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Resume Le traitement antiparasitaire du paludisme grave d'importation, pris en charge en France metropolitaine, fait appel a des molecules antipaludiques schizonticides, actives sur les souches de Plasmodium falciparum chloroquinoresistantes. La quinine, toujours tres efficace, reste la base de ce traitement. Ses proprietes pharmacocinetiques et pharmacodynamiques ont fait l'objet de nombreux travaux. Sa toxicite neurosensorielle et cardiovasculaire est bien etablie. L'artemether offre une alternative interessante en presence de souches poly-chimioresistantes. Une neurotoxicite a ete retrouvee lors d'etudes animales. La conduite pratique du traitement antiparasitaire privilegie l'utilisation de la quinine par voie intraveineuse. II existe des disparites dans l'expression des doses, les protocoles therapeutiques, les posologies maximales. Le recours a une dose de charge est l'objet de controverses. Les modalites de la surveillance du traitement ne sont pas formellement etablies. L'utilisation des antibiotiques et de l'artemether releve d'indications precises.

Resume De tous temps, les militaires en campagne ont paye un lourd tribut aux infections, notamment aux epidemies. Aujourd'hui, 40 000 militaires servent hors metropole pour des missions et dans des operations, de duree variable et dans des pays tres divers. Des risques infectieux persistent malgre la mise en oeuvre des mesures de prophylaxie ; ils sont d'abord lies aux carences de l'hygiene du milieu, a la vie en collectivite et a la situation operationnelle : diarrhees bacteriennes, amibiase, hepatites virales A et E. D'autres relevent de l'environnement tropical ; le paludisme reste preoccupant du fait de la chimioresistance ; les bilharzioses peuvent donner lieu a de petites epidemies; les leishmanioses cutanees ne sont pas rares en Guyane. Des infections exceptionnelles mais graves sont observees. Les risques infectieux lies a la guerre sont rappeles : guerre biologique, infections des blesses, des brules et des irradies.

The binding capacity to cardiolipin and the functional affinity of affinity-purified anticardiolipin (aCL) IgG of patients with autoimmune disease have been compared with those of individuals with malaria and acquired immunodeficiency syndrome (AIDS). The binding of autoimmune IgG aCL was enhanced gradually by the incorporation of increasing amounts of β2-glycoprotein I (β2GPI) into the assay, in contrast to that of patients with infectious diseases. In addition, there were significant reductions of functional affinity in autoimmune disease, but not in malaria or in AIDS. These results indicate that β2GPI requirement for binding to the target antigen varies inversely with functional affinity in autoimmune disease when β2GPI was present, and suggest that IgG aCL are more heterogeneous in this type of disorder than in patients with infectious disease.

Pentavalent antimony (PA) compounds remain the main therapeutic agents of cutaneous leishmaniasis (CL). CL infection resistant to PA is difficult to cure, limited by severe side effects and requiring a long course treatment of parenteral administration of recommended second line drugs. We report a case of CL unresponsive to meglumine antimoniate contracted in Djibouti, successfully treated with a short course treatment of AmBisome. In this case the subject had a recurrent thick crusted erythematous lesion on his left elbow associated with spreading micropapula on arms and thorax. The diagnosis of CL was confirmed by direct examination and genomic amplification by PCR of skin samples, cultures were negative. A short course treatment of parenteral AmBisome (18 mg/kg) has lead to clinical cure with no side effects and no relapse. In our hospital, the high cost of medication was counterbalanced by easiest administration, reduction of hospitalization duration, absence of adverse events and a gain of comfort. For this patient, a short course treatment of AmBisome proved to be a suitable alternative to traditional drugs used in CL resistant to PA.

Spontaneous splenic ruptures are rare but life-threatening complications of infectious diseases. Splenectomy is still the treatment of choice but numerous recent reports have documented favorable outcome with conservative treatment.We report three cases of splenic rupture occurring respectively with infectious mononucleosis, P. vivax infection and dengue fever. Diagnosis, treatment and indications are reviewed, an approach to management is suggested. The study included three military men respectively aged 23, 24 and 35 years, admitted for acute abdominal pain in the left upper quadrant. The abdominal computed tomography confirmed partial rupture (splenic hematoma) in the first two cases, and an hemoperitoneum in the dengue case. Splenic ruptures can reveal or complicate an evolving infection. Rupture can happen spontaneously or as a result of trauma, which may be minor and unnoticed. The typical presentation is acute, but progressive forms are described. The diagnosis is made by ultrasound and CT scan. Splenectomy dogma tends to be supplanted by conservative treatment. Non-operative management can be successful if appropriate criteria and a long period of follow-up are applied in carefully selected cases. When an operative approach is selected, conservative surgical treatment is attractive. Splenectomy should be reserved for patients with uncontrollable rupture or with recurrent splenic bleeding.Spontaneous splenic rupture are uncommon in infectious diseases. A multidisciplinary management is necessary. A conservative treatment should be considered in selected, closely monitored patients.

The in vitro susceptibility of chloroquine and the genomic profile of dihydrofolate reductase (DHFR) codon 108 was determined against african isolates of P. falciparum (Pf) from imported malaria cases without previous drug intake by an isotopic microtest or PCR + RFLP. Pf resistance to chloroquine or to the DHFR inhibitor was present in 49% and 46% of isolates, respectively. Pf drug resistance was more frequent in permanent than in seasonal malarial transmission areas and chloroquine plus DHFR resistance reached 28% in years 1995-97. Updating the guidelines for the prevention of malaria in travellers to Africa is necessary.

Antibiotic susceptibility of 649 gram-negative bacilli involved in severe infections and isolated in 18 teaching hospitals from January to December 1992 was evaluated.Minimal Inhibitory Concentrations were determined by agar dilution method for piperacillin, piperacillin+ tazobactam and imipenem, and by a microdilution method for 11 other antibiotics (amoxicillin, amoxicillin + clavulanic acid, cefotaxime, ceftazidime, aztreonam, ticarcillin, ciprofloxacin, fosfomycin, tobramycin, gentamicin, amikacin). Criteria of Comité Français de l'Antibiogramme de la Société Française de Microbiologie were followed for interpretation. Betalactamases were identified by isoelectric focusing and overproduction of cephalosporinase was defined by the resistance phenotype. The main species isolated were Escherichia coli (45%), Pseudomonas aeruginosa (14%), Klebsiella pneumoniae (7.8%), Salmonella spp. (7.5%), Enterobacter cloacae (4%) and Klebsiella oxytoca (4%). Most of the strains were isolated from blood culture (72.3%), respiratory tract (11.4%) and intraabdominal infections (8.6%). Most of the enterobacteria isolates were susceptible to imipenem, aztreonam, amikacin and ciprofloxacin (percentages of susceptibility were respectively 99.3, 98, 98.3 and 96.3); in most of cases clavulanic acid did not entirely restore sensitivity to amoxicillin of penicillinase-producing strains. Among 89 P. aeruginosa strains, 82% were susceptible to imipenem and ceftazidime, 81% to the association piperacillin + tazobactam and 51% to ticarcillin. Resistance rates are very high for Acinetobacter baumannii except for imipenem.Production of TEM-type penicillinase and over-production of the chromosomal cephalosporinase are the most widely observed mechanisms of resistance (respectively 22% and 9% of 649 strains). Prevalence of extended spectrum betalactamases was low (1%) and essentially observed for K. pneumoniae.

Military personnel in operations have always paid a high toll to infections, particularly epidemics. Currently, 40 000 servicemen serve overseas in various missions and operations of various durations in various countries. Infectious hazards persist in spite of the implementation of preventive measures. They are primarily due to poor sanitation, promiscuous living conditions, and the operational situation : bacterial diarrhea, amoebiasis, viral hepatitis A and E are relatively frequent. Others are due to the tropical environment ; malaria remains a concern due to its chemoresistance ; bilharziosis can also cause small epidemics, cutaneous leishmaniasis is not rare in Guyana. Exceptional but serious infections are observed. Infectious hazards associated with warfare are reviewed : biological warfare, infections of wounded, burnt and irradiated soldiers.

Cerebromeningitis after travel abroad is often acute and febrile and is a serious event. The most frequent and severe cause is pernicious malaria due to Plasmodium falciparum; diagnosis is rapid by thick blood film and thin blood smear; it requires specific emergency treatment. Many other aetologies exist but they are rare; they must nonetheless be considered, keeping in mind that cosmopolitan infections can be favoured by travel conditions.

Resume Introduction. – Les ruptures spontanees de rate sont des complications rares, potentiellement fatales de nombreuses maladies infectieuses. Le traitement classique reste la splenectomie mais plusieurs travaux recents ont souligne l’interet d’un traitement conservateur. Exegese. – Les auteurs rapportent trois cas de ruptures de rate compliquant respectivement une mononucleose infectieuse, un paludisme a P. vivax et une dengue. Les aspects diagnostiques, les moyens therapeutiques et les indications sont passes en revue, un algorithme decisionnel est propose. Il s’agissait de trois militaires âges respectivement de 23, 24 et 35 ans hospitalises pour des syndromes douloureux de l’hypochondre gauche. La tomodensitometrie abdominale a confirme une rupture partielle (hematome splenique) dans les deux premiers cas et une rupture complete avec hemoperitoine au cours de la dengue. L’abstention chirurgicale a permis la guerison dans les deux formes partielles, la splenectomie ayant ete inevitable dans le cas de dengue. Les ruptures spleniques sont inaugurales ou viennent compliquer l’evolution de l’infection. Elles surviennent spontanement ou au decours d’un traumatisme mineur pouvant etre passer inapercu. La forme typique est aigue imprevisible, mais il existe des formes progressives. Le diagnostic repose sur l’echographie et la tomodensitometrie abdominale. Le dogme de la splenectomie tend a etre remplace par une approche conservatrice medicale ou chirurgicale. Sous reserve de criteres cliniques stricts et de la possibilite d’une surveillance, l’abstention chirurgicale peut s’appliquer a des cas selectionnes. En cas d’indication chirurgicale, les techniques de preservations spleniques sont seduisantes. La splenectomie etant reservee aux formes graves et aux echecs du traitement initial. Conclusions. – Les ruptures spontanees de rate sont rares au cours des infections. Leur prise en charge est idealement medicochirurgicale. Un traitement conservateur est possible chez des patients selectionnes, sous reserve de criteres cliniques stricts et d’un suivi clinique et radiologique prolonge.

Resume Un cooperant de 26 ans presente, dix jours apres son retour du Cameroun, un acces pernicieux palustre avec etat de choc, troubles psychiques, anemie hemolytique, insuffisance renale debutante et coagulopathie de consommation menacante. En 24 h, la parasitemie passe de 4 a 35 %. En plus du traitement symptomatique et des sels de quinine, une erythropherese est realisee avec un appareil Haemonetics V50, permettant d'echanger une masse globulaire et demie contre des concentres erythrocytaires simples iso ABO iso rhesus. La totalite du plasma, riche en plaquettes, est restituee au malade. L'evolution est rapidement favorable. Cette technique, bien supportee cliniquement et biologiquement, est preferee a la classique exsanguino-transfusion habituellement realisee lorsque la parasitemie depasse 10 %, et ce pour deux raisons : les concentres erythrocytaires conserves sont plus facilement disponibles que le sang total frais, surtout en urgence ; de plus, on restitue au malade son propre plasma riche en plaquettes, ses propres anticorps et ses propres facteurs de coagulation. Cependant, la restitution du plasma autologue laisse persister des metabolites (en particulier la bilirubine) et les immuns-complexes plasmatiques. Une technique associant erythropherese et une demi-plasmapherese n'aurait pas cet inconvenient et meriterait d'etre evaluee. Enfin, quelle que soit la methode, il faut echanger une masse sanguine et demie (des quantites plus faibles exposent a des risques de rebond), poursuivre la perfusion de sels de quinine et prevenir l'hypocalcemie, induite par la solution anti-coagulante, par l'apport de gluconate de calcium.

Serum HBs antigen (HBs Ag) and anti-HBs antibody (anti-HBs), as determined by radioimmuno-assay or ELISA methods, were studied in a group of 77 patients with acute icterogenic viral hepatitis over a period of at least three months and correlated to the evolution of the disease either to return to good health or to a chronic state. The cumulative rate of patients in whom HBs Ag had disappeared (n = 53) was a linear function of time during the first sixteen weeks. Correlation seemed even stronger in the subgroup of patients restored to good health before the third month. Time of HBs Ag disappearance ranged from 5 days to 5 months in common forms of hepatitis. There was no evident correlation between the time of disappearance and the normalization of ALAT levels. Among the four cases of chronic persistent hepatitis, three had no detectable antigenemia six months later. Development of anti-HBs preceded the loss of HBs Ag in one case, was simultaneous or posterior to it in all other cases; the absence of any serologic HBV marker could last up to 4 months. No chronological link was found between seroconversion and normalization of ALAT levels. The correlation between time and HBs Ag disappearance from the blood could be specific for a given group of patients placed under specific conditions; its determination might help in understanding the factors that influence the course of the disease.

Ten days after his return from Cameroon, a twenty-six year old Frenchman, serving on voluntary service overseas, presented with fulminant falciparum malaria: shock, altered consciousness, haemolytic anaemia, threatening disseminated coagulation (platelets less than 150 X 10(-6).l-1; prothrombin time and Stuart factor less than 50%; fibrinogen less than 1.5 g.l-1). In spite of quinine therapy, parasitaemia increased from 4 to 35% within 24 h. Using an Haemonetics V50, the exchange of one and a half red blood cell masses was carried out with 17 red blood cell packs. Calcium gluconate was used to prevent the hypocalcaemia induced by the anticoagulant solution. The patient's platelets and plasma were completely reinjected. The result was very satisfactory. This kind of exchange, well tolerated clinically and biologically, would seem better than the classical exchange transfusion. When 10% of the red blood cells are infected by Plasmodium falciparum, it is necessary to exchange from one and a half to two blood masses. Lesser exchanges are always associated with important relapses and quinine therapy must be carried on during and after the exchange. Restricting this exchange only to red blood cells enabled the patient to benefit from his own coagulation factors, antibodies and platelets, and consequently to reduce the number of blood donors involved. However, metabolites (especially bilirubin and circulating immune complexes) were not eliminated. Partial plasmapheresis may be associated with erythropheresis using human albumin as plasma substitute. This technique needs to be assessed, in order to optimize immediate efficiency and post-transfusion infectious risk.

An epidemic of acute non-A, non-B hepatitis (NANBH), observed in 38 young French soldiers in Chad, presumed to be waterborne, allowed to describe the clinical picture of the disease. The main features of this entity were compared with those observed during previously described outbreaks of waterborne NANBH encountered in North Africa and in Asia as well as with 85 cases of viral type A hepatitis of various other geographical origins, observed during the same period of time. Similarities between the clinical features of the disease within every water-transmitted NANBH epidemic center were suggestive of a particular nosologic entity among the non-parenterally transmitted cases of NANBH. In young male subjects, the course of the disease proved to be milder than that of type A viral hepatitis. A 5 ml dose of non-specific French-prepared human immunoglobulins had no prophylactic effects on the disease.

24 cases of Plasmodium falciparum malaria in a group of 73 non-immune subjects coming mostly from central Africa have been tested in vitro for chloroquine sensitivity: 5 are sensitive, 19 are resistant among whom one is also quinine-resistant. The comparison of the major clinical and biological features in the two groups by methods of statistical calculation shows that the parasitological diagnosis is retarded and that hemolysis is more frequent in the strains of Plasmodium falciparum resistant to chloroquine. Thrombopenia is more frequent with chemosensitives strains. In any case, the delay between the first symptoms and the parasitological diagnosis is increased with an average of 17 days in comparison to what was observed in the 1970's. Under the influence of several complex factors including human ones, the clinical aspects are changed in comparison to forms usually observed. In this context of an extension of the emergence of the chemoresistance and in the aim of efficiency, only the quinine I.V., with an average dose of 16.5 mg/kg per day of quinine-base, has been chosen as a curative treatment during 5 days allowing a rapid recovery without after-effects for all the cases.