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Risk factors for death in an HIV-infected cohort in French Guiana were studied in 1374 patients between 1996 and 2005. Of these patients, 48.5% were male and 76% were immigrants. Covariates were measured at the time of consultation. There were 223 deaths. Addictions [adjusted hazard ratio (HR)=13; 95% confidence interval (CI) 5.5-30.6; P<0.001], age>60 years (HR=1.5; 95% CI 0.9-2.5; P=0.13), male gender (HR=1.5; 95% CI 1.03-2.5; P=0.03) and CD4 count<50 cells/microL (HR=9.1; 95% CI 5.1-16.3; P<0.001) were independently associated with death. These results suggest that strategies promoting early diagnosis and better follow-up of addicted patients would have a significant impact on mortality.

Background: Kaposi sarcoma (KS) is a complex tumor of uncertain clonality. Studying the viral clonality of the human herpesvirus 8 (HHV-8) in KS to determine clonality of the tumors, a strategy that has been used previously with Epstein-Barr virus and its associated tumors, may elucidate whether multicentric (disseminated) KS lesions correspond to metastatic lesions or to expansions of independent clones., Methods: A series of 139 KS biopsies (from skin, lymph node, or tonsil) was obtained from 98 patients, with 59 biopsies from 18 patients with disseminated multicentric KS skin lesions. The degree of spindle cell infiltration in biopsies was established by direct observation of hematoxylin-eosin-stained sections, and HHV-8 viral load was quantified by real-time polymerase chain reaction. To determine cellular clonality, the size heterogeneity of the HHV-8-fused terminal repeat (TR) region was determined by probing of electrophoresed restricted genomic DNA from KS biopsies for the HHV-8 TR sequence., Results: HHV-8 clonality analysis was performed on the 62 samples for which sufficient DNA was obtained. Most samples corresponded to histologically nodular lesions with high spindle cell infiltration and high viral load. A clonal HHV-8 pattern was determined for 59 samples; 11 were found to be monoclonal and 48 to be oligoclonal. The informative samples that were from disseminated KS skin lesions (n = 26, from six patients) were either monoclonal or oligoclonal, and the size of HHV-8 episomes varied between these samples., Conclusion: Although some tumor KS lesions were monoclonal expansions of HHV-8-infected spindle cells, most advanced lesions were oligoclonal proliferations. Furthermore, individual KS disseminated tumor skin lesions were found to represent distinct expansions of HHV-8-infected spindle cells. Thus, our results suggest that KS lesions, especially in patients with advanced skin tumors, are reactive proliferations rather than true malignancies with metastatic dissemination.

Cytokines are increasingly recognized as important components of the cellular immune responses to intracellular pathogens. In this study, we analyzed the production of TGF-beta, IL-10 and IFN-gamma by PBMC of unexposed naïve subjects and LCL patients after stimulation with live Leishmania guyanensis (L.g.). We demonstrated that IFN-gamma is produced in controls and LCL patients, IL-10 only in LCL patients and TGF-beta only in naïve subjects. Furthermore, in naive subjects, neutralization of TGF-beta induced IL-10 production. IL-10 produced in naïve subjects when TGF-beta is neutralized or in LCL patients did not modify the IFN-gamma production but inhibit reactive nitrogen species production. Analysis of the phenotype of IL-10 producing cells in naive subjects when TGF-beta is neutralized clearly showed that they are memory CD45RA- CD8+ T cells. In LCL patients, IL-10 producing cells are both CD45RA- CD4 and CD8+ T cells. The role of these IL-10 producing CD8+ T cells in the development of the diseases should be carefully evaluated.

We report the occurrence of myiasis owing to Dermatobia hominis (Dh) in a HIV-infected subject. HIV infection did not modify the pathogenicity of myiasis. However, the clinical presentation seemed unusual with voluminous inflammatory nodules. Use of topical ivermectin killed the larvae and facilitated their extraction.

In a retrospective study set in French Guiana, the efficacy and tolerance of the intramuscular treatment of cutaneous leishmaniasis (CL) with a single injection of pentamidine isethionate, at 7 mg/kg, were compared with those observed, earlier, using two such injections (given 48 h apart). Although 83.6% of the 281 patients given two injections each were cured, the single-injection protocol was generally as effective, curing 78.8% of 137 patients. The single-injection protocol was also associated with fewer adverse effects than the two-injection. In the treatment of "difficult" cases (those with satellite papules or relatively high numbers of amastigotes in their lesions), however, the two-injection protocol appeared significantly more effective than the single-injection. In French Guiana, therefore, patients with CL should be given one injection with pentamidine isethionate and only be given a second, 48 h later, if they have satellite papules and/or relatively high numbers of amastigotes in their lesions.

French Guiana is the region of France where the HIV epidemic is most prevalent. To determine the risk factors for being lost for follow-up, we followed a cohort of 1,213 patients between 1992 and 2002 and determined which variables were related to two definitions of being lost to follow-up: permanently disappearing from HIV clinics and coming back after more than 1 year of missed appointments. The incidence rate for permanent follow-up interruption was 17.2 per 100 person-years. The median time to lost to follow-up was 4.3 years (interquartile range = 1.4-8.4 years). Cox modeling showed that the younger age groups, foreigners, patients with initial CD4 counts at the time of HIV diagnosis less than 500/mm3, and patients followed before the availability of highly active antiretroviral therapy (HAART) were significantly more likely to be permanently lost to follow-up, suggesting that some of the patients may have died. When looking at temporary loss to follow-up, younger age groups, untreated patients, patients consulting before the availability of HAART, and patients with CD4 counts more than 500/mm3 were more likely to not come back for a period of more than 1 year.

To determine whether the initiation of highly active antiretroviral therapy (HAART) had any influence on the incidence of disseminated histoplasmosis, a retrospective cohort study was performed on 1551 patients followed for up to 12 years. After controlling for CD4 counts, age, and sex, patients taking HAART for 2 months or less were more likely to develop disseminated histoplasmosis than untreated patients (respectively, hazard ratio, 3.7 [95% confidence interval, 1.57-8.7]; P = 0.003). In contrast, after 6 months of HAART, treated patients were less likely to develop disseminated histoplasmosis than untreated patients (hazard ratio, 0.6 [95% confidence interval, 0.37-0.98], P = 0.04). This increased incidence suggests that the initiation of HAART and the subsequent immune reconstitution may reveal undiagnosed latent disseminated histoplasmosis.

Drug eluting stent is a new technology aimed to prevent the development of neointimal hyperplasia and restenosis following percutaneous coronary intervention. This review describes the direction for their use at the present time and the future of their utilization with the summary of the principals clinicals trials.

We evaluated the presence of human herpesvirus 8 (HHV-8) infection among groups of Amerindians in French Guiana. The overall prevalence of antibodies against lytic HHV-8 antigens was 23.0% (180/781), increasing from 18.4% in children <6 years old to approximately 30% in older persons (>45 years). Seroprevalence was higher in Amerindians living in remote localities than it was in those living in the coastal region. Analysis of a 725-base pair fragment of the K1 gene amplified from DNA from a Wayampi Amerindian showed that the virus belonged to molecular subtype E, which has hitherto been found in only a few Amerindians in Brazil and Ecuador.

Transforming growth factor beta (TGF-beta) has been shown to be a central immunomodulator used by leishmaniae to escape effective mechanisms of protection in human and murine infections with these parasites. However, all the information is derived from studies of established infection, while little is known about TGF-beta production in response to Leishmania stimulation in healthy subjects. In this study, TGF-beta1 production was demonstrated in peripheral blood mononuclear cells from healthy subjects never exposed to leishmaniae in response to live Leishmania guyanensis, and the TGF-beta1-producing cells were described as a distinct subpopulation of CD4(+) CD25(+) regulatory T cells. The suppressive properties of CD4(+) CD25(+) T cells were demonstrated in vitro by their inhibition of production of interleukin 2 (IL-2) and IL-10 by CD4(+) CD25(-) T cells in the presence of either anti-CD3 or L. guyanensis. Although neutralization of TGF-beta1 did not reverse the suppressive activity of CD4(+) CD25(+) T cells activated by anti-CD3, it reversed the suppressive activity of CD4(+) CD25(+) T cells activated by L. guyanensis. Altogether our data demonstrated that TGF-beta1 is involved in the suppressive activity of L. guyanensis-stimulated CD4(+) CD25(+) T cells from healthy controls.

Immune reconstitution syndrome (IRIS) is an unusual inflammatory reaction to an opportunistic infection in an HIV-positive patient. This syndrome occurs when immunity is restored in the first months of an effective highly active antiretroviral treatment (HAART). First, we described all patients with a cutaneous form of IRIS. Then, between 1992 and 2004 we conducted a retrospective cohort study comparing Herpes Zoster and Herpes Simplex infections among untreated patients, patients treated by HAART for < or = six months, and patients treated for > six months. We observed three cases of atypical leprosy and three original observations: two of these were fistulisation of lymph node histoplasmosis and tuberculosis, the third one reports the recurrence of a treated cutaneous leishmaniasis. Multivariate analysis showed that, after controlling for age, sex and CD4 counts, patients receiving HAART for < or = six months were more likely to develop Herpes Zoster or herpes simplex infections (p < 0.005). Herpes Simplex and Herpes Zoster infections are the two most frequent dermatological manifestations in our tropical setting. Although mycobacterial infections are more rarely observed than in visceral IRIS, the increased incidence of leprosy may be quite significant when the availability of HAART spreads to developing countries.

Risk factors for delayed HIV diagnosis in French Guiana were studied in 1952 patients between 1992 and 2003. At the time of diagnosis, 30% of patients had less than 200 CD4 lymphocytes/mm3; age, male sex, and foreign nationality were independently associated with a low CD4 cell count. The availability of highly active antiretroviral therapy was not associated with an earlier HIV diagnosis. Promoting HIV information and testing should be done in several languages to reach minorities.

Abstract The larval stages of the fly Cochliomyia hominivorax are responsible for myiasis, which primarily affects wounds. We report the case of a bed-ridden patient with dementia who developed right nasal myiasis during his stay at Cayenne Hospital. Progression was favorable, but the nasal pyramid was partially destroyed. In zones where this fly is endemic, particular attention should be given to hospitalized patients with wounds and consciousness problems.

Introduction: Histoplasma capsulatum var capsulatum is a dimorphic fungi predominating on the American continent. It is responsible for disseminated histoplasmosis associated with AIDS. The presentation in the form of cutaneous ulceration is uncommon and misleading., Observation: A 25 year-old man presented with 3 ulcerations, of 2 to 4 cm in diameter, localized on the lower lip and knees. The patient exhibited fever, alteration in his general status of health and a pulmonary interstitial syndrome. He was seropositive for the human immunodeficiency syndrome (HIV). His lymphocyte CD4+ level was of 1/mm3. Diagnosis of histoplasmosis was established by direct examination and culture of the cutaneous ulcerations and bronchoalveolar washing fluid., Discussion: The clinical aspect of cutaneous localizations of disseminated histoplasmosis is usually multiple, disseminated, papular or nodular-type lesions. Ulcerations represent less than 20% of the cases described. In our patient, the aspect of the lesions at first evoked cutaneous leishmaniosis. Direct mycological examination followed by culture confirmed the final diagnosis.

Introduction: Paracoccidio-domycosisis a deep mycosis due to a dimorphic fungus:Paracoccidioides brasiliensis. The principle endemic country is Brazil. We describe the first case of paracoccidio-domycosis, in its cutaneous-mucosal form, diagnosed in French Guiana., Observation: A 20 year-old Brazilian man, having mover to French Guiana a few months earlier, presented with multiple disseminated cutaneous lesions, predominating on the face, and composed of multiple nodules and two ulcerations. The clinical examination also revealed voluminous superficial lymph nodes and ulcerations of the pharynx and larynx. Direct examination, anatomopathology and culture of cutaneous biopsies revealed specific images of Paracoccidioides brasiliensis. HIV serology was negative. Treatment combining cotrimoxazole and itraconazole eliminated the lesions in one month., Discussion: Because the patient had just moved to Guiana, this observation probably corresponded to an imported disease. The principle differential diagnosis was leishmaniosis.

Background: Few data are available on cutaneous leishmaniasis caused by dermotropic species in human immunodeficiency virus (HIV)-infected patients., Objectives: To describe nine cases of cutaneous leishmaniasis in HIV+ patients and to compare their clinical features and their response to treatment with those of HIV- patients with the forms of leishmaniasis commonly found in French Guiana., Methods: A case-control study was carried out between July 1994 and December 2000 in French Guiana. We compared the following variables in nine HIV-infected patients with leishmaniasis and 27 matched controls: clinical type of leishmaniasis, number of lesions, presence of lymphangitis and adenopathy, the rate of recovery after treatment, and recurrence or reinfection., Results: Eight of the HIV-infected patients had localized cutaneous leishmaniasis and one had mucocutaneous leishmaniasis. All of the controls had localized cutaneous leishmaniasis. Leishmania guyanensis was the only species isolated from HIV-infected subjects. HIV-Leishmania coinfected patients had a higher rate of recurrence or reinfection (P < 0.02) and a lower rate of recovery after one treatment cycle with pentamidine (P < 0.02) than did HIV- subjects. The CD4+ lymphocyte counts exceeded 200 mm(-3) in all HIV+ patients at the time of the diagnosis with leishmaniasis., Conclusions: In French Guiana, cutaneous leishmaniasis in moderately immunosuppressed HIV-infected subjects (> 200 CD4+ T cells mm(-3)) is characterized by a higher rate of recurrence or reinfection and is more difficult to treat than that in HIV- subjects.

Disseminated cutaneous leishmaniasis is characterized by the presence of a large (> or =10) number of lesions at several anatomic sites (head, limbs, and trunk). Most of the lesions are small, papular, and appear simultaneously with or secondarily to one or several ulcerated lesions of localized cutaneous leishmaniasis. We report the first case of disseminated cutaneous leishmaniasis in French Guiana. It concerns a 24-year-old woman who tested negative for human immunodeficiency virus (HIV). The disease began with three lesions that became ulcerated. One week later, multiple papulo-nodular lesions appeared. We counted a total of 425 lesions. Leishmania were observed in the lesions. The species involved was L. guyanensis, which has never been described in a case of disseminated cutaneous leishmaniasis. The patient was rapidly cured by a single course of pentamidine. Disseminated cutaneous leishmaniasis should be distinguished from other types of leishmaniasis with multiple lesions. These include anergic diffuse cutaneous leishmaniasis, post-kala-azar leishmaniasis, and leishmaniasis associated with HIV infection.

Purpose: To report nine cases of external ophthalmomyiasis caused by Dermatobia hominis., Methods: Retrospective, non-comparative, interventional case series. Participants consisted of patients (n = 9) presenting at Cayenne Hospital between 1968 and 2003. The location and number of larvae, the larval stage, and the medical and surgical procedures applied were studied in each case., Results: Seven patients had palpebral myiasis (including one with three larvae) and two had conjunctival myiasis. Every patient had palpebral oedema. The larval respiratory pore was located on the palpebral skin or free margin or on the conjunctiva. Movements were present within the lesion in at least three patients. Petroleum ointment or ivermectine solution was used in at least four patients to smother or kill the larvae. Extraction under local anaesthesia was possible in six patients, while three required general anaesthesia., Conclusion: Several larvae may be present in a patient. Topical ivermectine may help to kill the larvae before extraction is attempted.

Background: Immune reconstitution inflammatory syndrome (IRIS) is an unusual inflammatory reaction to an opportunistic infection that occurs in human immunodeficiency virus (HIV)-positive patients with profound immunosuppression during the reconstitution of the immune system in the initial months of highly active antiretroviral treatment., Observations: We describe 3 cases of leprosy occurring in patients treated with a combination of 3 antiretroviral drugs who fulfilled the criteria for IRIS. A reactional state occurred in all 3 cases. Two of the 3 patients presented an unusual ulcerous progression of the lesions not generally observed in cases of leprosy. The outcome was favorable in all 3 cases. The frequency of IRIS associated with leprosy in French Guiana and Martinique is estimated at 3 cases per 1000 HIV-positive patients receiving highly active antiretroviral treatment., Conclusion: Leprosy should be recognized as an IRIS-associated infection with possibility of atypical presentation.

Objective: The survey "Mortality 2000" had for aim to describe the distribution of causes of death in HIV-infected adults in France., Method: Hospital wards involved in the management of HIV infection prospectively reported deaths occurring in 2000. The causes of death were documented using a standardized questionnaire., Results: In French Guyana and the French West Indies the five referent wards reported 81 deaths. The main underlying causes of death were AIDS-related (67%), non-AIDS and non-hepatitis related cancer (9%), cardiovascular disease (7%), bacterial infections (5%), and end stage liver disease (4%). Among AIDS-related deaths, the more frequent diseases were histoplasmosis and toxoplasmosis in Guyana and atypical mycobacterial infection, tuberculosis, and cytomegalovirus disease in the West Indies. Median age was 43 years, transmission of HIV infection was heterosexual in 79%; 56% lived in poor socio-economic conditions, and 30% were born abroad. One out of five had been recently diagnosed with HIV infection and one out of three had never received antiretroviral treatment., Conclusion: In 2000, two in three death cases in HIV-infected adults were AIDS-related in French Guyana and the French West Indies. Improved strategies for screening HIV infection before the occurrence of AIDS are still needed taking into consideration poor socio-economic and migrant conditions.

Introduction: Azithromycine is recommended in the treatment of donovanosis with a 7-day treatment cycle. We report the efficacy of a single cure of 1 gram in two patients., Observations: Four patients, presenting with donovanosis, were treated with azithromycine according to 2 regimens. The first used 500 mg/d the molecule during 1 week, the second used azithromycine in single cure of 1 gram. The latter led to the complete cure of 2 patients., Discussion: Many antibiotics are used in the treatment of donovanosis. Since 1996, Australian authors have used azithromycine in this indication. A single dose of this molecule appears effective in recent and confined donovanosis.

We aimed to identify prognostic factors for AIDS-associated disseminated histoplasmosis. In a multivariate analysis, we found that dyspnea, a platelet count of <100,000 platelets/mm3, and lactate dehydrogenase levels of >2 times the upper limit of the normal range were significantly independently associated with the death of the patient during the first 30 days of antifungal treatment.

Mycobacterium ulcerans infection is the third most important mycobacterial infection in the world. It has been described in many different countries including French Guiana. The diagnosis of M. ulcerans infection by culture is often difficult because culture is hard to perform in endemic areas and their sensitivity is not reliable. As a result the diagnosis of this infection is often delayed. However, molecular methods are now available to diagnose rapidly infections by M. ulcerans and distinguish it from other mycobacteria. We report three cases of skin infection due to M. ulcerans observed in French Guiana. Diagnosis was initially made by polymerase chain reaction and was confirmed later by culture (in two patients) and inoculation to mice (in one patient). A faster diagnosis of M. ulcerans infection should lead to a better prognosis of this infection.

In French Guiana, marked seasonal fluctuations have been observed in the numbers of individuals who present with cutaneous leishmaniasis (CL). To investigate the seasonal trends further, the clinical characteristics and responses to treatment of 455 cases of CL, who presented over a 3-year period (1995-1998), were compared against data on the weather for the calendar month of presentation (month 0) and for the month before presentation (month-1). Several statistically significant associations were observed. The number of sunlight hours in month -1 was lower for the treatment successes than for the treatment failures [adjusted odds ratio (AOR) for successful treatment=0.28; 95% confidence interval (CI)=0.13-0.6; P=0.001] and for those with long incubation periods than for those with relatively short incubation periods (multiple-regression coefficient=-0.003; P=0.002). However, the radiation intensity for month-1 was higher for the treatment successes than for the treatment failures (AOR=2.1; CI=1.1-3.8; P=0.02). Relatively high numbers of hours of sunlight on month-1 were associated with relatively high numbers of parasites on the skin smears (AOR=1.03; CI=1.01-1.04; P<0.001). Relatively high numbers of hours of sunlight during month 0 were associated with lymphangitis (AOR=0.4; CI=0.19-0.8; P=0.01). These results indicate that meteorological parameters may influence the evolution of CL, at least in French Guiana.

Background: Oral or cutaneous acquired immunodeficiency syndrome (AIDS)-related histoplasmosis is a rare presentation of disseminated histoplasmosis., Objective: To describe this clinical presentation and to compare it with other forms of AIDS-related disseminated histoplasmosis., Methods: A cross-sectional study of patients with AIDS-related disseminated histoplasmosis was performed. CD4 counts and survival were compared between patients with oral or cutaneous histoplasmosis and patients with nonmucocutaneous disseminated histoplasmosis., Results: The mean CD4 lymphocyte count was lower in patients with mucocutaneous lesions than in patients with nonmucocutaneous disseminated histoplasmosis (29 vs. 72/mm3, P = 0.002). The proportion of survivors 1 month after diagnosis did not differ significantly between the two groups (13/21 vs. 32/45, P = 0.4). At 6 months, the proportion of survivors was significantly lower for patients with mucocutaneous lesions (6/21 vs. 22/39, P = 0.03)., Conclusions: These results suggest that mucocutaneous lesions occur at a later stage of human immunodeficiency virus infection, but are not, in themselves, associated with a higher level of mortality. The excess mortality at 6 months reflects deaths from other complications of severe immunodepression. This study confirms the polymorphism of mucocutaneous lesions, emphasizing the need for systematic testing for Histoplasma in all cases of mucocutaneous lesions in AIDS patients.

Clinical symptoms of impetigo and staphylococcal scalded skin syndrome may not only be expressed as the splitting of cell layers within the epidermis but are often accompanied by some localized inflammation. Toxin patterns of Staphylococcus aureus isolates originating from patients with impetigo and also from those with other primary and secondary skin infections in a retrospective isolate collection in France and a prospective isolate collection in French Guiana revealed a significant association (75% of the cases studied) of impetigo with production of at least one of the epidermolysins A and B and the bicomponent leucotoxin LukE-LukD (P < 0.001). However, most of the isolates were able to produce one of the nonubiquitous enterotoxins. Pulsed-field gel electrophoresis (PFGE) of genomic DNA hydrolyzed with SmaI showed a polymorphism of the two groups of isolates despite the fact that endemic clones were suspected in French Guiana and France. The combination of toxin patterns with PFGE fingerprinting may provide further discrimination among isolates defined in a given cluster or a given pulsotype and account for a specific virulence. The new association of toxins with a clinical syndrome may reveal principles of the pathological process.

The cure 'rates' achieved using intramuscular pentamidine isethionate (two injections of 4 mg/kg separated by an interval of 48 h) were investigated in French Guiana, in 198 consecutive patients with cutaneous leishmaniasis caused by Leishmania braziliensis guyanensis. One aim was to see if initial clinical presentation could be used to predict treatment failure. The cure rate after one course of pentamidine isethionate was 87% and almost all (80%) of the treatment failures responded to an identical second course. Although many of the patients complained of adverse effects, most commonly of pain at the injection site (54%), none of these effects was severe. Although frequently associated with discomfort, the two-injection course, giving a total of 8 mg pentamidine isethionate/kg, appears to be an effective treatment for cutaneous leishmaniasis in French Guiana. The observation of satellite papules on presentation was associated with a significantly increased risk of failure of the first course of treatment (P = 0.01), with an odds ratio (and 95% confidence interval) estimated at 3.5 (1.3-11.1), after adjusting for other clinical presentations and lesion size and number. The presence of satellite papules perhaps indicates that the patient's immune system is unable to control the progression of the parasite. Patients with more than three lesions were also less likely to be cured after one course of pentamidine than those with fewer lesions (P = 0.01).

Background: Infection with human herpesvirus 8 (HHV8), also termed Kaposi's sarcoma (KS)-associated herpesvirus, is associated with all forms of KS, with primary effusion lymphoma (PEL), and with some forms of multicentric Castleman's disease (MCD), but the pathogenic role of HHV8 in these tumors and the clonal nature of KS are still unclear. The purpose of this study was to examine whether the number of terminal repeats (TRs) contained in the fused TR region of HHV8 could be used as a marker of clonality in HHV8-associated tumors., Methods: Pulsed-field gel electrophoresis (PFGE) and multiple-probe Southern blot analysis of the HHV8 TR region were performed on high-molecular-weight DNA obtained from tumoral KS, PEL, and MCD lesions., Results: These analysis showed that the fused TR region contains a large but variable number of TR units (ranging from 16 to 75) and that the viral genome is present as extrachromosomal circular DNA in these tumors in vivo, with occasional ladders of heterogeneous linear termini reflecting lytic replication. All PEL tumors and PEL-derived cell lines as well as some KS tumors contained monoclonal or oligoclonal fused TR fragments; however, the TR region appeared polyclonal in MCD tumors and in a few KS lesions., Conclusion: Several KS and PEL lesions are monoclonal expansions of a single infected cell, suggesting that HHV8 infection precedes tumor growth and thus supporting an etiologic role of latent HHV8 in these proliferations. Our finding that nodular KS lesions display all possible patterns of clonality supports the model according to which KS begins as a polyclonal disease with subsequent evolution to a monoclonal process.

Purpose: Histoplasmosis due to Histoplasma capsulatum is a granulomatous fungic infection which appears opportunistic and disseminated in immunocompromised patients, especially among HIV patients in whom it can lead to death. Histoplasmosis is endemic in numerous areas worldwide, but in Europe most of the cases reported are imported. We describe the clinical features and the available diagnosis methods issued from our experience in French Guyana., Methods: Contamination occurs by inhalation of spores contained in dust. Most endemic areas are located on the American continent, including the French West Indies, where the incidence of histoplasmosis among HIV patients in French Guyana varies from 1.2 to 2.2% per year. In non-immunocompromised patients, histoplasmosis is asymptomatic most of the time. In HIV patients, the disseminated form is common and may occur many years after exposure to the fungus., Results: Non-specific symptoms, similar to those of either tuberculosis or other opportunistic infections, may reveal disseminated histoplasmosis in patients with AIDS. Early treatment (amphotericin B or itraconazole) is effective; however, it should be followed by a lifelong antifungic treatment (itraconazole) to prevent relapse., Conclusion: The infection should be suspected in any febrile HIV-infected patient with CD4 blood cell count < 200/mm3, if he/she ever travelled in an endemic zone. Direct examination of smear relating to clinical symptoms help guide diagnosis, while culture will confirm it after at least 4 weeks. Efficient serologic techniques for HIV-infected patients are not available in Europe.

Objective: We evaluated pertinent features of impetigo in French Guyana due to the increasing number of therapeutic failures with macrolides and fusidic acid., Patients and Methods: A prospective study study was conducted over a 14-month period in the dermatology unit of the Cayenne hospital. Two groups of patients were identified: group 1 included patients with impetigo and group 2 patients with infected skin reactions. Epidemiological, bacteriological, toxinological (exofoliatines, leukocidine) and antibiotic data were recorded., Results: Forty-one patients with impetigo and 31 patients with infected skin reactions were included. Staphylococcus infection alone was identified in most patients (68 p. 100) in the impetigo group. Exfoliatine-producing strains were strongly associated with Staphylococcus-induced bullous and non-bullous impetigo (93 p. 100) compared with other origins (impetigo with streptococcal infection or infected skin reactions). Resistance to macrolides was high (erythromycin 41 p. 100, fusidic acid 42 p. 100) for all isolated strains of Staphylococcus aureus., Conclusion: A sub-group of patients with impetigo was identified. These patients had pure staphylococcal infections characterized by strong association with exfoliatine production. The rate of resistance to macrolides was particularly high in this sub-group. Resistance to fusidic acid was high for all Staphylococcus strains isolated.

Background: Certain caterpillars produce venomous substances and cases of human envenomation are regularly published., Case Reports: We report 5 cases of caterpillar-induced envenomation observed in French Guyana. The caterpillar bites produced variable clinical manifestations. Automeris liberia provoked acute pain and skin necrosis: Dirphia tarquinia, erythema; Hylesia, persistent erythematous plaque (4 days); Megalopyge, erythematous and edematous lesions at the site of the bite and distant skin lesions; Automeris, syncopal pain and edematous infiltration of the thigh lasting several days., Discussion: Caterpillar envenomation necessitates consultation, emergency unit care, or even hospitalization. It is important to identify the causal caterpillar species in case of envenomation in order to evaluate risk. Lonomia achelous must always be suspected because this species can cause major fibrinogenolysis.

Background: Polar and borderline lepromatosis leprosy can be complicated by type 2 reactional states, including erythema nodosum leprosum., Case Report: A 36-year-old man was treated for lepromatous leprosum. He consulted for recurrent erythema nodosum leprosum. Certain nodular lesions were bullous. Histopathology demonstrated major dermal edema causing bullous blisters. Treatment with thalidomide led to rapid regression., Discussion: The bullous form of erythema nodosum leprosum is rarely described in the literature. It raises the diffential diagnosis with other bullous dermatoses, particularly Sweet's syndrome.

Background: A strong association has been observed between furuncles and Panton-Valentine leukocidin-producing Staphylococcus aureus., Case Reports: Within one year, we cared for three men at the Cayenne hospital who had Staphylococcus aureus septicemia with severe pleuropulmonary involvement originating from furuncular lesions. The Staphylococcus aureus strains isolated from the skin lesions and from blood cultures produced Panton-Valentine leukocidin., Conclusion: These cases demonstrate the gravity of S. aureus septicemia in young patients with furunculosis. These cases are the first reported with severe S. aureus infections associated with Panton-Valentine leukocidin producing strains.

Background: Cutaneous leishmaniasis and disseminated histoplasmosis can be diagnosed by direct examination of pathology specimens after Giemsa staining., Case Report: An HIV-infected man developed cutaneous leishmaniasis and disseminated histoplasmosis with buccal lesions concomitantly. Smears stained with the RAL 555 kit provided the diagnosis of these two diseases., Discussion: This case illustrates how direct microscopic examinations can provide inexpensive, rapid and safe diagnosis of infectious diseases. Direct microscopic examinations are routine practice in a tropical dermatology unit.

Paederus sabaeus is a coleopter of the Staphylinidae family. With its toxins present in the hemolymph (pederin, pseudopederin, pederone), it causes a delayed vesicular inflammatory dermatosis. The contact between skin and toxin is only possible when the insect is injured or killed, which occurs most frequently when it is crushed on the skin. In November 1989, in Conakry, a huge proliferation of this insect was responsible for an epidemic of Paederus dermatitis. The European sailors working in the port of this town were affected preferentially, as well as the entire European population for sociocultural reasons. The clinical picture is very characteristic when the lesions are linear or "kissing lesions" on both sides of the folded part of an articular joint. This dermatosis is more frequent on the uncovered parts of the body. Healing is spontaneous, requiring 7 to 10 days, if there are no further infections.