[Multicentric reticulohistiocytosis with a 20-year follow-up ]

INTRODUCTION

Multicentric reticulo-histiocytosis also known as lipoid dermoarthritis is a rare systemic disease leading to a massive osteoarticular destruction and systemic complications.

EXEGESIS

This case report is a 44 year old black woman who was first seen with a rheumatoid arthritis clinical presentation associated with the presence of rheumatoïd factor. Five years later the diagnosis has been reconsidered after skin nodules histological examination. After that the patient has been lost from the follow up clinic. After a twenty years evolution she presented a complex clinical picture including: a cutaneous syndrome with a non pruriginous and hyperchromic papulonodular rash on the arms and fore-arms; a very destructive polyarthritis with major handicap; and systemic manifestations like cardiomyopathy with heart failure. The heart failure treatment associated first corticosteroids and secondary chloroquine was successful.

CONCLUSION

The rheumatoid factor presence should not avoid to consider the possibility of multicentric reticulohistiocytosis in case of polyarthritis associated with a papulonodular rash. Then skin biopsy must be performed. The severity of osteoarticular and systemic lesions require an early prescription of a treatment for which there is so far no compromise.

[An incomplete form of pachydermoperiostosis. Diagnosis of finger clubbing]

INTRODUCTION

The finger clubbing is most of the time associated with cardiovascular and pulmonary diseases. Pachydermoperiostosis also known as osteodermopathic syndrome, an hereditary disorder, is a rare cause of finger clubbing which might be difficult to diagnose in an incomplete form.

EXEGESIS

We report a 36 years old black man presenting over many years polyarthralgias, broadening of fingers and clubbing of the fingers and toes extremities. This was mentioned on other family members. The physical examination was otherwise unremarkable. There were no skin thickening, no psoriasis-like and cardio-pulmonary disease features. These following exams were normal; Hemogram, fibrinogen, C reactive protein, rheumatoïd factor, serum calcium and phosphorus, thyroid hormones, growth hormone, chest X-ray, gastroduodenoscopy, electrocardiogram. The skeletal X-ray documented a widespread bone formation, a sacro-iliac osteosclerosis and interosseous ossifications betwen tibias and fibulas.

CONCLUSION

Pachydermoperiostosis diagnosis was set up on 3 out of the 4 Borochowitz criteria. The absence of pachyderma defines this incomplete form. The osteoarticular manifestations lead mainly to differential diagnosis with the secondary hypertrophic osteoarthropathy and chronic inflammatory rheumatisms. The underlying pathogenic mechanism of this disease remains still unclear.

Amodiaquine-artesunate versus amodiaquine for uncomplicated Plasmodium falciparum malaria in African children: a randomised, multicentre trial

BACKGROUND

Increasing drug resistance limits the choice of efficacious chemotherapy against Plasmodium falciparum malaria in Africa. Amodiaquine still retains efficacy against P falciparum in many African countries. We assessed the safety, treatment efficacy, and effect on gametocyte carriage of adding artesunate to amodiaquine in three randomised trials in Kenya, Sénégal, and Gabon.

METHODS

We enrolled 941 children (400 in Kenya, 321 in Sénégal, and 220 in Gabon) who were 10 years or older and who had uncomplicated P falciparum malaria. Patients were randomly assigned amodiaquine (10 mg/kg per day for 3 days) plus artesunate (4 mg/kg per day for 3 days) or amodiaquine (as above) and placebo (for 3 days). The primary endpoints were parasitological cure rates at days 14 and 28. Analysis was by intention to treat and by an evaluability method.

FINDINGS

Both regimens were well tolerated. Six patients in the amodiaquine-artesunate group and five in the amodiaquine group developed early, drug-induced vomiting, necessitating alternative treatment. By intention-to-treat analysis, the day-14 cure rates for amodiaquine-artesunate versus amodiaquine were: 175/192 (91%) versus 140/188 (74%) in Kenya (D=16.7% [95% CI 9.3-24.1], p<0.0001), 148/160 (93%) versus 147/157 (94%) in Sénégal (-1.1% [-6.7 to 4.5], p=0.7), and 92/94 (98%) versus 86/96 (90%) in Gabon (8.3% [1.5-15.1], p=0.02). The corresponding rates for day 28 were: 123/180 (68%) versus 75/183 (41%) in Kenya (27.3% [17.5-37.2], p<0.0001), 130/159 (82%) versus 123/156 (79%) in Sénégal (2.9% [-5.9 to 11.7], p=0.5), and 80/94 (85%) versus 70/98 (71%) in Gabon (13.7% [2.2-25.2], p=0.02). Similar rates were obtained by evaluability analysis.

INTERPRETATION

The combination of artesunate and amodiaquine improved treatment efficacy in Gabon and Kenya, and was equivalent in Sénégal. Amodiaquine-artesunate is a potential combination for use in Africa. Further investigations to assess the potential effect on the evolution of drug resistance, disease transmission, and safety of amodiaquine-artesunate are warranted.

[Gastro-esophageal reflux in adults: clinical and endoscopic features at the Le Dantec Hospital of Dakar]

We carried out a prospective study in the digestive endoscopy unit of Medical Clinic of the University Hospital Le Dantec, in order to better clarify the clinical and endoscopic features of gastro-esophageal reflux ( GER ) in our country. Patients whose endoscopy was indicated by symptoms of GER and those who presented oesophagitis were concerned in this study. We so included 317 patients, representing 16.75% of all patients undergoing upper gastro-intestinal endoscopy from september 1999 to august 2000. Clinical symptoms could be analysed in 164 patients (51.74%). Mean age was 40 years and sex-ratio 0.83. The most frequent digestive symptoms were epigastric pains ( 72.6 % ), heartburn ( 60.4 % ), and acid regurgitations ( 56.7% ). Non gastro-intestinal symptoms were present in 43.9% of cases for Ear Nose and Throat signs. 36.6% for chest pains and 14.6% for pulmonary manifestations. Peptic oesophagitis was present in 40.69% of patients with a mean age of 44 years. Savary and Miller grade IV was rare and was represented by oesophageal ulcers only. GER aspects in our departement are characterized by high frequency of epigastric pains and atypical symptoms, and rarity of severe forms of oesophagitis.

[Ultrasonographic aspects of urinary schistosomiasis in children of the Dogon plateau and the Niger office; impact of praziquantel treatment]

Urinary bilharziasis is a parasitic infection responsible for vesical, urethral and renal lesions. The authors demonstrate the importance of ambulatory echography on a large scale and describe various echographic lesions. Vesical attacks occurred in 27% of the wall irregularity, 44% of the masses and polyps. Pyelic and urethral abnormalities occurred in 16.6% and 29.9% of cases respectively at the baseline in 1991. These prevalence rates decreased after seven years, in 1998. The authors discuss the utility of chemotherapy with praziquantel and the necessity of a periodical mass treatment in the areas with high bilharziasis endemicity in Mali.

[Ground and first singlet excited dissociation constants of 4-methylumbelliferone: application for indirect spectrofluorimetry of nitriles and nitrosamines]

The light adsorption process provides important changes in the electronic configuration of molecules. For phenolic derivatives, light adsorption contributes to acidity in the excited state. In aqueous medium, excitation of the molecular form (ArOH) undergoes dissociation at the first singlet excited state and subsequent fluorescence emission occurs from the excited ionized form (ArO-*). The emission is higher than from the molecular form and exhibits a shift to the red. The combination of these two phenomena allowed simultaneous increase in selectivity and sensitivity. In addition this method allowed an easy quantification of 4-methylumbelliferone at the nanomolar level and consequently trace levels of nitrates and N-nitrosamines after diazotization and/or denitrozation.

[Contribution of radiography and repeat microscopy in the diagnosis of pulmonary tuberculosis in the hospital environment of Bamako]

WHO and IUAT-LD recommend repeated microscopy in order to improve the detection of contagious cases of pulmonary tuberculosis. Our aim was to determine the contributions of radiology and microscopy in the diagnosis of pulmonary tuberculosis. From January 1998 to April 1999 radiography and microscopy were performed for 275 patients who were admitted to the pneumology service. Pulmonary tuberculosis prevalence was higher among women aged 10 to 29 years than among men of the same age (p = 10(-6)). 188 (68.4%) women tested positive, 49 (17.8%) tested positive at the second microscopy and 1 (0.36%) at the the third. The main radiological lesions were nodules + infiltrats (46.2%), nodules + infiltrats + cavity (26.2%) and infiltrats + cavity (6.5%). Repeated microscopy significantly increased the proportion of pulmonary tuberculosis cases detected (from a prevalence 68.4% to 86.5%).

[Methotrexate, liver and rheumatoid arthritis in tropical areas]

Rheumatoid arthritis (RA) is a common disease in tropical areas. Methotrexate which has become the main first-line treatment in western countries is increasingly used in tropics. Well documented liver toxicity of methotrexate led the American College of Rheumatology to provide guidelines about monitoring patients. In endemic areas of hepatitis B and C methotrexate may interfere with the natural history of these infections and exarcerbate liver damage, on the other hand, RA causes extra-articular manifestations which are rare and exceptionnally serious in the liver. The most important hepatic disorders associated with RA are: intrahepatic portal hypertension without cirrhosis, amyloidosis, drug hepato-toxicity and viral interferences. - Intrahepatic portal hypertension Several cases of portal hypertension without cirrhosis have been reported. Most cases were related to Nodural Regenerative Hyperplasia (NRH) which is made of diffuse nodules of hepatocytes without fibrosis. The pathogenesis of this entity is unknown. Distal vascular changes and abnormal perfusion of liver are mentioned. Presentation is cholestasis in one third of cases. Portal hypertension has no particularity and may cause esophageal variceal bleeding. NRH is closely associateed with Felty's syndrome. - Amyloidosis Hepatic amyloidosis is a classical complication of RA even rare. It is a secondary amyloidosis of AA type. Hepatic injury is generally silent and renal symptoms are dominant. - Drug hepatotoxicity Several medications used in the management of RA are potentially hepatotoxic : salicylates, nonsteroidal antiinflammatory drugs (NSAID), corticosteroids, gold, sulfasalazine and methotrexate above all. Methotrexate hepatotoxicity is well documented in carcinology with high doses but also in psoriasis patients treated with low doses. Hepatic damage related to methotrexate includes elevation of aminotransferases, portal fibrosis and cirrhosis. But data on methotrexate toxicity show small risk of serious liver disease in RA patients. Long duration of therapy and age (> 60 years) have been found to be independent risk factors for the development of hepatic disease. Other identified risk factors are alcohol intake, diabetes, obesity and prior history of hepatitis B or C. The American College of Rheumatology has published guidelines about monitoring patients for liver toxicity. Hepatic tests and Hepatitis B and C serologic studies are recommended before starting treatment with methotrexate. Liver biopsy is only recommended in case of alcoholism, prolonged abnormalities of aminotransferases and chronic hepatitis B or C infection. - Methotrexate and hepatitis B or C infection These infections are endemic in tropical areas. Chronic hepatitis B or C is a contra indication for methotrexate therapy, due to the immuno-suppressive effect of the drug. Positive ELISA tests to C virus must be confirmed with RIBA tests to avoïd false positive tests which have been reported in Africa. The "healthy" HBs Ag carrier state is not in theory a contra indication for methotrexate therapy but the risk of hepatitis B reactivation needs a close monitoring. The biological tests required for are sophisticated and quite impossible in routine practice in tropical areas. So HBs Ag carrier state is usually incompatible with methotrexate treatment. Studies would be useful to prove that in endemic areas of viral hepatitis B and C as in western countries, methotrexate is enough safe to become the main first-line treatment of rheumatoid arthritis.

[Epidemiological, clinical and progressive aspects of asthma observed at Bamako, Mali]

We carried out a prospective study of 106 of the 752 asthmatic patients attending the outpatient clinic of Point G Hospital, Bamako, between December 1997 and November 1998. We analyzed data for 61 patients whose lung function was assessed by measurement of peak expiratory flow. The frequency of asthma was 14.9%, suggesting regular progression of the disease. There were slightly more women than men (55.7% women) in the study population and the mean age of the patients was 31 years. Most of the patients (65.5%) were recruited in the dry season (November to May). Based on peak expiratory flow measurements, intermittent asthma was the most frequent type of asthma observed (37.8%), followed by moderate persistent asthma (34.4%), mild persistent asthma (18%) and severe persistent asthma (9.8%). The mean cost per episode of asthma was $36 (US) and the mean cost per patient was $432 (US) per year. In 52.45% of cases, the drugs required were available and the patient had access to them. They were available but not accessible in 26.22% of cases. To improve the management of asthma in countries with limited financial resources, generic drugs should be made available.

[Antifungal drug susceptibility of Candida causing oropharyngeal candidiasis in HIV infected patients]

Candidiasis are very usual infections of HIV infected patients. By medicine pressure, susceptibility to antifungal drugs decrease in some Candida strains. This study carded out in 1997 at hospital, aimed to identify the yeast species isolated from HIV infected patients with oropharyngeal candidiasis, test their susceptibility to antifungal drugs and a previous antifungal treatment impact. Thus, 60 patients yielded to questionnary were recruited. Isolated yeast colonies from buccal tract after culture on Sabouraud medium with chloramphenicol were identified with the API 20 C AUX (BioMérieux) system by assimilation of different sugars. Susceptibility was evaluated by ATB FUNGUS (BioMérieux) system. 55 from the 60 isolated yeasts were identified and among them C. albicans and C. tropicalis were the main species with 75% and 11,7% respectively rates. In HIV1 infected patients, all specieswere isolated and C. albicans predominated (80,4%) on the other hand, C. albicans and C. tropicalis were the only isolated yeasts from the HIV2 infected patients with 83,3% and 16,6% respectively rates. Susceptibility of C. albicans was 72,2% to nystatine, 58,3% to amphotericin B, 83,3% to flucytosin, 12,8% to miconazole, 8,5% to econazole and 10,6% to ketoconazole. Susceptibility of C. albicans to polyenes was modified by a previous antifungal treatment. This study indicated emergence of saprophytic yeasts of the buccal mucosa and seemed to be more fostered by HIV1 serotype than HIV2. So, C. albicans's susceptibility to polyenes decreased by untimely use of antifungal drugs and by controlling it one could improve the clinic conditions of HIV infected patients.

[Pneumocystosis in HIV infected patients presenting with acid-fast bacilli negative pneumopathy at the Central University Hospital at Dakar]

Pneumocystosis is an opportunist parasitic disease which occurs currently at Europe and United States in HIV infected patients. In Africa, the disease is not current. Pneumocystosis has been detected in the Fann medical universitary center at Dakar from HIV infected patients with acido alcoholo resistant bacilli negative pneumopathy. Analysis of broncho alveolar liquid(BAL) of 29 patients after Giemsa and Blue of Toluidin O staining allowed isolating of two cases of pneumocystosis. A man and a woman were the patients. They were HIV1 positive with at X ray bilateral interstitial syndrome. The CD4 lymphocytes count of the one was lower than 200/mm3 and for the other it was higher than 200/mm3.

[Malaria in the central health district of Dakar (Senegal). Entomological, parasitological and clinical data]

We previously investigated malaria in the southern health district of the city of Dakar, which includes the oldest neighborhoods. In this study, we investigated malaria in the central health district, corresponding to the central area of the conurbation. The study was carried out at 12 sites, from March 1996 to February 1997. The sites were selected such that the entire district was covered and included 2 sites in the shanty town and three in an old village that has been absorbed into the city. We carried out prospective monthly entomological analyses with a view to identifying the vectors and the mode of transmission of malaria. We also carried out clinical and parasitological follow up to determine the incidence of parasitemia and of bouts of malaria. Insects were collected overnight from humans and the insects remaining the next morning in 10 bedrooms in the health district were collected. For clinical and parasitological follow up, families were visited at home once per week and their clinical state was assessed. Blood smears were taken to facilitate the detection of bouts of malaria. Body temperature was measured and we checked for the presence of organisms in the blood systematically during the last weekly visit of each month. For a total of 308 collections at night from human volunteers and 1,395 bedroom collections of residual fauna, we obtained 12,879 Culicidae females, 199 (1.5%) of which were anopheles mosquitoes, with Culex quinquefasciatus accounting for 98% of the remaining mosquitoes. As in the southern district, A. arabiensis was the only species of the A. gambiae complex collected. Anopheles mosquitoes accounted for only 0.3 bites per man per night and 0.07 females per room. They were therefore poorly represented in this district and were not detected at all at five sites. They were found in large numbers only during the rainy season, especially in September, when they accounted for 2.25 bites per man per night and 0.3 females per room at 3 sites in an undeveloped zone in which 81.4% of all the anopheles mosquitoes were collected. The parturition frequency of the biting females was 32.6% and that of the females collected in houses was 50.0%. None of the A. arabiensis females dissected (98.5% of those collected) carried Plasmodium sporozoites. The clinical and parasitological follow up concerned 2,583 individuals, aged from 1 month to 80 years, from 285 families resident in Dakar who volunteered for the study; 41.9% of these individuals were less than 15 years old and 92.2% had been living in Dakar for more than 2 years. Thick and thin blood smears taken monthly showed the frequency of the parasite to be 1.0% and that of gametocytes to be 0.1%. P. falciparum was the only parasite detected in the subjects. Plasmodium infections were observed in all age groups, with a frequency of 0.4% (adults over the age of 20 years) to 1.6% (children under two years of age). Parasitized subjects were detected in every month of the study, with a frequency of 0.4% (in January) to 1.9% (in December). The largest number of cases detected in a three-month period (38.8% of all cases) was that for October to December, the three-month period immediately after the rainy season (July to September). Parasite frequency, which was no higher than 1. 2% at 10 sites, was clearly higher at two sites in the shanty town (3.8 and 6.8%), mostly inhabited by immigrants from rural areas. At the end of the study year, satisfactory weekly follow up was considered to have been achieved for 1,067 of the participants. The annual incidence of parasitemia in this cohort was 5.1% and that of malaria was 2.4%. Incidence did not vary significantly with age and was between 1.8% and 7.6% for parasitemia and between 0.8% and 3.5% for malaria. However, significant differences in incidence were observed between areas. Incidence was higher at the two sites in the shanty town, with rates of 12.1% and 36.5% for parasitemia and 6.1% and 15.9% for malaria. (ABSTRACT TR

[Management of severe malaria in children in developing countries. A protocol for economic evaluation]

This prospective one-year study was conducted as a preliminary phase to setting up a protocol for economic appraisal of management of severe malaria at Albert Royer Children's Hospital in Dakar, Senegal. Data was routinely collected using a standardized checklist. The four key indicators chosen for this study were nurse workload, adequacy of care (number of patients receiving adequate care), direct cost, and mortality rate. The mean daily care workload was estimated to be 27.2 minutes. This indicator assesses the relationship between supply and demand. Based on 5 criteria, care was considered as adequate in 54.5 p. 100 of patients. This indicator is helpful in judging the effectiveness of the therapeutic modalities used. The direct cost of treating severe malaria was estimated to be 45963 CFA francs. This indicator will be useful in establishing controls to reduce costs. The mortality rate was 12.2 p. 100. Comparison of this rate with previous years suggests little improvement in the outcome of malaria management at the institution. This indicator must be taken into account in the ongoing quality control program. Overall these findings should enable institutional decision-making to improve management of severe malaria based on objective measurable data.

[Treatment of rheumatoid polyarthritis with methotrexate in Dakar: efficacy, tolerance and cost]

Methotrexate (MTX), which has been used for years in cancer treatment, is now being proposed as a first-line treatment for rheumatoid arthritis (RA), despite its potential side effects. The aim of this study was to investigate the short-term efficacy, safety and relative cost of low-dose MTX for the treatment of RA. We carried out an open, nonrandomized trial in which patients received a 7 mg injection of MTX once per week, with clinical and biological follow up. A single physician performed the weekly assessments, which involved evaluation of the duration of morning stiffness, the number of night awakenings, the number of painful and swollen joints and Ritchie's index. Blood cell count and erythrocyte sedimentation rate were determined monthly. Twelve RA patients were enrolled in the trial, over a mean treatment period of 356 +/- 175 days. A significant improvement was observed in all variables except the number of swollen joints. Ritchie's index decreased from a mean of 31.8 +/- 11.85 to 6.5 +/- 8.98 (p<1.6 x 10- 4). Minor adverse reactions were observed but none indicated treatment withdrawal: 6 cases of nausea, 2 of a moderate increase in transaminase activity, 1 of bronchitis, in which the responsibility of MTX was not definitely established and 3 cases in which hemoglobin levels decreased. The monthly cost of the treatment, including the drug itself and laboratory tests, is lower than that of gold salt injection. Three issues of key importance in our region were investigated in this study: 1) the possible desire to become pregnant of female patients undergoing MTX treatment. In addition, some of the young and unmarried patients did not understand or appreciate the contraceptive effects of the treatment; 2) poor compliance with the treatment due to limited financial resources. Many patients did not regularly attend for their follow-up appointments and many stopped taking the medication. One third of the patients were lost to follow-up during this study; 3) the prevalence of chronic hepatitis, which may limit the use of MTX in our region. Serological tests should be performed before the treatment is started and a liver biopsy is recommended for patients with chronic hepatitis B or C.

[Intestinal parasitosis in the inhabitants of a suburban zone in which the groundwater is polluted by nitrates of fecal origin (Yeumbeul, Senegal)]

This study was carried out in 1997 to 1998, to determine the prevalence of intestinal parasite infestations due to groundwater pollution at Yeumbeul, Senegal, and to follow the progression of parasite infestations following anti-parasite treatment. The study included 705 people living in a suburban zone in which the water table was polluted with nitrates of fecal origin. These individuals consumed either well water or water from springs. The overall prevalence of parasite infestation was 42.26%, but varied significantly with age (p < 0.001). Individuals who consumed well water were more frequently infested than those who consumed spring water, but the difference was not significant (p > 0.3). Giardia and Entamoeba coli were the most frequently isolated parasites, with Giardia predominating in the 0 to 9 year age-group. There was no significant correlation between the prevalence of the various parasites and indicators of water pollution (R2 = 0.0566 for nitrates and 0.1086 for fecal coliform bacteria). Similarly, no correlation was found with water pollution factors such as the depth of the water table (R2 = 0.027) and the distance between the wells and the latrines (R2 = 0.00007). Following specific treatment, the prevalence of parasite infestation fell to 30.81%. This indicates the limitations of drug treatment, which is always used alone to combat intestinal parasites, in the face of possible reinfestation.

Amodiaquine remains effective for treating uncomplicated malaria in west and central Africa

Many countries in Africa are now confronted with the dilemma of shifting drug policies for uncomplicated falciparum malaria from chloroquine, which has become largely ineffective, to a new first-line drug and amodiaquine is one of the possible options. A multicentre, open-label randomized controlled trial of amodiaquine 30 mg/kg vs chloroquine 25 mg/kg over 3 days was performed in Senegal, Cameroon, Gabon, and Burkina Faso between 1996 and 1998 and patients were followed-up for 14 days. Sensitivity of isolates in vitro and whole blood levels of chloroquine and amodiaquine were also measured. The primary efficacy parameter was parasitological clearance on day 14 (parasitological success). The secondary efficacy parameter was absence of signs/symptoms of malaria on day 14 (clinical success). Among the 364 patients randomized and receiving the assigned treatment (chloroquine n = 185, amodiaquine n = 179), 137 and 139, respectively, reached the primary endpoint. Amodiaquine proved significantly more effective than chloroquine. The summary odds ratio (95% CI) was 7.79 (4.54-13.35) for parasitological success, and 6.3 (3.4-11.68) for clinical success. Sensitivity in vitro and chloroquine blood levels were good predictors of chloroquine failure. Amodiaquine remains effective for treating uncomplicated falciparum malaria in areas of West and Central Africa where chloroquine resistance is prevalent. However, measures should be taken to protect the lifespan of amodiaquine where the drug is introduced for use.

A comparison of thick smears, QBC malaria, PCR and PATH falciparum malaria test trip in Plasmodium falciparum diagnosis

Blood samples from 182 patients presenting at the out-patient clinic in Richard-Toll. Senegal were analysed by Thick smear microscopy, the QBC, PCR and the new dipstick PATH Malaria assay which detects the histidine rich protein II antigen of Plasmodium falciparum. Thick smear microscopy was used as the reference method. Sensitivity, specificity, predictive positive and negative values were 100%, 83.6%, 93.4% and 100% QBC respectively; 100%, 72.7%, 89.4% and 100% for PCR; 96%, 92.7%, 96.8% and 91% for the PATH assay. PATH assay failed to detect one positive sample with Plasmodium malariae. Assays were also compared with regard to the expense of equipment and reagents and speed and ease of use. The rapid PATH assay can be performed with minimal training and may be specially useful in areas where P. falciparum is the predominant malaria species, in epidemic malaria regions, and where skilled microscopy is not readily available.

[Malaria lethality in Dakar pediatric environment: study of risk factors]

To determine risk factors for fatal malaria in Senegalese children, a 3-year case-control study was carried out between October 1992 and November 1995 at the Albert Royer Hospital in Dakar. The case group included 52 children who died from documented malaria in the hospital. The matched control group consisted of children who responded favorably to hospital treatment. Exposure to risk was measured with regard to age, nutritional status, educational level of parents, self-medication prior to hospitalization, socioeconomic level, degree of fever, and blood parasite levels. Cases and controls were compared using statistical tests for matched groups. Age lower than 5 years, poor educational level of parents, delay of treatment more than 24 hours, nutritional status, and blood parasite levels greater than 5% were associated with a significantly higher risk of fatal outcome. Conversely, low socio-economic level, recent self-medication, and fever over 41 degrees C were not associated with higher fatality. These findings emphasize the need for more information campaigns to encourage people to seek institutionalized care when fever appears. Our results also suggest that prophylactic treatment may be advisable in children under 5 years of age and in some high risk groups.

[Heterogeneity of chloroquine resistant malaria in Senegal]

In order to evaluate the in vivo efficacy of chloroquine in the treatment of P. falciparum malaria, studies have been carried out in Richard-Toll, Fatick and Tambacounda, 3 areas where dynamics of transmission, population movements, as well as prophylactic and curative practises are different. Failure rates in treatment were 13% in site 1 (Richard-Toll) where medical pressure and population movements are high. In sites 2 and 3 (Fatick and Tambacounda), the failure rate was 3%. Even if medical pressure is lower in the latter site (Tambacounda), the higher transmission could be a factor in the spreading of resistance. A surveillance system and better use of chloroquine must be undertaken.

[Aspects of genital tuberculosis in women]

Thirteen cases of genital tuberculosis are reported to make emphasis onto the difficulties of diagnosis, management and prognosis of the disease. The average age of the patients is 31 years. Most of them were under 30. The circumstances of diagnosis were variable. The diagnosis was essentially made thanks to histology. The evolution was favorable under antibiotics. But clinical sequels as amenorrhea and infertility are frequent.

[Evolutive aspects of systemic lupus erythematosus in Dakar. Apropos of 30 cases]

To determine the characteristics of evolution of systemic lupus erythematosus (SLE), the authors studied 30 cases retrospectively. All were black women aged from 16 to 73 years (with a mean of 30 years) at the time of diagnosis. Dermatological manifestations consisting in discoid lupus or alopecia inaugurated the disease in 12 cases, joint symptoms in 10 cases. Polyarthritis was the most common inaugural manifestation, followed by discoid lupus. Corticosteroids therapy alone or associated to chloroquine or immunosuppressor led to good results; 88% of patients who received treatment had good outcomes in the first 5 months after diagnosis. After this time lapse, 6 cases of complications related to the corticosteroids therapy occurred. After one year, 5 patients presented one or more flare-ups and had to be re-hospitalized; 8 others were lost to the follow-up. The overall mortality rate was 27% (8 cases out of 30). Causes of death were first renal failure (3/8) followed by infectious complications (2/8). The management of SLE could be improved by a close follow-up and providing the patients and their family with adequate information.

[Comparison of the transmission of malaria in 2 epidemiological patterns in Senegal: the Sahel border and the Sudan-type savanna]

From September 1992 to October 1993 a longitudinal entomological study was carried out in two villages located in different ecological conditions of Senegal, a sahelian area and a sudan-type savanna. Mosquitoes were sampled by night-bites catches and by daytime pyrethrum spray collections. In both villages Anopheles gambiae s.l. is the main vector with An. gambiae in the savanna area of Wassadou and An. arabiensis in the sahelian area of Thiaye. Malaria transmission is mainly seasonal with a man biting rate (ma) and an entomological inoculation rate (h) higher in Wassadou than in Thiaye. In this last one (sahelian area), a high variation of An. gambiae s.l. density was observed, females disappear in the dry season. In the rainy season the main biting rate increases but no infected bite was recorded. In Wassadou (sudan-type savanna), a great difference in An. gambiae s.l. specific composition was observed with An. gambiae predominant in the rainy season and An. arabiensis generally more abundant in the dry season. The biting and inoculation rates were minimum during the dry season (ma = 4 bites/man/night; h = 0.07 infected bites/man/night-, they increase during the rainy season (ma: 52 bites/man/night; h = 1.6 infected bites/man/night). An inhabitant of this village gets annually some 63, bites and 220 infected bites of An. gambiae s.l., mainly during the six months of the rainy season and the early dry season.

[Scanning electron microscope sudy of the morphology of fungi isolated from patients at the Aristide La Dantec Hospital in Dakar, Senegal]

In order to improve the identification of fungi usually isolated among some patients at Dantec Hospital, a study by scanning electron microscopy has been carried out. It deals with four species of yeasts (Candida albicans, Candida parapsilosis, Rhodotorula rubra Sacharomyces cerevisiae) six species of dermatophytes (Trichophyton rubrum, Trichophyton soudanense, Trichophyton interdigitale, Microsporum canis, Trichophyton violaceum, Microsporum audouinii); two species of mildew, (Aspergullus flavus, Aspergillus niger) and one species of dimorphic fungi (Histoplasma duboisii). The yeasts get a smooth surface with, often, a mark of but on it. Microsporum canis presents some echinulate macroconidia. Trichophyton violaceum is characterized by the appearance of echinulate chlamydoconidium with a twofold bulge and Microsporum audouinii by a echinulate chlamydoconidium with a bulge only. Trichophyton rubrum presents macroconidia with smooth surface and in "sausage" form, as for Trichophyton soudanense it presents some arthroconidia that are cells which get more or less rectangular form and with smooth surface. Aspergillus flavus is characterized by the presence of a conidiophore with a verrucosis surface and an aspergillary head of about 36 microns having some spores with almost smooth inner surface. On the other hand, Aspergillus niger gets a conidiophore with smooth surface. As for Histoplasma duboisii, the surface of the chlamydoconidium presents some verrucosis that are real conidia in formation. The scanning electron microscopy enables use to discover the existence of characters that are likely to be used for the identification of fungi.

[Prevalence of malaria in Dakar, Senegal. Comparative study of the plasmodial indices in pregnant and non-pregnant women]

The comparison of the prevalence of malaria in pregnant and non pregnant women living in Dakar has interested 1819 women among whom 950 pregnant and 869 non pregnant. For all the examined women, the global plasmoidic index was 2.6% and the gametocytic index 0.1%. Plasmodium falciparum was the only observed species. According to the obtained results, pregnant women, with a plasmoidic index of 4.5% are more often parasited than the non pregnant women, only affected in a proportion of 0.5% Whatever the age, the number of previous pregnancy, the place of residence, the duration of the stay in Dakar may be, the pregnant women are always more often parasited than the non pregnant women and the registered differences are statistically significant. That situation could come from a greater receptivity of the pregnant women what is admitted by some authors. But a more important proportion of natives from rural area was observed among the pregnant women, from where a difference in the exposure to the risk of impaludation between the two groups that could explain the registered results. The global plasmoidic index of 2.6% obtained in the examined women, reflects well the present situation of the malaria endemy in Dakar, a weak hypo-endemic area.

[Evaluation of malaria chemoprevention among 359 pregnant women attending a health center in Dakar]

The authors carried out an epidemiological survey from october 12 to december 4, 1995, at Medina's mother and Child care centre (MCC) in Dakar in order to assess chemoprophylaxis among pregnant women in Dakar. The midwife/pregnant women ratio is 0.08 The mentioned diagnosis criteria were relevant regards to the references established for most of the answers because since the latter base malaria diagnosis on the following signs: fever, chills, headaches and vomiting. 64.6% of them assume compliance to antimalarial chemoporphylaxis. Education level seems to be the main determining factor in this trend. Although chloroquine is the most widely used drug, nevertheless 11.9% of pregnant women assuming compliance use it at inappropriate posology. Besides, pyrimethamine is used by 12.3% of them. 34% of pregnant women do show chloroquine in urine. The plasmodial index is 1.4%. Only 8.1% of these women are supplied by health centres where shortages are noted.

[Evaluation of parasitic risks for the population bordering on the Mbeubeuss public waste disposal, Dakar]

The authors carried out a parasitologic survey on 367 inhabitants of Malika, a village located in the immediate surroundings of M'Beubeuss disposal, as well as on 433 other residents of Keur Massar, a location 2 km farther, in order to assess parasitic hazards encountered by people neighbouring this disposal. As far as intestinal parasitosis are concerned, the prevalence rate was significantly higher in Malika (61.3%) than in Keur Massar (48.5%) The sex, social and economic status, level of education as well as the time of dwelling in the neighbouring area were identified as the risk factors of intestinal parasitism. Only the last one can be considered as significantly and independently related to a risk of intestinal parasitism. As for malaria, the plasmodial index in Malika was 6% versus 7.6% in Keur Massar (no significant difference). Thus, if it does exist for neighbouring people, an infestation risk by intestinal parasites related to exposure duration, contrarily, it does not exist for malaria. Appropriate steps should be taken to prevent the hazards encountered by inhabitants of surrounding villages.

[Prevalence of malaria in Dakar, Senegal. Results of serological survey of pregnant and non-pregnant women]

The study of malarial seroprevalence in Dakar has interested 598 women among whom 377 pregnant and 221 non pregnant, between 15 to 45 years old and happens during the dry season, period of which malaria transmission is practically stopped in the locality. Among the tested serums by indirect immunofluorescence with Plasmodium falciparum asexual blood forms as antigen, 24.4% contained antimalarial antibodies. The serological index does'nt vary significantly according to the months during the dry season, the women age and their previous pregnancy number. On the contrary, the women who live in Dakar since less than 2 years, have e higher seropositivity rate of 33.7% than those who are there since more than 2 years, 20.0%. It is likewise for the women practicing chemoprophylaxy with chloroquine of whom 16.5% have antibodies against 26.0% among those who don't practice it. The seropositivity rate doesn't vary significantly according as the women are pregnant (24.7% of positive) or not pregnant (24.0% of positive). The weakness of the serological rate in the examined women, can be explained by the situation of Dakar in a weak malarial hypoendemic area. II shows that the major examined subjects have lost or have never had contact with Plasmodium what predispose them to make severe and complicated malarial attacks.

[Identification of HLA-DR alleles for susceptibility to rheumatoid polyarthritis in Senegal]

Rheumatoid arthritis is the most frequent inflammatory rheumatism disease. Several studies were aimed to understand its physiopathogenesis in particular the association between some HLA-DR alleles and rheumatoid arthritis. A prospective study was carried out in 34 patients suffering from RA (30 Women and 4 men). The diagnosis was clinically and radiologically made. The control group included 220 persons of which the HLA-DR distribution was known. The HLA-DRB1 alleles were typed by PCR-SSP (Sequence Specific Primers). The most frequent HLA-DR alleles found in patients group were: DR10 (85.3%), DR52 (53%), DR14 (38.2%), DR11 (26.5%), and DR13 (20.3%). A significant difference was observed between RA patients and control group for the following alleles: DR3, DR10, DR18, and DR52 (p < 0.001; Chi square with Yates' correction). HLA-DR3 and DR10 were positively associated with RA. The relative risk was up 30 for DR10.

[Strongyloidiasis: current incidence in the Dakar pediatric environment]

The authors have conducted from November 20th 1992 to May 26th 1993 a study about the incidence of Strongyloidiasis in two pediatric units in Dakar. Direct examination followed by Lee and Baerman's concentration technic both applied to 610 stool specimen, have shown that 26.6% of children were carrying parasites. 9 cases of strongyloidiasis have been shown the incidence was 1.4%. These cases represent 5.5% and ranks at fifth position among intestinal parasitic diseases. They all come from suburbs of Dakar. Malignant forms could be easily detected among children suffering a secondary immune deficiency due to malnutrition, or corticotherapy.

[Current aspects of gastric cancer in Senegal. Epidemiological and clinical study of 220 cases (1984-1991)]

220 cases of gastric cancer were selected from Dakar Hospitals during seven years (1984-1991). This retrospective study confirms that gastric cancer is the most common cancer of the Gastro-intestinal tract (48.4%). The sex ratio was 2.7 (M/F) with mean age of 50 years. However, a steady progression of gastric cancer was noticed beginning at 40 years. Despite the introduction of upper gastro-intestinal endoscopy the classical evolved form was the most commonly found (83.2%). The associated lesions known to be premalignant were found in 22.7% of cases. The patients were seen with a long delay after the first symptoms. This is why we have long delays of diagnosis in our centers. 61.7% of them are seen 3 to 12 months after their first symptoms. In 70% of cases, lesions were found on antropyloric region. The most common histological type remain adenocarcinoma (90% of cases). Even though endoscopy has contributed to increase the incidence of gastric cancer, it did not allow to discover early gastric carcinoma.

[A case of joint toxicity from pefloxacin in the treatment of nephrotic syndrome in a child]

In order to improve the nephrotic syndrome management, we tried to treat one patient by pefloxacin. A polytenosynotis was noticed during this treatment and motivated it stopping. Remission of proteinuria was obtained after an eleven days treatment. This case give us the opportunity to discuss the possible toxicity of quinolones on joints and the efficacy of pefloxacin in this disease.

[Endemic parasitoses in the villages surrounding the Saloum fossil valley, Senegal]

In order to determine the prevalence rates of malaria, urinary schistosomiasis and intestinal parasitosis in Saloum's valley, the authors carried out a study which took place from november 16 to november 24, 1996. For malaria, the global parasites index was 22% (146/662). Malaria prevails at a hypoendemic level in N'Diobène and N'Guent-paté villages and at a medium-endemic level in Ribo-Escale and N'Dodj. The infestation index for urinary schistosomiasis was 8.9% (137/154) About intestinal parasite, among 868 persons screened, 124 showed one or several parasites, that is an infestation index of 14.3%. Appropriate steps should be taken to prevent an extension of these conditions along the fossil Saloum's valley.

[Prevalence of malaria in the Senegal river basin in 1991]

In order to determine the prevalence of malaria and its epidemiological characteristics, a survey was carried out in 11 villages situated in all the Basin of River Senegal (B.R.S.). 3306 (0-14 years) children are examined. The results show that malaria is hypo-endemic in the B.R.S. with a plasmodic index of 8.6% and a splenic index of 9.9%. But these malariametric indexes change according to the areas visited. Thus, malaria prevails at a hypo-endemic level in Dagana and Podor districts while at a medium if not hyperendemic level in Matam and Bakel districts. The plasmodial index also change according to age reaching a maximum within children from 10 to 14 years. As for the spleen index, it is low among children from 10-14 years. As for the spleen index, it is low among children from 0 to 4 years old, then increases among those aging from 5 to 9 years, before decreasing within children ranging from 10 to 14 years. P.falciparum is the most prevalent species, representing 96% of the cases; it is followed by P.malarioe (3%) and P.ovale (1%). If our results are compared with those obtained before by other authors, we can conclude that the recent hydro-agricultural plannings carried out in the area, have not yet provoked an increase of the cases of malaria. But, in order to avoid this risk, it is necessary to take from now some preventive measures.

[Malaria in an urban environment: the case of the city of Rufisque in Senegal]

From April to November 1994, we carried out a study in Rufisque, an urban area located in Dakar Region. During dry season, 5.32% of febrile outpatients were infected with Plasmodium falciparum with a mean parasitic density evaluated at 12,471 p/microliter. One case of cerebral malaria was noted. During raining season, malaria represented 58.75% of the fevers. Ten presented neurological signs; the mean parasitic density was high, 131,140 p/microliter. Two children died. Good efficiency of quinine was noted but chloroquine treatment failures was present: 50%. Generally malaria is less prevalent in urban areas. But in Rufisque ecological conditions are main factors which permit spreading of the disease. Prior measures of control such correct treatment of cases and good management of environment must be done.

[Toxoplasmosis in Dakar. Seroepidemiologic sampling of 353 women of reproductive age]

Thanks to a serological survey carried out in Dakar from January to November 1993 among 353 procreative women, immune cover regarding toxoplasmosis was assessed using ELISA methodology: 40.2% of the surveyed population had antibodies of toxoplasmosis. No evidence of age, pregnancy, number of previous pregnancies was noted in antitoxoplasmosis antibodies prevalence. The seroconversion risk seems to be low even when it has existed during pregnancy. Contamination occurred during childhood. Some sanitary education should be provided to the procreative population in order to achieve a better compliance with basic hygiene regulations during pregnancy.

[Malaria in the southern sanitary district of Dakar (Senegal). 1. Parasitemia and malarial attacks]

A survey of endemic malaria in Dakar was carried out in the southern sanitary district covering the city centre and neighbouring areas. The survey was scheduled from June 1994 to May 1995 in 12 sites distant from each other by 1000 to 1500 meters. Clinical and parasitological data were collected during weekly medical follow-ups at the patients' home with the systematic research of Plasmodium once a month. The study included 2,337 persons aged between 1 month and 88 years and belonging to 284 volunteer resident families. Through monthly parasitological examinations, a parasite rate (P.R.) of 0.3% and a gametocyte rate (G.R.) of 0.005% were recorded. Only Plasmodium falciparum was observed. The P.R. varied according to age: from 0.1% in the children under 2 years to 0.7% in the young adults (15-20 years) who appeared significantly more affected than the other age groups, including that of children from 2 to 9 years, of whom only 0.3% were infected by the parasite. The P.R. varied also according to the site surveyed: from 0% in the city centre to 1.3% at the periphery of the sanitary district and according to the time of year, reaching its height of 0.8%, between October and December, that is just after the rainy season. At the end of the year of survey, 929 among those surveyed were considered to have been satisfactorily followed. Their annual incidence rate was 2.4% for the parasitemia and of 1.5% for the malaria attacks. None of the participants aged under 2 years had the parasite. Among the others, the annual incidence rate varied according to the age--although not significantly--passing from 1.1% to 5.3% for parasitemia and from 0.4% to 3.0% for malaria attacks. Theses rates did not differ significantly according to site; the cases registered varied between 1% and 8% for parasitemia and 1% and 5.8% for malaria attacks. Only 10.6% of febrile subjects suffered from malaria attacks, but this rate seemed to go up between October to December, rising to 26.6% which corresponds to 1 case of malaria attacks for 4 cases of hyperthermia in that period. Weak density of Anopheline population and satisfactory medical surveillance explain the recorded results.

[Malaria in the southern sanitary district of Dakar (Senegal). 2. Entomologic data]

To complete a parasitological survey, entomological prospections were carried out in the southern sanitary District of Dakar, the most urbanized of the city and which includes the city centre and the oldest administrative districts. The prospections took place between June 1994 and May 1995 in sites 1.5 km apart, and distributed in such a manner that they covered the entire area. On a monthly basis, female Culicidae were collected in each site at night on human volunteers, followed the next day by the collection of early morning residual fauna in 10 bedrooms located in district concessions. For a total of 308 collections at night on human volunteers and from 1,510 rooms for the residual fauna, 22,901 female Culicidae were caught of which 167 anopheles, corresponding to 0.7%, the remaining 98.5% being Culex quinquefasciatus. This was the species that thus explained the mosquito-nuisance of which the inhabitants of the southern District complained during the period of survey. The female anopheles collected belonged to 2 species, An. arabiensis for 97.6% of those caught and An. pharoensis for 2.4%. An. arabiensis were very slightly represented in the southern District with a density of aggressive females of 0.26 bite/man/night (B/M/N) and a density per room of 0.05 female. The aggressive populations appeared to be relatively important only at the end of the rainy season (September-October) with an average of 0.65 B/M/N in sites located at the periphery of the district with a maximum of 1.33 B/M/N. The highest density of endophilic females registered at the end of the rainy season was 0.1 and its highest value in a given site was 0.36 female/room. The parturity rate of aggressive females was 43.5% and those collected in houses of 84% with an anthropophilic index of 0.98. None of the dissected An. arabiensis females (77.3% of those collected) was a carrier of Plasmodium sporozoites and the circum-sporozoite antigen was not found. A very weak density of An. arabiensis and absence of plasmodial infection among dissected females favoured the absence of malarial transmission in the southern District for the period considered. However malaria transmission could not be absolutely ruled out given the presence of hematozoa carriers, as was revealed by the longitudinal follow-up of a cohort carried out concurrently with the entomological prospections of whom some were residents having declared permanent residence in the city for over two years. This entomological data explain the results of the afore mentioned parasitological survey which, with a registered plasmodic index of 0.3%, means that the southern District can be considered as non endemic. The area is however exposed to the risk of epidemic malaria following an important proliferation of anopheles, which is always possible after heavy rains and flooding and/or an important immigration of persons coming from regions of high malarial endemicity.

Systemic lupus erythematosus and lupus syndromes in Senegal. A retrospective study of 30 patients seen over 10 years

OBJECTIVE

To define the presenting manifestations, course and prognosis of systemic lupus erythematosus in Senegal.

PATIENTS AND METHODS

Thirty cases of systemic lupus erythematosus and lupus syndromes seen over a ten-year period were reviewed retrospectively. Nineteen patients met American College of Rheumatology criteria for systemic lupus erythematosus. All 30 patients were Senegalese-born black women. Mean age at diagnosis was 30 years (range, 16-73 years).

RESULTS

Polyarthritis was the most common presenting picture (n = 8), followed by discoid lupus (n = 6). Eight per cent of patients had at least a combination of skin and joint symptoms at diagnosis. Prevalences of organ involvement were as follows: skin, 97%; joints, 97%; kidneys, 57%; serous membranes, 43%; nervous system, 23% and blood, 83%. Mean symptom duration at diagnosis was 24 months in systemic lupus erythematosus patients and 43 months in lupus syndrome patients. This significant diagnostic delay explains why as many as five of the 30 patients (17%) died either before or within five months of treatment initiation. Eight patients (32% of treated patients) who had a favorable course under therapy were lost to follow-up after discharge. The overall mortality rate was 26%. Renal failure was the main cause of death, followed by infectious and neurologic complications.

CONCLUSION

We anticipate that the reported prevalence of lupus in Senegal will rise in the near future as a result of improvements in diagnostic tools and of increased interest for lupus among physicians. We also hope that improved detection of mild and early forms, together with close long-term follow-up of patients, will translate into a better overall prognosis.

[Intestinal parasites in the vendors and consumers of street food. A study conducted in the Dakar area]

In order to assess the parasitic risk for street-food consumers, the authors conducted two studies from September to August 1996, one on street-food sellers (305) and the other on consumers (235). Among the consumers, 127 were considered as not exposed to risk, since they did not frequent the sector being surveyed, and 108 were exposed because they consumed at least one meal per day cooked by the sellers of this area. Both groups filled out a questionnaire and had their stools analysed according to the RITCHIE method. The infection rate was 60% among sellers and 45.5% among consumers. Protozoans were predominant in both groups. Among the consumers, those exposed were significantly more infected. Even though the sellers represent a parasitic risk due to their level of infection and the typology of parasites they shelter, one cannot assume that consumers are contaminated only by the sellers of street food. However, appropriate measures must be implemented in order to minimize risks for street-food consumers.

Diagnosis of Plasmodium falciparum malaria using ParaSight F, ICT malaria PF and malaria IgG CELISA assays

A battery of sixty-six blood samples from Senegal was analysed by the ParaSight F test, the ICT Malaria PF and the Malaria IgG CELISA. These three assays detect the histidine rich protein 2 antigen of Plasmodium falciparum. Thick smear microscopy was used as the reference method. Sensitivity, specificity, predictive positive and negative values were respectively 89%, 100%, 100%, 88% for the ICT; 86%, 93%, 94%, 85% for the paraSight and 88%, 87%, 88%, 87% for the Malaria IgG CELISA. The three assays failed to detect two positive samples with P. ovale and P. malariae. Assays were also compared with regard to the expense of equipment and reagents and speed and ease of use. The rapid ICT and ParaSight F test can be performed with minimal training and may be specially useful in areas where P. falciparum is the predominant malaria species, in epidemic malaria regions, and where skilled microscopy is not readily available.

[Impact of antimalarial drug accessibility on malarial morbidity and chloroquine resistance. A study carried out in Touba (Senegal)]

In Touba, more important accessibility to antimalarial drugs and their uncontrolled use let to assure that the rate of malarial morbidity would be lower there than in other place in Senegal whereas the rate of chloroquine resistance would be higher. A checking survey of these assumptions has been carried out from october 15 to november 10, 1995 in Touba's health center. Among 227 feverish subjects investigated, 111 were Plasmodium falciparum carriers. Malarial bouts accounted for 48.9% of the feverish fits observed and for the major cause of consultation during the rainy season. These figures are higher than those usually observed in urban environment. Conversely, the rate of chloroquine resistance is lower than those observed in urban zones, since the therapeutic efficacy of chloroquine on Plasmodium falciparum was 100% in that survey.

[Evaluation of parasitic risks related to the revitalization of the Ferlo fossil valley (Senegal)]

In order to assess the parasitic risks related to Ferlo's valley water launching, a study has been carried out from september 15 to october 10, 1996 in 12 villages. Four villages surrounding the Guiers lake, four lower within lower Ferlo already water launched 7 years ago, and four villages within upper Ferlo not water launched. Malaria strikes at hypoendemic level in the villages surrounding the Guiers lake (p.i = 6.2%) and at mesoendemic level in the area stretching along lower (P.I = 37.6%) and upper Ferlo (P.I = 34.3%) The prevalence rate of urinary bilharziosis is 0.002% in the first area, 1.3% in the second one and 14.5% in the third area. In these areas, intestinal parasitosis were prevailing respectively at rates of 38.2%, 36.4% and 22.2%. Although, there is no reason to fear immediately a worsening of the epidemiological situation due to Ferlo's valley revitalisation project, nevertheless, appropriate steps should be taken right now aiming at tacking the extension of conditions related to hydric medium.

[Knowledge and treatment of malaria in rural Senegal]

Evaluating knowledge about the diagnosis and treatment of malaria is a prerequisite for both understanding the development of chemoresistance and improving ongoing programs of chemotherapy and chemoprophylaxis. To gain such knowledge we distributed a questionnaire to 900 household heads in twelve villages in the M'Backe district of Senegal. Awareness of the main symptoms of malaria was satisfactory in comparison with previous references. Public health care facilities such as dispensaries were cited as the first resort for treatment by 72.6% of respondents. Chloroquine was mentioned as the first line antimalarial by 23% of respondents who practiced self-medication. Improper dosages were stated by 60% of the respondents. A total of 52.3% of respondents practiced chemoprophylaxis mainly using chloroquine. In 65.8% of cases antimalarial drugs were obtained from public health care units but drugs were purchased on the market in 15.7% of cases. These findings indicate the threefold Bamako initiative should be reinforced and that a campaign should be undertaken to educate people living in rural areas about malaria.

Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.

[Acute thoracic aortic dissection with occlusion of the left coronary artery]

Aortic dissection is the most common fatal condition that involves the aorta. Occasionally, symptoms mimic acute myocardial infarction leading to thrombolytic treatment. Accurate diagnosis in patients with chest pain is therefore essential. We describe a case of acute aortic dissection which resulted in myocardial infarction due to obstruction of the left coronary ostium. A 65-year-old female patient with no previous cardiac history was admitted to a local hospital because of severe chest pain of acute onset. Physical examination was normal except for a low blood pressure (90/50 mm Hg), heart rate 45 beats/min and parasthesia in both hands. The ECG showed sinus bradycardia with negative T-wave in VI and with 1 mm ST-segment elevation in V3. A chest X-ray was normal. Five hours later, the patient experienced once more severe chest pain followed by non-sustained polymorphic ventricular tachycardia (Figure 1). Another ECG showed bifascicular bundle branch block (right bundle branch block and left anterior fascicular block). The ECG was interpreted as showing acute myocardial infarction and treatment with intravenous streptokinase started. Since the patient remained severely hypotensive despite infusion of dobutamine, she was intubated, ventilated and transferred to our hospital. Cardiac catheterization showed acute dissection of the ascending aorta with an aortic intimal flap and an occlusion of the left coronary artery (Figures 2a and b). During catheterization, she suffered a cardiac arrest from which she could not be resuscitated. A postmortem examination confirmed the acute aortic dissection which reached to the ostium of the left coronary artery (Figures 3a and b, 4a and b) and an anterior myocardial infarction probably due to intermitted diastolic obstruction of the ostium of the left coronary artery by an aortic intimal flap.