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Background Maintenance ART with dolutegravir-based dual regimens have proved their efficacy among HIV-1-infected subjects in randomized trials. However, real-life data are scarce, with limited populations and follow-up. Objectives We assessed virological failure (VF) and resistance-associated mutations (RAMs) on dolutegravir maintenance regimens in combination with rilpivirine or with lamivudine or emtricitabine (xTC) and analysed the factors associated with VF. Methods Between 2014 and 2018, all HIV-1-infected adults included in the Dat’AIDS cohort and starting dolutegravir/rilpivirine or dolutegravir/xTC as a maintenance dolutegravir-based dual regimen were selected. VF was defined as two consecutive HIV RNA values >50 copies/mL or a single value >400 copies/mL. We compared cumulative genotypes before initiation of a maintenance dolutegravir-based dual regimen with genotype at VF. Results We analysed 1374 subjects (799 on dolutegravir/rilpivirine and 575 on dolutegravir/xTC) with a median follow-up of 20 months (IQR = 11–31) and 19 months (IQR = 11–31), respectively. VF occurred in 3.8% (n = 30) of dolutegravir/rilpivirine subjects and 2.6% (n = 15) of dolutegravir/xTC subjects. Among subjects receiving dolutegravir/rilpivirine, two genotypes harboured emerging RAMs at VF: E138K on NNRTI (n = 1); and E138K+K101E on NNRTI and N155H on INSTI (n = 1). Among subjects receiving dolutegravir/xTC, no new RAM was detected. The only predictive factor of VF on dolutegravir/rilpivirine was the history of failure on an NNRTI-based regimen (adjusted HR = 2.97, 95% CI = 1.28–6.93). No factor was associated with VF on dolutegravir/xTC. Conclusions In this large real-life cohort, dolutegravir/rilpivirine and dolutegravir/xTC sustained virological suppression and were associated with a low rate of VF and RAM emergence. Careful virological screening is essential before switching to dolutegravir/rilpivirine in virologically suppressed patients with a history of NNRTI therapy.

BackgroundIntegrase strand transfer inhibitors (INSTIs) are increasingly used in patients living with HIV due to their safety, effectiveness and high genetic barrier. However, an association with weight gain has recently been suggested and several cases of diabetes mellitus have been reported with raltegravir and dolutegravir. The long-time metabolic impact of these recent molecules remains unclear.ObjectivesTo assess if an INSTI as a third agent is statistically associated with new-onset diabetes mellitus compared with an NNRTI or a PI.Patients and methodsPatients undergoing first-line combined ART (cART) without diabetes at baseline were retrospectively included from the Dat’AIDS French cohort study (ClinicalTrials.gov NCT02898987). Incident diabetes mellitus was defined as a notification of new diabetes in the medical history, a glycated haemoglobin (HbA1c) level superior to 7.5% or the start of a diabetes therapy following the initiation of ART.ResultsFrom 2009 to 2017, 19 462 patients were included, among which 265 cases of diabetes mellitus occurred. Multivariate and survival analyses did not highlight an increase in new-onset diabetes in patients undergoing cART with an INSTI as a third agent compared with an NNRTI or a PI. BMI >30 kg/m2, age >37 years old (in survival analysis), black race or Hispanic ethnicity, arterial hypertension and AIDS were associated with a higher proportion of incident diabetes.ConclusionsINSTIs were not statistically associated with new-onset diabetes. However, clinicians should remain aware of this possible metabolic comorbidity, particularly in patients with a high BMI and older patients.

Background In late 2013, France was one of the first countries to recommend initiation of combination antiretroviral therapy (cART) irrespective of CD4 cell count. Methods To assess the impact of achieving the second and third Joint United Nations Programme on HIV/AIDS 90-90-90 targets (ie, 90% of diagnosed people on sustained cART, and, of those, 90% virologically controlled) on human immunodeficiency virus (HIV) incidence, we conducted a longitudinal study to describe the epidemiology of primary HIV infection (PHI) and/or recent HIV infection (patients with CD4 cell count ≥500/mm3 at HIV diagnosis; (PRHI) between 2007 and 2017 in a large French multicenter cohort. To identify changes in trends in PHI and PRHI, we used single breakpoint linear segmented regression analysis. Results During the study period, 61 822 patients were followed in the Dat’AIDS cohort; 2027 (10.0%) had PHI and 7314 (36.1%) had PRHI. The second and third targets were reached in 2014 and 2013, respectively. The median delay between HIV diagnosis and cART initiation decreased from 9.07 (interquartile range [IQR], 1.39–33.47) months in 2007 to 0.77 (IQR, 0.37–1.60) months in 2017. A decrease in PHI (−35.1%) and PRHI (−25.4%) was observed starting in 2013. The breakpoints for PHI and PRHI were 2012.6 (95% confidence interval [CI], 2010.8–2014.4) and 2013.1 (95% CI, 2011.3–2014.8), respectively. Conclusions Our findings show that the achievements of 2 public health targets in France and the early initiation of cART were accompanied by a reduction of about one-third in PHI and PRHI between 2013 and 2017. Clinical Trials Registration NCT02898987.

Introduction Les adolescents sont fortement exposes aux risques lies a la sexualite, qu’ils aient trait aux infections sexuellement transmissibles, violences sexuelles ou grossesses non desirees. Materiels et methodes CAPSEX est une enquete transversale multicentrique realisee en 2017–18 dans une population de lyceens scolarises en Seconde generale/technologique ou professionnelle, dans 2 regions administratives, reunis par sondage en grappe. Le recueil des donnees a fait appel a un auto-questionnaire en ligne. L’objectif de l’etude etait d’evaluer les connaissances, attitudes, pratiques en matiere de sante affective et sexuelle chez ces adolescents. Resultats Un total de 2247 eleves ont ete inclus (taux de participation = 73,5 %). Les resultats obtenus en entre les 2 regions etaient similaires. Globalement 86,2 % (n = 1926) des participants sont âges de 15 a 16 ans au moment de l’enquete, et 38,9 % declarent avoir deja eu un rapport sexuel (RS). Les connaissances de prevention sont insuffisantes avec une dissociation entre connaissances et pratiques: 91,6 % (n = 2056) des eleves citent le preservatif masculin comme un moyen de prevention des IST ou des grossesses, tandis que 44 % (n = 387) des eleves ayant declare avoir eu au moins un RS indiquent avoir utilise un moyen de prevention lors de leur premier RS. Les connaissances sur la contraception melaient le vrai et le faux dans 76,6 % des cas (n = 1716). L’interlocuteur privilegie des adolescents pour parler de sexualite est un membre de la famille pour 62,1 % (n = 1400), alors que seuls 19,6 % (n = 443) font confiance a un professionnel de sante. Les attitudes a l’egard de l’homosexualite sont frequemment negatives, avec 40,4 % (n = 908) a y voir « une sexualite contre nature ». Les attitudes face aux grossesses precoces sont favorables chez 12,7 % (n = 294) et les antecedents de grossesse frequents (9,7 % des filles ayant eu des RS, n = 41). Parmi les filles ayant deja eu des RS, 29,4 % (n = 114) declarent avoir deja eu recours a la contraception d’urgence. Deux tiers des participants (65,8 %, n = 1474) percevaient le VIH comme une infection potentiellement mortelle. L’exposition a la pedopornographie est importante: 73,4 % (n = 644) ont deja vu des images ou videos d’adolescents nus qu’ils connaissent. Les antecedents de violence sont nombreux, 15,8 % des filles (n = 235; 5,1 % de non-reponse) ont deja ete victimes de violence sexuelle, attouchement ou viol. Conclusion Le taux de participation temoigne de l’acceptabilite de la recherche parmi les personnels de l’Education nationale, les eleves et leurs parents, malgre de fortes contraintes reglementaires fixees par le protocole. Les donnees collectees paraissent de bonne qualite. CAPSEX offre une typologie des risques sexuels auxquels sont confrontes les adolescents dans ces 2 regions. Elle permettra une meilleure adaptation des actions educatives au contexte.

Summary A retrospective cohort study was conducted to determine the incidence and the predictive factors of depression in a cohort of 2737 HIV/AIDS-infected patients in Guadeloupe followed for a total of 8402 patient-years. The incidence rate of first observed depression was 2.2 per 100 person-years (95% confidence interval [CI], 1.9–2.6). A single failure Cox proportional hazards model showed that the 1997–2000 inclusion period (hazard ratio [HR] = 1.60; 95% CI = 1.10–2.40; p = 0.01), the 2001–2009 inclusion period (HR = 1.50; 95% CI = 1.02–2.40; p = 0.04), the more advanced CDC stage (HR = 2.30; 95% CI = 1.30–3.10; p = 0.000) and the annual frequency of visits > 10 (HR = 2.30; 95% CI = 1.70–3.30; p = 0.000) were associated with an increased risk of depression. Incidence of depression in this HIV cohort was high and the hazard function showed three peaks of depression (2, 7 and 12 years). Physicians should be vigilant to psychological distress throughout life with HIV.

International audience; Since the pathogen ecology differs between Caribbean regions, specific differences in the most frequent clinical presentations of acquired immunodeficiency syndrome (AIDS) may be expected. We therefore conducted the present retrospective cohort study in order to describe the main AIDS-defining events in Guadeloupe and to compare them with those observed in Metropolitan France and in French Guiana. We discuss the local pathogen ecology, the diagnostic limitations of hospitals in overseas territories and the drivers of the epidemic.

International audience; Direct-Acting Antivirals (DAAs) opened a new era in HCV treatment. We report the impact of HCV treatment in French HIV-HCV coinfected patients. METHODS: All HIV-HCV patients from the Dat'AIDS cohort followed between 2012 and 2015 were included. HCV status was defined yearly as naive, spontaneous cure, sustained virological response (SVR12), failure or reinfection. RESULTS: Among 32,945 HIV-infected patients, 15.2% were positive for anti-HCV antibodies. From 2012 to 2015, HCV incidence rate increased from 0.35%PY to 0.69%PY in MSM, while median incidence was 0.08%PY in other patients. Median reinfection rate was 2.56%PY in MSM and 0.22%PY in other patients. HCV treatment initiation rate rose from 8.2% in 2012 to 29.6% (48.0% in pre-treated patients vs 22.6% in naïve patients). SVR12 rate increased from 68.7% to 95.2%. By the end of 2015, 62.7% of the patients were cured either spontaneously or following SVR. CONCLUSIONS: HCV treatment dramatically increased in HIV-HCV patients in France from 2012 to 2015 resulting in HCV cure in nearly two-thirds of the patients in this cohort. Combined with a declining HCV prevalence, the prevalence of active HCV infection among HIV patients will drastically decrease in the forthcoming years.

Introduction L’accueil de sujets victimes de violences sexuelles necessite une prise en charge multidisciplinaire faisant intervenir de nombreux acteurs (police judiciaire, unite medico-judiciaire, gynecologue, psychologue) L’infectiologue intervient souvent en fin de parcours, pour la prise en charge du risque infectieux. Un traitement post-exposition pour le VIH est recommande en cas de viol. Bien qu’il s’agisse d’un probleme relativement frequent, il y a peu d’informations sur les modalites de la prise en charge de ce type de situations. Materiels et methodes Nous avons analyse les donnees recueillies dans le dossier medical informatise Nadis® pour toutes les consultations pour accident d’exposition sexuelle secondaire a une agression entre janvier 2010 au decembre 2017 en Guadeloupe, Martinique et Saint-Martin. Resultats Nous avons identifie 1565 consultations pour accidents d’exposition a risque viral suite a un rapport sexuel ; 258 (16,4 %) etaient consecutifs a des viols. La frequence etait variable selon le territoire : 24,4 % en Guadeloupe, 23 % a Saint-Martin et 11 % en Martinique. L’âge median des patients etait de 23 ans (18–36,75) et 246 patients etaient des femmes (95,3 %). L’acte sexuel avait entraine un saignement pour 40 patients (15,5 %). Deux cent vingt-deux rapports etaient vaginaux (85,6 %), 38 anaux (14,7 %) et 31 oraux (12 %). Le rapport etait homosexuel pour 14 patients (5,4 %). Un traitement post exposition a ete debute chez 172 patients (66,7 %), et dans les 48 premieres heures chez seulement 66,8 % (115 patients). Les patients etaient vus en consultation par un referent infectiologue dans un delai median de 2 jours apres l’agression. Conclusion Cette etude met en evidence une surrepresentation des viols parmi les patients Guadeloupeens consultant suite a un accident d’exposition a risque viral par rapport aux donnees observees en France metropolitaine. La faible proportion de patients recevant un traitement post-exposition (66,7 %) doit conduire a reconsiderer le circuit de prise en charge.

International audience; Background - Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency virus (HIV). Progression to end-stage renal disease can be slowed by appropriate medical management. Methods - To assess whether active promotion of guidelines improves CKD management, we conducted a cluster randomized controlled trial within the French Hospital Database on HIV (FHDH-ANRS CO4). We randomized 46 centers participating in the FHDH to either simple information on guideline availability or active promotion with a multifaceted and repeated intervention comprising reminders and audit feedback and targeting of local opinion leaders carried out between April 2009 and April 2010. Outcome measure was CKD management adequacy assessed before and 2 years after the beginning of the intervention in HIV-infected patients with moderate to severe CKD. CKD management was considered adequate in case of referral to a nephrologist or if proteinuria, blood pressure, low-density lipoprotein cholesterol level, and glycemia had been measured during the previous year and medications had been prescribed when necessary. Results - Three hundred six patients were enrolled, of whom 238 (78%) completed the 2 years of follow-up. During the study period, the percentage of patients receiving adequate CKD management improved from 64.1% to 70.4% (+6.3%) in the active arm and from 68.3% to 75.6% (+7.3%) in the control arm (adjusted mean difference, -0.7 percentage points [95% confidence interval: -9.2 to 7.9]; P = .95). The biggest impact of active promotion was on the management of proteinuria and blood pressure. Conclusions - Adequate compliance with CKD management guidelines improved slightly between 2009 and 2011, with no difference between the simple information and active promotion arms. Clinical trials registration - CCTIRS 10.150 and CNIL DR-2010-379.

Introduction Le syndrome des anticorps anti-synthetases est une maladie auto-immune dont les atteintes pulmonaires font la severite. La corticotherapie constitue le traitement de premiere intention mais l’association a un immunosuppresseur reste la regle en raison de la corticodependance et du risque de rechute. L’efficacite du mycophenolate dans cette situation a ete peu etudiee. L’objectif de cette etude etait d’evaluer l’efficacite et la tolerance du mycophenolate mofetil dans l’atteinte pulmonaire du syndrome des anti-synthetases. Patients et methodes Il s’agissait d’une etude monocentrique retrospective menee entre 2007 et 2015. Les criteres d’inclusion etaient : un syndrome des anti-synthetases avec un anticorps anti-ARNt synthetase positif, une atteinte pulmonaire avec une preuve scanographique et une alteration des resultats des epreuves fonctionnelles respiratoires. Enfin les patients devaient avoir recu un traitement par mycophenolate mofetil pendant au moins 6 mois, qui etait toujours associe a une corticotherapie. La decroissance de la corticotherapie etait a l’appreciation des medecins responsables. Le critere principal de jugement etait l’amelioration de la DLCO entre 12 et 24 apres le debut du traitement par mycophenolate. Les criteres secondaires etaient l’amelioration du VEMS, de la capacite pulmonaire totale et de capacite vitale forcee. Ces parametres etaient egalement compares entre la fin du traitement par le mycophenolate mofetil et ceux de debut de traitement. Resultats Treize patients ont ete inclus dont 12 femmes d’âge median de 45 ans (22–68) au moment du diagnostic. Sept patients (54 %) avaient un anticorps anti-JO1, 4 patients (30 %) un anti-PL12 et 2 patients (16 %) un anti-PL7. Additionnellement, 9 patients (69 %) avaient un anti-SSA et/ou un anti-RO52. Douze patients (92 %) avaient un pattern radiologique de type pneumopathie interstitielle non specifique et un (8 %) un pattern de pneumopathie interstitielle commune. Huit patients (61 %) avaient une atteinte articulaire, 8 (61 %) un syndrome de Raynaud, 5 (38 %) une atteinte oesophagienne et 4 (31 %) une atteinte musculaire associee. Le mycophenolate mofetil etait donne en deuxieme ligne de traitement (c’est-a-dire apres les corticoides) chez 3 patients (23 %), en troisieme ligne chez 6 patients (46 %) et apres la troisieme ligne chez 4 patients (31 %). La duree mediane du traitement par le mycophenolate mofetil etait de 41 mois (8–97). La DLCO (pourcentage de la theorique) passait d’une mediane de 37 % a l’instauration du traitement a 50 % apres 12 a 24 mois de traitement par le mycophenolate mofetil (p = 0,0313 n = 7). De meme, la capacite vitale forcee passait de 64 a 68 % (p = 0,02 n = 9). La capacite pulmonaire totale et le VEMS avaient tendance a s’ameliorer sans que cela soit significatif. La comparaison entre la DLCO initiale et de fin de traitement etait egalement en faveur d’une amelioration (p = 0,03). Le traitement par le mycophenolate mofetil etait arrete chez 5 patients : chez 2 patients (16 %) pour rechute ou aggravation (1 musculaire et 1 pulmonaire), chez 1 patient (8 %) pour effet indesirable (infection grave), chez 1 pour un projet de grossesse et 1 arret spontane par le patient. Conclusion Ces donnees retrospectives sont en faveur d’une probable efficacite du mycophenolate mofetil dans l’atteinte pulmonaire du syndrome des anti-synthetases, jugee sur la DCLO. Le traitement etait globalement bien tolere. L’effet benefique semble se maintenir sur le long-terme. Ces donnees devraient etre au mieux confirmees par une etude randomisee comparative, rendue difficile par la rarete de la pathologie et l’evolution lente de la maladie.

Introduction La maladie de Still de l’adulte (MSA) se caracterise par la triade : fievre, arthralgies et eruption cutanee typiquement pseudo urticarienne, contemporaine des poussees febriles. D’autres types d’eruption ont ete rapportes et sont consideres comme un facteur de severite de la maladie. L’objectif de notre travail etait de preciser les caracteristiques et la valeur pronostique de ces eruptions cutanees non typiques (ECNT). Materiel et methodes Les criteres d’inclusion dans cette etude multicentrique retrospective entre 1997 et 2017 etaient les suivants : (1) âge > 18 ans ; (2) MSA repondant aux criteres diagnostiques de Yamaguchi ; (3) eruption cutanee vue par un dermatologue avec description semeiologique et/ou photographies ± biopsie ; (4) suivi minimum de 6 mois. Ont ete exclus, les patients dont la MSA avait debute avant l’âge de 15 ans et les patients sans argumentaire diagnostique detaille dans leur dossier medical. Les ECNT ont ete definies comme toute eruption ne correspondant pas a la description classique : exantheme maculopapuleux, fugace, siegeant principalement sur le tronc et les membres. A la date de point (9/06/2017), la survenue d’un cancer a ete investiguee. Resultats Au total, 58 patients ont ete inclus, 43 femmes et 15 hommes, dont 18 afro-caribeens, d’âge moyen 43 ± 16 ans avec une mediane de suivi de 4 ans (Q1–Q3 : 1–8 ans). 14 patients (24 %) ont developpe une complication viscerale grave (CVG) necessitant un transfert en reanimation (n = 10) ou un syndrome d’activation macrophagique (n = 4). Une ECNT a ete observee chez17/58 patients (29 %). Fixe dans tous les cas, l’ECNT correspondait dans 4 cas a l’exantheme papuleux pigmente decrit comme « atypique » dans la litterature, a une urticaire profuse et fixe (n = 2), a un purpura vasculaire (n = 1), a une erythrodermie oedemateuse (n = 1), a un exantheme maculopapuleux evocateur de toxidermie (n = 6), a un placard oedemateux de l’avant-bras mimant un syndrome de Sweet (n = 1), a un erytheme periorbitaire (n = 2). Une dermatose neutrophilique urticarienne etait observee dans 12/17 cas. La comparaison des caracteristiques cliniques et biologiques des patients avec et sans CVG trouvait les facteurs de risque suivants : une ECNT (p = 0,003-OR : 5,9), une hypoalbuminemie 1000 (p Discussion Notre etude illustre le spectre de l’expression dermatologique de la MSA en rapportant des manifestations inhabituelles qui semblent avoir une signification pronostique. Le sur risque de cancer a long terme decrit ponctuellement dans litterature n’est pas observe dans notre serie. Conclusion La presence d’une ECNT lors du diagnostic de MSA semble etre associee a une evolution aigue plus severe.

Introduction Decrire les causes de deces chez les patients vivant avec le VIH (PVVIH) vivant dans quatre territoires ultramarins (TU), Guadeloupe, Guyane, Martinique, Reunion, et leur evolution entre 2000 et 2010. Materiels et methodes Dans ces 4 TU, 9 centres assurant la prise en charge de PVVIH ont declare prospectivement les deces survenus en 2010 a l’aide d’un questionnaire standardise (ANRS EN20–Mortalite 2010). Les donnees ont ete comparees avec celles recueillies selon les memes modalites en 2000 (ANRS Mortalite 2000) dans ces territoires et en 2010 en France metropolitaine. Resultats En 2010, l’effectif de la file active des PVVIH suivis dans les DOM etait de 5071. Soixante-seize deces ont ete declares (mortalite 1,5 %, vs 0,9 % en metropole). La mortalite est de 1,5 % dans les departements francais d’Amerique (DFA) et de 0,5 % a la Reunion. L’âge median des patients decedes est de 51 ans (IQR : 46,5–61,6) et 70 % sont de sexe masculin. Les principales causes de deces (2010 vs 2000) sont : sida (36 % vs 65 %), les deces liees a d’autres causes (30 % vs 10 %) et les infections bacteriennes (15 % vs 6 %). Les cancers NSNH (9 %), les causes cardiovasculaires (7 %), les causes hepatiques (4 %) restent stables entre 2000 et 2010. Pour les patients decedes du sida, les pathologies infectieuses predominent (20/27). Compare a la metropole en 2010 : les deces de causes SIDA (36 % vs 24 %), des infections bacteriennes (15 % vs 9 %), et les deces lies a d’autres causes (30 % vs 22 %), predominent dans les DOM a l’inverse des deces lies a des cancers NSNH (9 % vs 24 %), et des atteintes hepatiques (4 % vs 11 %). Le diagnostic est plus recent dans les DOM puisque le diagnostic date de moins de 6 mois pour 22 % PVVIH (vs 8 %) et la duree mediane connue de l’infection est de 5,5 ans (vs 15). Vingt-neuf pour cent des patients dans les DOM n’ont jamais pris de traitement antiretroviral au moment du deces (vs 7 %). L’infection par le VIH est moins bien controlee : taux CD4+ 50 copies/ml (72 % vs. 44 %). Les personnes decedees sont d’origine etrangere dans 49 % des cas (vs 25 % en metropole). La precarite socioeconomique touche 63 % des personnes decedees dans les DOM (vs 42 % en metropole). Par rapport a 2000 ce % est en hausse dans les DOM (56 %). Conclusion Malgre une baisse entre 2000 et 2010, le sida restait la principale cause de deces des PVVIH dans les TU. La precarite socioeconomique des PVVIH dans les TU restait un probleme majeur tant pour le diagnostic que pour la prise en charge.

Resume Introduction. – La fievre dengue, transmise par des moustiques Aedes en zone intertropicale, est la plus importante arbovirose humaine. Elle est classee parmi les maladies emergentes. Actualite et points forts.– Morbidite, mortalite et expansion geographique de la dengue sont en hausse constante depuis 20 ans, vraisemblablement en relation avec les changements bioclimatiques, sociodemographiques et comportementaux intervenus, eux-memes a l’origine d’un accroissement de la circulation des virus, de leur virulence et de la resistance des vecteurs aux insecticides. Les differentes presentations cliniques et biologiques (forme fruste de l’enfant ; forme classique, bruyante et benigne ; dengue hemorragique et/ou avec choc, potentiellement letale, formes atypiques), ainsi que les elements du diagnostic et de la physiopathologie (infections sequentielles heterologues, anticorps facilitants, fuite capillaire) sont passes en revue. Perspectives et projets. – La fievre dengue est bien davantage qu’une fievre du voyageur ou une curiosite exotique : la moitie de la population mondiale y est exposee. Elle constitue un modele d’infection virale par la complexite des relations virus–vecteur et hote–virus, et la variabilite de l’expression clinique. L’approche moleculaire devrait permettre une meilleure comprehension et maitrise du cycle pathogene, et deboucher sur la mise au point d’un vaccin.

Resume Parmi les causes principales d'acropathies ulceromutilantes-lepre, diabete, neuropathie amyloide, neuropathiessensitives hereditaires-la place de l'alcoolisme est controversee depuis les premieres observations l'incriminant ( Bureau et al, 1957 ). Une revue retrospective de 38 cas chez des Antillais grands consommateurs de rhum semble pourtant en confirmer la realite. La presentation clinique, non specifique, est constituee d'une triade: pied anesthesique, mal perforant plantaire et arthropathies deformantes et mutilantes de l'avant-pied. Seuls les membres inferieurs sont touches. La motricite est conservee. Les principales caracteristiques sont: le sexe masculin, une alcoolisation massive (≥ 150 g d'alcool pur par jour) et prolongee (≥ 12 ans), des carences d'hygiene, un notable contexte de misere physiologique et sociale, l'exposition a des microtraumatismes repetes des pieds, d'autres complications de l'alcoolisme, et, enfin, une lente evolution aboutissant a l'amputation spontanee ou chirurgicale. En depit de bases physiopathologiques obscures et d'incertitudes concernant une possible predisposition genetique ou une neurotoxicite particuliere du rhum antillais, les donnees epidemiocliniques rapportees invitent a rediscuter l'autonomie de ce ≪ pied alcoolique ≫, ou acropathie ulceromutilante alcoolique qu'il convient de distinguer de la polynevrite alcoolique commune.

Resume Les auteurs rapportent 2 observations d'arthrite reactionnelles a anguillule (Strongyloides stercoralis), parasite dont la prevalence reste elevee aux Antilles. Ils soulignent quelques particularites cliniques, biologiques et therapeutiques de ces arthrites : affection rare, se presentant volontiers comme une spondylarthropathie, absence d'HLA B27, resistance aux AINS, contre-indication des corticoides, efficacite spectaculaire des anti-parasitaires specifiques. Le cadre nosologique et les criteres diagnostiques des rhumatismes parasitaires sont brievement discutes.

Resume Diverses constatations anatomocliniques suggerent que le sida pourrait etre une cause sous-estimee de maladie cerebrovasculaire, notamment chez le sujet jeune. Huit cas retrospectifs d'accidents vasculaires cerebraux survenant chez des sideens des deux sexes (âge moyen: 39 ans, taux moyen de CD4: 57/mn 3 ) sont rapportes. Le mecanisme pathogenique n'apparait pas clairement, en particulier la place revenant aux infections opportunistes. Le pronostic n'est pas forcement pejoratif puisqu'un seul de nos sujets est decede de l'accident, six autres etant en vie a 6 mois sans recidive et avec des sequelles minimes ou absentes. L'abus d'alcool ou de cocaine (crack) est present dans un cas sur deux. Ces observations posent la question de l'existence de facteurs de risques propres a cette complication et, en consequence, d'une eventuelle prophylaxie specifique.

Resume Vingt-deux cas de malades, adultes, admis pour une listeriose neuromeningee sur une periode de 11 ans, sont rapportes. Une immunodepression a ete retrouvee dans cinq cas. Dix patients sur 22 ont eu une atteinte des nerfs crâniens et neuf ont presente d'autres signes neurologiques de localisation. L'etude du LCR a montre une proteinorachie moyenne a 1,92 g/l avec 455 elements blancs par ml dont 50 ± 25 p. cent de lymphocyte. L. monocytogenes a ete isolee dans le sang et le LCR dans 12 cas, seulement dans le LCR dans neuf cas et exclusivement dans le sang dans un cas. La mise en route d'un traitement adapte est effectuee 4,4 ± 3,8 jours apres le debut de la symptomatologie. Les patients ont ete traites par une aminopenicilline dans 18 cas, en monotherapie trois fois, associe a la rifampicine sept fois, aux tetracyclines sept fois et aux aminosides une fois. L'association trimethoprime-sulfamethoxazole a ete utilisee dans quatre cas, une fois en monotherapie et trois fois associee a la rifampicine. Deux patients sur vingt-deux sont decedes et cinq ont garde des sequelles neurologiques. La faible mortalite relevee dans cette serie pourrait etre en relation avec la strategie therapeutique qui privilegie la diffusion des antibiotiques plutot que les donnees bacteriologiques classiques.

The survey "Mortality 2000" had for aim to describe the distribution of causes of death in HIV-infected adults in France.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.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.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.

Demographic, clinical, biological and personal data were obtained from patients hospitalized with symptoms of leptospirosis in the Hospital of Pointe a Pitre, Guadeloupe, French West Indies from 1994 to 2001. Of the 897 screened patients, 212 were acute cases, 607 were non-infected and 78 were undetermined cases. There was no predominant age group. Leptospirosis transmission followed the rainfall cycle and was greater in rural areas. Jaundice and conjunctival suffusion were significantly more frequent in cases than non-cases. Males, professions considered to be at risk and contact with swine or bovine were associated with infection. Serogroups Icterohaemorrhagiae, Cynopteri, Australis, Sejroe, Pomona and Ballum were serovars presumed responsible for acute cases.

Introduction La maladie de Kikuchi Fujimoto (MKF) est une lymphadenite necrosante d’evolution benigne decrite initialement dans les populations asiatiques. Il n’y a aucune description des caracteristiques de cette maladie dans les populations originaires d’Afrique noire alors qu’elle est liee au lupus systemique (LS) dont on connait la frequence et la gravite dans les populations d’ascendance africaine. Il n’y a pas non de donnees epidemiologiques. L’objectif de cette etude est de (1) caracteriser la MKF dans les departements francais d’Amerique (DFA) ou la population est majoritairement d’origine africaine, (2) presenter une incidence en Martinique. Patients et methodes Etude retrospective multicentrique descriptive des patients porteurs d’une MKF suivis dans 7 hopitaux des 3 DFA. Etude epidemiologique par recoupement de sources sur la Martinique (2 seuls laboratoires d’anatomo-pathologie de l’ile, departement d’informatique du CHU de Martinique, services de medecine interne, ORL, rhumatologie, pediatrie). Les criteres d’inclusion etaient : patients d’origine martiniquaise, guadeloupeenne ou guyanaise au moment d’une biopsie compatible avec une MKF (habitant en Martinique pour l’etude epidemiologique) Resultats Il s’agissait de 27 femmes et 9 hommes d’âge moyen au diagnostic de 30,5 ans (5–59 ans) dont 9 presentaient au moins 2 episodes. Le delai moyen de diagnostic etait de 12,8 semaines (1–49). La localisation des adenopathies etait cervicale dans 88.8 %, axillaires dans 53.3 %. Les adenopathies etaient douloureuses dans 61.8 %. La fievre etait presente dans 83.3 %. Des manifestations extra-ganglionnaires etaient presentes : cutanees (37.9 %), organomegalie (17.8 %). Trois patients (8.33 %), tous lupiques, presentaient une forme severe : syndrome d’activation macrophagique (n = 2), neuropathie peripherique (n = 1). Sur l’ensemble de la cohorte, une maladie auto-immune associee etait presente dans 14 cas (38.8 %) : LS (n = 9 ; 25 %), lupus cutane chronique (n = 2 ; 5.6 %), Sjogren primaire probable (n = 2 ; 5.6 %), arthrite chronique juvenile (n = 1 ; 2.8 %). En Martinique a base de population, on retrouvait un lupus chez 27.3 % des MKF. Cette maladie etait decouverte concomitamment dans 8 cas, apparaissait apres la MKF dans 1 cas et etait deja presente dans 5 cas. La seule infection concomitante a une MKF est liee a un coxsackie avec syndrome pieds-mains-bouche, apparue chez la patiente ayant une arthrite chronique juvenile et dont la mere a un lupus. Un amaigrissement important, des lesions cutanees, une lymphopenie, et la presence d’anticorps antinucleaires chez une femme suggeraient l’existence d’un lupus sous jacent. Entre 1990 et 2013, 22 patients presentaient une MKF en Martinique, amenant a une incidence annuelle moyenne brute de 2.23 cas/1 000 000 habitants. Conclusion Les caracteristiques de la MKF dans notre population par rapport aux autres populations decrites dans la litterature sont une grande frequence de l’association avec le lupus. Il s’agit des premieres donnees sur l’epidemiologie de la MKF, qui semble peu frequente. Il reste difficile de dire si ces chiffres peuvent etre extrapoles a des populations d’autre origine ethnique.

Transmitted by Aedes mosquitoes all over the inter-tropical area, Dengue fever is the leading arboviral disease in humans. It is also an emerging disease.Increasing morbidity-mortality, and geographical expansion are the drastic changes noted in the recent epidemiology of the disease. They are related to those occurring at the bio-climatic, socio-demographic and behavioural levels, which in turn may have led to enhanced viral circulation and virulence, and also vectorial resistance. The various clinical patterns (undifferentiated febrile episode of children, acute and algid classic form, the potentially fatal dengue hemorrhagic fever/dengue shock syndrome, and the atypical forms) are reviewed, as well as the diagnostic methods, and the pathogenesis (sequential infections, facilitating antibodies, capillary leakage).Dengue fever is actually much more than a traveller's fever or an exotic curiosity. It presently threatens half the world's population, and remains a puzzling disease in many aspects, such as the virus-vector and host-virus relationships, and clinical expression variability. In this respect, dengue fever appears as a model of viral disease. The current molecular approach is expected to provide us with new insights into pathophysiology, more efficient tools for disease control, and also an efficient vaccine in the near future.

Dengue fever, unlike most other arboviral diseases, does not usually cause encephalitis. However, neurologic symptoms with poor prognosis have been regularly reported, mostly in Asian children affected by the severe dengue hemorrhagic fever/dengue shock syndrome, and attributed to a non specific, anoxic or metabolic encephalopathy. Recently, first isolations of dengue viruses from CSF or brain tissue, have renewed this concept. We report 3 dengue fever cases with neurologic manifestations and favorable outcome. Occurrence in adult age, during classic (benign) dengue fever (2 cases), and neurologic sequellae (1 case) were the three outstanding features. We point out the proteiform expression of these neurologic changes and their low incidence rate (3% in our series of adult dengue fever). Although their pathogenesis is poorly understood, different mechanisms are suggested: encephalopathy (case n. 1), acute specific encephalitis (questionable in case n(o) 2), or post-infective encephalitis (case n(o) 3).

CHANGING EPIDEMIOLOGY: During the last half of the 20th century, dengue has spread to most countries in the inter-tropical zone and today is the most common cause of human arbovirus infection. In tropical zones, dengue is a frequent cause of fever and can be observed in travellers returning from an endemic zone.Though variable, skin and mucosal manifestations are important to recognize. Exanthema occurs late after constitutional symptoms and is suggestive. Minimal hemorrhagic lesions involving the skin and mucosa are observed in common dengue. They usually do not signal progression to authentic hemorrhagic dengue or shock.Skin manifestations of dengue raise the more general problem of diagnosis in travellers returning from tropical zones who develop fever and rash.

Two outbreaks of dengue hemorrhagic fever occurred in Guadeloupe (French West Indies) in successive epidemics in 1994 and 1995. The first outbreak was caused by DEN-2 virus and the second by DEN-1.Seven life-threatening infections (WHO grade 3/4) were identified. Three previously healthy adults (including two brothers) died. Autopsy reports (2 patients) disclosed hemorrhagic serous effusions, disseminated intravascular coagulation, and in one case a spontaneous spleen rupture.Dengue fever is an emerging disease. Its severe hemorrhagic form tends to an uprising incidence and can no longer be considered a disease limited to children in Far-Eastern Asia. Fatalities may occur very suddenly and unexpectedly, even in optimal health care settings, in healthy adults living or travelling in endemic areas, notably the Caribbean.

Vibrio vulnificus is a non-choleric halophilic vibrion widely distributed in marine environments. Contamination in humans is uncommon except in coastal areas of the United States and Asia. We report the first documented case in the French West Indies.A 57-year-old native with alcoholic cirrhosis was hospitalized for septic shock. The infectious syndrome began suddenly a few hours earlier with fever, diarrhea, and intense pain in the calf muscles. In the absence of a suspected agent, a wide spectrum antibiotic was prescribed. On day 3, bullae developed over the legs and progressed, despite early surgical debridement, to bilateral rapidly extensive necrosing cellulitis. An above the knee amputation was required but did not prevent death on day 9 due to irreversible multiple organ failure. Blood cultures were positive for V. vulnificus.Primary septicemia due to V. vulnificus is mainly observed in subjects with an underlying liver disease and usually occurs after ingestion of contamined raw halieutic products such as oysters. The clinical presentation is characteristic with secondary necrotic ulcerations on the lower limbs. Improvement in the extremely poor prognosis of these infections depends on early initiation of an effective antibiotic with wide exeresis of necrotic tissue. Physicians should be aware of this severe infection despite its low frequency.

To describe muco-cutaneous manifestations of dengue fever, assessing their incidence and histopathological aspects.During a dengue 2 epidemic, occurring in Guadeloupe in 1994, all patients admitted with a confirmed diagnostic of dengue fever were assessed for dermatological changes by 2 clinicians; 5 patients underwent skin biopsy with immuno-fluorescence staining.Among 39 adult inpatients (Sex ratio 1.1, medium age 41 years) none presented a severe form of the disease, whereas 18/39 (46 p. 100) had some muco-cutaneous changes, associating rash (13 cases (33 p. 100)), mucous membranes involvement (7 cases (18 p. 100)), or minor haemorrhages (6 cases (15 p. 100)). The rash appeared macular, discrete, itching, troncular with peripheral extension, rather than maculo-papular (morbiliform) as usually described. Apart from cases which minor haemorrhagic changes, significatively associated with marked thrombocytopenia (medium 37 x 10(9)/1), dengue cases either with or without muco-cutaneous changes had similar clinical (duration, severity) or biological (neutro-lympho-thrombocytopenia, transaminases) features, and evolution. Histological changes appeared non specific (minor lymphocytic dermal vasculitis, non contributive immuno-fluorescence).Clinical and histological features of the rash are unspecific and inconstant: they do not allow an easy and accurate diagnosis. Complete clinical, epidemiological (very recent travel in endemic areas) or biological data should be collected, and early virological or later serological confirmation is needed. As well as travel facilities are growing, the dengue area is extending: dengue fever should therefore be considered in every traveller with fever and rash.

Occurrence of anguilluliasis always progresses to hyperinfestation or disseminated anguilluliasis with severe clinical manifestations in carriers of HTLV-1. This prognosis is further illustrated by two new cases of non-septic purulent meningitis observed in two male patients from Guadalope. Ages were 61 and 64 years. In both cases examination of cerebrospinal fluid (CSF) demonstrated pleiocytosis with more than 3000 cells (mostly polynuclear neutrophils) per mm3, protein content greater than 3 g/l, and low sugar level. No soluble germs or antigens were found in the CSF. In both patients Strongyloides stercoralis larvae were detected in stools but not in CSF. Meningitis responded to antibiotic treatment but follow-up tests showed the persistence of larvae in stools despite treatment using thiabendazole. While similar cases of meningitis have been reported in carriers of HTLV-1, the underlying mechanism is still unclear. Co-infection with Strongyloides stercoralis appears to be a predisposing factor. This association may warrant preventive anti-parasitic treatment in patients infected by HTLV-1.

Among principal causes of acrodystrophic neuropathy-ie, leprosy, diabetes, amyloid neuropathy, hereditary sensory neuropathies-alcoholism is controversial since first descriptions (Bureau et al, 1957) incriminating heavy drinking. This retrospective review of 38 cases occurring in West-Indian rhum abusers, tends however to confirm its etiologic role. Patients present with three non specific signs or symptoms of the lower extremities: anaesthetic foot, plantar ulcers, and chronic, indolent, mutilating arthropathies. Motor function is spared. Male gender, massive (or = 150 g pure alcohol daily) and prolonged (or = 12 years) rhum intake, hygiene deficiency, poverty and social distress, exposition to repeated foot microtrauma and a protracted, non fatal, but disabling course leading to amputation, are the main features of this syndrome. The pathophysiology is poorly documented, and many questions remain unanswered including a genetic predisposition or a particular neuro-toxicity of West Indian rhum. However, the clinical and epidemiologic data presented here favour the concept of an "alcoholic foot" or true alcoholic acrodystrophic neuropathy, quite different from the most common sensory-motor form.

A number of pathological and clinical data suggest that AIDS could be an underestimated cause of cerebro-vascular disease, especially in young individuals. Eight retrospective cases of stroke in AIDS patients are reported. Mean age was 39 years, mean CD4 cells count 57/mm3. Pathogenic mechanism, particularly the role of opportunistic infections remains unclear. Prognosis does not seem constantly pejorative: only one patient died from stroke, six are still alive with a 6 months follow-up, without relapse and with minor or no sequellae. Alcohol or cocaine (crack) abuse was present in half the cases. The role of specific risk factors and consequently adapted prophylaxis is questionned.

IgG antibodies of autoimmune SLE (Systemic Lupus Erythematosus) serum S detected a HeLa hnRNP 72 kDa protein, cross-reacting with the retroviral (MLV) p15-gag polypeptide. Since serum S disclosed a ubiquitous 72 kDa antigen in HeLa cell fractions, was prepared the so-called cytoplasmic "X fraction", enriched for the 72 kDa protein, defined here as p72. This autoantigen was detected by antibodies of HIV 1+ patients, recently of seroconverted (RSC) asymptomatic subjects, of HBV+ sera, and of primary Gougerot-Sjögren (prGS) sera. The presence of these autoantibodies in different autoimmune and infectious pathologies raises the question of the involvement of p72 in the immune processes and in the early HIV1 infection.

Summary The authors report a case of idiopathic CD4+ lymphocytopenia (nadir 110/mm 3 ) with esophageal candidiasis and other minor recurrent mucocutaneous infections, in a 30 year old white male followed-up during six year. Despite cumulative risk factors for HIV infection (IV drug abuse, unprotected promiscuous bisexual activity) the patient's remained negative and so did HIV RNA determined by PCR. He also had prolonged, benign, and unexplained agranulocytosis, as well as hypogammaglobulinemia, low titers of C4 complement fraction, and chronic hepatitis C infection with vasculitis due to mixed (type II) cryoglobulinemia. These associated features and the six year fluctuating but rather benign course, have not been described so far in idiopathic CD4+ lymphocytopenia.

Human T cell leukemia/lymphoma virus type 1 (HTLV-1) and pneuocystis carinii associated with T cell proliferation and haemophagocytic syndrome