Epilepsy and stigma in Africa: Viewpoint of healthcare professionals and combat strategies

Epilepsy is a major public health problem in developing countries where eighty percent (80%) of people with epilepsy (PWE) live. Stigma has psychological consequences as well as serious repercussions on patients' quality of life. This study assesses the perception of health professionals in Africa regarding the stigmatization of PWE.

METHODOLOGY

This is a multicenter descriptive, cross-sectional study, from 1st August 2020 to 1st September 2021. Medical practitioners from African countries involved in the management of epilepsy and who agreed to fill out forms were included in the study. Sampling was nonrandom and based on respondent choice. The data were analyzed using the EPI INFO 7 software.

RESULTS

A total of two hundred and twenty-nine (229) health workers from twenty-six (26) African countries participated in this survey. 24.89% of the respondents were specialists and 46.72% were neurologists. Ninety-one percent (91%) of practitioners felt that PWE were stigmatised. The main forms of stigma were isolation (68.56%), celibacy (60.70%), unemployment (53.28%), divorce (44.54%) and exclusion (37.99%)%). Community, school and family were recognized as the main places of stigmatization. The fight against this stigma was carried out mainly in hospitals and in isolation in 58.4% and 55.8% of cases, respectively. Only 0.4% of practitioners opted for mass awareness.

CONCLUSION

PWE are victims of various forms of stigmatization, particularly in community settings. Measures aimed at raising awareness of the public are essential to reduce this stigma and improve patients' quality of life.

Diagnosis and classification of optic neuritis

There is no consensus regarding the classification of optic neuritis, and precise diagnostic criteria are not available. This reality means that the diagnosis of disorders that have optic neuritis as the first manifestation can be challenging. Accurate diagnosis of optic neuritis at presentation can facilitate the timely treatment of individuals with multiple sclerosis, neuromyelitis optica spectrum disorder, or myelin oligodendrocyte glycoprotein antibody-associated disease. Epidemiological data show that, cumulatively, optic neuritis is most frequently caused by many conditions other than multiple sclerosis. Worldwide, the cause and management of optic neuritis varies with geographical location, treatment availability, and ethnic background. We have developed diagnostic criteria for optic neuritis and a classification of optic neuritis subgroups. Our diagnostic criteria are based on clinical features that permit a diagnosis of possible optic neuritis; further paraclinical tests, utilising brain, orbital, and retinal imaging, together with antibody and other protein biomarker data, can lead to a diagnosis of definite optic neuritis. Paraclinical tests can also be applied retrospectively on stored samples and historical brain or retinal scans, which will be useful for future validation studies. Our criteria have the potential to reduce the risk of misdiagnosis, provide information on optic neuritis disease course that can guide future treatment trial design, and enable physicians to judge the likelihood of a need for long-term pharmacological management, which might differ according to optic neuritis subgroups.

[Progressive myoclonic epilepsy in the department of neurology of the University Teaching hospital Point "G"]

Background

Progressive Myoclonic Epilepsy (PME) is a heterogeneous group of pathologies associating epileptic seizures and other neurological and non-neurological disorders.

Objectives

We aim to characterize patients with symptoms of PME and identify the underlying genetic disorder.

Methods

After informed consent, the patients seen in the protocol for hereditary neurological diseases and presenting signs of epilepsy without a secondary cause were clinically evaluated over a three-year period in the Department of Neurology of the CHU Point "G". EEG, brain imaging and laboratory tests were performed to consolidate our diagnosis. DNA was extracted for genetic analysis.

Results

141 families including five families with PME totaling eight cases were enrolled. The predominant symptoms in our patients were myoclonus in 87.5% (N = 8), followed by GTCS and cognitive impairment in 50%, each. A notion of parental consanguinity was found in 60% and autosomal recessive transmission evoked in 80% (N = 5). The EEG was pathological in 62.5% and imaging showed ponto-cerebellar atrophy in 25% (N = 8). The combination of sodium valproate and clonazepam was the main treatment. One case of death was recorded.

Conclusion

We report cases of PME in Mali with a possibility of discovering new genes.

Clinical and Genetic Aspects of Huntington's Disease in the Malian Population

BACKGROUND

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder caused by mutation in the HTT gene and characterized by involuntary movements as well as cognitive and behavioral impairment. Since its first description 150 years ago, studies have been reported worldwide. However, genetically confirmed cases have been scarce in Africa.

OBJECTIVE

To describe the clinical and genetic aspects of HD in the Malian population.

METHODS

Patients with HD phenotype and their relatives were enrolled after obtaining consent. Symptoms were assessed using the Total Motor Scale (TMS) of the United Huntington's Disease Rating Scale (UHDRS) and the Mini-Mental State Examination (MMSE). Brain imaging and blood tests were performed to exclude other causes. DNA was extracted for HTT sequencing.

RESULTS

Eighteen patients (13 families) with a HD phenotype were evaluated. A familial history of the disease was found in 84.6% with 55.5% of maternal transmission. The average length of the HTT CAG repeat was 43.6±11.5 (39-56) CAGs. The mean age at onset was 43.1±9.7years. Choreic movements were the predominant symptoms (100% of the cases) with an average TMS of 49.4±30.8, followed by cognitive impairment (average MMSE score: 23.0±12.0) and psychiatric symptoms with 22.2% and 44.4%, respectively.

CONCLUSION

This is one of the largest HD cohorts reported in Africa. Increasing access to genetic testing could uncover many other HD cases and disease-modifying genetic variants. Future haplotype and psychosocial studies may inform the origin of the Malian mutation and the impact of the disease on patients and their relatives.

[Hospital epidemiology of psychiatric disorders in Mali]

INTRODUCTION

in Mali, there are no data on the prevalence of mental disorders. The purpose of this study was to describe the clinical and epidemiological features of patients hospitalised in the Department of Psychiatry.

METHODS

we conducted a cross-sectional study in the Department of Psychiatry at the University Hospital of Point G between January 2014 and December 2018. Data were collected from the medical records of 1105 patients hospitalised for psychiatric disorders.

RESULTS

the average age of patients was 32.6 ± 11.1 years, ranging from 13 to 82 years. Male patients accounted for 83.8% (926/1105) of enrolled subjects, 53.2% (588/1105) were single, 18.8% (208/1105) were not employed and 28.2% (310/1105) had primary education. Seventy-four percent (818/1105) had a history of psychiatric disorders, 22.7% (251/1105) were born to consanguineous parents. Drug use was reported in 42.9% (474/1105) of cases, including tobacco 32.6% (361/1105), cannabis 26.0% (287/1105) and/or alcohol 15.6% (172/1105). The demand for care came from families in 87.5% (967/1105) of cases. Aggression was the most common reason for consultation (44.5%; 492/1105). In 67.8% (749/1105) of cases, the diagnosis was schizophrenia, schizotypic disorders or delusional disorders. The first use of care was traditional in 58.7% (649/1105) of cases.

CONCLUSION

people hospitalised for psychiatric disorders from 2014 to 2018 were predominantly young and male with a history of psychiatric disorders. They mainly had schizophrenia, schizotypic disorders and delusional disorders.

Descriptive study of cases of schizophrenia in the Malian population

BACKGROUND

Schizophrenia is a relatively common disease worldwide with a point prevalence of around 5/1000 in the population. The aim of this present work was to assess the demographic, clinical, familial, and environmental factors associated with schizophrenia in Mali.

METHODS

This was a prospective descriptive study on a series of 164 patients aged at least 12 years who came for a follow-up consultation at the psychiatry department of the University Hospital Center (CHU) Point G in Mali between February 2019 and January 2020 for schizophrenia spectrum disorder as defined by DSM-5 diagnostic criteria.

RESULTS

Our results revealed that the male sex was predominant (80.5%). The 25-34 age group was more represented with 44.5%. The place of birth for the majority of our patients was the urban area (52.4%), which also represented the place of the first year of life for the majority of our patients (56.1%). We noted that the unemployed and single people accounted for 56.1 and 61% respectively. More than half of our patients 58.5% reported having reached secondary school level. With the exception of education level, there was a statistically significant difference in the distribution of demographic parameters. Familial schizophrenia cases accounted for 51.7% versus 49.3% for non-familial cases. The different clinical forms were represented by the paranoid form, followed by the undifferentiated form, and the hebephrenic form with respectively 34, 28 and 17.1%. We noted that almost half (48.8%) of patients were born during the cold season. Cannabis use history was not observed in 68.7% of the patients. The proportions of patients with an out-of-school father or an out-of-school mother were 51.2 and 64.2%, respectively.

CONCLUSION

The onset of schizophrenia in the Malian population has been associated with socio-demographic, clinical, genetic and environmental characteristics.

[Haemorrhagic Stroke after Snakebite Envenomation Resulting in Irreversible Blindness in a 6-Year-Old Child in Mali]

Introduction

Snakebite envenomation can cause serious damage. Here, we report the case of a six-year-old male child bitten by a snake.

Clinical description

The child presented a gingivorrhagia, abdominal pain, bloody vomiting and severe headache from a snakebite. Neurological examination showed paralysis of the III cranial nerve associated with bilateral blindness and mydriasis, unreactive on the right. The brain scan revealed a left frontal hematoma. The course on antivenom was marked by the disappearance of clinical signs except blindness which remained 18 months after discharge.

Discussion - Conclusion

The hemorrhagic syndrome evoked viper bite. Blindness is rarely seen as a result of viperine envenomation. In our case, the presence of intracranial hypertension, absence of ocular lesions and scanner were in favor of compression of the optic nerves which resulted in permanent blindness.

Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and description

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses.

Epilepsy surgery in Africa: state of the art and challenges

OBJECTIVE

Epilepsy is an important public health problem representing 0.6% of the global burden of disease that particularly impacts people living in the lowest income countries where epilepsy incidence may be 10 fold more than in the developed world. The battery of treatments designed to counteract the clinical manifestations of this disease are various and range from a wide spectrum of antiseizure medicationand specific diets, to surgical techniques for resection of the epileptogenic focus. The aim of our study was to describe the State of the art of Epilepsy Surgery (ES) in Africa and examine ways to deal with the high surgical treatment gap.

METHODOLOGY

In an observational study, we prospectively disseminated questionnaires via email or directly administered to main epileptologists and neurologists involved in epilepsy care, in key African countries. We also conducted a literature search using PubMed, Google scholar on ES in all the African countries.

RESULTS

We received responses from the majority of African countries, which allowed us to identify 3 levels of care for ES in African countries, a first level that uses ES with invasive presurgical evaluation, a second level that uses ES but without invasive presurgical evaluation, and a third level that does not use ES, and we summarized these results on a map.

DISCUSSION

This paper studied the availability of ES as a treatment modality in several African countries. We aimed to establish optimal pathways for initiating ES with noninvasive Electroencephalography and readily available investigations. This could be achieved through collaboration with epilepsy programs in developed countries directly or by using telemedicine.

Neuropathic pain in Mali: The current situation, comprehensive hypothesis, which therapeutic strategy for Africa?

INTRODUCTION

According to the taxonomy of the International Association for the Study of Pain (IASP 2011), neuropathic pain (NeuP) is defined as "pain caused by a lesion or disease of the somatosensory nervous system". NeuP is currently well-defined clinically, despite a high degree of etiological variation, and it has become a significant public health problem. This work aimed to study the situation regarding NeuP in current practice in Mali, as well as to analyze the therapeutic environment of the patients.

METHODOLOGY

This was a retrospective and cross-sectional study, carried out in two phases: (1) compilation of the files of patients according to the ICD-11, over a period of 24 months (2) a second prospective phase regarding the Knowledge, Attitudes, and Practices (KAP) of general practitioners and neurologists in regard to NeuP. The focus of the first phase of the study was the files of the patients who had undergone a consultation at the Gabriel Touré UHC. The second phase of the study focused on the general practitioners (Community Health Centers (comHC) of Bamako) and neurologists (Malian or not).

RESULTS

Over the period of the study, 7840 patients were seen in consultation in the Department of Neurology, of whom 903 for NeuP, thus amounting to a NeuP frequency of 11.5%. Women accounted for 58.9% (532/903), with a sex ratio of 1.4. Using a comparative normal law, the difference in frequency was statistically significant between males and females (p < 10-7) and between two age groups (p 〈10-3). The 49-58 years of age group was represented the most. Diabetic NeuP (21%), lumbar radiculopathies (14%), HIV/AIDS NeuP (13%), and post-stroke NeuP (11%) were the most represented. The survey among the carers revealed: a need for training, a low level of compliance with the therapeutic guidelines, and the use of traditional medicine by the patients.

DISCUSSION/CONCLUSION

This work confirms that NeuP is encountered frequently in current practice, and its optimal management will involve specific training of carers and improvement of access to the medications recommended in this indication. In light of this issue, we revisit the debate regarding the concept of essential medications and the relevance of taking into account effective medications for the treatment of NeuP.

Diabetic polyneuropathy with/out neuropathic pain in Mali: A cross-sectional study in two reference diabetes treatment centers in Bamako (Mali), Western Africa

INTRODUCTION

Diabetic polyneuropathy (DPN) with or without neuropathic pain is a frequent complication of diabetes. This work aimed to determine the prevalence of diabetic polyneuropathy, to describe its epidemiological aspects, and to analyze the therapeutic itinerary of patients with DPN.

METHODS

This was a cross-sectional, descriptive study performed synchronously over six months at two major follow-up sites for patients with diabetes in Mali. DPN was diagnosed based on the Michigan Neuropathy Screening Instrument (MNSI). The neuropathic nature of the pain and the quality of life of patients were evaluated by the DN4 and the ED-5D scale, respectively. We used three (3) different questionnaires to collect data from patients (one at inclusion and another during the follow-up consultation) and from the caregivers of patients with DPN.

RESULTS

We included 252 patients with diabetes, and DPN was found to have a healthcare facility-based prevalence of 69.8% (176/252). The sex ratio was approximately three females for every male patient. The patients were mostly 31 to 60 years of age, 83% had type 2 diabetes, and 86.9% had neuropathic pain Approximately half of the patients (48.3%) had autonomic neuropathy and they reported moderate to intense pain, which was mainly described as a burning sensation. The patients exhibited impaired exteroceptive and proprioceptive sensations in 51.7% of cases. The patients smoked tobacco in 3.4% of cases, while 36.6% of the patients were obese and had dyslipidemia. The caregivers clearly indicated that appropriate medications were not readily accessible or available for their patients with DPN.

CONCLUSION

The healthcare facility-based prevalence of DPN with or without neuropathic pain was high in our cohort. These inexpensive and easy-to-use tools (MNSI, DN4) can be used to adequately diagnose DPN in the African context. In Mali, screening and early treatment of patients at risk of DPN should allow for a reduction of the burden of the disease, while caregivers need to be adequately trained to manage DPN.

Correlates of diabetic polyneuropathy of the elderly in Sub-Saharan Africa

Background

Diabetic polyneuropathy is associated with significant physical disability among older adults. However, their frequency and correlates are not well known in the older adults in Sub-Saharan-Africa. The objectives were to evaluate the hospital-based prevalence of diabetic polyneuropathy and identify its correlates in older adults.

Methods

Over a period of 5 months, a cross-sectional survey was carried out at Douala Laquintinie Hospital (DLH), a main reference hospital in Douala, the economic capital of Cameroon. Participants in our study group comprised all patients with type 2 diabetes, whatever the reason for their reporting to the hospital. Diabetic Polyneuropathy was defined according to a Diabetic Neuropathy Examination score > 3/16.

Results

A total of 159 older adults with diabetes were examined during this recruitment period, among whom 106 (66.7%) were women. The mean age was 68.3 ± 6.5 years. Diabetes median duration was 108 months. For all patients assessed using the Diabetic Neuropathy Examination score, polyneuropathy was reported in 31.4%; among them, polyneuropathy proved symptomatic in 78% of them. Correlates of polyneuropathy were glycated hemoglobin (p = 0.049), HIV infection (p = 0.031) and albuminuria (p< 0.001), even after adjustment for age, gender and duration of diabetes.

Conclusion

A third of older adults with diabetes who visited our hospital were diagnosed with prevalent diabetes-related polyneuropathy. It shows that early detection is required through routine screening and regular follow-up examinations in order to reduce the risk of disability and improve the quality of life in elderly diabetics.

Epilepsy Research in Mali: A Pilot Pharmacokinetics Study on First-Line Antiepileptic Drug Treatment

Background and Purpose

The indication and benefit of plasma level of antiepileptic (AEDs) has been debating in the monitoring of people living with epilepsy and the epilepsy treatment gap has largely been documented in developed countries. This study was aimed to highlight the epilepsy treatment gap between rural and urban Mali.

Methods

We conducted a pilot study on AEDs treatment from September 2016 to May 2019. For 6 months, 120 children and young adults living with epilepsy (rural site, 90; urban site, 30) received phenobarbital, valproic acid and/or carbamazepine. At our rural study site, we determined the AED plasma levels, monitored the frequency, severity and the duration of seizure, and administered monthly the McGill quality of life questionnaire. At our urban study site, each patient underwent an electroencephalogram and brain computed tomography scan without close monitoring.

Results

At the rural study site, patients were mostly on monotherapy; AED levels at 1 month (M1) (n=90) and at 3 months (M3) (n=27) after inclusion were normal in 50% at M1 versus 55.6% at M3, low in 42.2% at M1 versus 33.3% at M3 and high in 7.8% at M1 versus 11.1% at M3. AED levels at M1 and at M3 were significantly different p<0.0001. By M3, seizures (n=90) were <1/month in 26.7%, and lasted less than 1 minute in 16.7%. After a yearlong follow up, all 90 patients reported a good or excellent quality of life. At our urban study site, patients (n=30) were on carbamazepine and valproid acid in 66.67% and monotherapy (carbamazepine) in 33.33%. By November 2018, only six out 30 patients (on bi-therapy) were still taking their medications.

Conclusions

Epilepsy diagnostic and treatment are a real concern in Mali. Our data showed appropriate AED treatment with close follow up resulted in a better quality of life of patients in rural Mali. We will promote the approach of personalized medicine in AED treatment in Mali.

[Exceptional Neurological Complication of Snakebite Envenomation: A Case in Mali]

Envenomation by snakebite can lead to hematological, circulatory, digestive, renal, and neurological complications. Brain abscess after snakebite envenomation is exceptional and very rarely reported in the literature. In this article, we describe the clinical case of a 45-year-old woman with no particular history, admitted to our department for vigilance disturbances linked to a motor deficit on the right side and fever after viper bite on the left thumb. The clinical examination showed a marked biological inflammatory syndrome. The brain scan with iodine injection suggested a left fronto-parietal brain abscess. Tri-antibiotic therapy, combined with the administration of corticosteroids, resulted in favorable outcome.

[Healthcare associated infections in the neurosurgical department of Gabriel Touré teaching Hospital in Bamako]

INTRODUCTION

Healthcare-associated infections or nosocomial infections are a public health problem due to their frequency, severity and economic impact. They cause an increase of the morbidity, the mortality, the hospital stay and the expenses of taking care of the patients. According to the WHO, 7.1 million people are affected each year, of which about 100,000 die.

AIM OF STUDY

The aim of this study was to determine the frequency of healthcare-associated infections in the Neurosurgery Department of Gabriel Touré University teaching Hospital and to identify the risk factors associated with these infections.

MATERIAL AND METHODS

This was an epidemiological, descriptive, analytic, cross-sectional and prospective study lasting 6 months from May 29 to November 30, 2016. The study focused on patients who stayed more than 48 hours in the Neurosurgical department Gabriel Touré teaching hospital. The collected data focused on the clinical and biological characteristics of the patients during their hospitalization. The maximum size of the sample was 200 patients. A sample was taken for each type of infection. The criteria used for the diagnosis of Healthcare-associated infections were those of the CDC (Center for Disease Control) and the realization of a thick drop in our context. The chi-square test was used for the comparison of qualitative variables and Kruskal Wallis and Anova for quantitative variables. The materiality threshold has been set to a value of p less than 0.05.

RESULTS

At the end of our study, we had 34 infected patients out of 200, a rate of 17%. The significant risk factors found in our study were: high age (p = 0.04), ASA class (p = 0.002), pre-surgical shaving (p = 0.02), long duration surgical intervention (p = 0.002) and long hospital stay (p = 0.004). The types of infections associated with the care found were: urinary in 18 (53%) cases, respiratory in 9 (26%) cases, operative site in 6 (18%) cases and 1 (3%) cases of bacteremia. The bacterial spectrum of these infections was dominated by Negative Gram Bacilli, among which Escherichia coli in 11 (32.3%) cases. The clinical course of patients treated for these infections was marked by healing in 31 (91.2%) cases, complications in 2 (5.9%) cases, and death in 1 (2.9%) case.

CONCLUSION

The prevalence of Healthcare-associated infections in our department remains high compared to that found in developed countries. This study allowed us to identify the main risk factors associated with these infections. A stricter adherence to the rules of hygiene and prevention of Healthcare-associated infections is needed to reduce this rate.

[Impact of migraine on life quality in school environment in Bamako, Mali]

INTRODUCTION

Migraine is a disabiliting disease accounting for 3%. Its prevalence and impact on the schoolar population deserves to be known.

METHODOLOGY

This is a five-month cross-sectional and descriptive study of students under 23 years of age at the high school in Bamako, Mali. The sampling was exhaustive and the population was stratified into school classes. Data related to the impact and disability of migraine were collected from a survey sheet integrating internationally validated items (GRIM, MIDAS, Headache Impact Test).

RESULTS

The prevalence of migraine was 21.0%. The sex ratio was 0.58. The average age was 17 years. Headache was pulsatile in 88.3% of cases, exacerbated by physical activities in 5.4%, unilateral topography in 73.2% of students. Phonophobia, photophobia were the most described signs of accompaniment. The intensity of pain was between 9 -10 in 69.5%. School absenteeism was ranged from 1 to 14 days in 91.2% of cases.

CONCLUSION

Migraine is a real public health concern in schools in Bamako because of its prevalence and its impact on academic performance.

Clinical aspects, neuroimaging, and electroencephalography of 35 cases of hemiconvulsion-hemiplegia syndrome

INTRODUCTION

The hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome is a rare consequence of febrile seizures during childhood. It is characterized by the presence of prolonged unilateral clonic seizures occurring during febrile illness in a child less than 4years of age. Then, a flaccid unilateral hemiplegia with variable duration occurs.

OBJECTIVES

The objective of the study was to describe the clinical, electroencephalogram (EEG), and neuroimaging treatment and outcome of series of cases of HHE syndrome followed for 10years in our clinical neurophysiology department of the specialty hospital of Rabat.

PATIENTS AND METHODS

We report a retrospective study of 35 patients followed up for HHE syndrome from January 2005 to December 2015. All patients included in the study met the definition criteria for HHE syndrome.

RESULTS

The age of onset ranged from 1 to 10years. Hemiplegia or spastic hemiparesis of the ipsilateral side to the convulsion was present in all patients. Abnormal brain magnetic resonance imaging (MRI) was found in all patients. All patients developed drug-resistant focal epilepsy during the course of the disease.

CONCLUSIONS

The management of HHE syndrome constitutes a real public health problem in developing countries like Morocco. The neurological morbidity and the severe sequels are of high impact in these young kids. On the one hand, authors highlight the need for improving emergency care of status epilepticus. On the other hand, in our context, the prophylaxis of febrile seizures seems to be the corner stone of the prevention of HHE Syndrome.

[Myeloradiculitis due to Schistosoma haematobium: about an observation in Dakar (Senegal)]

Nervous localisations of schistosomiasis are rare. We report the case of a 25 year-old Senegalese patient admitted for a progressive myeloradiculitis onset, over a one week period. The diagnosis of Schistosoma haematobium myeloradiculitis was made in front of a positive serum serology for S. haematobium, presence of S. haematobium eggs in urine, hyperproteinorachia, endemicity of S. haematobium in the region where the patient was originating and a past medical history of macroscopic hematuria in a context of river bathing. There was also no arguments for another cause to these neurological manifestations. Our patient was treated with praziquantel, prednisone and physiotherapy. Evolution was marked 6 weeks after the beginning of treatment by a significant improvement of motor deficit, enabling the patient to walk again. There was also a regression of genitosphincter dysfunction. Work-up for patients presenting with paraplegia in tropical countries, should also include search for S. heamatobium infection.

Does the survival motor neuron copy number variation play a role in the onset and severity of sporadic amyotrophic lateral sclerosis in Malians?

Introduction

Spinal muscular atrophy (SMA) and sporadic amyotrophic lateral sclerosis (SALS) are both motor neuron disorders. SMA results from the deletion of the survival motor neuron (SMN) 1 gene. High or low SMN1 copy number and the absence of SMN2 have been reported as risk factors for the development or severity of SALS.

Objective

To investigate the role of SMN gene copy number in the onset and severity of SALS in Malians.

Material and Methods

We determined the SMN1 and SMN2 copy number in genomic DNA samples from 391 Malian adult volunteers, 120 Yoruba from Nigeria, 120 Luyha from Kenya and 74 U.S. Caucasians using a Taqman quantitative PCR assay. We evaluated the SALS risk based on the estimated SMA protein level using the Veldink formula (SMN1 copy number + 0.2 ∗ SMN2 copy number). We also characterized the disease natural history in 15 ALS patients at the teaching hospital of Point G, Bamako, Mali.

Results

We found that 131 of 391 (33.5%) had an estimated SMN protein expression of ≤ 2.2; 60 out of 391 (15.3%) had an estimated SMN protein expression < 2 and would be at risk of ALS and the disease onset was as early as 16 years old. All 15 patients were male and some were physically handicapped within 1-2 years in the disease course.

Conclusion

Because of the short survival time of our patients, family histories and sample DNA for testing were not done. However, our results show that sporadic ALS is of earlier onset and shorter survival time as compared to patients elsewhere. We plan to establish a network of neurologists and researchers for early screening of ALS.

Designing slanted soil system for greywater treatment for irrigation purposes in rural area of arid regions

To solve the unpleasant disposal of greywater in rural area and allow its collection for reuse in gardening, a slanted soil treatment system (SSTS) was designed and installed in two households. Granitic gravel of 1-9 mm size was used as the filter medium. The aim of this study was to design a SSTS and assess its suitability as a treatment system allowing greywater reuse in gardening. The efficiency of the SSTS was assessed based on organic matter and bacterial pollution removal. The developed SSTS allowed the collection of greywater from three main sources (shower, dishwashing and laundry) in rural area. The SSTS is efficient in removing at least 50% of suspended solids, chemical oxygen demand and biological oxygen demand. The study highlighted that, contrary to the common perception, greywater streams in rural area are heavily polluted with faecal indicators. The removal efficiency of faecal indicators was lower than 2 log units, and the bacteriological quality of the effluents is generally higher than the WHO reuse guidelines for restricted irrigation. Longer retention time is required to increase the efficiency. The possibility of reusing the treated greywater as irrigation water is discussed on the basis of various qualitative parameters. The SSTS is a promising greywater treatment system for small communities in the rural area in the Sahelian region. To increase the treatment efficiency, future research will focus on the characteristics of the SSTS, the grain size and the establishment of a pretreatment step.

Epilepsy genetics in Africa: challenges and future perspectives

Despite the diversity of the African population, genetic studies, of epilepsy in particular, have been limited, especially in sub-Saharan Africa. In recent years, with the regression of infectious diseases in developing countries, the focus has shifted more towards non communicable disorders. The prevalence of epilepsy in Africa is higher compared to other continents. Although this has been attributed to the high rate of infectious diseases, genetic contributions should not be ignored. Research in genetic epilepsy in Africa could well benefit from the decreasing cost of genetic analysis, and could contribute to further our knowledge on the spectrum of these diseases in Africa. The growing collaboration between African research institutions and those of developed countries offers a unique opportunity to boost research in Africa and improve our global understanding of human disease, thus leading to the development of better therapeutic approaches.

Genetics of low spinal muscular atrophy carrier frequency in sub-Saharan Africa

Objective

Spinal muscular atrophy (SMA) is one of the most common severe hereditary diseases of infancy and early childhood in North America, Europe, and Asia. SMA is usually caused by deletions of the survival motor neuron 1 (SMN1) gene. A closely related gene, SMN2, modifies the disease severity. SMA carriers have only 1 copy of SMN1 and are relatively common (1 in 30–50) in populations of European and Asian descent. SMN copy numbers and SMA carrier frequencies have not been reliably estimated in Malians and other sub‐Saharan Africans.

Methods

We used a quantitative polymerase chain reaction assay to determine SMN1 and SMN2 copy numbers in 628 Malians, 120 Nigerians, and 120 Kenyans. We also explored possible mechanisms for SMN1 and SMN2 copy number differences in Malians, and investigated their effects on SMN mRNA and protein levels.

Results

The SMA carrier frequency in Malians is 1 in 209, lower than in Eurasians. Malians and other sub‐Saharan Africans are more likely to have ≥3 copies of SMN1 than Eurasians, and more likely to lack SMN2 than Europeans. There was no evidence of gene conversion, gene locus duplication, or natural selection from malaria resistance to account for the higher SMN1 copy numbers in Malians. High SMN1 copy numbers were not associated with increased SMN mRNA or protein levels in human cell lines.

Interpretation

SMA carrier frequencies are much lower in sub‐Saharan Africans than in Eurasians. This finding is important to consider in SMA genetic counseling in individuals with black African ancestry. Ann Neurol 2014;75:525–532

Current beliefs and attitudes regarding epilepsy in Mali

PURPOSE

In Mali, epilepsy affects 15 individuals per thousand. Perceptions and attitudes have not seemingly evolved with advancing medical knowledge. The objective of this study was to assess parental beliefs and attitudes in families with and without affected children.

METHODS

We enrolled 720 pediatric patients, half of whom had epilepsy, at Mali's largest hospital. We conducted semistructured interviews with the accompanying parent. Control families with unaffected patients and also had affected children were excluded.

RESULTS

In total, 67% and 24% of families with and without epilepsy, respectively, lived in rural environments. Interviewees were mostly mothers in their 30s; 80% had not completed high school. About 22% of parents without an affected child had witnessed a seizure. During a seizure, 94% of parents with an affected child and 49% of parents without an affected child, respectively, would intervene; 7.5% and 21%, respectively, would wet the patient's face with cool water. Although parents with an affected child had more intimate knowledge of seizures, misconceptions prevailed, perhaps more so than in families without epilepsy: 79% and 66% of parents, respectively, considered epilepsy contagious; 43% vs. 69% thought that it inevitably led to psychosis; and 53% vs. 29% attributed epilepsy to supernatural causes. Finally, 63% of parents with an affected child reported consulting a traditional healer as first-line management for epilepsy.

CONCLUSIONS

Our study demonstrates widespread misconceptions in Mali regarding epilepsy. Our findings argue for more education initiatives focused on the entire population, including traditional healers, to provide knowledge, reduce stigma, and improve quality of life for individuals living with epilepsy.

[Indications and anomalies of extended electrocardiogram recording (24 hours) at the Gabriel Toure university hospital in Bamako]

AIM

To specify indications and main anomalies of the 24 hours electrocardiogram in Bamako.

METHODOLOGY

The study was retrospective and conducted from 1st January 2008 to 31st July 2013, on patients whose file comprised a readable recording holter. The Holter recordings were analyzed by the software synetec (syneview 2) of ELA medical. Patients data were analyzed by SPSS 18 and redaction made using Word 2010.

RESULTS

90.2% of the recordings were retained. Mean Age of the sample was of 44,02 ± 16,95 years, the sex-ratio H: F 1,18 with 79.3% of patients coming from the services of cardiology. The indications were: palpitations (32.6%), suspicions of disorder of the rate/rhythm (27.2%), loss of consciousness, cerebral vascular accidents ischemic each one 15.2% and seeks of cause of faintness in (9.8%). An anomaly was found for the indications of disorder of the cardiac rhythm, palpitations, the cerebral vascular accidents ischemic, fainting and the losses of consciousness in resp. 80%, 66.6%, 28.5%, 22.2% and 14.2%.

CONCLUSION

The 24 hours electrocardiographic recording is an examination of a great value in looking for cardiac rhythm disorders field of the disorders of the cardiac rhythm. Its provision will have to be effective in the university structures and the evolution towards the forms at longer duration quickly undertaken in Mali.

[Longitudinal study of cervico-brachial neuralgia in the Neurology Department of CHU Gabriel Touré, Bamako (Mali)]

Introduction

La Névralgie Cervico-Brachiale (NCB) est une pathologie relativement fréquente dans la pratique courante. Elle est pourvoyeuse d'importants coûts médicaux et socio-économiques. Peu de données existent sur la NCB en Afrique.

Méthodes

Il s'agit d'une étude longitudinale, descriptive et prospective qui s'est déroulée du 1er novembre 2009 au 30 Août 2010 au CHU Gabriel Touré de Bamako, Mali. Elle a pour objectif d’étudier les caractéristiques épidémiologiques et cliniques de la NCB. Le diagnostic à été strictement clinique, et la DN4 a permis de déterminer les caractéristiques de cette névralgie. L'intensité de la douleur a été évaluée par l’échelle verbale simple (EVS). L’échelle concis de la douleur et l’échelle HAD ont permis d’étudier l'impact de la douleur sur la qualité de vie des patients.

Résultats

La fréquence de la NCB est de 10,9%. Les ménagères sont les plus touchées, 21(40,4%). L’âge moyen des patients est de 48 ±7 ans. La tranche d’âge de 50-59 ans représente la classe modale. La douleur est à prédominance nocturne chez 75,0% des patients. Les décharges électriques sont la caractéristique principale soit 48,1% des patients et 57,7% malades présentent une douleur intense. Sur le plan topographique, la racine C7, est la plus atteinte soit 50,0%. Sur la qualité de la vie, 44,2% des malades présentent des troubles du sommeil. Sur le plan thérapeutique l’évolution a été favorable chez 78,8% des patients sous AINS, Tramadol et Amitriptilline.

Conclusion

otre travail à l'instar des études antérieures sur la NCB montre que cette pathologie reste une entité clinique relativement courante. Le pronostic généralement favorable est fonction d'un diagnostic précoce et d'une prise en charge adaptée.

[Cervical and intracranial artery dissections]

Cervical and intracranial artery dissections result from the occurrence of an intramural hematoma. Arterial dissection is one of the main causes of ischemic stroke in young adults. Pathophysiology remains misunderstood but probably results from the association of a triggering environmental factor with an underlying arteriopathy. Usually, headache or neck pain, sometimes associated with local signs (e.g., Horner's sign) occurs after a trivial trauma, followed some hours or days later by cerebral infarct. Diagnosis may be confirmed by CT-scan or MRI with angiogram. In the absence of randomized studies, acute treatment of cervical artery dissection is based on antithrombotics. IV thrombolysis is recommended in acute stroke. Outcome is favorable in most cases, related to infarct severity. Recurrences are very rare.

[Modalities of stroke management in Mali (West Africa): a survey of practices]

The upsurge and the impact of stroke in terms of mortality and morbidity in Africa are well documented. But their current stroke management modalities remain to be evaluated.

METHODS

This study investigated the modalities of healthcare practitioners working in structures involved in stroke management in seven of the eight regions and the capital city of Bamako. A questionnaire was sent out to all potential participants identified in the designated areas, whereas the relevant medical personnel were systematically enrolled to take part. 149 practitioners (90%) including 68 general practitioners, 12 specialists, and 69 residents responded to the questionnaire. Six CT-scan, 15 echocardiographs, and 21 electrocardiographs were available. The team directly involved in patient management included six neurologists, seventeen cardiologists, six neurosurgeons, 86 physical therapists, three orthophonists, and two ergotherapists. Hemiplegia was the revealing symptom of stroke in 61.1% of cases. Almost all infrastructures and the personnel are located in a geographic area representing less than 10% of the country, where only 14 % of the population live. These findings emphasize the lack and unequal distribution of resources allocated to stroke management.

CONCLUSION

Problems related to stroke in Mali need a re-organization of patient management networks. An initial and continued training of health practitioners should be implemented.

[Clinical and therapeutic aspects of brain abscesses: 17 cases reviewed at the Gabriel Toure teaching hospital In Bamako]

OBJECTIVE

The purpose of this study was to determine the incidence, clinical features, localization, and therapeutic aspects of the evolution of the brain abscess.

PATIENTS AND METHODS

This was a retrospective study which included patients admitted for brain abscess at the Gabriel Touré Hospital in Bamako between January 2007 and September 2010.

RESULTS

We collated the data of 17 patients. Fever was the predominant symptom in 14 patients and headache in 13. The main clinical signs were hemiparesis (11 patients) and vomiting (8 patients). The origin of infection was especially posttraumatic in 5 patients, locoregional by contiguity in 5 where 3 whose originated in the sinuses. All patients received triple antibiotic therapy. The surgical management by trépanoponction was indicated in 16 patients. The clinical outcome was favorable in 14 patients. Three patients died.

CONCLUSION

Brain abscess is a common condition in Mali. Despite improved diagnostics and treatment of patients, mortality remains high hence the interest of prevention through early diagnosis and treatment of infectious ORL.

Coma in the elderly: Etiological factors, management, and prognosis in the department of anesthesia and intensive care

Objective:

To study the etiologies, therapeutic and prognosis factors of coma in the elderly in the Department of Anesthesia and Intensive Care of Gabriel TOURE Teaching Hospital, Mali.

Materials and Methods:

This was a prospective descriptive study of all cases of coma in the elderly, registered from February 1, 2008 to January 31, 2009 at the Department of Anesthesiology CHU Gabriel Touré, Bamako.

Results:

During the study period, 564 patients were admitted to the intensive care unit (ICU) in which 174 (30.85%) were older people. We collected 100 subjects with impaired consciousness, the object of our study, which represented 17.73% of all admissions in the Department of Anesthesiology during the study period and 57.47% of all admissions of older people; 66% of our subjects were male. Hypertensive patients accounted for 60% of cases. In 46% of cases, it was a coma from cardiovascular causes and in 28% of cases; it was a coma of metabolic origin. The diagnoses made in the wake of the care of the elderly in ICU were predominantly stroke (46%) and electrolyte disturbances (13%). The coma was sudden onset in 58% of cases, including 28 cases of stroke whether 48.27%. The prognosis was marked by a fatality with 51% of deaths in our sample.

Conclusion:

The prognosis improvement of the elderly in coma through to the introduction of proxy measures.

[Knowledge of epilepsy and practices of parents in Mali: a community study]

The prevalence of epilepsy in Sub-Saharan Africa is about 15 per thousand; against 6 to 8 per thousand in industrialized countries. Health, social, economic conditions and misknowledge could explain this situation. The objective of this survey was to study the knowledge of parents of children with or without epilepsy about this disease in Mali. 423 adults were interviewed, 15% children with epilepsy. The mean age was 34 ± 9,3 years; females represents 60% of the population. 26% of interviewed subjects heard about epilepsy from their neighbourhood, 20% from traditional healers, 11% from health care professional; the tonic-clonic crisis was the most known form of the disease. 59% thought epilepsy to be contagious. The organicity of the disease was known by 51% of the population. 23 % of the population believed there was a link between the onset of the crisis and the presence of the hole moon. 78% of subjects have already seen at least one crisis of epilepsy, but only 33% have got an attitude of first help that was to pour fresh water on the face of the patient in 22% of cases. 57% of subject's acknowledge having as first recourse traditional medicine. The fight against epilepsy in Mali as in the others countries of the third world should go through information and education of the population, in particular parents.

[Spinal tuberculosis (Pott's disease): epidemiological, clinical, radiological and evolutionary aspects at the University Hospital of Point G]

The spinal tuberculosis or Pott's disease is the most common form of osteoarticular tuberculosis in countries with high prevalence of tuberculosis and HIV / AIDS, but the definitive diagnosis remains difficult. The aim of this work was to study the epidemiological, clinical, radiological and evolutionary aspects of Pott's disease in the absence of evidence bacteriologically and histologically.

METHOD

This is a retrospective study focused on records collected in the service of pneumo-phtisiology UHC of Point G, January 2005-December 2009. Were selected, all folders with the probable diagnosis of spinal tuberculosis and whose antibiotic treatment was instituted.

RESULTS

In total, 178 cases of Pott's disease were reported on 3560 cases of tuberculosis all forms 5%, with an average of 35 ± 6 cases per year. We noted a male predominance (102 men against 76 women) with a sex ratio of 1.3. The average age of patients was 41 ± 15 years. Signs regularly found with their high frequencies more than 80% are impaired general condition, tiredness, vesperal fever, inflammatory spinal pain, elevated velocity settling, spondylodiscitis, back to the apyrexia, improving general health. HIV serology was positive in 5.2% of 152 patients tested.

CONCLUSION

Pott's disease is increasing gradually. The diagnosis is often very presumptive. Also, must you know the time to start TB treatment, for minimizing the post-treatment sequelae.

[Tuberculoma of the posterior fossa: 3 cases in the departement of neurosurgery, university hospital of Gabriel Toure]

The cerebral tuberculoma is an expansive process of slow evolution of the tuberculous bacillus. Bacteriological diagnosis is rarely made. It is usually radiological or histological. The treatment is medical and surgical. We conducted a retrospective study from March 2007 to February 2010 which focused on three cases of cerebral tuberculoma. Two of our patients were male, 75% against 25% female: The age of our three patients was respectively 47, 23, and 4 years. The history of extrapulmonary tuberculosis was found in one case. The heaviness of the head was the pattern in a patient operated on for Pott's disease. The diagnosis was suspected by neuroradiology in 3 patients and histological confirmation was made in 2 cases. The polychimiotherapy of 12 months was established and the improvement has been obtained from the third month of treatment.

[Impact of market place activity on the spread of STI/AIDS in Sikasso, Mali]

Since the beginning of the global HIV pandemic, more than 47 million people have been infected and more than 14 millions of people have died with 95% living in developing countries. Mali is located in West Africa that has been relatively less affected. However Mali is a country with a migratory culture. This study was conducted in primary health care centers located on the main road to neighboring countries with higher HIV prevalence. Attention was focused on healthcare services provided around market places in the main cities where diverse populations converge on a weekly basis. Attendance measured at five health centers on market day was compared with attendance on the other days of the week. In addition the level of sexually transmitted infections (STI) diagnosed on market days was determined to compare prevalence in the resident versus non-resident population in function of market activity. Attendance at all the centers was significantly higher on market days. This increase was due mainly to the non-resident population (60.2% vs. 46.5%; p=0.005). Findings also showed that the proportion of STI diagnosed was higher in the non-resident than resident population, but the difference was not statistically significant (15.6% vs. 11.3%; p=0.320). These results indicate that migration has an impact on the spread of STI. This is probably the same for HIV since these pathologies are known to be linked. Control strategies to fight against STI/AIDS could be improved by taking into account market place activity that is common in all localities of Mali and Africa.

[Epilepsy and women's life: particularities of their management. Literature review]

Eight in 1,000 people in the world suffer from epilepsy, and 80 % of them are in the developing countries [1]. Sub-Saharan Africa and Latin America have higher median prevalence's 15.4 % and 12.4 %, respectively, compared to the prevalence in Europe, 5.4 %, and in North America, 5-10 % [2]. On this epidemiological inequality overlays a considerable disparity in the quality of care given to people with epilepsy, between developed and developing countries, and rural and urban areas. In this context, one of the most controversial subject regarding epilepsy is the care given to epileptic patients and their offspring. In fact, being a woman with epilepsy is not as being a man. The specific concerns about women with epilepsy are essentially sexual development, contraception, reproduction, fertility, and anatomic and cognitive teratogenicity of anti-epileptic drugs. The awareness campaign of women with epilepsy starts from puberty until menopause. About one third of epileptic women experience variations in their disease linked to menses, probably due to the neurotoxicity of oestrogens (not counterbalanced by progestatives). The problem with the teratogenicity of anti-epileptic drugs is not resolved yet despite the availability of new molecules. A close collaboration between health practitioners (obstetricians and neurologists) and an awareness of health professionals are essential for a global care of pregnant epileptic women or at age to conceive.

[Presentation of cerebral toxocariasis with mental confusion in an adult: case report and review of the literature]

Toxocariasis is usually responsible for visceral larva migrans syndroms. Nervous system involvement is a rare complication. In this report, we describe one case of meningoencephalitis due to Toxocara canis in a 73-year-old man presenting with mental confusion. The diagnosis of cerebral toxocariasis was confirmed by immunodiagnosis in both serum and cerebro-spinal fluid. Cerebral toxocariasis may be suspected in patients presenting with some neurological patterns including: confusion, meningitis, meningo-encephalitis, meningo-myelitis, when the etiological assessment remains negative and the environmental context is favourable. Finding evidence of specific antibodies in both cerebro spinal fluid and serum is mandatory for the diagnosis. The main clinical features concerning cerebral toxocariasis, diagnostic tools, and therapeutic measures are discussed.

Accentuation des crises tonico-cloniques sous lamotrigine dans l’épilepsie myoclonique juvénile

INTRODUCTION

Lamotrigine is an anti-epileptic drug considered as a first-line therapy in idiopathic generalised epilepsy. Lamotrigine is well-tolerated and secondary aggravation of epileptic syndromes has rarely been reported.

CASE REPORT

We report the case of a 19 year-old man with juvenile myoclonic epilepsy in whom lamotrigine lead to the exacerbation of generalised tonico-clonic seizures, reversible when lamotrigine was stopped and substituted by valproic acid.

CONCLUSION

Lamotrogine may induce exacerbation of generalised tonico-clonic seizures and myoclonic jerks in juvenile myoclonic epilepsy.

[Imported cerebral malaria]

Cerebral malaria is one of the most serious complications of Plasmodium falciparum infection. Its diagnosis may sometimes be difficult. We report the case of a 63-year-old woman who presented with abdominal pain and nausea, rapidly followed by delirium and stupor, a few days after a travel in Africa. No prophylactic measures were prescribed. The main clinical features concerning cerebral malaria, diagnostic tools and therapeutic measures are discussed.

[Indirect immunofluorescence in onchocerciasis in Mali: comparison of O. volvulus antigen and D. viteae antigen for detecting circulating antibodies]

In Mali, a comparative study of O. volvulus and D. viteae filariasis antigens was made on 52 onchocerciasis sera with immunofluorescence immunoassay. At a dilution greater than 1/40, 34 sera are positive with homologous Ag against 24 with heterologous Ag.