Aspects épidémiologiques, cliniques, thérapeutiques et évolutifs de l’aspergillome pulmonaire à Dakar

The estimated burden of fungal diseases in Mali

Mali is a developing country facing several health challenges with a high rate of tuberculosis (TB) and a moderate HIV infection burden. Little is known or done about fungal diseases, yet they represent a significant public health problem in certain populations. The aim of this study was to estimate the national burden of fungal disease, and summarize data, diagnostic and treatment gaps. We used national demographics and PubMed searches to retrieve articles on published data on these infections and at-risk populations (pulmonary TB, HIV/AIDS patients, patients receiving critical care etc.) in Mali. The estimated Malian population was 21,251,000 in 2020 (UN), of which 45% were children <14 years. Among HIV patients, we estimate an annual incidence of 611 cryptococcosis, 1393 Pneumocystis pneumonia, 180 histoplasmosis and >5,700 esophageal candidiasis and some microsporidiosis cases. Our prevalence estimates for tinea capitis are 2.3 million, for recurrent vulvovaginal candidiasis 272,460, ∼60,000 fungal asthma and 7,290 cases of chronic pulmonary aspergillosis (often mistaken for TB). Less common acute fungal infections are probably invasive aspergillosis (n=1230), fungal keratitis (n=2820), candidaemia (>1,060) and mucormycosis (n=43). Histoplasmin was found in 6% in general population. A few cases of mycetoma are described in Mali. Many WHO Essential medicines and Diagnostics are not available in Mali. This shows a marked disparity in documented and estimated cases of fungal diseases in Mali. These infections are underestimated due to the lack of accurate diagnosis tools and lack of support for fungal diseases diagnosis and management.

Mapping of Chronic Pulmonary Aspergillosis in Africa

Africa has a high burden of tuberculosis, which is the most important risk factor for chronic pulmonary aspergillosis (CPA). Our goal was to systematically evaluate the burden of CPA in Africa and map it by country. We conducted an extensive literature search for publications on CPA in Africa using the online databases. We reviewed a total of 41 studies published between 1976 and 2021, including a total of 1247 CPA cases from 14 African countries. Most of the cases came from Morocco (n = 764, 62.3%), followed by South Africa (n = 122, 9.9%) and Senegal (n = 99, 8.1%). Seventeen (41.5%) studies were retrospective, 12 (29.3%) were case reports, 5 case series (12.2%), 5 prospective cohorts, and 2 cross-sectional studies. The majority of the cases (67.1%, n = 645) were diagnosed in men, with a median age of 41 years (interquartile range: 36–45). Active/previously treated pulmonary tuberculosis (n = 764, 61.3%), human immunodeficiency virus infection (n = 29, 2.3%), diabetes mellitus (n = 19, 1.5%), and chronic obstructive pulmonary disease (n = 10, 0.8%) were the common co-morbidities. Haemoptysis was the most frequent presenting symptom, reported in up to 717 (57%) cases. Smoking (n = 69, 5.5%), recurrent lung infections (n = 41, 3%) and bronchorrhea (n = 33, 3%) were noted. This study confirms that CPA is common in Africa, with pulmonary tuberculosis being the most important risk factor.

Surgical management of chronic pulmonary aspergillosis in Africa: A systematic review of 891 cases

Chronic pulmonary aspergillosis (CPA) is an emerging fungal infectious disease of public health importance. We conducted a systematic review of studies reporting the outcomes of patients with CPA managed surgically in Africa. A search of Medline, Embase, Web of Science, Google Scholar and African Journals Online was conducted to identify studies indexed from inception to June 2021 that examined surgical management of CPA in Africa. All articles that presented primary data, including case reports and case series, were included. We excluded review articles. A total of 891 cases (557 males (62.5%), mean age 39.3 years) extracted from 27 eligible studies published between 1976 and 2020 from 11 African countries were included. Morocco (524, 59%) and Senegal (99, 11%) contributed the majority of cases. Active or previous pulmonary tuberculosis was reported in 677 (76.0%) cases. Haemoptysis was reported in 682 (76.5%) cases. Lobectomy (either unilateral or bilateral, n = 493, 55.3%), pneumonectomy (n = 154, 17.3%) and segmentectomy (n = 117, 13.1%) were the most frequently performed surgical procedures. Thirty (4.9%) cases from South Africa received bronchial artery embolisation. Empyema (n = 59, 27.4%), significant haemorrhage (n = 38, 173.7%), incomplete lung expansion (n = 26, 12.1%) and prolonged air leak (n = 24, 11.2%) were the most frequent complications. Overall, 45 (5.1%) patients died. The causes of death included respiratory failure (n = 14), bacterial superinfection/sepsis (n = 10), severe haemorrhage (n = 5), cardiopulmonary arrest (n = 3) and complications of chronic obstructive pulmonary disease (n = 3). The cause of death was either unknown or unspecified in 9 cases. We conclude that surgical treatment had very low mortality rates and maybe considered as first-line management option in centres with experience and expertise in Africa.

[Severity Factors of Pulmonary Aspergilloma in the Surgical Intensive Care Unit of Joseph Ravoahangy Andrianavalona Hospital, Antananarivo, Madagascar]

Objective

This retrospective study was designed to study the clinical profile, post-operative outcome with analysis of severity factors of pulmonary aspergilloma operated in our institute.

Patients and methodology

During a 5-year period (June 2009 to June 2014), 34 patients underwent surgery for pulmonary aspergilloma and were admitted in the surgical intensive care unit of the CHU/JRA Antananarivo.

Results

The group consist of 23 male patients and 11 female patients with a mean age of 42 ± 9.9 years. In 29.4% of cases, it was a complex aspergilloma. The procedures performed were segmental resection (n = 3), lobectomy (n = 21), bi-lobectomy (n = 2), pneumonectomy (n = 7) and cavernostomy (n = 1). Median hospital stay was 4.5 ± 3 days. The postoperative lethality rate was 14.7% caused by respiratory failure, infection and underlying diseases. Main complications included bleeding, respiratory failures, and pulmonary infection.

Conclusion

Factors associated to increased postoperative complications included: the ASA score, decreased preoperative lung function, urgent procedures, smoking, postoperative mechanical ventilation, bleeding, hyperleukocytosis and surgery duration.

[Indications and results of pulmonary resections in a developing country]

INTRODUCTION

Indications for pulmonary excision are dominated by infectious pulmonary pathologies in developing countries. We conducted this study to describe the indications and results of pulmonary resections in the thoracic surgery department of the Mali hospital.

PATIENTS AND METHODS

This is a retrospective and descriptive study from January 2012 to December 2019, carried out in the thoracic surgery department of the Mali hospital. It involved 76 patients who had a pulmonary resection. The variables studied were the epidemiological data, the operating indications, the therapeutic data and the prognosis.

RESULTS

The mean age of the patients was 35.5 years. The sex ratio was 1.7. The average consultation time in thoracic surgery was 11.6 months with extremes of 7 days and 96 months. A history of pulmonary tuberculosis was noted in 46.1% of patients. The main indications for pulmonary resection were infectious parenchymal destruction in 64.5%, bullous dystrophy in 14.5%, bronchopulmonary cancer in 11.8% and thoracic trauma in 4% of the cases. The procedures performed were: a lobectomy (39.5%), atypical resection (36.8%), culminectomy (7.9%) and pneumonectomy (15.8%). Morbidity was dominated by thoracic empyema (9.2%) postoperative hemorrhage (5.2%), parietal suppuration (7.8%) and bronchopleural fistula (1.3%). The average length of hospital stay was 14.3 days. Mortality was 10.5%. There was a statistically significant correlation between pneumonectomy and deaths (P=0.01).

CONCLUSION

Infectious lung destruction is the main indication for pulmonary resection in Mali. The consultation period is quite long. Morbidity and mortality remains high.

[Mycoses and antifungals: What is the situation in Senegal in the current context?]

In the context of increasing incidence of fungal infections worldwide, the availability of antifungal drugs was studied in Senegal, a country with limited resources where diagnosis of invasive fungal infections is not often established by lack of specialists and/or diagnostic tools. After a background on the country's situation with regard to fungal infections and the drug distribution network in Senegal, a compilation of the various available antifungals was presented before concluding with recommendations to prepare for a situation that could allow to treat appropriately invasive mycoses.

Burden of fungal infections in Senegal

Senegal has a high rate of tuberculosis and a low HIV seropositivity rate and aspergilloma, life-threatening fungal infections, dermatophytosis and mycetoma have been reported in this study. All published epidemiology papers reporting fungal infection rates from Senegal were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in each to estimate national incidence or prevalence. The results show that tinea capitis is common being found in 25% of children, ~1.5 million. About 191,000 Senegalese women get recurrent vaginal thrush, ≥4 times annually. We estimate 685 incident cases of chronic pulmonary aspergillosis (CPA) following TB and prevalence of 2160 cases. Asthma prevalence in adults varies from 3.2% to 8.2% (mean 5%); 9976 adults have allergic bronchopulmonary aspergillosis (ABPA) and 13,168 have severe asthma with fungal sensitisation (SAFS). Of the 59,000 estimated HIV-positive patients, 366 develop cryptococcal meningitis; 1149 develop Pneumocystis pneumonia and 1946 develop oesophageal candidiasis, in which oral candidiasis (53%) and dermatophytosis (16%) are common. Since 2008-2010, 113 cases of mycetoma were diagnosed. In conclusion, we estimate that 1,743,507 (12.5%) people in Senegal suffer from a fungal infection, excluding oral candidiasis, fungal keratitis, invasive candidiasis or aspergillosis. Diagnostic and treatment deficiencies should be rectified to allow epidemiological studies.

[Result of surgical treatment of pulmonary aspergillosis secondary to a sequelae of tuberculosis in CHU/JRA]

La prise en charge d’un aspergillome pulmonaire, dans le cas des lésions limitées accessibles, est une des activités courantes en chirurgie thoracique dans les pays endémique à la tuberculose comme Madagascar. Sur une période allant de janvier 2005 en mars 2010, 15 patients, ancien tuberculeux, atteints d’une aspergillome pulmonaire sont traités par une résection segmentaire ou une lobectomie. La circonstance de découverte repose sur la clinique par des tableaux très polymorphes. L’imagerie garde une place importante. L’examen histologique des pièces d’exérèse chirurgicale confirme le diagnostic. Tous les patients ont été opérés de manière élective. Le résultat a été pour l’ensemble des patients jugés satisfaisant. Ces patients sont suivis pendant 1 à 39 mois. L’étude des résultats à distance est encore en cours et est fondamentale si le traitement chirurgical a un effet bénéfique sur la survie et la qualité de vie des malades. Le but de ce travail a été, à partir de la revue de la littérature et de notre petite expérience, de définir quels éléments pertinents mis en exergue sur le sujet.