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Insects of the genus Rhodnius are broadly involved in Chagas disease transmission. In French Guiana, where the disease remains a public health problem, R. robustus and R. pictipes are vectors, but so far few genetic analyses of these local species have been reported. Here, we explored three mitochondrial genes (Cytb, Lsu-rRNA, and ND1) and one nuclear gene (D2) in 49 adult specimens morphologically characterized as R. robustus. We analyzed genetic polymorphisms and haplotype distributions, and we built phylogenetic trees using the available GenBank sequences from R. robustus and related species. The molecular taxonomy analysis confirmed that 35 insects, closely related to Brazilian species and separated by a few mutations, truly belong to R. robustus; two others were attributed to the R. prolixus complex and for 12 no sequence was obtained. The geographical haplotype distribution indicates a likely geographical structuring and evidenced true differentiation between the two main urban centers, Cayenne and Saint-Laurent-du-Maroni.

Resume Du 24 juin au 6 juillet 2005, neuf hommes se sont presentes successivement aux urgences de l’hopital de Fort-de-France (Martinique, Antilles francaise) avec une symptomatologie pulmonaire plus ou moins marquee associee dans deux cas a la presence de lesions cutanees. Ces neuf hommes avaient tous realise des travaux dans une maison abandonnee trois semaines auparavant. Le diagnostic d’histoplasmose a pu etre etabli grâce aux examens mycologiques realises sur les prelevements pulmonaires (l’examen direct et la culture), la biologie moleculaire et les serologies. L’interrogatoire et l’enquete environnementale sur la zone presumee de l’exposition aux spores d’ H . capsulatum var. capsulatum a permis de confirmer les lieux et les modalites de contamination.

International audience; HIV-associated histoplasmosis is mainly misdiagnosed for granulomatous diseases, such as tuberculosis. Nonetheless, malignancy-like lesions have been reported sporadically in HIV-infected patients. Although the main reported lesions are erosive or ulcerated, here a rare case of oral tumor is reported. This case raises the awareness of this presentation, and the importance of accurate identification in the laboratory. Performing systematic specific stains for fungal elements and culture on tissue samples ensures accurate differential diagnosis.

The outbreak of acute Chagas disease due to oral transmission of the parasite is a well-known phenomenon mainly occurring in the Amazon. Such an event is described here for the first time in French Guiana. Eight patients of the same family, presenting epidemiological and clinical histories compatible with recent Trypanosoma cruzi infection of Chagas disease due to the ingestion of palm Oenocarpus bacaba juice were, rather late after the putative date of infection, underwent four parasitological and two serological specific tests for confirmation of the diagnosis. Real-time PCR results were positive for all the patients; strains were isolated by hemoculture from four patients, PCR identification of TcI DTU was made for six patients, while parasites were not detected in any of the patients by direct microscopic examination. The results of two serologic tests were positive. All patients were treated with benznidazole, and two patients were additionally given nifurtimox. A 6-year follow-up was possible for six patients. Real-time PCR was negative for these patients after 1 year, while the antibody rates decreased slowly and serology results were negative only after several years (1–5 years). Our findings confirm the occurrence of an outbreak of Chagas infection in members of the same family, with the oral mode of infection being the most likely hypothesis to explain this group of cases. Our results show the successful treatment of patients infected by TcI and the usefulness of real-time PCR for the emergency diagnosis of recent Chagas disease cases and in posttreatment follow-up. Fil: Blanchet, Denis. Centre Hospitalier Andrée Rosemon. Université des Antilles et de la Guyane. Laboratoire Hospitalier et Universitaire de Parasitologie et Mycologie Médicale; Guayana Francesa Fil: Brenière, Simone Frédérique. Institut de Recherche pour le Développement, Interactions hôtes-vecteurs-parasites dans les infections par trypanosomatidae; Francia Fil: Schijman, Alejandro Gabriel. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Investigaciones en Ingeniería Genética y Biología Molecular; Argentina Fil: Bisio, Margarita María Catalina. Gobierno de la Ciudad de Buenos Aires. Hospital General de Niños "R. Gutierrez". Servicio de Parasitología y Chagas; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Investigaciones en Ingeniería Genética y Biología Molecular; Argentina Fil: Simon, Stéphane. Centre Hospitalier Andrée Rosemon. Université des Antilles et de la Guyane. Laboratoire Hospitalier et Universitaire de Parasitologie et Mycologie Médicale; Guayana Francesa Fil: Veron, Vincent. Centre Hospitalier Andrée Rosemon. Université des Antilles et de la Guyane. Laboratoire Hospitalier et Universitaire de Parasitologie et Mycologie Médicale; Guayana Francesa Fil: Mayence, Claire. Centre Hospitalier de l’Ouest Guyanais. Service d’accueil des urgences; Guayana Francesa Fil: Demar Pierre, Magalie. Centre Hospitalier Andrée Rosemon. Université des Antilles et de la Guyane. Laboratoire Hospitalier et Universitaire de Parasitologie et Mycologie Médicale; Guayana Francesa Fil: Djossou, Félix . Centre Hospitalier Andrée Rosemon. Service de maladie infectieuse et tropicale; Guayana Francesa Fil: Aznar, Christine. Centre Hospitalier Andrée Rosemon. Université des Antilles et de la Guyane. Laboratoire Hospitalier et Universitaire de Parasitologie et Mycologie Médicale; Guayana Francesa

Resume Introduction La paracoccidioidomycose est une infection fongique systemique frequente en Amerique latine. Les atteintes cutanees sont frequentes et habituellement multiples, le plus souvent associees a des lesions de la muqueuse oro-pharyngee. La forme cutanee isolee est rare. Observation Nous rapportons un cas de paracoccidioidomycose cutanee isolee de l’oreille chez un homme immunocompetent de 43 ans. La lesion formait un placard partiellement ulcere du pavillon de l’oreille gauche. L’examen mycologique direct, l’examen anatomopathologique et la PCR permettaient de mettre en evidence, dans la lesion cutanee, des levures identifiees comme Paracoccidioides brasiliensis. Discussion Les localisations a l’oreille de la paracoccidioidomycose peuvent etre confondues avec d’autres pathologies tropicales frequentes en region amazonienne, notamment la leishmaniose, la lepre ou la lobomycose. Le caractere unique de cette localisation cutanee faisait discuter son origine primitive ou secondaire.

Chagas disease is an anthropozoonotic infection caused by Trypanosoma cruzi, transmitted by a hematophagous triatomine insect vector belonging to the Reduviidae family, while taking a blood meal. There is a large reservoir of wild and domestic mammals. Human contamination may come via vectorial, transplacental, and digestive routes, blood transfusion, organ or tissue transplantation, and by accident. The disease has two phases. The acute phase, oligosymptomatic, is frequently undiagnosed. It is followed by a chronic phase. Most of the infected patients remain asymptomatic all life-long. But 10 or 25 years later, one third of infected patients present with cardiac or digestive complications. Chagas disease is endemic in Latin America, from Mexico to Argentina. In French Guyana, the prevalence of the infection was estimated at 0.25% and 0.5% (from 500 to 1000 infected patients) on blood samples collected from 1992 to 1998. In 2000 and 2009, 192 cases were diagnosed. In this district, there is no established domestic vector and the transmission risk is low. The vector is very easily found in forest habitats and even in the peridomestic persistent forest, with an infection rate of 46 to 86%. Vectorial eradication is impossible. Fighting against Chagas disease in French Guyana relies more on individual protection, control of blood transfusion, prevention of mother-to-child transmission, diagnosis, and treatment of infected patients than on vectorial control.

We carried out a soil sampling survey in September 2008 in central Cayenne, French Guiana, using molecular methods to assess the presence of the dimorphic fungus Histoplasma capsulatum. Four of the 31 samples collected (12.9 %) tested positive by PCR, with confirmation of the result by DNA sequencing. H. capsulatum is therefore present in urban environments in French Guiana. These results provide additional support for the primary prophylaxis of AIDS-related histoplasmosis in French Guiana.

We report a TaqMan® real-time polymerase chain reaction (PCR) protocol for diagnosing cryptococcosis. Specificity was tested with 33 fungal strains. The 7 clinical samples found positive by culture also tested positive by real-time PCR. No false negatives were found among the 94 clinical samples that were negative by culture for Cryptococcus spp. The sensitivity threshold was about 10 plasmid copies per assay.

Untreated histoplasmosis is life threatening, especially in immunosuppressed patients. In French Guiana, South America, it is one of the most common opportunistic infections in AIDS patients. Twenty-one cases of disseminated histoplasmosis were diagnosed in 2004 in the mycology laboratory of Cayenne hospital. Culture samples for histoplasmosis diagnosis is simple, sensitive, and specific, but it is a lengthy process. Management of the disease is then dangerously delayed. In this work, we tested a polymerase chain reaction (PCR) method on 40 samples from patients with suspected disseminated histoplasmosis. The recently described Hcp100 nested PCR method was used to detect Histoplasma capsulatum DNA in these samples. All of the positive cultures for H. capsulatum were also positive with PCR method. Tested on other fungi or negative culture, it also showed high specificity. Furthermore, it allows treating patients more rapidly. Culture remains necessary, but histoplasmosis PCR offers great prospects, on a clinical point of view.

International audience; Human polycystic echinococcosis is a parasitic infection caused by the larval stage of Echinococcus vogeli which occurs in rural areas of Central and South America. Abdominal echinococcosis caused by E. vogeli is reported for the first time in a child, a 6-year-old boy in French Guiana. The diagnosis was made by histological and molecular techniques. In tropical regions, this neglected disease must be considered even in children.

Background: Trypanosoma cruzi has been classified into six Discrete Typing Units (DTUs), designated as TcI–TcVI. In order to effectively use this standardized nomenclature, a reproducible genotyping strategy is imperative. Several typing schemes have been developed with variable levels of complexity, selectivity and analytical sensitivity. Most of them can be only applied to cultured stocks. In this context, we aimed to develop a multiplex Real-Time PCR method to identify the six T. cruzi DTUs using TaqMan probes (MTq-PCR)., Methods/Principal Findings: The MTq-PCR has been evaluated in 39 cultured stocks and 307 biological samples from vectors, reservoirs and patients from different geographical regions and transmission cycles in comparison with a multi-locus conventional PCR algorithm. The MTq-PCR was inclusive for laboratory stocks and natural isolates and sensitive for direct typing of different biological samples from vectors, reservoirs and patients with acute, congenital infection or Chagas reactivation. The first round SL-IR MTq-PCR detected 1 fg DNA/reaction tube of TcI, TcII and TcIII and 1 pg DNA/reaction tube of TcIV, TcV and TcVI reference strains. The MTq-PCR was able to characterize DTUs in 83% of triatomine and 96% of reservoir samples that had been typed by conventional PCR methods. Regarding clinical samples, 100% of those derived from acute infected patients, 62.5% from congenitally infected children and 50% from patients with clinical reactivation could be genotyped. Sensitivity for direct typing of blood samples from chronic Chagas disease patients (32.8% from asymptomatic and 22.2% from symptomatic patients) and mixed infections was lower than that of the conventional PCR algorithm., Conclusions/Significance: Typing is resolved after a single or a second round of Real-Time PCR, depending on the DTU. This format reduces carryover contamination and is amenable to quantification, automation and kit production., This work received financial support from the Ministry of Science and Technology of Argentina [PICT 2011-0207 to AGS] and the National Scientific and Technical Research Council in Argentina (CONICET) [PIP 112 2011-010-0974 to AGS]. Work related to evaluation of biological samples was partially sponsored by the Pan-American Health Organization (PAHO) [Small Grants Program PAHO-TDR]; the Drugs and Neglected Diseases Initiative (DNDi, Geneva, Switzerland), Wellcome Trust (London, United Kingdom), SANOFI-AVENTIS (Buenos Aires, Argentina) and the National Council for Science and Technology in Mexico (CONACYT) [FONSEC 161405 to JMR].

An international study was performed by 26 experienced PCR laboratories from 14 countries to assess the performance of duplex quantitative real-time PCR (qPCR) strategies on the basis of TaqMan probes for detection and quantification of parasitic loads in peripheral blood samples from Chagas disease patients. Two methods were studied: Satellite DNA (SatDNA) qPCR and kinetoplastid DNA (kDNA) qPCR. Both methods included an internal amplification control. Reportable range, analytical sensitivity, limits of detection and quantification, and precision were estimated according to international guidelines. In addition, inclusivity and exclusivity were estimated with DNA from stocks representing the different Trypanosoma cruzi discrete typing units and Trypanosoma rangeli and Leishmania spp. Both methods were challenged against 156 blood samples provided by the participant laboratories, including samples from acute and chronic patients with varied clinical findings, infected by oral route or vectorial transmission. kDNA qPCR showed better analytical sensitivity than SatDNA qPCR with limits of detection of 0.23 and 0.70 parasite equivalents/mL, respectively. Analyses of clinical samples revealed a high concordance in terms of sensitivity and parasitic loads determined by both SatDNA and kDNA qPCRs. This effort is a major step toward international validation of qPCR methods for the quantification of T. cruzi DNA in human blood samples, aiming to provide an accurate surrogate biomarker for diagnosis and treatment monitoring for patients with Chagas disease.

Histoplasmosis due to Histoplasma capsulatum var capsulatum is a frequent systemic fungal infection in the Americas. Diagnostic and therapeutic options differ between North and South America. Disseminated histoplasmosis is an AIDS-defining infection. Prognostic factors of potentially severe presentations must be evaluated in order to facilitate the initial therapeutic choice.Patients with HIV with disseminated infections presenting with severe pulmonary and renal impairment have a poor prognosis. Cutaneous presentations are more frequent in HIV patients in South America than in North America. A murine model has shown that South American isolates have a greater virulence that North American isolates. These differences are due in part to diagnostic delays in resource-poor countries.Direct examination of May-Grünwald-Giemsa-stained smears or tissues in suspected histoplasmosis is a simple means of confirming the diagnosis in resource-poor settings. Studies of prognostic factors should further refine indication criteria to guide first-line treatment choice between amphotericin B and itraconazole. The association of tuberculosis and histoplasmosis is frequent in HIV patients and presents diagnostic and therapeutic challenges that may be difficult to resolve in resource-poor settings. It is important that affordable generic drugs for treating histoplasmosis be made widely available in resource-poor countries.

Resume Introduction La paracoccidioidomycose est une mycose profonde due a un champignon dimorphique : Paracoccidioides brasiliensis . Le principal foyer d’endemie est le Bresil. Nous decrivons le premier cas de paracoccidioidomycose, dans sa forme cutaneo-muqueuse, diagnostique en Guyane Francaise. Observation Un homme de 20 ans d’origine bresilienne, residant en Guyane depuis quelques mois, consultait pour des lesions cutanees multiples disseminees mais predominant au visage comprenant de nombreux nodules et deux ulcerations. L’examen clinique revelait par ailleurs de tres volumineuses adenopathies superficielles et des ulcerations pharyngolaryngees. L’examen direct, l’examen anatomopathologique et la culture des biopsies cutanees mettaient en evidence des images specifiques de Paracoccidioides brasiliensis . La serologie VIH etait negative. Un traitement associant cotrimoxazole et itraconazole permettait la disparition des lesions en 1 mois. Discussion Il s’agit probablement dans notre observation d’une maladie d’importation car le malade venait d’arriver en Guyane. Le diagnostic differentiel principal etait la leishmaniose.

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.

Resume Introduction L’infective dermatitis est une dermatose chronique de l’enfant associee a l’infection par le HTLV-1. Nous rapportons une observation chez une enfant haitienne en Guyane francaise. Observation Une enfant de 8 ans avait une dermatose recidivante, affectant le cuir chevelu et les aisselles depuis l’âge de 2 ans. L’examen clinique initial montrait la presence de micropapules centrofaciales associees a une pyodermite narinaire. Le prelevement bacteriologique de celle-ci isolait un staphylocoque dore. Son analyse phenotypique ne montrait pas de production d’exfoliatine ni de leucocidine. La serologie pour le HTLV1 etait positive. Par ailleurs, l’enfant avait une anguillulose symptomatique recidivante malgre de nombreux traitements antihelminthiques. Un traitement par ivermectine en cure mensuelle sequentielle entrainait une guerison clinique et parasitologique. Commentaires Il s’agit du premier cas d’infective dermatitis rapporte en Guyane francaise. Le tableau clinique ayant permis le diagnostic correspond a une forme mineure de cette dermatose. L’analyse phenotypique du staphylocoque dore isole des lesions cutanees n’a pas mis en evidence les facteurs de virulence habituellement associes aux pyodermites en Guyane. Il s’agit du premier cas d’association d’une anguillulose digestive chronique, parasitose classiquement associee a l’infection par le HTLV-1 chez l’adulte, a une infective dermatitis.

We aimed to identify prognostic factors for AIDS-associated disseminated histoplasmosis. In a multivariate analysis, we found that dyspnea, a platelet count of100,000 platelets/mm3, and lactate dehydrogenase levels of2 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.

A serologic survey for Toxoplasma gondii in 18 free-ranging forest mammal species (n = 456) in French Guiana was undertaken with a direct agglutination test. Serum antibody prevalence varied from 0-71%. The relationships between ecologic features of the species and seroprevalence were investigated. Terrestrial mammals were significantly more exposed to T. gondii than other mammals. This result is concordant with oral exposure to T. gondii related to ground dwelling behavior and/or carnivory.

Histoplasmosis is an endemic fungal infection that causes no symptoms or minor self-limited illnesses in most cases. Severe forms are commonly reported in patients with immunodeficiency disorders; histoplasmosis is considered to be an opportunistic infection in patients with AIDS. We report a case of disseminated histoplasmosis in a patient with no induced active suppression of the immune response. The infection was fulminant, and antifungal treatment was delayed because of a misdiagnosis of tuberculosis.

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.

Introduction Les cryptococcoses disseminees des patients vivant avec le VIH sont bien decrites dans la litterature a contrario des patients consideres comme immunocompetents. Nous decrivons six observations de cryptococcose disseminee chez des patients non infectes par le VIH en pointant les particularites clinico-epidemiologiques et mycologiques. Parallelement, nous rapportons les resultats des explorations immunologiques visant a rechercher un eventuel « deficit immunitaire sous-jacent et meconnu ». Materiels et methodes Une etude prospective a ete menee de 2011 a 2016. Six patients ont ete identifies comme presentant une cryptococcose disseminee sans facteurs de risque evidents. En plus d’un bilan immunologique initial comprenant les serologies VIH et HTLV1, l’immunophenotypage des lymphocytes circulants, le dosage ponderal des immunoglobulines, un bilan plus specifique avec l’etude de l’axe interferon gamma, la recherche d’anticorps anti-GM CSF et le sequencage du gene STAT1 a ete realise pour chacun des cas. Resultats Les patients etaient principalement de jeunes hommes avec un sex-ratio H/F de 2 et une moyenne d’âge de 26,3 ans (sd = 18,2). Le delai moyen de diagnostic depuis le debut des symptomes etait de 34,3 jours (sd = 32,8) jours avec des tableaux cliniques varies allant de la fievre prolongee au tableau d’hypertension intracrânienne severe. La localisation pulmonaire etait retrouvee chez 2 patients. Les deux patients infectes par Cryptococcus gattii ne presentaient pas de sequelles a l’inverse de ceux infectes par C. grubii . Une seule patiente presentait des anticorps anti-GM CSF. Le reste du bilan immunologique etait normal pour l’ensemble des patients. Conclusion Les cryptococcoses disseminees du patient sans facteurs de risque sont rares et rapportees de facon tres sporadiques. Elles doivent etre connues et particulierement evoquees chez des patients vivant ou revenant de Guyane, du fait des particularites cliniques fonction des souches, du mauvais pronostic potentiel de leur evolution. Bien que l’hypothese probable puisse etre la virulence de la souche de Cryptococcus sp, l’exploration de ces cas necessiterait la realisation d’un bilan immunologique exhaustif chez tous ces patients apparemment « immunocompetents ».

Diaporthe phaseolorum (syn. Phomopsis phaseoli) is a frequent fungal parasite of plants, present on all continents around the world. It has rarely been involved in human diseases. We report a case of eumycetoma with osteomyelitis of the forefoot caused by this fungus and diagnosed by molecular biology. The patient had positive HTLV-1 serology and was a farmer from French Guiana who walked barefoot. He was successfully treated with long-term oral itraconazole (400 mg/day). A review of the literature underlines the essential roles of plants and host immunosuppression in this infection and the favourable outcome with a triazole antifungal treatment.

Background Histoplasmosis is an endemic fungal infection in French Guiana. It is the most common AIDS-defining illness and the leading cause of AIDS-related deaths. Diagnosis is difficult, but in the past 2 decades, it has improved in this French overseas territory which offers an interesting model of Amazonian pathogen ecology. The objectives of the present study were to describe the temporal trends of incidence and mortality indicators for HIV-associated histoplasmosis in French Guiana. Methods A retrospective study was conducted to describe early mortality rates observed in persons diagnosed with incident cases of HIV-associated Histoplasma capsulatum var. capsulatum histoplasmosis admitted in one of the three main hospitals in French Guiana between 1992 and 2011. Early mortality was defined by death occurring within 30 days after antifungal treatment initiation. Data were collected on standardized case report forms and analysed using standard statistical methods. Results There were 124 deaths (45.3%) and 46 early deaths (16.8%) among 274 patients. Three time periods of particular interest were identified: 1992–1997, 1998–2004 and 2005–2011. The two main temporal trends were: the proportion of early deaths among annual incident histoplasmosis cases significantly declined four fold (χ2, p, Author Summary Histoplasmosis is an endemic fungal infection in French Guiana. It is the most common AIDS-defining illness and the leading cause of AIDS-related deaths. Diagnosis is difficult, but in the past 2 decades, it has improved. The objectives of the present study were to describe the temporal trends of incidence and mortality indicators for HIV-associated histoplasmosis in French Guiana. A retrospective study was conducted to describe early mortality rates observed in persons diagnosed with incident cases of HIV-associated histoplasmosis admitted in one of the three main hospitals of French Guiana between 1992 and 2011. Early mortality was defined by death occurring within 30 days after antifungal treatment initiation. Data were collected on standardized case report forms and analysed using standard statistical methods. Among 274 patients there were 46 early deaths (16.8%). The two main temporal trends were: the proportion of early deaths significantly divided four fold and the number of annual incident histoplasmosis cases increased three fold. The present example testifies that rapid progress could be at reach if awareness increases and leads to clinical and laboratory capacity building in order to diagnose and treat this curable disease.

Diagnosis: lacaziosis, or lobomycosis [1]. The diagnosis was confirmed by direct examination of the skin biopsy, highlighting the presence of round or oval yeastlike organisms 6–12 μm in diameter, either isolated or in chains, with a birefringent membrane (Figure 1). The periodic acid-Schiff–stained and the Gomori-Grocott methenamine silver–stained sections of the sample revealed short chains of lemon-shaped fungal cells connected by thin, tubelike bridges (Figure 2). Morphology was consistent with the appearance of Lacazia loboi. There was a minor improvement of the lesion after pentamidine treatment, whereas the Leishmania research by microscopic examination, culture, and molecular biology was negative. However, these exams were done after treatment initiation, so an initial coinfection cannot be ruled out. Mycological culturesonSabouraud-gentamicin-cycloheximide withandwithout actidionewereperformedandwerenegativeafter 2 months. The patient is currently under treatment with terbinafine (250 mg twice daily), awaiting surgical excision of the lesion. Lacaziosis, or lobomycosis [1], is a chronic infectious disease that was first described in 1930 in Brazil by the dermatologist Jorge Lobo [2]. Since then, >500 human cases have been reported [3], mainly in Central and South America. The etiological agent, Lacazia loboi ( formerly known as Loboa loboi), an Onygenales dimorphic fungus [4], seems to be saprophytic in vegetation, soil, and water. It gains access to the skin following cutaneous traumatism, or animal bites [5]. After the initial lesion, there is a slow local dissemination period leading to pleomorphic lesions. The typical clinical aspect is generally multiple keloidal lesions, with a smooth, shiny aspect, but can also appear as papules, nodules, ulcers, sclerodermiform, or verrucous plaques [6]. These lesions are painless and hypoor hyperchromic. Clinical diagnosis is generally difficult because of pathology scarcity and frequently atypical cases. For example, infiltrated plaque-type lesions can be mistaken for cutaneous leishmaniasis; lesions with a keloidal aspect can be mistaken for lepromatous leprosy [7]; and lesions with a verrucous, vegetating, or nodular aspect can be mistaken for sporotrichosis, chromoblastomycosis, paracoccidioidomycosis, keloids, or neoplastic processes [6]. The diagnosis is based onmacroscopic examination of the lesions and on direct microscopic examination of biopsy or curettage. The diagnostic feature of Lacazia loboi is the chain of samesized buds, unlike Paracoccidioides, whose buds are smaller than the mother cell. Figure 1. Skin biopsy: round or oval yeast-like organisms from 6 to 12 μm in diameter, isolated or in chains with a bi-refringent membrane; direct microscopic examination (×1000 magnification). Figure 2. Skin biopsy section. Short chains of lemon-shaped fungal cells connected by thin, tubelike bridges (arrow). A, Periodic acidSchiff stain. B, Gomori-Grocott methenamine silver stain (×1000 magnification).

Histoplasma capsulatum is responsible for histoplasmosis, a fungal disease with worldwide distribution that can affect both immunocompromised and imunocompetent individuals. During the highly active antiretroviral therapy (HAART) era, morbidity and mortality due to histoplasmosis remained a public heatlh problem in low-income and high-income countries. The true burden of HIV-associated histoplasmosis is either not fully known or neglected since it is not a notifiable disease. Progress has been made in DNA patterns of strains and understanding of pathogenesis, and hopefully these will help identify new therapeutic targets. Unfortunately, histoplasmosis is still widely mistaken for multidrug-resistant tuberculosis, leading to numerous avoidable deaths, even if they are easily distinguishable. The new diagnostic tools and therapeutics developments have still not been made available in most endemic regions. Still, recent developments are promising because of their good clinical characteristics and also because they will be commercially available and affordable. This review of published data and gaps may help define and guide future research.

International audience; In disease-endemic areas, histoplasmosis is the main differential diagnosis for tuberculosis among human immunodeficiency virus (HIV)-infected patients. However, no study has compared the two diseases. Thus, the objective of this study was to compare tuberculosis and histoplasmosis in HIV-infected patients. A population of 205 HIV-infected patients (99 with tuberculosis and 106 with histoplasmosis) hospitalized in Cayenne, French Guiana during January 1, 1997-December 31, 2008 were selected retrospectively from the French Hospital Database on HIV. Multivariate analysis showed that tuberculosis was associated with cough (adjusted odds ratio [AOR] = 0.20, 95% confidence interval [CI] = 0.05-0.73) and a C-reactive protein level > 70 mg/L (AOR = 0.98, 95% CI = 0.97-0.99). Variables associated with disseminated histoplasmosis were a γ-glutamyl transferase level > 72 IU/L (AOR = 4.99, 95% CI = 1.31-18.99), origin from French Guiana (AOR = 5.20, 95% CI = 1.30-20.73), disseminated localization (AOR = 6.40, 95% CI = 1.44-28.45), a concomitant opportunistic infection (AOR = 6.71, 95% CI = 1.50-29.96), a neutrophil count < 2,750 cells/mm(3) (AOR = 10.54, 95% CI = 2.83-39.24), a CD4 cell count < 60 cells/mm(3) (AOR = 11.62, 95% CI = 2.30-58.63), and a platelet count < 150,000/mm(3) (AOR = 19.20, 95% CI = 3.35-110.14). Tuberculosis and histoplasmosis have similarities, but some factors show a greater association with one of these diseases. Thus, adapted therapeutic choices can be made by using simple clinical and paraclinical criteria.

We report a case of invasive gastric infection caused by Monascus ruber observed in a patient from French Guiana with gastric adenocarcinoma. The originality of this case is that, first, this invasive mycosis is extremely rare and, second, the probable mode of infection was by the consumption of Monascus ruber -contaminated food.

In South America, disseminated histoplasmosis due to Histoplasma capsulatum var. capsulatum (H. capsulatum), is a severe and frequent opportunistic infection in AIDS patients. In areas outside the USA where specific-Histoplasma antigen detection is not available, the diagnosis is difficult. With the galactomannan antigen (GM) detection, a test commonly used for invasive aspergillosis diagnosis, there is a cross-reactivity with H. capsulatum that can be helpful for the diagnosis of histoplasmosis. The aim of this study was to evaluate the GM detection for the diagnosis of disseminated histoplasmosis in AIDS patients. The performance of the GM detection was evaluated with serum collected in French Guiana where H. capsulatum is highly endemic. Sera from AIDS patients with disseminated histoplasmosis occurring from 2002 to 2009 and from control HIV-positive patients without histoplasmosis were tested with the GM detection and Histoplasma-specific antibody detection (IEP). In 39 AIDS patients with proven disseminated histoplasmosis, the sensitivity of the Histoplasma IEP was only 35.9% and was linked to the TCD4+ lymphocyte level. For the GM detection, the sensitivity (Se) was 76.9% and specificity (Sp) was 100% with the recommended threshold for aspergillosis diagnosis (0.5). The test was more efficient with a threshold of 0.4 (Se: 0.82 [95% CI: 0.66-0.92], Sp: 1.00 [95% CI: 0.86-1.00], LR+: >10, LR-: 0.18). This study confirms that the GM detection can be a surrogate marker for the diagnosis of disseminated histoplasmosis in AIDS patients in endemic areas where Histoplasma EIA is not available.

International audience; Histoplasmosis is the first cause of acquired immunodeficiency syndrome (AIDS) and AIDS-related deaths in French Guiana. Cohort data were used to determine whether primary prophylaxis with 100 mg itraconazole for patients with CD4 counts < 150/mm(3) was cost-effective with different scenarios. For a scenario where 12% of patients died, 60% were aware of their human immunodeficiency virus (HIV) infection and adherence was only 50%, primary prophylaxis would prevent 1 death and 9 cases of histoplasmosis for a cost of 36,792 Euros per averted death, 1,533 per life-year saved, 4,415 Euros per averted case, when only counting the costs of itraconazole prophylaxis. Taking into account the total costs of hospitalization showed that primary prophylaxis would allow a savings of 185,178 Euros per year. Even in a scenario of low adherence, primary prophylaxis would be cost-effective in French Guiana, and presumably in the rest of the Guianas and the Amazon.

La trypanosomose americaine ou maladie de Chagas se distingue de la trypanosomose africaine (ou maladie du sommeil) par le parasite, le vecteur et les symptomes cliniques. Cette infection parasitaire est localisee au continent americain et plus particulierement a l'Amerique latine. La maladie de Chagas n'est plus consideree aujourd'hui comme un probleme de sante publique grâce aux efforts conjugues pour le controle des vecteurs au niveau regional et des banques de sang. Il ne faut cependant pas sous-estimer la difficulte du maintien des campagnes de controle, l'existence de cycles sylvestres echappant a l'action des insecticides, et le contact des animaux reservoirs avec l'hote.

To the Editor: The Zygomycetes are a class of filamentous fungi that are ubiquitous in the environment. Most of the species known to cause human or animal infections belong to a few genera within the order Mucorales. Saksenaea vasiformis, isolated from soil in India and described by Saksena in 1953, was reported to cause human infection for the first time by Ajello et al. (1). We report a case of a cutaneous lesion caused by S. vasiformis in French Guiana. A nonimmunocompromised 47-year-old woman with a long history of non–type 1 diabetes mellitus, who had lived in French Guiana for many years, was admitted to Cayenne Hospital on November 18, 2005, with a cutaneous lesion of the abdominal wall and a fever that had lasted for 5 days before she was hospitalized. A skin biopsy specimen was obtained, and the first surgical debridement was performed on day 4 of hospitalization. A diagnosis of zygomycosis was made after direct examination and histopathologic examination of the tissue samples. Treatment was initiated on day 8, beginning with liposomal amphotericin B and itraconazole for 10 days, followed by liposomal amphotericin B alone for 12 days. Persistence of necrotic tissues at the infection site required additional surgical debridement on day 10. Histopathologic examination of the resected tissues showed damaged hyphae of zygomycetes. Resolution of clinical signs was excellent. Additional biopsy specimens taken by the end of treatment on day 21 were negative for fungi by direct examination and culture. Finally, a cicatrix was formed. Histologic examination of the initial excised tissues showed a localized periumbilical cutaneous lesion of 14 cm × 13 cm. The skin was covered by a 1-mm layer of necrosis. The necrosis extended into all the abdominal adipose tissue at the rectus abdominis muscle and linea alba. Microscopy examination showed extensive superficial mycotic proliferation, with wide and irregular ribbonlike nonseptate hyphae and right-angle branching. These hyphae extended toward the hypodermic fat tissues and were associated with a break in the cell membrane of adipocytes and with crystals inside the adipocytes. These lesions were associated with massive nonsuppurative vascular thrombosis. Culture of tissues samples on Sabouraud-chloramphenicol-gentamicin agar after 4 days at 30°C and 37°C grew a white aerial mold, which covered the entire surface of the agar. Examination by microscopy showed nonseptate sterile hyphae typical of a zygomycete. The fungal isolate was sent to the National Reference Center for Mycology and Antifungals at the Institut Pasteur, Paris. Subcultures on different media including malt extract agar and potato dextrose agar grew sterile mycelia. The isolates were then cultured in nutritionally deficient medium consisting of sterile distilled water supplemented with 0.05% filter-sterilized yeast extract (Difco, Becton, Dickinson and Company, Sparks, MD, USA) solution for 7 days at 37°C (2). Typical flask-shaped sporangia enabled identification of S. vasiformis (Figure). Sporulation also occurred on Czapek agar after 7 days’ incubation at 37°C. Figure Microscopic characteristics of the isolate of Saksenaea vasiformis cultured on Czapek agar. A) Typical flask-shaped sporangia (scale bar = 25 μm) containing B) smooth-walled, rectangular sporangiospores (scale bar = 10 μm). Molecular identification based on PCR amplification and sequencing of rDNA internal transcribed spacer (ITS) regions was also performed. Briefly, mycelia were grown in liquid Roswell Park Memorial Institute medium, and DNA was extracted as previously described (3). Ribosomal DNA, including the complete ITS1–5.8S-ITS2 region, was amplified with the fungal universal primer pairs V9D/LS266 (4) and ITS1/ITS4 (5), and both strands of PCR products were sequenced. The sequence has been deposited in GenBank (accession no. {"type":"entrez-nucleotide","attrs":{"text":"EU182902","term_id":"158323875"}}EU182902). Sequence alignment with the only S. vasiformis ITS sequence available in the GenBank database showed 82% similarity over 530 bp. This low degree of sequence homology is probably reflective of the need for further phylogenetic study of this genus. Sporulation on Czapek agar enabled preparation of a sporangiospore suspension used for antifungal susceptibility testing. Sporangiospore suspension was counted microscopically and adjusted to the required density. MICs, determined by the EUCAST reference microdilution method (6), after 48 h of incubation were >8, 2, >8, 0.5, and >8 µg/mL for amphotericin B, itraconazole, voriconazole, posaconazole, and caspofungin, respectively. The MIC of 0.5 µg/mL for posaconazole suggests the potential clinical utility of this agent. S. vasiformis has been isolated from soil samples in different parts of the world (7). This fungus has been rarely responsible for human infections. A recent review (8), which did not include infrequently cited articles (9,10), found only 30 human cases. This scarcity may occur because the diagnosis is often based on histologic features and S. vasiformis does not sporulate in routine mycology media. Due to zygomycetes’ lack of susceptibility to most of the antifungal agents, identification of a zygomycete as the etiologic agent of an infection is essential for rapid and accurate management of the disease. Rare Zygomycetes species such as S. vasiformis or Apophysomyces elegans should be suspected when a nonsporulating zygomycete is isolated from an infected lesion. When this acute infection is suspected after examination of tissue by microscopy, the fungi should be cultured in specific culture media to induce sporulation or they should be identified by molecular tools.

Immune reconstitution after HAART initiation is often complicated by adverse clinical manifestations caused either by the unmasking of preexisting untreated opportunistic infections or the clinical deterioration of a known and treated opportunistic infection. The present study was conducted to determine whether the initiation of HAART was followed by an increase in the incidence of mucosal candidiases, a possible manifestation of immune reconstitution disease of the unmasking type.

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.

Resume Introduction Histoplasma capsulatum var capsulatum est un champignon dimorphique, principalement present sur le continent americain. Il est responsable de l’histoplasmose disseminee associee au SIDA. La presentation sous la forme d’une ulceration cutanee est inhabituelle et trompeuse. Observation Un homme de 25 ans consultait en raison de la survenue de 3 ulcerations, de 2 a 4 cm de diametre, localisees a la levre inferieure et aux genoux. Il existait un etat febrile, une alteration de l’etat general et un syndrome interstitiel pulmonaire. Le malade etait seropositif pour le virus de l’immunodeficience humaine (VIH). Son taux de lymphocytes CD4+ etait a 1/mm 3 . Le diagnostic d’histoplasmose etait etabli par l’examen direct et la culture des ulcerations cutanees et du liquide de lavage broncho-alveolaire. Discussion L’aspect clinique des localisations cutanees de l’histoplasmose disseminee est habituellement celui de lesions multiples disseminees a type de papules ou de nodules. Les ulcerations ne representent que moins de 20 p. 100 des cas decrits. Chez le malade presente, l’aspect des lesions faisait avant tout penser a une leishmaniose cutanee. L’examen mycologique direct puis les cultures ont permis le diagnostic.