François Vachon

Let it be sexual: how health care transmission of AIDS in Africa was ignored

The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in African adults emerged no later than 1988. We examine evidence available through 1988, including risk measures associating HIV with sexual behaviour, health care, and socioeconomic variables, HIV in children, and risks for HIV in prostitutes and STD patients. Evidence permits the interpretation that health care exposures caused more HIV than sexual transmission. In general population studies, crude risk measures associate more than half of HIV infections in adults with health care exposures. Early studies did not resolve questions about direction of causation (between injections and HIV) and confound (between injections and STD). Preconceptions about African sexuality and a desire to maintain public trust in health care may have encouraged discounting of evidence. We urge renewed, evidence-based, investigations into the proportion of African HIV from non-sexual exposures.

Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm

In North America Europe and many parts of Asia the ignition of regional epidemics and rapid HIV transmission has been associated principally with the sharing of contaminated injecting equipment and with anal intercourse. Though heterosexual intercourse has been virtually the sole explanation offered for the AIDS epidemic in sub-Saharan Africa to our knowledge in no other part of the world has penile-vaginal exposure (as opposed to “heterosexual sex”) been demonstrated to initiate or sustain rapid HIV propagation. HIV is not transmitted by “sex” but only by specific risky practices. It is not transmitted by “injections” but only by contaminated implements which need to be clearly differentiated as to type and frequency of injection and by the conditions of the exposure setting. In virtually all societies affected by HIV to date both routes seem to play important roles. If we are to understand and intervene in each of these epidemics well-designed studies at both the population and individual levels are urgently needed. It is vital that these be properly controlled for parenteral exposure specific sexual practices and other co-factors and the complex and specific social patterns and networks that accompany them. (excerpt)

Resurgence of Blackwater Fever in Long-Term European Expatriates in Africa: Report of 21 Cases and Review

Blackwater fever (BWF) is a severe clinical syndrome, characterized by intravascular hemolysis, hemoglobinuria, and acute renal failure that is classically seen in European expatriates chronically exposed to Plasmodium falciparum and irregularly taking quinine. BWF virtually disappeared after 1950, when chloroquine superseded quinine. We report 21 cases of BWF seen in France from 1990 through 1999 in European expatriates who lived in sub-Saharan Africa. All patients had macroscopic hemoglobinuria, jaundice, and anemia. Acute renal failure occurred in 15 patients (71%), 7 of whom required dialysis. The presumed triggers of BWF were halofantrine (38%), quinine (24%), mefloquine (24%), and halofantrine or quinine (14%). Glucose-6-phosphate dehydrogenase (G6PD) activity was normal in the 14 patients who underwent this test. Low-level P. falciparum parasitemia was found in 8 patients. All 21 patients survived. Our data and 13 cases reported in the literature suggest a resurgence of classic BWF among Europeans living in Africa and a need to discuss attendant therapeutic implications.

ANTI-ERYTHROCYTE AUTOIMMUNISATION DURING CHRONIC FALCIPARUM MALARIA

Anaemia during malaria is not completely understood. Fourteen cases of antierythrocyte autoimmunisation with anti-I specificity were investigated in a Paris hospital during a period of 2 years. The patients lived in Gabon and had not been taking antimalarial chemoprophylaxis. All had chronic malaria (strongly positive antimalarial immunofluorescent antibody tests). All the recognised caused for anti-erythrocyte autoimmunity were excluded. One possible explanation for these observations is some sort of interaction between I antigen and Plasmodium, the result of which facilitated penetration of the erythrocyte by the malarial parasite.

Ruptured mycotic pulmonary artery aneurysm: an unusual complication of right-sided endocarditis.

Mycotic pulmonary aneurysm is an infrequently diagnosed complication of endocarditis. We report here a case of mycotic pulmonary aneurysm and a review of 25 cases from the literature. The mortality rate is greater than 50%. Prompt diagnosis is necessary because early intrasaccular embolization and/or surgical repair is essential to avoid death from rupture of the aneurysm.

Possible prognostic significance of a brief rise in parasitaemia following quinine treatment of severe Plasmodium falciparum malaria.

An increase in parasitaemia is not uncommon after initiation of treatment for Plasmodium falciparum malaria, but its exact significance is unknown. The time-course of parasitaemia was assessed retrospectively in 33 patients with severe imported malaria. In 19 patients (group 1) mean parasitaemia (+/- SEM) fell promptly after starting quinine treatment, from 24.9 +/- 4.1% on day 0 to 9.7 +/- 2.3% on day 1 and 1.8 +/- 0.7% on day 2. In 14 other patients (group 2), parasitaemia did not change significantly or increased, with mean parasitaemia (+/- SEM) of 9.5 +/- 2.1% on day 0, 17.2 +/- 2.6% on day 1, and 3.7 +/- 1.8% on day 2. Simplified acute physiology scores on admission (mean +/- SEM) were 17.4 +/- 1.4 in group 1 and 11.7 +/- 1.0 in group 2 (P = 0.006). The mean number of complications of malaria per patient (+/- SEM) was 2.9 +/- 0.5 in group 1 and 1.6 +/- 0.3 in group 2 (P = 0.046). Two group 1 patients died. Initially, more than 95% of peripheral blood parasites were tiny and small rings in both groups, and this distribution was unchanged on day 1, suggesting that the parasitaemia increase in group 2 was not due to release of sequestered mature parasites. In severe falciparum malaria, a rise in parasitaemia after treatment initiation may be of favourable prognostic significance and should not lead to aggressive therapeutic approaches such as exchange transfusion.

Fatal Invasive Aspergillosis Complicating Severe Plasmodium falciparum Malaria

We report the first 2 cases of fatal invasive aspergillosis complicating severe malaria. In 2 nonimmune European adults without underlying disease, death was directly ascribable to invasive aspergillosis. We believe that transient malaria-induced immunosuppression allowed massive growth and overwhelming dissemination of preexisting Aspergillus colonization.

Serum Carcinoembryonic Antigen: A Prognostic Marker in HIV-related Pneumocystis carinii Pneumonia

Serum concentrations of carcinoembryonic antigen (CEA) were measured in 43 consecutive patients with HIV-related Pneumocystis carinii pneumonia (PCP). The subjects were divided into 2 groups according to the severity of the PCP:PaO2 in ambient air (AA) less than or equal to 50 mmHg on admission (n = 22, group 1) and PaO2 greater than 50 mmHg (n = 21, group 2). In addition, 57 HIV patients with either non-PCP pulmonary diseases (n = 34, group 3) or extrapulmonary disease (n = 23, group 4) were studied. Mean CEA levels (ng/ml) were 13 +/- 10 in group 1 and 4.9 +/- 5.5 in group 2 (p less than 0.001). The corresponding values in groups 3 and 4 were much lower (2.7 +/- 1.8 and 2.4 +/- 1.8, respectively). In group 1, mean initial CEA levels were higher (p less than 0.001) in the patients who died (n = 6; 23.5 +/- 11) than in the survivors (n = 16; 8.9 +/- 7), although the initial mean PaO2 were identical (39 +/- 7 and 39 +/- 8 mmHg, respectively) and the initial mean LDH levels were not significantly different (1544 +/- 530 and 1200 +/- 457 IU/l). CEA levels fell during specific anti-PCP therapy associated with corticosteroids but returned to normal only in the survivors. We conclude that CEA levels are increased in patients with PCP and acute respiratory distress. Among the patients with PaO2 levels of less than or equal to 50 mmHg before treatment, only high levels of CEA (greater than 20 ng/ml) were associated with a fatal outcome, regardless of anti-PCP therapy associated with corticosteroids.(ABSTRACT TRUNCATED AT 250 WORDS)

Pitfalls in the diagnosis of airport malaria. Seven cases observed in the Paris area in 1994.

Clinical and biological pitfalls that lead to incorrect or delayed diagnoses of airport malaria are described based on 7 cases reported from the Paris region in the summer of 1994. We also report the outcome and the epidemiological features of these patients.