[Pulmonary hypertension revealing systemic diseases: two Senegalese case reports]

INTRODUCTION

Pulmonary hypertension (PH) is a complication of autoimmune diseases which worsen the prognosis. In Senegal, a few cases of PH have been previously reported in patients with systemic sclerosis.

CASE REPORTS

We report two cases of patients with PH that revealed autoimmune diseases (Sharp' syndrome and Sjögren syndrome). Epidemiological, clinical, evolutive and laboratory data were analyzed. Evolution of disease was favourable for one patient and fatal for the other.

CONCLUSION

These two cases show necessity of early diagnosis of systemic diseases in our countries. PH should be screened in each patient with autoimmune disease before installation of irreversible pulmonary arterial lesions that respond to treatment. New therapy used in idiopathic PH are not yet accessible for our patients.

[Sarcoidosis in Dakar: 30 case reports]

INTRODUCTION

Sarcoidosis cases had been rarely reported in Senegal in spite of the high frequency of sarcoidosis in black people. The purpose of this work was to determine the epidemiological, clinical and evaluative profile of sarcoidosis in Dakar.

MATERIAL AND METHODS

We performed a multicentric retrospective trial in order to characterise sarcoidosis cases in Senegal from 1968 to 2004.

RESULTS

Twenty cases (21 females and 9 men) were observed. The average age was 40 years. Duration before first medical attention was up to one year in 20 cases. Ten patients received an anti tuberculosis treatment before sarcoidosis diagnosis. Sarcoidosis was a systemic disease in 76% of cases and only cutaneous in 24%. Cutaneous lesions were found in 66,66% of cases. Presenting features were cutaneous (46%), general (30%), rheumatoid, (16,6%), Lofgren syndrome (3 cases). The cutaneous lesions were specific in 94% of cases as small nodules (50%), placards (20%), great nodules (15%) and scars sarcoidosis (10%). Extra cutaneous involvement were pulmonary (73,33%), lymphadenopathy (66,66%), and rheumatoid (20%). Pulmonary tuberculosis was associated in 4 cases.

DISCUSSION

Our data confirmed rarity of sarcoidosis in Senegal opposite to the high reported frequency in other black population in developed country. Clinical features were polymorph and the systemic forms predominant. Tuberculosis may be rule out in order to avoid miss diagnosis.

[Cutaneous side effects of antiretroviral drugs]

The goal of our study was to report cutaneous side effects of anti retroviral drugs. For this purpose we performed a transversal prospective trial during 6 month in the dermatological department and in the out patients management department of Dakar. Heighty four (84) cutaneous side effects were encounted in 38 HIV infected patients. There were 6,1% of toxidermies, severe in 3 cases (2 Stevens Johnson syndrome d 1 DRESS), 3,5% of immunitary restauration syndrome (2 zonas, 4 herpes) and 3,9% of lipodystrophy. The putative drugs of toxidermies were Nevirapine, Effavirenz and Zidovudine and antiproteases and Stavudine were the cause of lipodystrophy. The duration before apparitions of the lesions was 16,9 days for toxidermies, 45,5% for immunitary restauration syndrome and 40,72 months for the lipodystrophy.

[Elephantiasic pretibial myxoedema: study of five cases]

INTRODUCTION

Elephantiasic myxoedema is very rare. We report 5 pretibial myxoedema cases observed in the Dermatological department of Le Dantec hospital in Dakar.

PATIENTS AND METHODS

Our 5 cases were 3 women (age: 52, 45 and 18 years) and 2 men (age: 54 and 32 years).

RESULTS

All the cases were enormous, multinodular pachydermic, bilateral, elephantiasis in the low leg and associated to Graves 'disease. The duration was 4 month to 12 year. In 3 cases there was a Diamond syndrome which is a severe form. The cutaneous lesions were not influenced by medical treatment of thyroid disease. Systemic steroids achieved improvement of the elephantiasis in 1 case.

CONCLUSION

Elephantiasis is a very unusual presentation of pretibial myxoedema and its occurrence doesn't depend to the intensity of thyrotoxicosis and its evolution. However in our cases, it was a severity indicator factor, like Diamond syndrome. Local and systemic steroids give very rarely improvement.

[Current aspects of systemic lupus erythematosus in Dakar. About 74 cases]

INTRODUCTION

previously reported studies on systemic lupus erythematosus in Senegal were more then ten years old and reported few cases of patients. Our objectives were to update epidemiological, clinical, laboratory and evolutive aspects of systemic lupus erythematosus throughout a study of 74 patients.

PATIENTS AND METHODS

we conducted a retrospective study in the internal medicine and the dermatology units of the university teaching hospital Aristide Le Dantec from January 1993 to December 2002. All patients with systemic lupus erythematosus according to the ACR criteria were included. Those who didn't meet ACR criteria were excluded.

RESULTS

we included 74 patients; their mean age was 32 years and the sex ratio 0.1 (male to female). At the entry general symptoms were constants, and cutaneous signs were found in 96% of cases, joints signs in 58.1% and renal sign in 56.8%. Haematological and immunologic abnormalities were nearly constant. All the patients received corticosteroids and in 35.71% they had in addition immunosuppressive drugs. Shorts term evolution was satisfactory. At the medium term 27.02% of the patients were lost and 10.81% of them died.

CONCLUSION

currents aspects of systemic lupus erythematosus in Dakar are improved by the early diagnosis when the disease is pauci-symptomatic and by the use immunosuppressive drugs in association with corticosteroids.

Radiotherapy for metastatic melanoma presenting in pregnancy

We describe the study of a patient with metastatic melanoma to axillary nodes presenting during pregnancy. The factors considered in her management are discussed, including issues related to staging, the decision not to terminate the pregnancy and the relative efficacy and fetal toxicity of the available treatment options. An overview of the known effects of radiotherapy on the fetus is presented and the technical alterations that were used to decrease the toxicity of radiotherapy are discussed.

[Cardiovascular emergencies in Subsaharan Africa]

BACKGROUND

The increasing prevalence of cardiovascular diseases in subsaharan Africa and their related mortality and morbidity have been established. A large number of them present as emergencies. The purpose of this first multicentric study was to assess the causes, management and outcome of cardiovascular emergencies in savannah and forest environments.

METHODS

A total of 665 patients were included from seven participating centers in seven countries: 417 were classified as belonging to the savannah zone (Dakar, Nouakchott, Ouagadougou, N'djamena) whereas 248 patients were from the forest zone (Abidjan, Libreville, Yaounde). Patients were examinated by one or several cardiologists. Statistical analysis was performed by the Medical Statistic Unit of the Hopital Nord, Marseille (France).

RESULTS

There were more men (53.4%) than women (46.6%). 77.7% of the patients lived in urban areas. Most of them had low or very low incomes. Patients reached the hospitals in ambulances only in 6.2% of cases. The remaining others were transported by routine urban vehicle or bicycle or ambulation. The mean delay between the onset of symptoms and the arrival to the emergency unit was 6.8 days. Three immediate situations were preponderant: severe hypertension (32.2%), heart failures NYHA IV (27.5%), stroke (20.3%). Underlying conditions were: mainly chronic hypertension (52.3%), cardiomyopathies (20.6%), valvular heart diseases (11.1%). Coronary heart diseases were rare (6.1%). The observed mortality was 21.2% without any differences in age groups. The most common emergencies resulting in death included: stroke (31.9%), vascular collapses (18.4%), pulmonary embolism (9.2%). The patients from the savannah zone were younger, more often classified in the low or average socioeconomic level. Hypertension was more frequent in forest zones. Valvular heart diseases were more frequent in savannah. Cardiomyopathies were comparable in both zones. Coronary heart disease was slightly more common in the savannah area.

DISCUSSION

Compared with patients from western countries, the African patients are younger because some diseases affect young people like rheumatic heart disease or postpartum and infectious cardiomyopathies. The difficulties to reach health care facilities made the outcome more severe. Hypertension and valvular heart disease deserve priority in preventive strategy. Cardiomyopathies have to be studied to precise their causes. Finally, the management of cardiovascular emergencies needs a special care in the hospitals owing to their increasing frequency and their severity.

[Relation between lupus-antiphospholipids antibodies and heart disorders]

BACKGROUND AND AIM

Antiphospholipids antibodies (APL) are autoantibodies found in lupus erythematosus and disorders like. Their frequency varies between 2 and 62% according to the literature. An increased frequency of cardiac disorders in antiphospholipids (APL) positive lupus has been reported. The aim of our study was to evaluate the role of APL as an independent risk factor of cardiac disorders in patients with systemic lupus erythematosus.

MATERIAL AND METHOD

A prospective study during 14 months has been designed with the cooperation of dermatologic, internal medicine and cardiology departments of the Aristide Le Dantec hospital of Dakar. Platelets count (Beckmann Coulter analyzer), activated partial thromboplastin time (Diagnostiga stago analyzer) and antiphospholipids antibodies (Elisa) were determined.

RESULTS

37 patients affected by lupus were included in this study with a net feminine prevalence (89%); 8 (14.6%) had APL's significant results and 20 presented an echographic heart abnormality. The analysis of our data did not reveal an increased risk of cardiac diseases among APL positive lupic patients as compared to the negative group (p = 1).

CONCLUSION

The presence of APL in patients with systemic lupus does not so seem to be an independant risk factor of heart diseases.

[Cardiovascular events in the course of tetanus: a prospective study on 30 cases in the infectious diseases clinic, in the Fann teaching hospital, Dakar]

OBJECTIVES

This prospective study had for aim to determine the frequency and characteristics of cardiovascular events in the course of tetanus.

PATIENTS AND METHODS

From September to December 2002, we studied all patients over 4 years of age presenting with tetanus without any documented underlying disease.

RESULTS

Thirty cases were included (mean age 36+/-20 years; sex-ratio 2.3). Seventy-three per cent had a mild-gravity tetanus (stage II of Mollaret) upon admission. One hundred and seventeen ECG were recorded and 93.3% of the patients had more than one abnormality: arrhythmia (24 cases), prolonged QT interval (23 cases), ventricular hypertrophia (17 cases), and atrial hypertrophia (4 cases) especially left (3 cases), failure of AV conduction (3 cases), ST segment depression (3 cases), left and right axis deviation (3 cases), baseline undulation (3 cases) and repolarization disturbances (1 case). All patients had a normal Doppler echocardiographic examination. The mean hospitalization stay was 11.6+/-1.4 days and complications were noted in 60%; sinus tachycardia in apyrexia (5 cases), instable BP (5 cases), excessive sweatiness in apyrexia (1 case), and access of bradycardia with sudden cardiac arrest (2 cases). 8 patients died (26.7%). Six patients with cardiac autonomic dysfunction died, the case fatality rate being statistically higher in this group (P=0.007). A prolonged QT interval, sinus tachycardia and left ventricular hypertrophia were statistically more frequent at the acute phase of the illness.

CONCLUSION

The case fatality rate of tetanus is still high, due among others to autonomic dysfunctions.

[Active rheumatic heart disease: findings from an 17-case series in the University Hospital Center of Dakar, Senegal]

This report is based on retrospective review of the charts of 18 patients with pre-existing active rheumatic heart disease compiled over a period of two years (January 2000 to December 2001). The purpose of this study was to determine the incidence of acute degenerative joint disease, to describe the clinical features and natural course of the disease, and to highlight the main points in the fight against degenerative joint disease and rheumatic heart disease. The prevalence of active rheumatic disease was 3.7%. Mean patient age was 15.5 years (range: 8 to 25 years). Female sex was predominant with 13 girls and 4 boys (sex ratio: 3.25). The most common clinical symptoms were migratory polyarthritis involving large joints in 14 cases (82.3%) and left heart insufficiency in 13 (76.4%). Additional clinical findings included oscillating fever in 8 cases (47.05%), tooth decay in 11 (73.3%), and poor buccodental hygiene in 14 (93.3%). Blood tests to evaluate inflammation demonstrated high values in all patients with mean ASLO titer of 950 UI/l, mean serum fibrin level of 7.8 g/l, and mean C-reactive protein level of 28.5 mg/l. The erythrocyte sedimentation rate was high in 15 cases (88.2%). In addition to showing heart valve disease, electrocardiography demonstrated first-degree atrioventricular block in 1 case. Chest x-ray revealed cardiomegaly in 15 cases (88.2%). Doppler ultrasonography of the heart showed isolated rheumatoid disease in 11 cases (64.7%). All patients responded favourably to treatment with corticosteroids and penicillin. The incidence of recurrence of active disease was high (70.5%) thus supporting use of high loading doses. Rheumatic heart disease is a public health problem in Africa and requires appropriate preventive measures.

[Pyoderma gangrenosum in dakar: about 14 cases]

From January 1990 to December 2001, we undertook a retrospective study in the dermatology department of Aristide le Dantec hospital in order to assess the epidemiologic, clinical and evolutionary profiles of pyoderma gangrenosum (P.G). All files of patients diagnosed with PG were reviewed. The diagnosis was based on clinical and histological aspects. Fourteen files of patients with PG were reviewed. They were constituted of 8 males and 6 females, with a median age of 24.5 (extreme 4 and 54 years). Paediatric forms represented 30 % of the cases. The typical aspect with an ulceration with elevated edge comprising of purulent hutchs was observed in all the cases. The localization on the level of the lower limbs was noted among 12 patients (85.7 %). The PG was associated to chronic ulcerative colitis (1 case), rheumatoid spondylitis (1 case) and rheumatoid arthritis in all cases. After 11 weeks treatment by oral corticothérapy at the daily posology of 1 mg/kg/, cicatrization of cutaneous lesions were noted in all the cases. Five reccurences were observed. P.G remains a rare pathology with no difference on races and regions . this is particularly true on children. Our serie, is remarkable by the high frequency of its paediatric forms. As for clinical and evolutive aspects as well as associated pathologies, findings are comparable with those described other series

Bluetongue surveillance methods in the United States of America

Historical surveillance for bluetongue virus (BTV) exposure in the United States of America (USA) has relied on periodical serological surveillance using samples collected from cattle at slaughter. Most of this surveillance has been focused on the north-eastern portion of the USA due to the lack of competent vectors of BTV in this region. For most of the states tested in this region, the prevalence of seropositive animals has been less than 2%. Recently, a study was conducted in north-central USA using sentinel cattle herds. Results of serological testing showed an increasing gradient of exposure from north to south. In addition, detection of Culicoides sonorensis showed a similar gradient with detection in the northern areas being relatively rare. The results of these studies indicate that cattle herds in the northern and north-eastern areas of the USA are likely to be free of BTV.

[A new case of rhinoscleroma with skin extension]

Scleroma is a chronic and specific granulomatous disease of bacterial origin. Klebsialla rhinoscleromatis, a gram-negative bacillus. The majority of cases affect the upper airways, particularly the nose, thus justifying the term of rhinoscleroma. Extension to the palate, the upper lip and the skin is possible. A new case of rhinoscleroma with skin extension is reported. To us, this is the second case in Senegal (Casamance). Epidemiological, clinical, bacteriological and histological aspects of the disease are reviewed. Under suitable antibiotic, evolution is currently favorable.

[Electrocardiographic recording of long duration (Holter) of 24 hours during idiopathic cardiomyopathy of the peripartum]

The idiopathic myocardiopathy of the peripartum (IMPP) is a frequent disease in the Soudano-Sahelian zone of Africa whose evolution is loaded with many complications hemodynamic, thrombo-embolic and rhythmic. The prevalence and the meaning of the rhythm disorders are unknown. The aims of this prospective study are to measure and to describe the prevalence of the anomalies observed in Holter ECG of 24 hours. It's about a description cross-sectional study realized at the Cardiology Department (CHU Dakar) and 19 patients with IMPP were included, from October 2000 to July 2002. A recording ECG of 24 hours (Holter) was realized on all the patients. The average age was 29.4+/-6.9 years with a low socio-economic level (100%). The diagnosis of IMPP done before childbirth in 4 cases (21%) and the post partum on 15 patients (78.9%). The dyspnea was constant, the chest pain in 12 cases (63.1%) and palpitations in 8 cases (42%). The average rate of hemoglobin was of 10.85+/-2.05 g/dL. The standard electrocardiogram recorded a sinusal tachycardia (68.4%), a cavitary hypertrophy (78.8%), and disorders of the repolarization (47.3%). The cardiac echo-Doppler noted a cavitary dilatation (84.2%), a constant alteration of the left ventricular systolic function with a fraction of average ejection of 29.7+/-10.3%. The anatomy of the valves was normal. The recording Holter ECG of 24 hours recorded a sinusal tachycardia in 17 cases (89.4%), ventricular extrasystoles on 7 patients (36.8%), 4 cases of ventricular tachycardia non-sustained and double ventricular extrasystole on 1 patient, auricular extrasystoles in 4 cases (21%) and 1 case of auriculo-ventricular block of the first degree. The study of heart rate variability founded a mean value of 106 ms.

[Tricuspid valve stenosis. A prospective study of 35 cases]

Authors report the results of prospective and longitudinal study. The aims of this study were to evaluate among 35 patients, prevalence, diagnosis and treatment aspects of tricuspid stenosis (TS), as well as evolution and pronostical factors. The prevalence of TS was about 4.2%. The main clinical signs were: dyspnoea (94.2%), jugular veinus pulses (42.8%), superior cave syndrom (68.8%), diastolic rumble (74.3%). ECG showed sinus rhythm (51.4%), a right atrial hypertrophy (48.5%). Echocardiography showed tricuspid leaflets thickened (82.8%), a right atrial hypertrophy (48.5%), a mean gradient between right atrial and right ventricle: 8.6 +/- 3.14 mmHg (65.7%) and mean tricuspid area about 1.41 +/- 0.83 cm2 (continuous equation); about 1.74 +/- 1.29 cm2 (Hatle formula) and 1.11 0.84 cm2 (simplified Hatle formula). Aetiology was only rheumatic fever. After a follow-up of 8.53 +/- 6.06 months, the mortality rate was 28.5%. Complications were irreducible heart failure (24 cases), liver failure (2 cases) and stroke (3 cases). Factors associated with mortality were: severity of tricuspid stenosis and pulmonary hypertension, importance of dyspnea and heart failure (p < 0.041).

[Pheochromocytoma in Dakar: report of nine cases]

Pheochromocytoma is a catecholamine-secreting neoplasm of chromaffin tissue. The most common symptom is hypertension but there are incidentally discovered forms at imaging. From 1981 to 1998, the authors observed nine pheochromocytomas through three hospitals in Dakar. This study included seven male and two female patients. The average age was 31.61 years. Hypertension was present in 77% of the cases. Headache, palpitations and sweating were the authors most frequent symptoms, occuring in 55% of cases. Measurement of vanillyl mandelic acid level in six cases and urinary metanephrines in three cases made the diagnosis. There were six adrenal and three extra adrenal pheochromocytomas with two malignant tumors features. In our countries, measurement of urinary metanephrines and computed tomography processing may improve detection of pheochromocytomas.

[Management of mycetoma in West-Africa]

Mycetoma is still endemic in the northern areas of West-Africa. This infection is more common in males, rural inhabitants, between 20 and 40 years of age. Mycetoma is generally easy to identify on clinical presentation, it is a chronic subcutaneous inflammatory tumor with discharging sinuses. The commonest affected site is the foot (70%), leg, knee, thigh, hand and arm are the most frequent extrapodal localizations. Diagnosis must be confirmed by the presence of grains at direct and histological examinations. It is indispensable to distinguish actinomycetoma (caused by aerobic bacteria) and eumycetoma (caused by fungi) as their treatments are different. The main etiological agents in West-Africa: Streptomyces somaliensis, Actinomadura pelletieri, Actinomadura madurae (actinomycetes), Madurella mycetomatis and Leptosphaeria sp (fungi) can be identified in most cases by histological examination of the grain. In the West Sahelian belt actinomycetoma is more frequent than eumycetoma except in Mauritania. When a mycetoma is diagnosed it is fundamental to determine as precisely as possible the extent of the lesion. Bone involvement is the major complication and must be systematically investigated by radiology. Mycetoma has characteristic ultrasonographic features, ultrasonographic technique appears to be very useful in medical centers where no mycological tests can be done. Ultrasonography is also an accurate technique to delimit the extent of the process. Computed tomography is also sensitive to assess the extent of mycetoma in soft tissues and can detect early bone involvement but is more onerous than ultrasonography. Ketoconazole or itraconazole in combination with surgery is recommended for eumycetoma patients. Actinomycetoma responds to antibacterial agents, different therapeutic schemes can be proposed and depend on the etiological agent.

[The athlete's heart: an echocardiographic case-control study on Senegalese athletes]

The aim of this work is to study the echocardiographic parameters of male trained athletes. It is about a case-control study comparing 3 groups: basketball players, cyclists and not sports healthy subjects. All the subjects benefited from an echocardiography (time motion, two-dimensional and pulse Doppler). The mean age is of 23.5 years for the cyclists group, 24 years for the basketball players and of 26.2 years for the control group. Compared with the control group, the left ventricular telediastolic dimensions, left ventricular mass index and the pulmonary flow velocity are higher in athletes group. The basketball players have a higher left ventricular diameter and parameter of systolic function than cyclists group. The septal diameter is higher in the cyclists group. This study finds some differencies in Senegalese athletes in the characteristics of the standard athletic heart syndrome.