Giant anogenital tumor of Buschke-Löwenstein in a patient living with human immunodeficiency virus/acquired immunodeficiency syndrome: a case report

Background

Buschke–Löwenstein tumor is a giant condyloma acuminata infection that is characterized by degeneration, invasion, and recurrence. It is associated with human papilloma virus infection. It develops around the genital and perineal area, sometimes causing a large budding ulcerated lesion. Although human immunodeficiency virus infection is frequent in Africa, there are few descriptions of Buschke–Löwenstein tumor diagnosis and its management. Screening for other sexually transmitted infections must be systematic among these patients.

Case presentation

We report herein the case of a 21-year-old African origin male patient who developed a perineal swelling. Physical examination showed evidence of a huge exophytic tumor made up of budding pinkish vegetations, with serrated crests, a ‘’butterfly wing’’ structure, and a cauliflower-like appearance crowned with centrifugal circinate lesions. Multiple condylomatous lesions of the anal margin were also present. The patient tested positive for human immunodeficiency virus (cluster of differentiation 4 count of 119 cells/mm³) and hepatitis B infections. Real-time polymerase chain reaction revealed human papilloma virus-16 and other high-risk human papilloma virus deoxyribonucleic acid. The diagnosis of Buschke–Löwenstein tumor was made on mass biopsy, and the patient underwent multidisciplinary intervention (surgery, podophyllin application, and antiretroviral therapy). Medium-term evolution was, however, fatal due to opportunistic infection.

Conclusion

Buschke–Löwenstein tumor is a rare tumor associated with human immunodeficiency virus infection. It is more frequent in male human immunodeficiency virus-positive patients. There is a need to screen for other sexually transmitted infections. In most cases, the treatment is surgical, in association with local therapies. However, recurrences are common.

Variation of HLA class I (-A and -C) genes in individuals infected with hepatitis B or hepatitis C virus in Cameroon

The Human Leucocyte Antigens (HLA) work in concert with other immune factors to modulate immunity to viral infections. Extensive variation has been reported in the genetic sequences and functions of classical HLA class I genes in many (mostly Western) populations, and several HLA associations with infectious disease outcomes have been reported. Little is known about their role in the susceptibility or resistance to hepatitis viruses in Central African populations. The aim of this study was to determine variants of two HLA class I genes (HLA-A and -C) in adults infected with hepatitis B (HBV)- or -C (HCV) virus in Cameroon. In this case-control study, a total of 169 unrelated adults comprising 68 HCV-infected, 38 HBV-infected and 63 uninfected (controls) individuals participated. Each consented participant was screened for HBV, HCV, and HIV infections and willingly donated a single blood sample for genomic DNA isolation and some clinical laboratory tests. HLA-A and HLA-C were genotyped using previously described sequence-based techniques (SBT). A total of 54 HLA alleles were identified in the study population (27 HLA-A and 27 HLA-C). HLA-A∗23:01 and HLA-C∗07:01 were the most common alleles with genotype frequencies of 31.4% and 29.3%, respectively. Hepatitis individuals were six times more likely to be HLA-A∗30:01 carriers than uninfected controls (OR = 6.30, p = 0.020 (HBV); OR = 6.21, p = 0.010 (HCV), respectively). Similarly, carriers of HLA-C∗17:01 were over-represented in the HBV-infected compared to the uninfected control group (21.9% vs. 6.4%, respectively) suggesting that this allele could play a role in the susceptibility to HBV infection. These findings demonstrate that carriers of HLA-A∗30:01 were over-represented in the hepatitis group compared to uninfected controls while HLA-C∗17:01 was completely absent in the HCV + group.

Evaluation of hepatic fibrosis in HIV/HCV co-infected individuals in Yaoundé, Cameroon: usefulness of APRI score in resource-constrained settings

Background

HIV infection exacerbates the prognosis of HCV infection, with a faster progression of hepatitis. Hepatic fibrosis is the major disruption of the hepatic tissue architecture characterized by anarchic deposition and excess of the extracellular matrix. The objective of this study was to evaluate hepatic fibrosis in HIV/HCV co-infected individuals as compared to HCV mono-infected.

Methods

A total of 97 participants (mean age 60.2 ± 14.3 years and 0.76 male/female sex ratio) was enrolled in a study conducted in Yaoundé, Cameroon from November 2018 to January 2019. Liver fibrosis was assessed by the APRI score (Aspartate Aminotransferase or AST/Platelet Ratio Index) which identifies the stage of fibrosis as classified by the Metavir system (F0 to F4). CD4 counts and plasmatic HIV viral load of HIV/HCV co-infected individuals were determined and the correlation between hepatic fibrosis and immuno-virological status established. Statistical analysis was done using Microsoft Excel 2016 and EpiInfo7 software.

Results

A high proportion (63.6%) of HIV/HCV co-infected participants had an abnormal AST level: 73.6 ± 45.8 IU/L as compared to 58.5 ± 39.3 IU/L (59.3%) among HCV mono-infected participants. The frequency of thrombocytopenia was 63.6% with a mean platelet count of 137 ± 50 ×  10³ IU/L in HIV/HCV co-infected participants as compared to 176 ± 67 × 10³ IU/L in HCV mono-infected participants (38.4%). The progression of hepatic fibrosis in participants with clinically significant fibrosis: F2, F3 and F4 was higher among HIV/HCV co-infected and the mean APRI score was 1.7 ± 1.4 versus 1 ± 0.8 among HCV mono-infected (26.7%). All participants (100%) with detectable HIV viral load had clinically significant fibrosis compared to 33.4% in those with undetectable HIV viral load (p = 0.55). Only 42.9% participants with CD4 >  500 cells/μL had clinically significant fibrosis (p = 0.72) while 100% participants with CD4 <  200 cells/μL had clinically significant fibrosis (p = 0.58).

Conclusions

A high level of AST combined with thrombocytopenia (APRI score > 1.5) is an indicator of hepatic fibrosis in HIV/HCV co-infected individuals. Because of its non-invasive and less costly nature, the APRI score can be a suitable biomarker to monitor hepatic fibrosis in HIV/HCV co-infected individuals in resource constrained settings.

[Severe high blood pressure recently diagnosed in an urban milieu from Subsahelian Africa: Epidemiologic, clinical, therapeutic and evolutionary aspects]

OBJECTIVES

High Blood Pressure (HBP) is a worldwide public health problem. It can be particularly severe in the Black race. Recent studies in Cameroon, showed an alarming prevalence, leading us to want to study the epidemiological, clinical, therapeutic and evaluative aspects of severe, (BP op to 180/110mmHg), recently diagnosed HBP in Yaounde. Our objective was to determine its clinical presentation and evolution.

METHODS

We conducted nine months prospective cohort study, from January to September 2016. We recruited from the active population participants who voluntarily accepted blood pressure screening offered in various localities in Yaounde, and were aged from 18 years and above.

RESULTS

Of a total of 6519 people who participated in the screening, 1875 (28.8%.), presented a HBP and 363 (5.6%) had severe HBP. Our cohort comprised 153 (42.1%) of these individuals with sustained severe hypertension, not on medication, who accepted the invitation to participate in the study. The range of 45-54 years and 55-64 years were the most represented; the sex ratio was 0.9. The cardiovascular risk factors number range from 5 to 8 with a median of 6. Systolic BP ranged from 184 to 225mmHg with a median of 200mmHg; while the diastolic BP ranged between 111-132.5mmHg with a median of 119mmHg. Kidney injury (77.8%) was the main complications. We identified 3 clinical forms: hypertensive emergencies 121 (79.1%) cases and hypertensive crises 32 (20.9%) cases. In these two groups, 33 (21.6%) patients presented with "super HBP" (a blood pressure>250/150mmHg). The average rate of BP control over 6 month was 39%. The main cause of poor BP control was lack of therapeutic compliance. We registered one death at the 3rd month of follow up due to acute kidney injury.

CONCLUSION

Severe HBP prevalence in Yaounde is high in the active fraction of the population insidiously affected. Particularly, unsuspected renal impairment appears to be the major complication. The bad blood pressure control is linked to poor therapeutic observance and persistence.

[Cryoglobulin and factors associated with it in patient with anti-hepatitis-C antibodies living in resource-limited countries]

Introduction

hepatitis C virus (HCV) has several extra-hepatic manifestations including cryoglubulinemia. Cryoglobulinemia is defined as the abnormal presence in the blood of one or several proteins (cryoglobulins) that can precipitate at low temperatures.

Method

We conducted a cross-sectional analytical study in the Laboratory of Biology and in the Unit of Hepatology of the General Hospital in Douala (HGD) over a period of 6 months. All patients agreeing to participate to the study and with anti-hepatitis-C antibodies under treatment or not were enrolled. Cryoglobulins were detected using biuret method and the classification was performed using Brouet immunoelectrophoresis. A multivariate analysis was conducted, confounding factors such as age, sex and the length of time after Hepatitis C Virus screening were adjusted.

Results

The study enrolled 116 patients. The average age of patients was 58.47±9.95 years. Male sex accounted for 50.86% of cases. Arthralgia was found in 69.80% of cases. Cryoglobulin was found in 63.80% of patients. After adjustment, female sex (OR =2.18; CI 95% [0,97-4,90]; p= 0.059), asthenia alone (OR =2.45;CI 95% [1,04-5,80]; p= 0.041), asthenia combined with arthralgia (OR =2.84;CI 95% [1,13-7, 10]; p= 0.026) and the presence of HCV RNA (OR =2.84;CI 95% [1,13-7,10]; p= 0.028) were factors independently associated with the presence of cryoglobulin.

Conclusion

The prevalence of cryoglobubin is high in patients with anti-hepatitis-C antibodies at the HGD. Simple biological methods are used to detect it. Cryoglobulin test in patients with HCV is essential in resource-limited countries.

High Burden of HBV-Infection and Atypical HBV Strains among HIV-infected Cameroonians

AIM

To investigate the prevalence and genotypic profile of overt and occult hepatitis-B infection (OBI) among HIV-infected individuals in Cameroon.

METHODS

212 HIV-infected Cameroonians, aged 37.6 [IQR: 32.6-46.6] followed-up at the University Health Centre in Yaoundé, were tested for HBsAg, anti-HBs, anti-HBc IgG/IgM, HBV-DNA and anti-HCV IgG. HBV positive cases were tested for Hepatitis Delta virus (HDV) using anti-HDV IgG and HDV-RNA. Liver function was assessed by alanine and aspartate aminotransaminases. OBI was defined as negative-HBsAg and detectable HBV-DNA. In occult or overt HBVinfected participants, HBV reverse transcriptase (RT)/surface (S) sequences were analyzed for drug resistance, immuneescape mutants, and phylogeny.

RESULTS

Overall, 78.3% (166/212) participants had past/ongoing HBV-exposure, with 39.1% (83/212) carrying "HBcAbpositive alone". Prevalence of overt HBV (positive-HBsAg) was 11.8% (25/212), prevalence of HBV and HDV was respectively 6.9% (12/175) and 12% (3/25). Phylogeny of HBV-RT/S revealed the co-circulation of genotypes A and E. All HBV-coinfected participants harbored HBV strains with at least one immune-escape mutation. Of note, one HBV variant carried the vaccine-escape mutation G145R that hinders HBsAg neutralization by antibodies. For the first time, a novel 9 aa-deletion (s115-s123), located in the HBsAg "a" determinant, was found concomitantly with OBI. A stop codon in the S region (associated with increased risk of hepatocellular carcinoma) was found in six cases.

CONCLUSION

High prevalence of overt/occult HBV-infection and circulating atypical strains highlight the importance of HBV-surveillance among HIV-infected Cameroonians and strategies to detect OBI in highly endemic countries.

Epidemiology of hepatitis C: related hepatocellular carcinoma in Cameroon

Introduction

Hepatocellular carcinoma (HCC) is a global public health problem. Hepatitis C virus (HCV) infection accounts for close to 24% of HCC in developing countries especially when associated with cirrhosis. There exists no vaccine against HCV to prevent the occurrence of HCV-related HCC. A sound knowledge of the epidemiology and prevention of the initial infection is vital. The aim of our study was to determine the epidemiologic profile of HCV-related HCC in Cameroon to improve its’ management.

Methods

It was a prospective study of histologically proven HCV-related HCC seen in two University Centers in Yaounde, Cameroon from March 2012 to January 2013. Demographic data (age, gender), alcohol abuse (>80g/day), presence of cirrhosis, tobacco abuse and parenteral exposition were analyzed.

Results

Twenty-six patients with histologically proven HCV–related HCC were included (18 men (69.2%) and 8 women (30.8%); mean age +/- SD, 61.46+/-10.18 years). A total of 22 (84.6%) patients had a parenteral exposition, 02 (7.7%) patients were alcoholics and 06 (23.1%) patients were smokers. The proportion of patients with cirrhosis was 69.2% against 30.8% cirrhosis-free. Patients with cirrhosis were relatively younger than those cirrhosis-free (mean age +/- SD, 59.05+/-10.05 years vs 66.87+/- 8.72 years, p=0.06). HCV-related HCC was more prevalent in 60 years and above patients (53.8%, 95%CI: 33.4-73.4). The relative risk of HCC among alcoholics patients was high (RR: 1.5, 95%CI: 1.13-1.99, p<0.05).

Conclusion

In Cameroon, HCV-related HCC is more prevalent among age older than 60 years, a finding which is relatively less to that found in western countries, male gender is twice more at risk than female gender and cirrhosis frequency is less compared to that observed elsewhere. HCV and alcohol play a synergistic role in the occurrence of HCC in our environment.

[Ultrasonographic features of liver abscess based on a 58-case series in Cameroon]

Amoebic abscess is the most frequent type of liver abscess in tropical areas, including in immunocompromised patients. Abscesses affect the right lobe in 74% of cases and are solitary in more than 80%. The ultrasonographic features of liver abscess vary according to stage, viscosity of liquid contents, amount of debris inside and presence of gas bubbles. Multiple small abcesses are mainly associated with pyogenic abscess and are promoted by HIV infection.

Diagnosis of fibrosis and cirrhosis using liver stiffness measurement in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is one of the most common liver diseases in affluent countries. Accurate noninvasive tests for liver injury are urgently needed. The aim of this study was to evaluate the accuracy of transient elastography for the diagnosis of fibrosis and cirrhosis in patients with NAFLD and to study factors associated with discordance between transient elastography and histology. Two hundred forty-six consecutive patients from two ethnic groups had successful liver stiffness measurement and satisfactory liver biopsy specimens. The area under the receiver-operating characteristics curve (AUROC) of transient elastography for F3 or higher and F4 disease was 0.93 and 0.95, respectively, and was significantly higher than that of the aspartate aminotransferase-to-alanine aminotransferase ratio, aspartate aminotransferase-to-platelet ratio index, FIB-4, BARD, and NAFLD fibrosis scores (AUROC ranged from 0.62 to 0.81, P < 0.05 for all comparisons). At a cutoff value of 7.9 kPa, the sensitivity, specificity, and positive and negative predictive values for F3 or greater disease were 91%, 75%, 52%, and 97%, respectively. Liver stiffness was not affected by hepatic steatosis, necroinflammation, or body mass index. Discordance of at least two stages between transient elastography and histology was observed in 33 (13.4%) patients. By multivariate analysis, liver biopsy length less than 20 mm and F0-2 disease were associated with discordance.

CONCLUSION

Transient elastography is accurate in most NAFLD patients. Unsatisfactory liver biopsy specimens rather than transient elastography technique account for most cases of discordance. With high negative predictive value and modest positive predictive value, transient elastography is useful as a screening test to exclude advanced fibrosis. Liver biopsy may be considered in NAFLD patients with liver stiffness of at least 7.9 kPa.

The tolerance and efficacy of a postponed retreatment with infliximab in Crohn's disease primary responders

BACKGROUND

In Crohn's disease (CD) patients naïve to immunomodulators primary responding to infliximab (IFX) induction, maintenance with scheduled IFX or with immunomodulators is possible. The benefit of additional IFX infusions after failure of maintenance with immunomodulators is not known.

AIM

To assess the efficacy and factors associated with efficacy of postponed IFX retreatment.

METHODS

All CD primary responders to an IFX induction regimen in maintenance with immunomodulators were retrospectively included when they received at least one additional IFX infusion after week 14. Efficacy was defined as clinical response at week 4 and absence of intolerance leading to discontinuation.

RESULTS

Sixty-one patients were retreated with IFX with a 38-week median time from induction. Efficacy was achieved in 80% patients. Twelve patients had no clinical benefit: seven acute hypersensitivity reactions and five loss of response. By multivariate analysis, the only factor associated with no efficacy was a median time >50 weeks from induction to retreatment (odds ratio = 7.38; 95%CI: 1.38-39.59; P = 0.02).

CONCLUSION

Postponed retreatment with IFX in CD primary responders should be administered within 50 weeks after induction, for better efficacy and tolerance.

A survey of blood pressure distribution in Pygmy and Bantu populations in Cameroon

A blood pressure survey was performed in isolated Pygmy communities and Bantu population samples living either in close relationship with the Pygmies or in separate areas within the same region. The Pygmies are still living as hunter-gatherers, whereas the Bantus rely on agriculture for food provision. Mean blood pressures in Pygmies were 130/85 mm Hg in males and 126/80 mm Hg in females and in Bantus were 137/87 mm Hg in males and 136/84 mm Hg in females. In spot urine the mean urinary sodium concentration was higher in Bantus than Pygmies (86 versus 37 mmol/L in males; 95 versus 56 mmol/L in females). In the total population urinary potassium concentration was very high (150 mmol/L), calcium concentration very low (0.4 mmol/L), and urea concentration low (6.9 g/L). After adjustment for age, height, weight, and sex, no racial differences in blood pressure were present. Blood pressure increased with age but body mass index did not. Diastolic pressure correlated significantly but negatively with urinary sodium in multiple regression analysis. Our study demonstrates that blood pressure increases with age in hunter-gatherer populations on a low to moderately high sodium diet in the presence of a low urinary excretion of calcium coupled with a low protein intake.