Les cas de tuberculose déclarés en France en 2001Cases of tuberculosis declared in France in 2001☆

Les tuberculoses extrapulmonaires (TBE) représentent un pourcentage croissant de toutes les formes de tuberculose, atteignant 20 à 40 % d’entre elles selon les séries. La proportion de TBE semble plus élevée chez les sujets de race noire, les femmes et les patients immunosupprimés ; une proportion non négligeable des sujets atteints ont une radiographie du thorax normale lors du diagnostic. Les atteintes les plus fréquentes sont ganglionnaires, pleurales ou ostéoarticulaires. Les tuberculoses digestives, urogénitales ou méningées ne sont pas rares et leur diagnostic est souvent différé par un diagnostic différentiel large et par des tests diagnostiques qui manquent de sensibilité, y compris les cultures et les tests d’amplification génique. La présentation clinique des TBE est décrite de même que le rendement des divers tests à disposition. Les recommandations thérapeutiques internationales sont rappelées ainsi que des recommandations pratiques relatives aux différentes présentations cliniques.

Extrapulmonary tuberculosis represents an increasing proportion of all cases of tuberculosis reaching 20 to 40% according to published reports. Extrapulmonary TB is found in a higher proportion of women, black people and immunosuppressed individuals. A significant proportion of cases have a normal chest X-Ray at the time of diagnosis. The most frequent clinical presentations are lymphadenitis, pleuritis and osteoarticular TB. Peritoneal, urogenital or meningeal tuberculosis are less frequent, and their diagnosis is often difficult due to the often wide differential diagnosis and the low sensitivity of diagnostic tests including cultures and genetic amplification tests. The key clinical elements are reported and for each form the diagnostic yield of available tests. International therapeutic recommendations and practical issues are reviewed according to clinical presentation.

The majority of cases of tuberculosis occur among males, but the majority of cases with extrapulmonary tuberculosis (EPTB) occur among females. The aim of this study was to identify independent risk factors associated with EPTB.

A multivariable logistic regression model was used. Eighteen thousand, six hundred seventeen cases of tuberculosis, notified through the French national mandatory network between 1 January 1997 through 31 December 2001, were included in the analysis. Because of multiple interactions, different multivariable models were built for each area of birth (Europe, North Africa, Sub-Saharan Africa, and Asia).

Risk factors for EPTB vary according to area of birth. Women born in Asia or North Africa were at a higher risk of developing an EPTB than men. In Sub-Saharan Africa, age was associated with EPTB. Human immunodeficiency virus infection was an independent risk factor for EPTB in the European groups only with an OR of 2.48 (CI 99% 1.84–3.34).

This analysis contributes to a better understanding of host-related factors associated with EPTB. As clinical presentation of EPTB is extremely variable, the identification of groups at higher risk may help in the early detection of cases.

Les tuberculoses extrapulmonaires disséminées sont rares, surtout chez les sujets immunocompétents. Nous rapportons le cas d'une femme âgée de 38 ans, d'origine ivoirienne, souffrant d'une ostéomyélite humérale droite avec abcès froid du grand pectoral, spondylite de D11, adénopathies profondes, nodules péritonéaux et hépatite, sans immunodépression associée. Le seul facteur de risque trouvé est son origine d'un pays d'endémie. L'évolution a été favorable sous traitement antituberculeux. Ce cas illustre l'évolution épidémiologique actuelle de la tuberculose en France ou l'incidence chez les migrants est en augmentation. De plus, il rappelle l'insidiosité de cette infection chronique paucibacillaire. En effet, dans son cas, les symptômes évoluaient depuis deux ans sous la forme de douleurs latentes de l'épaule droite et rachidiennes, d'allure commune.

Disseminated extrapulmonary tuberculosis is uncommon, particularly among immunocompetent individuals. We report the case of a 38-year-old woman from the Ivory Coast who had osteomyelitis in the right humerus, a cold abscess in the pectoralis major muscle, T11 spondylitis, deep lymphadenopathies, peritoneal nodules, and hepatitis. She had no evidence of immune deficiency, and her only risk factor for tuberculosis was her origin from an endemic area. The outcome was favorable after treatment with antitubercular drugs. This case illustrates the recent changes in the epidemiology of tuberculosis in France, where the incidence among immigrants is rising. It also serves as a reminder that tuberculosis can run a chronic and extremely insidious course. At diagnosis, our patient had a 2-year history of chronic pain in her right shoulder and back suggestive of a minor mechanical disorder.

Disseminated extrapulmonary tuberculosis is uncommon, particularly among immunocompentent individuals. We report the case of a 38-year-old woman from the Ivory Coast who had osteomyelitis in the right humerus, a cold abscess in the pectoralis major muscle, T11 spondylitis, deep lymphadenopathies, peritoneal nodules, and hepatitis. She had no evidence of immune deficiency, and her only risk factor for tuberculosis was her origin from an endemic area. The outcome was favorable after treatment with antitubercular drugs. This case illustrates the recent changes in the epidemiology of tuberculosis in France, where the incidence among immigrants is rising. It also serves as a reminder that tuberculosis can run a chronic and extremely insidious course. At diagnosis, our patient had a 2-year history of chronic pain in her right shoulder and back, suggestive of a minor mechanical disorder.

Les Sans Abris ou sans domicile fixe représentent une population à risque pour certaines maladies infectieuses à transmission respiratoire comme la grippe ou la tuberculose, les infections liées aux arthropodes notamment les bartonelloses, les maladies sexuellement transmissibles ou liées à la toxicomanie, comme l’hépatite B, l’hépatite C, le VIH et la syphilis. Par ailleurs, ces personnes ont très souvent des infections cutanées et des pieds. Ceci est très étroitement lié à leurs conditions de vie dans une hygiène précaire et une promiscuité importante. Promouvoir les vaccinations hépatite A et B, diphtérie, tétanos et grippe, veiller aux soins des pieds, hospitaliser pour suspicion de tuberculose tous les patients avec une toux chronique, une aide vestimentaire et la mise à disposition de préservatifs nous semblent être les éléments indispensables pour la prévention de ces maladies de la pauvreté.

Homeless are specifically exposed to infectious diseases such as influenza and tuberculosis, arthropod-borne infections especially bartonellosis, STD or IVDA-related infections such as hepatitis B and C, HIV and syphilis. Foot problems and skin infections are frequent in this population. All these diseases are related to their living conditions with deprived hygiene and promiscuity. Promoting vaccination for hepatitis A and B, diphtheria, tetanus, influenza, taking care of foot problems and skin infections, investigating the patient with chronic caught for tuberculosis, changing regularly clothes and offering free condoms are mandatory support to avoid such infection in this exposed population.