Hernie lombaire du triangle inferieur: une forme rare de hernie parietale à propos d'un cas au Centre National Hospitalier et Universitaire Hubert Koutoukou Maga de Cotonou

Les hernies lombaires sont rares. Elles se font soit à travers le triangle lombaire de Jean-Louis Petit qui est inférieur et superficiel, soit à travers le triangle lombaire de Grynfelt qui est supérieur et profond. Très peu de cas d'hernie lombaire primaire ont été publié dans la littérature. Nous rapportons un cas clinique de hernie lombaire primaire de Jean-Louis Petit chez un homme de 65 ans. Il a consulté pour tuméfaction lombaire droite évoluant depuis deux ans environ. L'examen a montré une tuméfaction de la fosse lombaire droite au dessus de la crête iliaque, de consistance molle, réductible et impulsive à la toux. Elle a bénéficié d'une cure herniaire par raphie. Les suites opératoires ont été simples. Les hernies lombaires sont classées en hernies congénitales (20%) et hernies acquises (80%). Ces dernières sont soit des hernies de faiblesse, soit des hernies post traumatiques ou post-chirurgicales. La douleur lombaire et une voussure lombaire souple, réductible et impulsive à la toux sont les signes évocateurs. Le scanner est toujours nécessaire et montre la taille de la brèche et le contenu du sac herniaire. Très peu de chirurgien auront l'occasion de rencontrer une hernie lombaire au cours de leur expérience. Le diagnostic est basé sur les signes cliniques évocateurs et confirmé par le scanner abdominal. La cure herniaire peut se faire par simple raphie ou avec prothèse en fonction de la taille de la brèche, de la cause, de la qualité des structures avoisinantes, et du matériel disponible

Lumbar puncture must it be preceded by the ocular fundus? Misconceptions and bad practices at the University Hospital of Brazzaville

Background: The ocular fundus is the basis for the diagnosis of eye posterior segment lesions. Increasing the pressure of the cerebrospinal fluid that surrounds the optic nerve; whatever the cause; can lead to papilledema which signing intra cranial hypertension. The ophthalmology department of the University Hospital of Brazzaville (UHB) performs about twenty ocular fundus a week. It is not uncommon to read the ocular fundus to exclude intra cranial hypertension and then perform a lumbar puncture. Objective: To remember that the intra-cranial hypertension does not mean that there is a risk of cerebral engagement. Design: Transversal and analytical study. Subjects: Hospitalised patients'. Results: A total of 35 applications form were read. All (100%) had as indication of ocular fundus to exclude intra-cranial hypertension for achieving a lumbar puncture. Conclusion: Confusion between intra-cranial hypertension and the risk of cerebral engagement is still common at the UHB. This has the effect of delaying or not realising the lumbar puncture which is the basis for the diagnosis of meningitis; increasing the morality associated with this serious disease. Do not make a lumbar puncture pending ocular fundus is a medical error that can be fatal for the patient

An audit of consent practices and perceptions of lumbar puncture, Botswana inpatient setting experience

Introduction:The epidemic of HIV/AIDS in sub-Saharan Africa has led to significant increases in the burden of meningitis; especially cryptococcal meningitis. Morbidity and mortality resulting from meningitis occur partly due to delays in performing lumbar punctures both for diagnostic and therapeutic purposes. This study was conducted with the primary objective of exploring the attitudes and concerns that patients have with regard to lumbar puncture; and also to assess current consenting practices of doctors with regard to lumbar puncture. Methods : A descriptive cross-sectional study was conducted in medical wards of Princess Marina Hospital; a tertiary hospital in Gaborone; Botswana. Data were collected by means of a questionnaire-based survey involving patients or their next of kin; and doctors. Other relevant information was obtained from patient charts. Data collection involved 12 patients and 23 doctors. Results :Of the 12 patients interviewed; four stated that the reasons for doing lumbar puncture (LP) were explained to them. One respondent stated that LP risks were mentioned; while two stated that they were given the option to refuse LP. Most patients' possible reasons for refusal of LP was attributed to fear of pain. Five (42.7) patients/next of kin had never heard of LP before; and most of the interviewed patients associated the procedure with death and paralysis; while none associated with meningitis or HIV. Twenty-two (95.7) of 23 doctors stated that they routinely consent patients for LP; 11 (47.8) mentioned risks; and nine (39.1) stated that the patient has the option to decline the procedure. Only 26 of doctors routinely used local anaesthesia while 22 routinely asked for written consent. Conclusion: Contrasting responses between doctors and patients indicates a need for standard consenting practices among doctors. Also; patients' attitudes and receptiveness to lumbar punctures can be improved through education on lumbar puncture indications; benefits; and risks

CT before lumbar puncture in suspected meningitis in Botswana: how established guidelines may not apply

Introduction:According to established guidelines from high-income countries; computed tomography of the head (CT) is indicated before lumbar puncture (LP) in the evaluation of suspected meningitis in HIV patients. In Botswana; meningitis in HIV-infected patients is common but CT is not widely available.Objective:Develop a rational; evidence-based approach to CT use in the emergency evaluation of suspected meningitis in a population with high HIV prevalence.Methods :Emergency center (EC) staff at Princess Marina Hospital in Gaborone; Botswana; reviewed indications for CT and LP in suspected meningitis. The authors considered existing evidence for CT before LP (mostly from high-income countries) and considered the epidemiology of central nervous system infections in Southern Africa. Draft guidelines were circulated to emergency center doctors and nurses; and to specialists in other hospital departments for review and comment before finalization. Result: Available literature seems to indicate that in Botswana it would be possible to significantly limit the use of head CT before LP in HIV positive patients without increasing the incidence or risk of herniation. The guideline includes scenarios where an LP might be indicated in the presence of focal neurological findings and in the absence of a CT; in contradiction to established guidelines. Discussion: The applicability of established guidelines for CT use in suspected meningitis is dependent on local epidemiology and resources

Cerebral malaria [letter]

When young children are infected with P. falciparum; meningitis is often incidentally associated with parasitaemia and can be difficult to distinguish clinically from cerebral malaria. There is yet no clear evidence that lumbar puncture is dangerous in cerebral malaria and it is reasonable to do lumbar punctures to exclude bacterial meningitis in children with fever and coma in areas where malaria is endemic