus has been largely studied in developed countries (North America and Europe) and in Brazil. In these geographical settings, pemphigus presents two very different epidemiological and clinical patterns. Little is known about pemphigus in other regions of the world, particularly in Africa. We report here a study of 30 cases of pemphigus observed in Bamako, Mali. Our data suggest that pemphigus in this area presents a distinctive pattern. Our cases of pemphigus were diagnosed on the basis of clinical, histological and direct immunofluorescence studies. We estimated the annual incidence in the Bamako region to be 0.29 cases per 100,000 inhabitants. There was no endemic focus in Mali. The disease was observed mainly in women (24 of 30; 80%), especially those older than 40 years (mean age, 46.7 years), and in the Fulani ethnic group (10 of 30; 33%). Our study group was composed of 25 cases of pemphigus foliaceus (PF) (83%), four cases of pemphigus vulgaris and one case of pemphigus vegetans. Pustules with hypopyon were observed in 11 patients (37%). A diffuse verrucous change in the skin was noted in four cases of erythrodermic PF. In 16 patients with PF, localized verrucous lesions mimicking seborrhoeic keratoses were observed when oral corticosteroid treatment was decreased. Histopathological examination demonstrated eosinophilic spongiosis in 50% of patients. These data suggest that pemphigus in Mali differs from the two main known patterns of the disease: the North American/European one, and the Brazilian pattern, with which it shares the predominance of superficial forms but otherwise differs in many features.

Skin diseases of children in Mali: a public health problem

In order to estimate the importance as a public health problem of skin diseases, we investigated the prevalence and severity of skin diseases in a representative sample of children in Mali. 1817 children were randomly selected in 30 clusters by probability-proportional-to-size sampling in Koulikoro region. The mean prevalence (+/- 2 SD) of skin diseases was 34 +/- 4%. The most frequent dermatoses were pyoderma (12.3 +/- 1.6%), tinea capitis (9.5 +/- 2.5%), pediculosis capitis (4.7 +/- 1.4%), scabies (4.3 +/- 1.5%), and molluscum contagiosum (3.6 +/- 1%). The most troublesome dermatoses were scabies and severe pyoderma. Pyoderma was the only dermatosis associated with poor individual or household hygiene. Public health services were little used by the population for skin diseases, probably because of the lack of an adequate response by the services and the high cost of treatment. The high prevalence and the severity of many of the lesions, and the discomfort caused, make pyoderma and scabies a significant public health problem in Mali.

Relapses after a single dose of rifampin in skin-smear negative multibacillary patients after dapsone monotherapy

Between 1982 and 1985, a single 1500 mg dose of rifampin (RMP) was given to 136 multibacillary leprosy patients who had become clinically inactive and skin-smear negative after various durations of dapsone monotherapy, and then antileprosy chemotherapy was totally stopped. By the end of June 1992, 15 relapses were detected among these patients. The overall relapse rate was 11%; the relapse rate per 100 patient-years was 2.1%, which was the highest among those published to date; the cumulative risk of relapse at year 7 of follow up was 8.8%. All of these figures indicate that the relapse rate among this group was at least the same as in other studies where patients received dapsone monotherapy only. Therefore, the administration of a single large dose of RMP could neither prevent relapse nor reduce its rate among multibacillary patients who had already become clinically and skin-smear negative after dapsone monotherapy.

Powerful bactericidal activities of clarithromycin and minocycline against Mycobacterium leprae in lepromatous leprosy

Thirty-six patients with newly diagnosed lepromatous leprosy were allocated randomly to three groups and treated for 56 days with minocycline (100 mg daily), clarithromycin (500 mg daily), or clarithromycin (500 mg) plus minocycline (100 mg daily). All groups had rapid and remarkable clinical improvement and significant decline of the bacterial and morphologic indices in skin smears during treatment. More than 99% and > 99.9% of the viable Mycobacterium leprae had been killed by 28 and 56 days of treatment, respectively, as measured by inoculation of organisms recovered from skin samples, taken before and during treatment, into the footpads of immunocompetent and nude mice. Clinical improvement and bactericidal activity did not differ significantly among the three groups. Adverse reactions were rare and mild, and no laboratory abnormality was detected during the trial. Both clarithromycin and minocycline displayed powerful bactericidal activities against M. leprae in leprosy patients and may be considered important components of new multidrug regimens for the treatment of multibacillary leprosy.

Specific anti-M leprae PGL-I antibodies and Mitsuda reaction in the management of household contacts in New Caledonia

Household contacts of leprosy patients have been tested for anti-phenolic glycolipid-I IgM antibodies (anti-PGL-I IgM) by an ELISA using the natural disaccharide (NDO) and natural trisaccharide (NTO) synthetic antigens. A group of healthy subjects without known exposure to Mycobacterium leprae served as controls. The percentages of positivity observed in multibacillary patients, paucibacillary patients, and household contacts were significantly higher than those of the negative controls. The absorbance values using NDO and NTO correlated well (range 0.59-0.91) when analysis of each subject group was performed. As reported here, NDO and NTO antigens seem to be equal in detecting leprosy cases; 100% of multibacillary and 21.43% of paucibacillary cases were detected as seropositive. For the screening of household contacts, NDO appears to be more sensitive and NTO more specific. There were more seropositive cases in the young age groups of household contacts, suggesting a higher rate of transmission of M. leprae infection in those age groups. Lepromin and anti-PGL-I IgG tests were also performed in contacts who were followed. The 2 paucibacillary subjects (1 borderline tuberculoid, 1 indeterminate) were Mitsuda negative. At diagnosis, their anti-PGL-I IgM levels were much higher than those of previous results; their anti-PGL-I IgG levels showed an increase in one and a decrease in the other. However, for the entire group anti-PGL-I IgM and anti-PGL-I IgG levels were positively correlated. The data reported here suggest that an increase in specific anti-M. leprae IgM levels in Mitsuda-negative household contacts could reveal the development of overt disease.

[Malignant melanoma among the ethnic Melanesian population of New Caledonia]

Melanesian population amounts to 61,270 out of 145,368 inhabitants in New Caledonia according to the last census. Melanesians of phototype VI have no predisposition in regard to malignant melanoma. From 1977 to 1987, 7 cases have been reported. Localisations are always in some zones not exposed to sunlight: 3 acral-lentiginous melanoma of the sole, 2 tumorous nodules of the anus margin and the vulva, 2 choroidal localisations. So, incidence of cutaneous malignant melanoma is very low (0.7/100,000 per annum) and in accordance with classical data regarding black people. But one has to keep in mind its being in some characteristic localisations. All the above referred cases have been detected at an advanced local extension.

Primary and secondary dapsone resistance of M. leprae in Martinique, Guadeloupe, New Caledonia, Tahiti, Senegal, and Paris between 1980 and 1985

Primary and secondary dapsone resistance were studied among lepromatous patients living in Martinique, Guadeloupe, New Caledonia, Tahiti, Senegal, and Paris. Four hundred fifteen biopsies were taken from clinically active and bacteriologically positive (bacterial index greater than 2) patients in the 6-year period of 1980-1985. Among these, 280 biopsies that contained 5 x 10(4) acid-fast bacilli per ml with a morphological index of at least 0.10 were inoculated into the mouse foot pad, and 229 harbored infective Mycobacterium leprae. Among the 129 infective M. leprae isolated from new cases, 54% had some degree of dapsone resistance, a low degree being prominent in all cases. Among the 100 infective M. leprae isolated from relapsed cases, 79% had a high or an intermediate degree of dapsone resistance. The annual incidence of secondary dapsone resistance was estimated to be about 0.55% in Guadeloupe.