* CORRESPO~~ING AUTHOR. YAWS/PMVH/jtf-88 IN CENTRAL AFRICA IMMUNOFLUORESCENCE FOR DIAGNOSIS GONZALEZ. MARTIN. M.H. GEORGES-COURBOT M.C. PALISSON. M.J.
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1 YAWS/PMVH/jtf-88 YA~S IN CENTRAL AFRICA CLINICAL ASPECTS AND USEFULNESS OF INDIRECT ABSORBED IMMUNOFLUORESCENCE FOR DIAGNOSIS MARTIN. P.M.V.* GONZALEZ. J.P. MARTIN. M.H. GEORGES-COURBOT M.C. PALISSON. M.J. GEORGES.A.J. INSTITur PASTEUR. BP 923. BANGUr. CENTRAL AfRICAN REPUBLlC (CAR) * CORRESPO~~ING AUTHOR
2 YAWS/PMVM/jtf-88 YAWS IN CENTRAL AFRICA : CLINICAL ASPECTS AND USEFULNESS OF INDIRECT ABSORBED IMMUNOFLUORESCENCE FOR DIAGNOSIS MARTIN, P.M.V.* GONZALEZ, J.P. MARTIN, M.H. GEORGES-COURBOT M.C. PALISSON, M.J. GEORGES,A.J. INSTITUT PASTEUR, BP 923, BANGUI, CENTRAL AFRICAN REPUBLIC (CAR) * CORRESPON~ING AUTHOR
3 A BST RAC T During a survey n 533 pygmies frm Central African Republic, it appeared that there is still an impressive incidence in pygmy children with pr hygiene. Labratry investigatin shwed that the Trepnemal pallidum hemagglutinatin assay is ften negative during the first stage f the disease, while the Flurescent Trepnemal antibdy absrptin test is psitive and thus mre sensitive.
4 3 Yaws (frambesia trpica. pian) was ne f the wrld's mst prevalent diseases befre the initiatin f mass penicillin therapy campaigns in the early fifties. and ccured in humid. trpical regins where hygiene was pr(3). Then. the disease became a rarity in Central Africa. except in ne ethnic grup: the pygmies. The diagnsis f an infectin by Trepnema pertenue. the causative rganism which has nt been differenelated bacterilgically r immunlgically frm T.pallidum yet. is based n three criteria: (1) the emergence f the disease in an endemic regin, (2) clinically typical papillma lesins and (3) seractivity in a trepnemal antigen test. Demnstratin f T.pertenue by darkfield examinatin f exudate frm a suspected lesin cnfirms the diagnsis. but it is ften mst difficult. due t frequent superinfectins by ther bacteria. Here. we present the results f a suryeillance f yaws in pygmies living in a large jungle area in the suth f the CAR. Frm March t August 1987, we perfrmed fur surveys n pygmies ppulatins frm tw znes: the Sangha and the Lbaye valleys. Eight villages in the Sangha and thirteen in the Lbaye were visited. and all children. and adults present, were examined. When a suspected lesin was detected. a bld sample was taken and the patient was treated with benzathine-benzylpenicilline (2.4 millins units intramuscularly in adults.half dse in children and a quarter in babies under 1 year f age). Sera were separated within 48 hurs and frzen at -20 C until used. Antibdies against trepnemal antigens were detected by the Trepnemal Passive Hemagglutinatin Assay (TPHA) (Sera-Tek, MHA-TP; Ames Divisin. Miles, Paris) by tw-fld dilutins beginning at 1/80,and sera fund
5 4 negative were tested by the flurescent trepnemal antibdy absrptin test (FTA-ABS test, BiMerieux, Marey l'etile. France) as described by the manufacturers. A ttal f 533 pygmies were examined: 335 children under 15 and 198 adults (209 and 69 1n the Sangha. and 126 and 129 in the Lbaye. respectively). In 15/21 villages. the whle ppulatin was seen, and there were 198 adults fr 187 children. In 7/21 villages. mst if nt all adults were in the frest.50 nly children were examined. Amng the entire ppulatin. 39 clinically suspect cases were detected: 2 in adults and 37 in children. Of these. nly 27 were psitive by TPHA. while 6 were psitive by indirect immunflurescence (FTA-ABS) nly, and 6 were sernegative. In villages in which the entire ppulatin was seen, there were 2/198 (1 %) adults and 28/187 (15 %) children with serlgically cnfirmed yaws,i.e. 93.3% f the cases ccured in children under 15. As regard t their access t medicine, children in villages were classified int three grups: ne with gd medical care and hygiene, where missinaries lived permanently; ne with spradic medical care; and ne in cmpletely wild cnditins. We detected 0/79 (0%) (10.4%) and 7/25 (28%) cases f yaws in each grup respectively. This demnstrates a clear increase in the incidence f the disease when general hygiene cnditins are pr as there ~ was n preventive pen11lin cmpaigns cnducted prir t ur survey in the area f the cuntry. Whether the 6 sernegatives had lesins due t ther cnditins is difficult t ascertain. As shwn in table I, all 6 TPHA negatives and FTA psitive patients had nly I, r 2 side-by-side lesins, while TPHA-psitives ften had
6 5 several such lesins. All sernegative children had the same clinical pattern as the TPHA-negative~ FTA-psitive grup (Table 1). In ne case, a sernegative child had a typical primary frambesia. while his brther living in the same hut had serlgically cnfirmed yaws. Papillma were mst frequently situated n the lwer extremities (9 cases), face (9 cases including 1 n the skull), trunk and neck (7 cases), and buttcks (5 cases including 2 vulvar primary frambesia); but were als seen n the upper extremities (2 cases). In ne case, a primary unique papillma was lcalised n the sle f the ft. and in fur cases f generalized frms, 20 t 50 papillma were disseminated ver the whle bdy. The mean age f children with disseminated frms was 3.75 ± 2.6 years, and 6.43 ±3.S years fr nn-disseminated frms. Our wrk shws that yaws is still far frm being eradicated and that there is an impressive incidence in pygmy children with pr hygiene. In ur shrt series, n bne cmplicatins were detected. Hwever, the large number f lesins bserved amng children with the disseminated frm f yaws. make superinfectin highly pssible and such a cmplicatin wuld be life-threatining. This shuld prmpt health authrities t start mass penicillin therapy campaigns. Serlgical reactivity n the flurescent trepnemal antibdy absrptin (FTA-ABS) test fr yaws is prly dcumented. likely due t the requirement fr a flurescent micrscpe. and the relatively recent current use f this test (2). Our study shws the usefulness f the FTA-ABS test, particularly during the first stage f the disease, when the micr-hemagglutinatin test is still negative.
7 6 Systematic serlgical survey perfrmed n the same pigmy ppulatin 10 years ag by Cirera et al. (1) shwed that as much as 807. f the adults were psitive fr syphilis. It is likely that many f these syphilis psitive adult were actually psitive fr T.pertenue and they crss-reacted n the r.pallidum test. Thus. we feel that it is necessary t differenciate the immune respnse t T.pertenue frm that t T. pallidum.
8 LITERATURE CITED (1) Cirera P. M.J. Palissn. G. Pinerd. and G. Jaeger La serlgie trepnemique dans une ppulatin pygmee BI-AKA Centrafricaine. Bull.Sc.Path.Ext., (2) Deacn. W.E J.B. Lucas. and E.V. Price, Flurescent trepnemal antibdy-absrptin (FTA-ABS) test fr syphilis. J.Am.Med.Assc (3) Perine. P.L Yaws, p In G.T. Strickland (ed.). Hunter's Trpical Medicine. W.B. Saunders C. Philadelphia.
9 . 8 TABLE 1 : Serlgical respnse t trepnemal antigen in patients with yaws : crrelatin with number f frambesia. Serlgical Number f cases with the fllwing test (Nb) number f frambesia lesins lO (generalized) TPHA (+) (27) TPHA (-) (6) ITA-ABS (+) 6 TPHA (-) ITA-ABS (-) (6) 6 TPHA Trepnema Pal1idum Hemagglutfnatin Assay FIA-ABS - Flurescent Trepnema! Antibdy Absrptin Test.
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