Non-tubercular caseous adenopathy in Senegal

The authors report the case of a 22-year-old man referred seven months after the onset of papulo-nodular skin lesions, lymphadenopathy, splenomegaly and hepatomegaly. Mycologic and histologic examination of skin lesions enabled the diagnosis of African histoplasmosis, by Histoplasma capsulatum var duboisii. The lymph nodes were caseous. The culture in Lowenstein-Jensen medium was negative.

[Multifocal histoplasmosis due to Histoplasma capsulatum var. duboisii in a 22 year-old Senegalese patient without proven immunodepression]

The authors report a case of multifocal African histoplasmosis with polymorphic skin involvement occuring in a patient without proven immunosuppression. He was a young 22-year-old patient from eastern Senegal - but born in Ouganda - who presented with polymorphic skin lesions: ombilicated papulo-nodules, gums and ulcerative and budding lesions. He showed lymphadenopathies without clinical inflammation and with a cheesy appearance of the biopsy but without tuberculosis and also hepatosplenic and bone involvement. Mycological samples of the skin and lymph nodes biopsies revealed yeasts of Histoplasma capsulatum var. duboisii with a positive culture on Sabouraud medium. HIV serology, HTLV1et 2, the serum proteins electrophoresis were unremarkable. Treatment with amphotericin B was irregular because of its inaccessibility in the national territory and its cost. The patient died of sepsis together with the aggravation of his disease.

Lupus nephritis in Senegal: a study of 42 cases

Renal involvement determines the prognosis of systemic lupus erythematosus (SLE). The aims of this study were to assess the clinical, laboratory and therapeutic aspects of lupus nephritis (LN) in Senegal in order to improve its management. We included all patients presenting with SLE followed-up in the Internal Medicine and Dermatology Clinics of the Aristide Le Dantec University Teaching Hospital of Dakar, from January 1993 to December 2002. Patients with SLE without evidence of LN (defined by proteinuria more than 0.5 g/24 hours and/or hematuria) were excluded. A total of 74 patients with a diagnosis of SLE were studied, 42 of whom (56.75%) had features of LN. Their mean age was 29.6 years and male-female ratio was 0.13. The nephrotic syndrome was seen in 45.23% of the cases and renal insufficiency in 37.71%. Renal biopsy was performed in 52.38% of the cases, which showed predominantly WHO classes IV and V lesions. The main treatment modality employed was corticosteroids, while immunosuppressive drugs in addition were used in 35.71% of the patients. The short-term prognosis was favorable but in the middle-term, many patients were lost to follow-up. We conclude that early diagnosis by systematic urine screening, good patient information, percutaneous renal biopsy and use of appropriate immunosuppressive therapy will help improving the prognosis of LN in Senegal.

[Antiphospholipid antibodies syndrome in dermatology in Dakar: 11 case report]

INTRODUCTION

Our aim was to report the cutaneous features of antiphospholipid antibodies syndrome in Dermatology in Dakar.

METHODS

Our study was retrospective from January 2000 to December 2001. All patients were diagnosed according to the criteria of the international consensus statement in 1999 on the antiphospholipid antibodies.

RESULTS

Eleven cases (all female) were collected with a median age of 28 years. A systemic lupus was associated in 7 cases, a scleroderma in 1 case and mix connectivity in 1 case. The dermatological manifestations found in all patients were necrosis of the extremities (4 cases), purpuric lesions (4), cutaneous ulcers (3), acrocyanosis (2), livedo (1) and subungual splinter hemorrhage (1). The obstetrical incidents were noted in 82% of cases; there were precocious and repeated abortions (in 5 cases), foetal loss (in 4 patients), precocious delivery (in 2 cases), lateness of growth in uterus (in 1 case). It was an arterial thrombosis in 2 cases. The mean level of anticardiolipin antibodies was 60 UGPL and a dissociation of the syphilitic serology was present in 9 patients. A severe thrombopenia in 1 case was observed. The evolution was favorable in 7 patients. In other cases, we noted foetal loss in 2 cases and distal necrosis relapse in 2 cases.

CONCLUSION

Cutaneous manifestations are diverse. They can be lupus involvements or microcirculatory thrombosis and they make the diagnostic easy.

[Lupus nephritis in Senegal: study of 42 cases]

INTRODUCTION

Renal involvement determines the prognosis of systemic lupus erythematosus. The aims of this study were to precise clinical, laboratory, therapeutic and evolutive aspects of lupus nephritis in Senegal in order to improve its management.

PATIENTS AND METHODS

According to ACR criteria we included all patients presenting a systemic lupus erythematosus followed in internal medicine and in the dermatology services of university teaching hospital Aristide le Dantec of Dakar from January 1993 to December 2002. All the patients who didn't have a lupus nephritis defined by the existence of more than 0.5 g/24 h of proteinuria and or hematuria were excluded.

RESULTS

The prevalence of lupus nephritis was 56.75% among 74 patients with systemic lupus erythematosus. Mean age was 29.6 years and sex ratio 0.13 (male to female). There was a nephritic syndrome in 45.23% of the cases and renal insufficiency in 37.71%. Renal biopsy performed in 52.38% of cases showed predominantly WHO classes IV and V. The key treatment was corticotherapy while immunosuppressive were used in 35.71%. The short term evolution was favourable but in the medium term, many patients were lost or followed up irregularly.

CONCLUSION

To improve the management and the prognosis of lupus nephritis in Senegal it is necessary to make patients with a systemic lupus erythematosus sensitive to it and to make systematically urine tests aiming the screening for an early diagnosis of lupus nephritis. In addition we should have aggressive policies in order to lower the costs of immunosuppressive therapy and haemodialysis.

[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.

Lymphome T cutané épidermotrope CD8+ cytotoxique d’évolution très agressive

BACKGROUND

Cutaneous CD8+ epidermotropic cytotoxic T-cell lymphoma is a recently described rare primary cutaneous lymphoma exhibiting aggressive clinical behavior. Only about twenty cases have been described in the literature. Below we report a case involving unusual association of cutaneous vasculitis and lymphoproliferation.

CASE REPORT

A 42-year-old senegalese man was hospitalized for cutaneous nodular lesions, which rapidly spread and became necrotic and ulcerated. he had recent weight loss with fever and multiple enlarged lymph nodes. Cutaneous histological analysis showed epidermotropic dermal infiltrate comprising medium and large cd8+ cytotoxic t-cells of unusual angiocentricity with cutaneous vasculitis and fibrinoid necrosis. the patient died 4 months after initiation of treatment with multi-agent chemotherapy.

DISCUSSION

This patient presented the characteristics of primary cutaneous CD8+ epidermotropic cytotoxic T-cell lymphoma described by Berti. The clinical findings in most cases consist of nodular and ulcerative cutaneous lesions. Histologically, the cutaneous infiltrate is composed of pleomorphic lymphocytes with marked and constant epidermotropism. Immunohistochemistry shows lymphocytes expressing a CD8+ phenotype and cytotoxic proteins, which probably accounts for the local and systemic aggressiveness of the disease, as well as the angiodestructive nature of the infiltrate and the necrotic lesions.

[Actinomycetomas in Senegal: study of 90 cases]

Mycetoma is a pathological process during which eumycetomic (fungal) or actinomycotic causative agents from exogenous source produce grains. Medical treatment is available for actinomycetomas and surgery is still the main treatment for eumycetoma. We report 90 cases of actinomycetoma occuring in male adult patients coming mainly from central Senegal. Patients living far from health structures consult after a long evolution period for tumors and pains which prevent them from carrying out their activities. The three etiological agents in our patients were Actinomadura pelletieri (60 cases), Actinomadura madurae (25 cases) and Streptomyces somaliensis (5 cases). The three clinical features are inflammatory forms (75 cases) mainly due to Actinomadura pelletieri, tumoral forms (13 cases) and cystic forms (2 cases). Lesions are localized on the foot in 50% of cases and in other part of the body for the other half. Bone damage was observed in 55% of cases. 83% of the patients were cured after a one-year treatment of sulfametoxazole adminstered orally. Two patients died of visceral involvement.

[Dermatomyositis in Senegal. Study of 56 cases]

INTRODUCTION

Dermatomyositis (DM) is rarely reported in black African. We report a retrospective study of epidemiological, clinical and evolutive aspects of dermatomyositis observed from 1983 to 2001 in dermatological department of Senegal.

MATERIALS AND METHOD

The diagnosis of D M was a ccepted when patients proved to fulfil Bohan and Peter's diagnostic criteria. We had recruited 56 African black patients of average age 34.5 years and of sex-ratio (M/F) 0.27.

RESULTS

The first clinical manifestation was cutaneous in 94% of cases. Dermatoligical signs were dominated bye rythema (77%), characterized by zebra-like aspect on extension faces of limbs. The erythema was pruriginous in 45% of cases. The others clinical manifestations were: muscular (86%), a rticular (60%), cardiac (34%), broncho-pulmonary (30.4%), digestive (30%), Raynaud's phenomena (20%) and ocular (7%). Muscular enzymes were increased in 95% for lacticodeshydrogenase and 71% for creatininine phosphokinase. Electromyography (in 25 cases), revealed a myogenic tracing in all cases, associated in 22 cases with a decreasing speed of the peripheral nervous conduction. Muscular biopsy made in 3 patients showed specific signs of DM and in one case, those were associated to a perivascular infiltration in the muscles and nerves with axonal nervous degeneration images. Dermatomyositis were p araneoplasic in 6 cases and the cancers were genital in all cases. The evolution after corticotherapy was favourable in 59% of cases. The cases of death (14 cases) were caused by the associated cancer (6 cases), repirator distress (4 cases) and infectious's complication of corticotherapy (4 cases). The relapses (16%) were secondary to treatement's interruption.

CONCLUSION

DM in Senegal affects young people with zebra-like erythema, often scratched and frequently associated with peripheral neuropathy. Genital cancers predomined in paraneoplasic forms.

[Cutaneous leishmaniasis in hospital area: epidemiological and clinical aspects, about 16 cases]

Cutaneous leishmaniasis, a chronic infectious ulcerative skin disease caused by a protozoan parasite of the genus Leishmania, is transmitted by the bite of sandflies. We report 16 cases of cutaneous leishmaniasis observed in Dakar from 1990 to 2000. The aim of this retrospective study was to determine the epidemiological and clinical features. Their age range was 10 to 78 years (mean 41.12 years). The sex ratio was 3. The most commun presentation was the ulcero-crusted lesions (bouton d'orient) observed in 56.25% of cases. The other clinical presentation are the sporotrichoid lesions (25%), the lupoid lesions observed in 12.5% and the cutaneous diffus leishmaniasis in 12.5%. In all these cases, there were many lesions. On treatment we observed 87.5% of total remission.

[Behçet's disease in Dakar (Senegal): epidemiological and clinical features]

We report epidemiological and clinical characteristics of 17 consecutives patients with Behçet disease during 26 years in Dakar(Sénégal). All the patients were black, with a mean age of 27.5 years (11- 42 years) and the disease was more common between 20 and 30 years. The sex ratio was 2.4 (12 men -5 women). The majority live in cost area (64.7). Clinical features frequencies were as follow muco-cutaneous (94.11%), ocular (58.82%) neurological (47.05%) articular (47.05) psychiatric (41.17%) vascular (35.29%) digestives (11.76%). Epidemiological characteristics of Behçet disease in Sénégal are common however, the important frequency of neuropsychiatrics manifestations is remarkable.

[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.

[Systemic scleroderma: 92 cases in Dakar]

We performed a retrospective study in order to characterize epidemiological data and signs of systemic scleroderma in Sénégal. All patients with the diagnosis according the ACR's criteria of scleroderma were recruited. We included 92 patients, the mean age was 33 years and sex ratio male to female was 0.19 (15 men and 77 women). There were 8 children in our series (8.9%). The initial complaints were cutaneous manifestations (64%) and Raynaud's syndrome (16.3%). Clinical manifestations at admission were muco-cutaneous (100%), osteo-articular and muscular (59%) and Raynaud's syndrome (57%). Focal hypopigmentation was common (70%). Anti-nuclear antibodies were present in 67.4% of patients. Skin biopsy was contributive in all patients in which it was performed (79 cases). Electrocardiogram was abnormal in 55%, non specific inflammatory syndrome was present in 44% and pulmonary function was abnormal in 52%. Our data suggest that systemic scleroderma is more common in younger people in black population. Disorders of pigmentation are common and Raynaud's syndrome is uncommon.

[Sharp syndrome complicating pulmonary tuberculosis: apropos of a case]

This study concerns a case-report about a 28 year old Senegalese woman suffering from a SHARP syndrome complicated by a bilateral bacillary pulmonary tuberculosis. The prevalence of this disease is underestimated but a female predominance is often reported. The mechanisms of this disease strongly depends upon the context in with it occurs. The diagnostic has been established by the ALARCON SEGOVIA criteria including clinical symptoms (Raynaud phenomenon, puffy fingers and myalgia) and biological features such as high positive immunofluorescent reactivity revealing the presence of anti RNP antibody at a level superior to 1/1000. The subsequent development figure of the disease emphasizes: persistence of polymyositis pattern revealed by higher limbs localized myalgia involving the thighs and symptoms of lupus including alopecia and glomerulonephritis remaining of the mixed characteristic comparable to the cases published in the literature. appearance of a bilateral bacillary pulmonary tuberculosis with a severe involvement of the right lung. The treatment composed by anti inflammatory and antituberculosis drugs lead to an early improvement of the clinical symptoms associated to a rapid cleaning of radiological manifestations. Sequelae were represented by cavities detected in the right lung and related to the pharmacological effects of corticosteroid drugs.

[Crusted scabies in Dakar apropos of 11 cases seen in a year]

We reported 11 cases of crusted scabies observed during one year in our department. The mean age of the patients was 33 years with extremes at 14 and 49 years. The sex ratio was 1,2. HIV infection was the most common associated disease (45% of the patients). Ten patients had been treated with Ivermectin (200 micrograms/kg). The drug was efficient and well tolerated. For these reasons, we recommend to use Ivermectin as a drug of choice in the treatment of crusted scabies.

[Necrotizing dermatitis due to Vibrio Vulnificus]

BACKGROUND

Vibrio vulnificus is a Gram-negative halophilic pathogen for man that can cause septicemia in patients with chronic liver disease. In healthy subjects, infections are generally local or regional. We report two cases of necrotizing dermo-hypodermitis due to Vibrio vulnificus.

CASE REPORTS

The first patient was a 21-year-old fisherman who developed extensive necrotizing dermo-hypodermitis 24 hours after a penetrating scratch with a fish bone. The second patient was also a fisherman. This 35-year-old man developed a massive area of necrotic tissue on the left leg, also 48 hours after a penetrating fish bone scratch. Both patients exhibited neutrophil hyperleukocytosis and thrombocytopenia. Bacteriological study of the pus and damaged tissue identified Vibrio vulnificus. Blood cultures were negative. Liver tests and liver ultrasound were normal. The course was favorable in both cases with antibiotic treatment and excision of the necrotic tissue.

DISCUSSION

For these two cases of Vibrio vulnificus necrotizing dermo-hypodermitis, the diagnosis was based on epidemiological, clinical and bacteriological arguments. Neither of these patients had liver disease, explaining the limited locoregional nature of the infection. The severity of the skin necrosis and its rapid course are related to the toxins produced by V. vulnificus. Curative medical and surgical care is generally effective in cases without septicemia and prognosis is good. Education of exposed subjects, fishermen and patients with chronic liver disease, should be helpful for prevention.

[Xeroderma pigmentosum: report of 6 cases in Dakar]

We report 6 cases of black Senegalese boys with xeroderma pigmentosum. They were between 2 and 16 year-old and presented features of hypersensitivity to UV (keratosis, lentigines, poikilodermia and photophobia). Our cases were remarkable by the early occurrence of squamous cell and basal cell carcinoma located in photoexposed sites causing the death of 5 of them. Xeroderma pigmentosum must be considered as the first preneoplastic genodermatosis.

[Skin toxicity of thiacetazone (TB1) at a hospital service in Dakar]

From 1980 to 1997 we had observed 50 cases of cutaneous side effects of thiacetazone. There were 25 cases of Steven-Jonhson syndrome, 23 cases of Lyell syndrome, a case of erythrodermia and a case of lichenoid toxidermia. The mortality was 40% with 16 cases of Lyell syndrome and 4 cases of Steven Johnson syndrome. Thiacetazone is a minor tuberculostatic drug used widely in the national program against tuberculosis. Our results confirm the seriousness of cutaneous side effects due to this drug. So like in other neighboring countries, we suggest to avoid use of this drug in Senegal.

[Squamous cell carcinoma arising on cutaneous discoid lupus erythematosus. Report of 3 cases]

We report 3 cases of squamous cell carcinoma arising respectively after 30, 6 and 19 years of spontaneous evolution of cutaneous discoid lupus erythematosus. In each case the histopathologic examination confirmed the diagnosis of cutaneous lupus discoid and squamous cell carcinoma. As phagedenic ulcer which is the main preneoplastic dermatosis, discoid lupus erythematosis must be considered. The long duration before the cancerisation allows a correct treatment of the disease to prevent the transformation.

Leucoderma associated with flares of erythrodermic cutaneous T-cell lymphomas: four cases. The French Study Group of Cutaneous Lymphomas

We describe four patients with erythrodermic cutaneous T-cell lymphomas (two with erythrodermic mycosis fungoides, and two with Sézary syndrome) who presented with extensive hypopigmented lesions that occurred during flares of their cutaneous disease. These cases must be distinguished from previously described hypopigmented mycosis fungoides where hypopigmented lesions were the sole manifestation of the lymphoma. In two cases a biopsy was performed on hypopigmented skin, showing an infiltrate of atypical lymphocytes with epidermotropism and absence of melanocytes, as in vitiligo. It is suggested that the hypopigmentation could be due to the cytotoxicity of tumour or reactional lymphocytes directed against melanocytes.

[Scabies complicated by acute glomerulonephritis in children: 114 cases observed in two years in a pediatric service in Dakar]

We performed a retrospective study during 2 years in order to determine the clinical and epidemilogic characteristics of 144 cases of scabiosis with acute glomerulo-nephritis in Dakar. The 144 cases of scabiosis complicated with glomerulo-nephritis represented 56.6% of the whole 205 cases of scabiosis observed in the same period. The most important part of the cases was observed between November and January. Usually children came from poor and numerous family. The scabios lesions were mostly generalised and the infection was recent. The main features of the kidney disease were: oedemas(93.2%), high blood pressure (89.1%) and haematuria(54.70%). Cardiac and neurological involvement were the main complications. The global mortality was very low(1 case). The evolution was good in 97% of the case with complete cure.

[Neuroendocrine carcinoma: first case observed in Dakar]

Neuro endocrine carcinoma is an unusual malignant tumor occurring in white elderly persons. It's most common location is the skin of head and neck. We report the first case of of Merkel cell carcinoma from Dakar. It was a woman of 21 years with history of three nodular lesion on the left foot which occurred 8 month before her arrival in our department. Inguinal and poplital lymph nodes were enlarged. Histopathology and immunocytochemistry confirmed the diagnosis of Merkel cell carcinoma. Our case is remarkable by the young age of our patient, her black race, the relative importance of the size and the localization of the tumor and the early occurrence of lymph node and pulmonary metastases.

[Crusted (Norwegian) scabies in Dakar (Senegal)]

Between January 1993 and June 1997, 30 patients with crusted scabies were seen at the dermatological clinic in Dakar (Senegal). Seventeen of these patients were male and 13 were female. Six were children aged 5 to 15 years and 24 were adults aged 18 to 70 years. Diagnosis of crusted scabies was straightforward because this condition, which was rare in Dakar before 1990, has become much more common and is now familiar to Senegalese dermatologists. The infection presented as an extensive scaly or crusted eruption with symmetrical lesions affecting the hands, feet, knees, elbows and ears in particular. Scalp involvement was reported in 25 patients. Erythrodermia was present in 4 cases and pachyonychia in 4 cases. Twenty-seven of the 30 patients had moderate or severe pruritus, whereas an absence of pruritus is regarded as a classical characteristic of crusted scabies. Diagnosis was readily confirmed by examination of hyperkeratotic material under the microscope: numerous mites and eggs were present. The two most common etiological factors were auto-immune diseases (6 cases, 4 of whom were receiving no steroid or other immunosuppressive treatment at the time of onset of crusted scabies) and malnutrition (5 of the 6 children in the study). The other associated conditions identified were: physical debilitation (4 cases), HIV infection (3), mental disability-Down's syndrome (3) and long term use of topical steroids for artificial depigmentation (2). Two patients were immunocompetent and 5 patients died shortly after diagnosis, before any underlying conditions could be identified. Seven patients were cured with benzyl benzoate. Seven others, all adults, received a single oral dose of ivermectin (200 mg/kg) and topical kerolytic drugs. Ivermectin was ineffective in 1 case, and an improvement was observed in another case, although a complete cure was achieved only after a second dose. The other patients were all cured and showed no signs of scabies one month after ivermectin treatment. A recurrence was observed in 3 patients a few months later however, suggesting that these patients were reinfected. No side effects were reported in any of the patients treated with ivermectin.

[Cardiovascular manifestations in systemic scleroderma]

OBJECTIVES

Patients with systemic scleroderma often have latent heart disease which could play an important role in morbidity and mortality. We therefore conducted a prospective study of cardiovascular manifestations in patients with systemic scleroderma.

PATIENTS AND METHODS

A prospective cross-sectional study included 29 patients with systemic scleroderma who underwent a complete cardiovascular work-up including physical examination, electrocardiogram, chest x-ray and Doppler-echocardiogram from July 1993 to February 1996.

RESULTS

Hypertension was observed in 6 patients (20.7%) and was positively correlated with age (p = 0.007). Raynaud syndrome was also found in 6 patients (20.6%). Heart disease was observed in 14 patients (48.3%) and was positively correlated with age and lack of treatment for scleroderma (p = 0.008). Myocardial disease was the most frequent (11 patients, 37.9%), followed by pericardial disease and valve disease (4 cases each, 13.8%). Rhythm and conduction disorders were found in 2 (6.9%) and 8 (27.6%) of the patients.

CONCLUSION

Cardiovascular manifestations are frequent but often latent in patients with systemic scleroderma. This finding emphasizes the importance of routine cardiovascular work-up in all patients with scleroderma.

[Pregnancy and systemic scleroderma. A case report]

The systemic scleroderma is an auto-immune affection characterised by diffuse lesions of the connective tissues with inflammatory predominance. As less frequent as this association with pregnancy, it usually occurs to the woman at the end of genital life activity. The obstetrical past history of a G5P2 of 40 years old affected with systemic scleroderma, is marked by four tardive abortions and two premature deliveries. The evolution of the disease was progressively unfavourable with visceral, digestive and pulmonary blows them sclerodermatomyositis. A review of literature reveals the interactions between this affection and pregnancy. The aggravation of the disease during pregnancy is possible: nephopatic scleroderma is then the most frequent complication. The gynaecological and obstetrical consequences are sterility, habitual abortions, intra-uterine growth retardation, intra-uterine foetal death, premature delivery and expulsion difficulties. The infant prognostic is specially related to the risk prematurity. The corticotherapy is the only acceptable treatment during pregnancy.

[Diffuse cutaneous leishmaniasis and acquired immunodeficiency syndrome in a Senegalese patient]

Tegumentary leishmaniasis cases associated with HIV infections were rarely reported. We present a case of diffuse cutaneous leishmaniasis in a senegalese patient with HIV 1 infection. The diagnosis was supported by a cutaneous biopsy but no Leishmania strain could be isolated by cultures from cutaneous specimens.

Crossover study of thalidomide vs placebo in Jessner's lymphocytic infiltration of the skin

BACKGROUND AND DESIGN

An effective therapy is still unavailable for Jessner-Kanof lymphocytic infiltration of the skin. Thalidomide's efficacy was suggested in an open study. Twenty-eight patients were randomly assigned to receive thalidomide (100 mg/d) or placebo over a period of 2 months and were then switched to the other treatment.

RESULTS

After the first period, 11 of 13 patients treated with thalidomide were in complete remission (CR), and there were two failures. There was no CR in the patients who received placebo (chi y2 = 17.5; P < .0001). After the second period, nine of 14 patients who had received thalidomide were in CR. Eleven of the 13 patients who had received thalidomide during the first period were given placebo (two were unavailable for follow-up). Ten of them were in CR: four were still free of lesions at the end of the second period, and six experienced a relapse of their lesions after a mean duration of 26 +/- 10 (SD) days. A total of 25 patients participated in the two study periods; CR was observed in 19 (76%) after thalidomide therapy and in four (16%) after treatment with placebo (chi y2 = 11.1; P < .001). Of 27 patients who received thalidomide, 16 (59%) were in CR after 1 month and 20 (74%) were in CR after 2 months. Two patients treated with thalidomide experienced neurologic changes that were not consistent with typical thalidomide-induced neuropathy.

CONCLUSIONS

A therapeutic regimen of thalidomide administered at a dosage of 100 mg/d for 2 months is able to suppress the clinical symptoms of Jessner-Kanof lymphocytic infiltration of the skin. The long-term risk-benefit has still to be evaluated.

[Mycetomas in Africa]

Mycetoma is the pathological process in which exogenous fungal or actinomycotic etiological agents generate grains. These agents belong to two groups: fungi and aerobic actinomycetes. Eumycetoma (caused by fungi) and actinomycetoma (caused by actinomycetes) must be distinguished as their treatments are different. These causative agents are introduced by traumas. Mycetomas are frequent in the northern tropical zones of America in Mexico and Venezuela, Africa in Senegal, Mauritania and Sudan and Asia in India, but can also be observed beyond these areas. In Africa, a high endemicity has been noted in a Sahelian band spanning from Senegal and Mauritania in the west to Somalia and the Republic of Djibouti in the east where there are long dry seasons and short rainy seasons. In this zone, M. mycetomatis (fungi) and S. somaliensis (actinomycetes) are predominant. A. pelletieri is common only in West Africa. Rainfall influences the distribution of these agents. S. somaliensis is more often found in desert areas, and A. pelletieri in more rainy areas. Mycetoma is more frequent in males and affects the age group between the second and fourth decades. Most of the patients are outdoor workers. In Africa, the foot is the most frequent localisation of the disease followed by the leg. Mycetoma is characterized by tumefaction, subcutaneous nodules and in most cases discharging sinuses that drain exudate containing grains. It gradually invades the tissues and bones causing a functional disability. Bone involvement depends on the duration of the disease, the site of the lesion and the causative agent. Invasion of lymph nodes is observed in rare cases, usually with actinomycetes.(ABSTRACT TRUNCATED AT 250 WORDS)