[Huge aspergilloma developed within a zone of scleroderma-related pulmonary fibrosis]. / Volumineux aspergillome développé au sein d'une lésion de fibrose pulmonaire secondaire à une sclérodermie.

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.

[A case of curable encephalomyelitis in a tropical area: pernicious anemia]. / Un cas d'encéphalomyélopathie reversible en milieu tropical: anemie de biermer.

Pernicious anemia is uncommon in Africa. The purpose of this report is to describe a case of pernicious anemia observed in Madagascar. The revealing manifestation was encephalomyelitis with combined medullar sclerosis that responded favorably to vitamin B12 replacement therapy. Clinical symptoms included paresthesia associated with allodynia of all four extremities and with tetrapyramidal syndrome, medullar ataxia and minor cognitive disturbances ongoing for 5 months. Hemogram testing revealed macrocytic anemia. Serum cobalamin level was low. Anti-intrinsic factor antibody was detected. Spinal cord magnetic resonance imaging showed diffuse high-signal intensity along the posterior spinal cord extending from C1 to C4. Vitamin B12 replacement therapy led to full regression of clinical signs after six weeks. Association of central nervous system involvement with macrocytic anemia suggests vitamin B12 deficiency and pernicious anemia should be suspected. This disease can be considered as a curable form of myelitis in Africa and Madagascar.

[A rare case of huge aspergilloma developed within a lesion of pulmonary fibrosis secondary with a systemic scleroderma in an immunocompetent patient in Madagascar]. / Un cas rare d'aspergillome volumineux développé au sein d'une lésion de fibrose pulmonaire secondaire à une sclérodermie systémique chez une malade immunocompétente à Madagascar.

We report a rare case of a huge aspergilloma developed within a bronchiectasis due to pulling by a pulmonary fibrosis of systemic scleroderma. The patient is a 58-year-old woman presenting a deterioration of the general state associated with repeating hemoptysis, dyspnea, dysphagia, sclérodactylia, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no antecedent pulmonary tuberculosis. The patient had a pulmonary arterial hypertension complicated by a chronic pulmonary heart at the stage of right cardiac decompensation. Aspergillosis serology was positive and the immunological assessment confirmed scleroderma. The computed tomography showed a huge oblong opacity in a small round bell shape ("signe du grelot", Monad's sign) in the left upper lobe developed within a bronchiectasis, and a bilateral pulmonary fibrosis. Although surgery remains the recommended treatment of an aspergilloma, the management of our patient was medical in front of contra-indication for surgery. The evolution was marked by repeating hemoptysis and stability of the pulmonary lesions 2 years later. The management of this entity remains difficult and complicated; the prognosis is in general unfavourable and depends at the same time on the evolution of scleroderma and the aspergilloma infection.

Hepatite fulminante associee a un traitement antituberculeux: entite clinique grave mais pas toujours fatale

L'hepatite fulminante est definie par l'association de signes d'encephalopathie hepatique a une chute du taux de prothrombine inferieur a 50survenant moins de deux semaines apres l'apparition d'un ictere. Elle est grave et mortelle en absence de transplantation hepatique. Cependant; nous rapportons un cas d'hepatite fulminante d'evolution favorable sous traitement medical seul. Il s'agissait d'un cas secondaire a un traitement antituberculeux qui a ete arrete tout de suite et remplace par un lavement au lactulose des l'apparition des signes d'encephalopathie hepatique. L'evolution etait marque par un retour progressif de l'etat de conscience a la normale et une amelioration nette du bilan hepatique

[Causes of death in a sample of cirrhotic patients from Madagascar]. / Les causes de mortalité dans une population de patients cirrhotiques malgaches.

OBJECTIVE: Cirrhotic patients have poorer life expectancy than the general population. The purpose of this study was to identify causes of death in a sample of cirrhotic patients from Madagascar. METHODS: A retrospective analytic and descriptive study was conducted on the files of cirrhotic inpatients admitted to the gastroenterology department of the Joseph Raseta Befelatanana University Hospital Center in Antananarivo, Madagascar from January 1, 2003 to June 30, 2007. RESULTS: The files of 117 patients were reviewed. Death occurred in 31 cases for a mortality rate of 26.5%. The main causes of death were disorders of consciousness (51.6%) and hypovolemic shock (25.8%). Jaundice, encephalopathy, and gastrointestinal bleeding were predictive factors for mortality. CONCLUSION: Cirrhotic patients in this study were hospitalized at a late stage of disease. Further prospective study in a larger sample will be needed to standardize the management protocol in Madagascar.

[A misleading case of hypereosinophilia revealing colonic adenocarcinoma in a patient from a tropical area]. / Une hyperéosinophilie trompeuse en milieu tropical. Hyperéosinophilie paranéoplasique.

Although paraneoplastic hypereosinophilia has been documented in patients with colon cancer, this association is rare. The purpose of this report is to describe a case of paraneoplastic hypereosinophilia associated with colic adenocarcinoma. This case underlines the value of methodical investigation of hypereosinophilia in tropical areas where parasitic aetiologies are frequent.

L'hemoperitoine spontane: une complication rare des anticoagulants

L'hemoperitoine spontane est defini par la presence de sang dans la cavite peritoneale en l'absence de tout traumatisme. Il s'agit d'un accident rare mais grave. Nous rapportons le cas d'une jeune femme de 28 ans; sous traitement anticoagulant oral; qui presentait une douleur abdominale aigue; une instabilite hemodynamique et une deglobulisation sans notion de traumatisme. Le traitement medical doit etre propose en premiere intention en cas d'hemoperitoine. La prevention reste la meilleure strategie dans la prise en charge des accidents des anticoagulants

[Portopulmonary hypertension due to schistosomiasis in two Malagasy patients]. / Hypertension porto-pulmonaire d'origine bilharzienne chez deux patients malgaches.

Portopulmonary hypertension is characterized by a chronic liver disease associated with a mean pulmonary artery pressure >25 mmHg at rest, an increased pulmonary vascular resistance and a capillary pulmonary pressure <15 mmHg with portal hypertension. Schistosomiasis may be an aetiology of this syndrome, however, few cases have been reported. We describe the first cases of portopulmonary hypertension with schistosomiasis in Malagasy patients. There were 2 men aged of 18 and 20 from hyperendemic area of schistosomiasis in Madagascar Both had a history of repeated water contact. They presented a dyspnea associated with ascites and oedema. Clinical examination showed portal and pulmonary hypertension with right ventricular heart failure. Cardiac examination revealed a systolic murmur and splint of the second heart pulmonary Pulmonary hypertension was confirmed by cardiac ultrasonogaphy Serology of bilharzias was positive. Parasitological examination showed eggs of S. mansoni. The treatment based on salt-free diet, spironolactone and praziquantel led to a better evolution of symptoms (case 1). Symptoms of right heart failure remained for the second patient even though improvement was noted. In tropical countries, schistosomiasis may be one of the cause of portopulmonary hypertension and may appear in early age. Its treatment remains difficult as the drugs recommended are not affordable.

[Seroprevalence of Helicobacter pylori infection in Malagasy population]. / Séroprévalence de l'infection due à Helicobacter pylori dans un échantillon de population malgache.

Helicobacter pylori is a worldwide infection. However very few data are actually available on H. pylori seroprevalence in the Malagasy population. We carried out a transversal study in a sample of persons who met the following criteria: older than 15 years old, presence in the medicine internal unit 2 (University Hospital Center of Antananarivo) during the period of the study whatever the reason. H. pylori infection was identified serologically by using ELISA (G.A.P IgG H. pylori ELISA, Bio-Rad, France). Several factors were evaluated including serological status, demographic information, the reason of the presence in the unit, factors influencing H. pylori infection: socio-economic status, siblings, promiscuity consumption of alcohol, use of tobacco, water source and history of gastroscopy. The presence of clinical symptoms, such as dyspepsia and abdominal pain, was determined. Forty-five men and 45 women were included (mean age: 41.8 +/- 3.4 years). The seroprevalence of H. pylori infection was 82%. H. pylori infection was higher in men than in women (p < 0.02). Promiscuity constituted the principal factor influencing H. pylori infection. The seroprevalence of the H. pylori infection appears to be comparable to the rate encountered in developing countries. Considering this high rate of the H. pylori infection, eradication of H. pylori should be commonly recommended when facing gastrointestinal pathologies potentially induced by H. pylori.

[Is manioc a diabetogenic factor? Apropos of a case of diabetes mellitus with a large consumption of crude manioc]. / Le manioc est-il un facteur diabétogène? A propos d'un cas de diabète sucré chez un gros mangeur de manioc cru.

The case of a 24 year-old Comorian male patient consuming large amounts of cooked and uncooked cassava and suffering of malnutrition since his boyhood is reported. The patient presented a diabetes mellitus by chronic calcific pancreatitis with retinopathy and neuropathy. The protein deficiency associated with eating uncooked cassava may be recognised as a factor of calcific pancreatitis diabetes. Other factors might be associated such as the environment as well as immunological and genetic characteristics.

[Prevalence of uro-nephrologic complications of urinary bilharziasis in hyperendemic focus in Madagascar]. / Prévalence des retentissements uro-néphrologiques de la bilharziose urinaire dans un foyer hyperendémique de Madagascar.

This prospective study was designed to look for and describe urologic and nephrologic consequences of urinary bilharziosis due to schistosoma haematobium in a hyperendemic hotbed in the middle west of Madagascar. Methodology included clinical examination, kidney and bladder ultrasonography, urine dipsticks and creatininemia. Amongst a population of 574 persons aged 5 years ore more, 436 (76%) had bilharziosis ova in the urine (filtration method). From the clinical point of view, 257 patients (58.9%) had microscopic hematuria, 178 (40.8%) had presently an hematuria; 111 patients (25.5%) suffered from dysuria; 18 patients (4.1%) had limb oedema when 3 patients had present oedema (0.7%). Among 436 checked people, 267 (61.2%) had an ultrasonography abnormality. In 252, it was bladder wall abnormalities (57.8%). They were wall irregularities in 182 cases (41.7%); vesico-ureteral reflux in 22 cases (5.3%); ureteral dilatations in 22 cases (5.3%) and pyelocalyceal dilatations in 61 cases (13.9%). Prevalence of proteinuria 75.2% (316 amongst 420 checked people) of whom 5.7% (24 cases) had 5 g/l or more. Hematuria was found in 352 patients (83.8%) of whom 238 (56.7%) had more than 250 erythrocytes per microliter. Prevalence of leucocyturia was 56.7% (238 cases). Creatininemia was measured in 140 people with positive filtration; it was normal in all except two patients. This study highlights the parallel evolution between parasitic infection and uronephrological manifestations of the disease.

[Effect of praziquantel on the uro-nephrologic complications of urinary bilharziasis]. / Effet du praziquantel sur les retentissements uro-néphrologiques de la bilharziose urinaire.

This study shows the effect of praziquantel as a 12 month treatment on the uro-nephrological consequences of Schistosoma haematobium chronic infection. This was done in a hyperendemic setting in the middle west of Madagascar. 435 people with ova in their urine filtration test were followed up with clinical examination, ultrasonography, urinary sticks and creatininemia. The prevalence of macroscopic hematuria decreased significantly from 32.5% (153 patients) to 4.3% (20 patients) (p < 0.05). Other abnormalities decreased but not significantly. The prevalence of proteinuria decreased from 62.3% (271 cases) to 20.2% (88 cases) (p < 0.05%) when microscopic hematuria varied from 72.4% (315 cases) to 31.5% (271 cases). Leukocyturia remained stable from 49% (213 cases) to 47.8% (207 cases). On ultrasonography, the whole abnormalities varied from 54.1% (256 patients) to 16.7% (79 patients). Prevalence of bladder abnormalities decreased from 50% (237 cases) to 16.3% (77 cases) (p < 0.05); prevalence of vesico-ureteral reflux decreased from 5.1% (23 cases) to 0.2% (1 case) (p < 0.05) and that of pyelocaliceal from 14.6% (54 cases) to 2.5% (12 cases). The reference drug, praziquantel has a clear-cut effect on this chronic pathology. Bladder wall abnormalities are particularly interested by this favourable effects.

[Hypocomplementary membrano-proliferative glomerulonephritis in a Malagasy patient with schistosomiasis mansoni (detection of bilharzial antigen on glomerular basement membrane using monoclonal antibodies)]. / Glomérulonéphrite membranoproliférative hypocomplémentaire chez un Malgache atteint de bilharziose à Schistosoma mansoni (détection d'antigène bilharzien sur les membranes basales glomérulaires par anticorps monoclonal).

Schistosomiasis due to Schistosoma mansoni affects more than 40 millions people all over the world. Renal involvement is observed mainly in endemic areas. We report a case of hypocomplementemic membrano-proliferative glomerulonephritis in a malagasy man who suffered also from hepatosplenic bilharziosis. The relation between Schistosoma mansoni and the nephropathy was proved by indirect immunofluorescence test using a monoclonal antibody directed against the caecum of adult Schistosoma mansoni.