Gentiane Monsel

Recent developments in dermatological syndromes in returning travelers.

Purpose of review Dermatoses are one of the three most common healthcare problems in returning travelers. Knowledge of imported dermatoses among Western physicians is however limited. In order to provide more effective pretravel counseling and better posttravel diagnosis and treatment, improvement is called for. This review highlights the most recent developments regarding dermatological syndromes in returning travelers. Recent findings The spectrum of travel-related dermatoses is broad, including tropical and cosmopolitan infections as well as environmental skin diseases. New infections such as Panton–Valentine leukocidin-positive Staphylococcus aureus infections have begun to emerge in returning travelers. Localized cutaneous leishmaniasis can be managed with multiple drug therapies, but precise identification of the species allows tailored therapeutic management. Clearer definitions of cutaneous larva migrans, a syndrome, and creeping eruption, a cutaneous sign, have been established lately whereas the term hookworm-related cutaneous larva migrans is more widely used to define the corresponding disease. Lastly, chikungunya has emerged as a cause of febrile exanthema among travelers returning from endemic areas and has to be distinguished from dengue and measles. Summary Bacterial infections continue to be the main cause of consultation in returning travelers. Most of these infections are cosmopolitan and are secondary to arthropod exposure. Conversely, tropical skin infections are less commonly observed.

Anévrysmes aortiques multiples au cours d’une polychondrite atrophiante

Resume Introduction Les complications cardiovasculaires de la polychondrite atrophiante sont rares, mais representent la deuxieme cause de mortalite, apres les chondrites du tractus respiratoire ; les plus frequentes sont les valvulopathies et les anevrysmes aortiques. Observation Nous rapportons une observation de polychondrite atrophiante associee a des anevrysmes aortiques multiples, asymptomatiques mais evolutifs en depit d’une corticotherapie generale associee a un traitement immunosuppresseur. Discussion L’evolution des anevrysmes aortiques au cours de la polychondrite atrophiante n’est souvent pas parallele a celle des manifestations extravasculaires. Alors meme que la maladie semble en remission, les lesions vasculaires peuvent continuer a progresser de facon independante. Cette observation illustre les limites du traitement medical dans la prise en charge de ces anevrysmes. Ainsi, l’indication chirurgicale doit etre portee au moment opportun.

Febrile exanthema revealing toxocariasis: a case report.

Celine Bernardeschi1, Gentiane Monsel1, Camille Frances2, Francois Bricaire1, Luc Paris3 and Eric Caumes1* 1Tropical and Infectious Diseases and 3Parasitology-Mycology Departments, Pitie-Salpetriere Hospital, 47-83 Boulevard de l’Hopital, FR-75013 Paris, and 2Department of Dermatology, Hopital Tenon, Universite Pierre et Marie Curie-Paris 6, Paris, France. *E-mail: eric.caumes@psl.aphp.fr Accepted September 27, 2010.

Marine envenomations in returning French travellers seen in a tropical diseases unit, 2008–13

BACKGROUND Travel and aquatic activities are increasing in tropical regions. The risk and the spectrum of marine envenomation are unknown in travellers. This work aims to evaluate the prevalence and the characteristics of marine envenomations in returning travellers. METHODS We retrospectively studied the medical charts of all returning travellers presenting with a health problem in a French tropical disease unit between 2008 and 2013, with focus on travellers complaining of marine envenomation. Characteristics of each type of envenomation are described. RESULTS Of the 3315 travellers seen during the study period, 43 consulted for a presumed marine envenomation. Six patients were excluded, leaving 37 cases of confirmed marine envenomation. It corresponds to a prevalence of 1.1%. Sex ratio was balanced with 18 men and 19 women. Median age was 42 years (range 25-68 years). Median travel duration was 14 days (range: 6-62 days). The main travel destination was Southeast Asia in 10 cases, followed by islands of East Africa in seven cases. Median elapsed time between envenomation and consultation was 14 days (range: 2-130 days). The purpose of travel was tourism in all cases. The main clinical aspects were oedema, sting marks, cellulitis and flagellations. Eleven cases were presumably caused by corals, 10 by stonefish, 8 by jellyfish, 2 by weever fish, 2 by starfish, 2 by stingray, 1 by lionfish and 1 by sea anemone. CONCLUSION Prevalence of marine envenomation is low in returning travellers. They are mostly caused by corals, stonefish and jellyfish.

Neurological presentation of schistosomiasis

In June, 2012, a 25-year-old woman presented to our clinic with a 3-month history of excruciating lower back pain radiating to both legs and lower limb weakness. She had been healthy until March, 2012, when she experi enced recurrent episodes of right sciatic nerve pain, with increasing frequency and night predominance. These episodes of pain were associated with right ankle instability, leading to an ankle sprain. The patient described intense dysaesthesias in both legs but stated she had no fever, weight loss, headaches, or stiff ness. On examination, right-side predominant proximal lower limb weakness was noted. Muscle bulk was normal. Deep tendon refl exes were diminished in lower limbs. Flexor plantar responses were elicited bilaterally. She had no tactile sensory loss, but decreased vibration sense was noted in lower limbs. Neurological examination of upper limbs and cranial nerves was normal. She had no anal sphincter dysfunction. Spinal cord MRI showed a diff use contrast enhancement of the cauda equina and a nodular lesion in the conus medullaris. This imaging fi nding suggested a tumoral or granulomatous lesion (fi gure). Lumbar punc ture was normal except for increased protein content (0·88 g/L). Standard biological tests were unremarkable. Mild hypereosinophilia was noted on one occasion (600 cells per mm3). After 1 week, a second lumbar puncture showed 21 white cells per mm3 (91% lymphocytes, 7% granulocytes, 2% others), raised protein content, and normal glucose concentrations. 2 days later, a third lumbar puncture showed similar results. Thoraco-abdominal CT, pelvic ultrasound examination, breast ultra sound examination, and mammography were normal. Heart MRI, angiotensinconverting enzyme, and ventila tory function tests were also normal. Whole body PET scan showed intense uptake in conus medullaris and cauda equina. Before doing a meningeal biopsy, we decided to do a fourth lumbar puncture, 14 days after the third one. Pathological examination showed few eosino philic cells in CSF. The diagnosis of spinal cord schistosomiasis was considered. Schistosoma haematobium eggs were identifi ed on a centrifuged urine sample. Serological testing for S haematobium was positive. Haemagglutination and immuno fl uorescence titres were 1/128 and 1/100, respectively. The patient remembered bathing in a river in Pays Dogon-Mali 2 years earlier. Treatment with steroids after pretreatment by ivermectin to prevent malignant strongyloidiasis was administered (methylprednisolone 1 mg/kg once, followed by prednisone 1 mg/kg daily). Specifi c anti parasitic drug therapy was initiated with high dose praziquantel (80 mg/kg) in two parts to prevent drug interactions between praziquantel and steroids. Steroids were stopped after 1 month. A second course of praziquantel was given 3 months later. Recovery was nearly complete, and pain completely disappeared. When the patient was last seen in December, 2012, only ankle instability persisted. Neurological forms of schistosomial infection are rare, even in endemic areas. In western countries, cases are exceptional and all are imported. Neurological forms consist of encephalopathy and tumour-like brain and spinal cord lesions. Usually, neuroschistosomiasis is a complication of acute or early infection. Here, symptoms appeared after a 2-year delay, which is unusual, making the diagnosis especially diffi cult in this case. Early recognition is essential to obtain optimum recovery. In our case, the presence of eosinophilic cells, although non-specifi c, was a clue to diagnosis on pathological examination on the last lumbar puncture, avoiding a risky surgical procedure. This case report illustrates the diffi culties raised by diagnoses lying at the border of diff erent specialties, particularly for diseases that are endemic in some areas but unusual in others.

Rickettsia sibirica mongolitimonae infection in a woman travelling from Cameroon: a case report and review of the literature

Rickettsia sibirica mongolitimonae is now a well-known cause of human rickettsial infection, with 52 reported cases, including 47 in southern Europe and one in South Africa. We report the first case of R. sibirica mongolitimonae in Central Africa, likely a sentinel case for a more common disease than originally suspected.

Cutaneous melioidosis: a review of the literature

Melioidosis is mainly observed in South‐East Asia, where Burkholderia pseudomallei is endemic. Cutaneous melioidosis (CM) has rarely been described and in contrast to systemic forms, there are no therapeutic recommendations to guide management.

Holistic approach in patients with presumed Lyme borreliosis leads to less than 10% of confirmation and more than 80% of antibiotics failure

BACKGROUND There is no precise idea whether patients with chronic symptoms attributed to Lyme borreliosis (LB) have LB or another disease. METHODS We evaluated patients consulting for a presumed LB with a holistic approach including presumptive treatment. We included symptomatic patients consulting for presumed LB. They were classified as confirmed LB when they met four criteria, and possible LB if three with a positive clinical response to presumptive treatment. RESULTS Amongst the 301 patients, 275 (91%) were exposed to tick bites, and 165 (54%) were bitten by a tick. At presentation, 151 patients (50.1%) had already been treated with a median of one (1-22) course of antimicrobials, during 34 (28-730) days. Median number of symptoms was three (1-12) with a median duration of 16 (1-68) months. Median number of signs was zero (0-2). ELISA was positive in 84/295 (28.4%) for IgM and 86/295 (29.1%) for IgG, and immunoblot was positive in 21/191 (10.9%) for IgM and 50/191 (26.1 %) for IgG. Presumptive treatment after presentation failed in 46/88 patients (52%). Diagnosis of LB was confirmed in 29 patients (9.6%), and possible in 9 (2.9%). Of the 243 patients with non-LB diagnosis, diseases were psychological, musculoskeletal, neurological or other origin in 76 (31.2%), 48 (19.7%), 37 (15.2%) and 82 (33.7%) patients respectively. Patients with other diseases were significantly younger, having more symptoms, longest duration of symptoms, less clinical signs and less frequent LB positive serologies. CONCLUSIONS Overdiagnosis and overtreatment of LB is worsening. Health authorities should investigate this phenomenon.

Itch, Infections and Infestations

Itch is one of the leading skin complaints in patients presenting with skin infections, more particularly in case of skin infestation by mites or insects. Pruritus may be either localized or generalized. The spectrum of pruritic dermatoses of infectious origin includes exotic and cosmopolitan infections, mostly related to helminths or to ectoparasites.

Dermatologic Presentations of Tropical Diseases in Travelers

Dermatoses are one of the three most common presenting health care problems in returning travelers. The spectrum of travel-related dermatoses is broad, and includes tropical, cosmopolitan, and environmental skin diseases. Bacterial infections are the main cause of skin consultations in returning travelers. Most of these infections are not specific to the tropics and are the consequences of arthropod bites. Conversely, tropical skin infections are less commonly observed. Knowledge of imported dermatoses among Western physicians is limited, even though it is becoming increasingly important that doctors be able to recognize and differentiate between the diverse varieties of diseases. This review highlights the most recent developments regarding dermatologic presentations of tropical diseases in travelers in order to provide more effective pre-travel counseling and an up-to-date aid to post-travel diagnosis and treatment.