A retrospective cohort analysis of people living with HIV/AIDS enrolled in HIV care at a reference center in Antananarivo, Madagascar

Background

The impact of the "Treat all" policy on the individual and in terms of public health is closely related to early diagnosis and retention in care. Patient-level data are scarce in Madagascar. In this study, we aimed to describe the profile of a cohort of newly diagnosed people living with HIV/AIDS (PLHIV), identify their outcomes, and assess factors associated with attrition from care and advanced HIV disease (AHD) at presentation.

Methods

We conducted a retrospective cohort study of PLHIV aged ≥15 years newly diagnosed at the University Hospital Joseph Raseta Befelatanana Antananarivo from 1 January 2010 to 31 December 2016.

Results

A total of 490 PLHIV were included in the cohort analysis. In total, 67.1% were male. The median age (interquartile range) at enrollment in care was 29 years (24-38). Overall, 36.1% of PLHIV were diagnosed with AHD at baseline. The proportion of patients with WHO stage IV at baseline increased significantly from 3.3% in 2010 to 31% in 2016 (p = 0.001 for trend). The probability of retention in care after the diagnosis at 12 months, 24 months, and 36 months was 71.8%, 65.5%, and 61.3%, respectively. Age ≥ 40 years (aHR: 1.55; 95% CI: 1.05-2.29; p = 0.026), low level of education (aHR:1.62; 95% CI: 1.11-2.36; p = 0,013), unspecified level of education (aHR:2.18; 95% CI: 1.37-3.47; p = 0.001) and unemployment (aHR:1.52; 95% CI: 1.07-2.16; p = 0.019) were independently associated with attrition from care. Factors associated with AHD at baseline were age ≥ 40 (aOR: 2.77; 95% CI: 1.38-5.57, p = 0.004), unspecified level of education (aOR: 3.80; 95% CI: 1.58-9.16, p = 0.003) and presence of clinical symptoms at baseline (aOR: 23.81; 95% CI: 10.7-52.98; p < 0.001). Sex workers were independently less likely to have an AHD at presentation (aOR: 0.23; 95% CI: 0.05-0.96, p = 0.044).

Conclusion

Sociodemographic determinants influenced retention in care more than clinical factors. The presence of clinical symptoms and sociodemographic determinants were the main factors associated with AHD at baseline.

Prevalence and factors associated with carotid atherosclerosis in a Malagasy population with Type 2 diabetes mellitus: A cross-sectional retrospective study

AIM

Our study aims to determine the prevalence and factors associated with carotid atherosclerosis in Malagasy Type 2 diabetes mellitus (T2DM).

METHODS

This was a cross-sectional retrospective study, carried out over a period of 30 months. The diagnosis of carotid atherosclerosis is established by the presence of a carotid plaque increased carotid intima-media thickness ≥1.1 mm on Doppler ultrasound.

RESULTS

We included 132 T2DM. The prevalence of carotid atherosclerosis was 63.6% (38.6% carotid plaque and 25% intima-media thickening). After univariate analysis, the factors associated with carotid atherosclerosis were age ≥70 years (3.28 [1.18-10, 62]), previous intake of oral antidiabetics (0.33 [0.14-0.73]), insulin (0.28 [0.11-0.66]) and angiotensin receptor blocker (0.45 [0.20-0.98]), and current smoking (5.93 [1.64-32.6]). After adjustment for age and gender, previous intake of oral antidiabetics (0.29 [0.13-0.64]), insulin (0.27 [0.12-0.61]) and angiotensin receptor blocker (0.40 [0.19-0.86]), and current smoking (5.98 [1.61-22.1]) were associated with carotid atherosclerosis.

CONCLUSION

Smoking cessation, education on therapeutic compliance and comprehensive management of all cardiovascular risk factors and T2DM are therefore essential in order to reduce the occurrence of carotid atherosclerosis.

An extensive arterial thrombosis with lower limb ischemia in a COVID-19 patient: A case report

The coronavirus disease 2019 (COVID-19) pandemic is responsible for huge morbidity and mortality throughout the world. Several serious complications of this disease have been reported. It can cause hypercoagulability, which may lead to venous and arterial thromboembolic diseases. This hypercoagulability state is also associated with high morbidity and mortality. Arterial thrombosis in COVID-19 is poorly described compared to venous thrombosis and pulmonary embolism. We report a case of an extensive arterial thrombosis leading to a limb ischemia with extremely high D-dimer in a COVID-19 patient. A 69-year-old man was hospitalized for febrile dyspnea. He is a hypertensive and diabetic patient. On admission, pulse oxygen saturation was 72% on room air. He had cyanosis of the left foot up to the mid-thigh. The left pedal, posterior tibial, popliteal and femoral pulses were abolished. Chest CT scan was in favor of COVID-19. He has a high D-dimer level of 257,344 ng/mL. Arterial Echo-Doppler found an extensive intraluminal thrombus along the arterial axes of the left lower limb, completely obstructing them, starting from the primitive iliac artery just after its bifurcation with the aorta, and extending distally (external iliac; common femoral; superficial femoral; popliteal; anterior tibial; posterior tibial; fibular and pedal). The patient was diagnosed with COVID-19 critical form, associated with ischemia of the left lower limb secondary to an extensive arterial thrombosis. He was receiving anticoagulation, and underwent surgical amputation of the ischemic limb. The patient survived the event; however, he was on long-term oxygen therapy at home. Arterial thrombosis may occur during COVID-19 and may be responsible for peripheral or central ischemia aggravating morbidity and mortality. The occurrence of these events is related to the D-dimer value. Anticoagulation is an important part of the management of COVID-19, especially in severe forms in order to limit the occurrence of these thromboembolic diseases.

Urinary tract infection in diabetics hospitalized in Befelatanana Hospital, Antananarivo: Epidemiological, clinical, biological profiles and risk factors for multidrug-resistant bacterial infection

Key Clinical Message

The main type of urinary tract infection in hospitalized diabetics in Antananarivo is acute pyelonephritis; Escherichia coli is the most isolated uropathogen; imipenem, amikacin, fosfomycin and ceftriaxone are the major antibiotics for which Escherichia coli retain good sensitivity; Type 2 diabetes is predictive factor for infection by multidrug resistant bacteria.

Abstract

This study aimed to describe the epidemiological-clinical profiles of diabetics hospitalized for bacterial urinary tract infections in the Endocrinology Department of Befelatanana Hospital, to identify the main bacteria responsible, their antibiotic sensitivity profile and the factors associated with multidrug-resistant bacterial infection. A cross-sectional study was conducted between March 2017 and March 2020 involving all diabetics hospitalized for documented community-acquired bacterial urinary tract infection during this period. The hospital prevalence of urinary tract infections was 4.64%. The mean age of the patients was 59.06 ± 14.26 years and the sex ratio was 0.15. The main sign was fever (55.76%). The main clinical form was uncomplicated acute pyelonephritis (38.46%). Fifty-seven bacterial uropathogens were isolated. The most frequent was Escherichia coli (77.19%). Escherichia coli was sensitive to ertapenem and nitrofurantoin in 100% of cases, to Amikacin in 97.5% of cases, to Fosfomycin in 94.4% of cases and to Ceftriaxone in 80.65% of cases. Thirteen patients were infected with multidrug-resistant bacteria, all of them are extended-spectrum beta-lactamase-producing Enterobacteriaceae. Only the type of diabetes was associated with multidrug-resistant bacteria infection. The epidemiological-clinical and biological characteristics of urinary tract infections in our diabetics are similar to those reported in the literature. Compliance with the rules of proper antibiotic use is imperative to limit the emergence and spread of multidrug-resistant bacteria.

[Characteristics of chest pain in acute coronary syndromes seen in the cardiology department of Befelatanana (Madagascar)]

INTRODUCTION

Chest pain is one of the different elements of orientation for the diagnosis of acute coronary syndrome. Sometimes its clinical presentation is misleading. The objective of this study was to describe the characteristics of chest pain during an acute coronary syndrome in the cardiology department of the Joseph Raseta Befelatanana University Hospital Center, Antananarivo, Madagascar.

METHODS

We carried out a cross-sectional, descriptive study of 10 months from January 2019 to October 2019. All patients diagnosed with acute coronary syndrome during this period were included.

RESULTS

Sixty-five cases were included. A "typical chest pain" was only encountered in 7.7% of cases. Advanced age (p = 0.04) and sedentary lifestyle (p = 0.03) were associated with the occurrence of silent myocardial ischemia, and. hypertension with a prolonged duration (≥15 minutes) of chest pain (p = 0.03). Dyslipidemia was associated with atypical irradiation of chest pain (p = 0.003). Alcoholism had an impact on pain triggered by effort (p = 0.01) and relieved by rest (p = 0.04).

CONCLUSION

The current symptomatology of acute coronary syndrome is increasingly atypical. Knowledge of the factors that can influence the different characteristics of chest pain could serve as a benchmark in clinical practice in our population.

[Epidemiologic-clinical, biological and radiological features of pulmonary tuberculosis in patients with diabetes in Antananarivo, Madagascar]

Pulmonary tuberculosis is frequently associated with diabetes mellitus and, sometimes, it may present with atypical signs. The purpose of this study is to identify the epidemiological, clinical, biological and radiological features of pulmonary tuberculosis in patients with diabetes versus patients without diabetes in order to improve treatment. We conducted a retrospective, cross-sectional descriptive and analytical study in the Department of Endocrinology and Pneumology at the Joseph Raseta Befelatanana University Hospital Center and in the Department of Respiratory Diseases at the Soavinandriana Hospital Center in Antananarivo, Madagascar. It involved patients diagnosed with pulmonary tuberculosis who presented a positive bacilloscopy exam from January 2018 to January 2020 (25 months). In our study, the overall prevalence of diabetes among TB patients was 20.31 %. Older age, insidious clinical course, severe biologic inflammatory syndrome, fewer caves but more systematized opacities and diffuse radiological lesions in the basal zone (more commonly unilateral right lesions) were mainly detected in patients with diabetes compared to patients without diabetes. Knowledge of signs of pulmonary TB in patients with diabetes can help health care workers to make a diagnosis, even in patients with atypical signs. Moreover, as the majority of pulmonary tuberculosis occur in patients with unstable diabetes, a good glycemic balance can certainly reduce its incidence.

Clinical and epidemiological features discriminating confirmed COVID-19 patients from SARS-CoV-2 negative patients at screening centres in Madagascar

Early and fast detection of COVID-19 patients help limit the transmission and wide spread of the virus in the community and will have impact on mortality by reducing the incidence of infection among vulnerable people. Therefore, community-based screening is critical. We aimed to identify clinical signs and symptoms and epidemiological features that could help discriminate confirmed cases of COVID-19 from SARS-CoV-2 negative patients. We found that age (aOR:1.02, 95%CI:1.02–1.03, p < 0.001), symptoms onset between 3 and 14 days (aOR:1.35, 95%CI:1.09)1.68, p = 0.006), fever or history of fever (aOR:1.75, 95%CI:1.42–2.14, p < 0.001), cough (aOR:1.68, 95%CI:1.31–2.04), sore throat (aOR:0.65, 95%CI:0.49–0.85, p = 0.002), ageusia (aOR:2.24, 95%CI:1.42–3.54, p = 0.001), anosmia (aOR:6.04, 95%CI:4.19–8.69, p < 0.001), chest pain (aOR:0.63, 95%CI:0.47–0.85, p = 0.003), myalgia and/or arthralgia (aOR:1.64, 95%CI:1.31–2.04, p < 0.001), household cluster (aOR:1.49, 95%CI:1.17–1.91, p = 0.001) and evidence of confirmed cases in the neighbourhood (aOR:1.92, 95%CI:1.56–2.37, p < 0.001) could help discriminate COVID-19 patients from SARS-CoV-2 negative. A screening score derived from multivariate logistic regression was developed to assess the probability of COVID-19 in patients. We suggest that a patient with a score ≥14 should undergo SARS-CoV-2 PCR testing. A patient with a score ≥30 should be considered at high risk of COVID-19 and should undergo testing but also needs prompt isolation and contact tracing.

Knowledge, attitudes, perception and practices regarding antiretroviral therapy among HIV-infected adults in Antananarivo, Madagascar: a cross-sectional survey

Background

Adherence to antiretroviral therapy (ART) may be influenced by knowledge, perception and perception regarding ART. The purpose of this study was to assess knowledge, attitude/perception and practice regarding ART among people living with HIV/AIDS (PLHIV).

Methods

We conducted a cross-sectional survey to assess knowledge, attitudes, perception and practices ART in PLHIV. The survey was suggested to all PLHIV of at least 18 years old and who were on ART for at least 1 month. PLHIV who were unable to answer questions correctly and those who did not complete the survey for any reason were excluded.

Results

During the study period, 234 PLHIV were included. Participants were mostly men (75.2%). The median age was 33 years (IQR: 27–41). The median time since HIV diagnosis was 25 months (IQR: 9–56) and the median duration of ART was 18 months (IQR: 8–48). 87.6% had an overall good knowledge of ART. However, only 3.2% knew the name of their ART, 31.2% were aware that ART should be taken at a fixed time and 17.1% knew how to take ART in relation to food intake. 75.6% of participants had an overall positive attitude/perception of ART. However, 10.7% were convinced that other methods were more effective than ART for treating HIV and 42.7% thought that taking ART was shameful. The assessment of practices showed that in case of missed dose, 48.3% of participants routinely skipped this dose instead of trying to take it as soon as possible. In multivariate analysis, good knowledge of ART was independently associated with high level of education (aOR: 4.7, IC95%: 1.6–13.7, p = 0.004) and disclosure of HIV status (aOR: 2.7, IC95%: 1.1–6.6, p = 0.029).

Conclusions

This study showed an overall good knowledge and a predominantly positive attitude/perception of ART. However, accurate knowledge of ART intake was insufficient and the stigma associated with taking ART remained very present. Furthermore, very heterogeneous practices may reflect lack of instruction given by the physician regarding ART intake.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4173-3) contains supplementary material, which is available to authorized users.

Hospitalization of HIV positive patients in a referral tertiary care hospital in Antananarivo Madagascar, 2010-2016: Trends, causes and outcome

BACKGROUND

During the last few years, significant efforts have been made to improve access to antiretroviral therapy which led to dramatic reduction in AIDS-related events and mortality in HIV positive patients at the global level. However, current data in Africa suggested modest impact of widespread antiretroviral therapy scale-up especially regarding HIV-related hospitalization. In this study, we aimed to describe causes of hospitalization and factors associated with AIDS-defining events and inpatient mortality.

MATERIALS AND METHODS

A retrospective study was performed on medical records of HIV positive patients admitted for at least 24 hours in the Infectious Diseases Unit of the University Hospital Joseph Raseta Befelatanana Antananarivo. Cause of hospitalization was considered as the main diagnosis related to the symptoms at admission. Diagnostic criteria were based on criteria described in WHO guidelines. AIDS-defining events were defined as diseases corresponding to WHO stage 4 or category C of CDC classification.

RESULTS

From 2010 to 2016, 236 hospital admissions were included. AIDS-defining events were the most frequent cause of hospitalization (61.9%) with an increasing trend during the study period. Tuberculosis (28.4%), pneumocystis pneumonia (11.4%), cerebral toxoplasmosis (7.2%) and cryptococcosis (5.5%) were the most frequent AIDS-defining events. Tuberculosis was also the most frequent cause of overall hospitalization. In multivariate analysis, recent HIV diagnosis (aOR = 2.0, 95% CI: 1.0-3.9), CD4<200 cells/μl (aOR = 4.0, 95%CI: 1.9-8.1), persistent fever (aOR = 4.4, 95%CI: 2.1-9.0), duration of symptoms≥ 6 weeks (aOR = 2.6, 95%CI: 1.2-5.4) were associated with AIDS-defining events. Overall inpatient mortality was 19.5%. Age≥55 years (aOR = 4.9, 95%CI: 1.5-16.6), neurological signs (aOR = 3.2, 95%CI: 1.5-6.9) and AIDS-defining events (aOR = 2.9, 95%CI: 1.2--7.2) were associated with inpatient mortality.

CONCLUSIONS

AIDS-defining events were the most frequent cause of hospitalization during the study period. Factors associated with AIDS-defining events mostly reflected delay in HIV diagnosis. Factors associated with mortality were advanced age, neurological signs and AIDS-defining events.

[Huge aspergilloma developed within a zone of scleroderma-related pulmonary fibrosis]

In pulmonary aspergilloma, Aspergillus colonizes and proliferates as a saprophyte in deterged cavities deprived of local defense. Although pulmonary tuberculosis constitutes the one well-know predisposing factor, other causes can create favorable conditions. We describe a first published case of a huge aspergilloma which developed within a zone of pulmonary fibrosis secondary to systemic scleroderma. The patient was a 58-year-old woman in poor general health who experienced repeated episodes of hemoptysis and dyspnea. Physical examination disclosed sclerodactyly, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no clinical history of pulmonary tuberculosis or bronchectasis. Aspergillosis serology was positive. Broncho-alveolar liquid was positive for Aspergillus fumigatus at direct examination and after culture. Immunological assessment confirmed scleroderma. The chest computed tomography scan showed a huge oblong-shaped opacity in the upper left lobe which had developed within a zone of pulmonary fibrosis. Medical management was instituted. The clinical course was marked by repeating hemoptysis and the stability of pulmonary lesions after two years. Management of scleroderma-related pulmonary aspergiloma remains difficult and complicated. Prognosis depends on the course of both conditions, scleroderma and aspergillosis.

[Paradoxical lymphadenopathy during treatment of cavitary tuberculosis in an immunocompetent patient]

The paradoxical reactions during antituberculosis treatment are defined as a transient, clinical and/or radiological increase in preexisting tuberculous lesions or as the emergence of new symptoms, while treatment is adapted and correctly taken. The authors report a case of paradoxical left axillary lymphadenopathy during the treatment of cavitary tuberculosis, which appeared after seven months of treatment. No consensus on the therapeutic management of this entity has been developed to date but many authors propose an extension of antituberculosis treatment, a short corticosteroid therapy, an aspiration puncture and/or a surgical excision of the lymphadenopathy.