[Severity Factors of Pulmonary Aspergilloma in the Surgical Intensive Care Unit of Joseph Ravoahangy Andrianavalona Hospital, Antananarivo, Madagascar]. / Facteurs de Gravité de L'aspergillome Pulmonaire en Réanimation Chirurgicale à L'hôpital Joseph Ravoahangy Andrianavalona, Antananarivo, Madagascar.

Objective: This retrospective study was designed to study the clinical profile, post-operative outcome with analysis of severity factors of pulmonary aspergilloma operated in our institute. Patients and methodology: During a 5-year period (June 2009 to June 2014), 34 patients underwent surgery for pulmonary aspergilloma and were admitted in the surgical intensive care unit of the CHU/JRA Antananarivo. Results: The group consist of 23 male patients and 11 female patients with a mean age of 42 ± 9.9 years. In 29.4% of cases, it was a complex aspergilloma. The procedures performed were segmental resection (n = 3), lobectomy (n = 21), bi-lobectomy (n = 2), pneumonectomy (n = 7) and cavernostomy (n = 1). Median hospital stay was 4.5 ± 3 days. The postoperative lethality rate was 14.7% caused by respiratory failure, infection and underlying diseases. Main complications included bleeding, respiratory failures, and pulmonary infection. Conclusion: Factors associated to increased postoperative complications included: the ASA score, decreased preoperative lung function, urgent procedures, smoking, postoperative mechanical ventilation, bleeding, hyperleukocytosis and surgery duration.

Evaluation of the Xpert MTB/RIF assay for the diagnosis of smear-negative pulmonary and extrapulmonary tuberculosis in Madagascar.

OBJECTIVE: To evaluate the feasibility of the implementation of a commercial rapid molecular diagnostic test (Xpert MTB/RIF) for the routine diagnosis of smear-negative or extrapulmonary tuberculosis (TB) and its diagnostic accuracy, and to assess HIV prevalence in a real-life setting in Madagascar. This study was set in a tertiary care hospital in Madagascar. METHODS: A prospective cohort study was conducted of all consecutive cases with suspected smear-negative and/or extrapulmonary TB over a 2-year period. Cases were classified as proven, probable, or possible TB cases, or as having an alternative diagnosis. RESULTS: Of the 363 patients included, 183 (50.4%) had suspected smear-negative pulmonary TB and 180 (49.6%) had suspected extrapulmonary TB. For proven cases, the sensitivity, specificity, positive and negative predictive values of Xpert MTB/RIF were 82.4%, 98.8%, 98.3%, and 86.6%, respectively; for proven and probable cases grouped together, these values were 65%, 98.8%, 98.5%, and 64%, respectively. The diagnostic accuracy was slightly lower for extrapulmonary TB compared to smear-negative pulmonary TB. The prevalence of HIV infection was 12.1%, but almost half of these cases did not have TB (alternative diagnosis group). CONCLUSIONS: The implementation of a rapid diagnosis programme for TB in a resource-poor setting is feasible. The performance of the Xpert-MTB/RIF was remarkable in this difficult-to-diagnose population. HIV prevalence in this study was much higher than the prevalence reported in the general population in Madagascar, in patients with TB and patients with conditions other than TB.

[Tuberculosis of the female genital tract discovered during work-ups for infertility: the first two cases at the Fianarantsoa Teaching Hospital in Madagascar]. / La tuberculose génitale découverte devant une stérilité: deux premiers cas observés au CHU Fianarantsoa Madagascar.

The rarity of genital tuberculosis and the non-specificity of its manifestations lead to delayed diagnosis and the need to treat this disease at an advanced stage. We report two cases observed and treated at the Fianarantsoa Teaching Hospital: two young women (aged 22 and 33 years) discovered during work-ups for primary infertility and secondary amenorrhea. The diagnosis was established by histological examination of granulomatous tissue with caseous necrosis, pathognomonic for tuberculous. Isolation of mycobacterium by inoculation on Lowenstein-Jensen medium and culture are not available in Fianarantsoa. Chemotherapy against tuberculosis is most often effective for the disease, but fertility is definitely compromised, even though in vitro fertilization is possible in some cases.

[Adhesion of physicians to the national malaria policy: situation in Antananarivo (Madagascar), 5 years after the policy revision]. / Adhésion des médecins à la politique nationale de lutte contre le paludisme cinq ans après sa révision: situation à Antananarivo (Madagascar).

Our goal was to evaluate and analyze physicians' adherence to the national malaria policy in Antananarivo, 5 years after its revision. This prospective descriptive study was conducted in public and private health centers in Antananarivo in 2010, from May 1 to June 30. Adhesion to the new policy included adoption of the rapid diagnostic test for malaria (RDT) and/or microscopy as diagnostic methods and prescription of artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria. A questionnaire was used to collect data from 106 physicians. Their average age was 43.9 years (range: 26 to 59 years). The male-female sex-ratio was 0.59. Physicians trained in using RDTs were confident in this means of diagnosis (p < 10(-4)). Prescription of ACT by physicians was associated with their participation in malaria training (p = 0.02). Only 2/3 of the physicians adhered to the current policy. Adherence increased with trust (p < 10(-4)), availability of RDT (p < 10(-5)), and training about the policy. Physician adhesion, training and confidence are essential to this policy and to changing physician behavior. Improvement of the health system is also needed.

[Hemophagocytic syndrome secondary to cavitary pulmonary tuberculosis]. / Syndrome d'activation macrophagique secondaire à une tuberculose pulmonaire cavitaire.

Hemophagocytic syndrome is due to the activation and nonmalignant proliferation of macrophages and T lymphocytes. The purpose of this report is to describe a 25-year-old man who presented with fever, coughing, and weight loss over the past month. Laboratory findings demonstrated pancytopenia, hyperferritinemia, and cytolysis. The myelogram showed a hemophagocytic syndrome, and tuberculosis bacilli were found in the sputum. Chest radiography and thoracic computed tomography depicted a cavitary lesion suggestive of pulmonary tuberculosis. Treatment of tuberculosis alone, without an immunosuppressant agent, was effective and led to improvement. In a country where tuberculosis is highly endemic, hemophagocytic syndrome should be considered in the differential diagnosis of patients with active tuberculosis complicated by pancytopenia.

[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.

[Disseminated pulmonary actinomycosis with hepatic injury: a misleading form mimicking a polymetastatic picture]. / Actinomycose pulmonaire disséminée avec atteinte hépatique: une forme trompeuse mimant un tableau polymétastatique.

INTRODUCTION: Thoracic actinomycosis, caused by bacteria of the Actinomyces genus, is a rare infection, with poor prognosis if untreated, whose clinical and radiological picture is misleading, which can simulate a tumoral or tuberculous disease. CLINICAL CASE: This is a case of generalised pseudotumoral pulmonary actinomycosis in a non-smoking, non-drinking 48-year-old man, who for one month has been presenting a cough with haemoptoic sputum, dyspnoea associated with fever and a deterioration in general condition. The clinical examination discovered weight loss, diffuse crackling rales and multiple dental caries. Biologically, he presented an inflammatory syndrome. The radiological imaging and lung and liver CT-scans discovered a peripheral lung mass right side associated with multiple nodular cannon-ball opacities, multiple liver lesions of metastatic appearance. The bacteriological examination of the bronchoalveolar lavage fluid (Gram stain and culture) and the transparietal biopsy of the lung mass confirmed the presence of Actinomyces. Progress under treatment with 10 million international units of parenteral penicillin G daily over a period of six weeks substituted by three grams of amoxicillin/clavulanic acid daily over a period of 12 months and following an oral preparatory procedure was favourable. The thoraco-abdominal scan carried out three months after the treatment showed that the lesions had completely disappeared. CONCLUSION: Our case illustrates the diagnostic difficulty of actinomycosis particularly faced with a picture of multiple lung and liver metastasis. Hence, the importance of a histological and bacteriological examination of samples. The prognosis of this complaint is generally good following well-managed, prolonged treatment; and the prognosis peculiar to disseminated forms is less certain.

[Paradoxical lymphadenopathy during treatment of cavitary tuberculosis in an immunocompetent patient]. / Adénopathie paradoxale au cours du traitement d'une tuberculose cavitaire chez un malade immunocompétent.

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.

[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.

[Organizing pneumonia secondary to a hiatal hernia]. / Pneumopathie organisée secondaire à une hernie hiatale.

Organizing pneumonia secondary to a hiatal hernia is a specific kind of inflammatory and fibroproliferative lung reaction due to a pulmonary aggression involving micro-inhalation of the digestive contents. The authors report the case of a 74-year-old woman presenting pneumonia of infectious speed, resistant to a triple antibiotic treatment. Clinically, her general condition changed and associated cough, fever, dirty sputum and dyspnoea. The bacteriological and immunological tests were normal. The respiratory functional explorations showed a moderate restrictive syndrome and hypoxemia. The broncho-alveolar wash found a mixed alveolite of predominantly lymphocyte and polynuclear neutrophiles. The thoracic scanner detected pleural alveolar opaqueness with the characteristic of organizing pneumonia as well as a voluminous hiatal hernia discovered by chance. No lung samples were taken because of a precarious general state of the patient and the respiratory instability. The strong corticosensitivity to the corticosteroid therapy backed up the authors' diagnostic hypothesis. The clinical and radiological evolution was good after six months of treatment. The patient benefited from a medical and then surgical treatment with a good evolution and without any recurrence.

[Pulmonary abscess: a 111-case series in Madagascar]. / Abcès pulmonaires: 111 observations a Madagascar.

The purpose of this report is to present a series of 111 cases of pulmonary abscess observed over a 4-year period in Madagascar. There were 75 men (67.6%) and 36 women (32.4%) with a mean age of 38 years. Alcohol and tobacco use was found in 32.2% of cases. Thirteen patients (11.7%) used chewing tobacco and all patients were exposed to passive smoking. Eighty-eight patients (79.2%) had a history of bronchopulmonary disorders. Onset was progressive in 63% of cases. The main symptoms were fever (81.9%), pulmonary condensation (74.7%) and pleurisy (9.9%). Coughing was productive in 91.8% cases including 54% of patients having muco-purulent expectorations. In 49 patients (44.1%), chest radiography showed an opacity with a hydroaeric level. The abscess was solitary in 40 cases, multiple in 9, and bilateral in 5. In-hospital antibiotherapy was performed on a presumptive basis: tritherapy in 92 patients (82.9%), bitherapy in 18 (16.2%) and monotherapy in one (0.9%). Other treatment modalities inculuded respiratory kinesitherapy in 57 cases (51.3%), surgical drainage in four (3.6%) and pneumonectomy in one (0.9%). Outcome was favorable in 93 cases (8,7%) but there were 18 deaths (16.2%). This study emphasizes the value of achieving early diagnosis, identifying supporting factors and starting appropriate treatment promptly.

[Huge dorsolumbar cold abscess associated with Pott's disease]. / Volumineux abcès froid péripottique dorsolombaire.

Pott's disease, or tuberculosis of the spine, is the most common osteoarticular tuberculosis. Among them, dorsolumbar impairment is predominant. The authors report the case of a patient with a huge cold lumbar abscess associated with Pott's disease. The patient is a 32-year-old man presenting dorsolumbar tumefaction associated with an alteration in his general condition and fever for three months. Treatment by "traditional healers" did not provide any improvement. He consulted for mild lumbar pain triggered by fatigue appearing one week before and after the failure of the traditional practitioner. The clinical examination found a temperature of 38.5°C, cachexia, mild lumber kyphosis and impressive, soft, painless and non inflammatory dorsolumbar bruised tumefaction, 40 cm high, 15 cm wide and 7 cm deep. He did not present any neurological signs. The dorsolumbar X-ray of the spine revealed a lesion associated with Pott's disease in the first and second lumbar vertebrae with pinching of the disc, punched-out lesions and osteocondensation. The ultrasound examination of the soft tissue revealed the presence of a laterovertebral collection of fluid diffusing in the subcutaneous region. The psoas major and the paravertebral muscles were not affected. A scan or MRI of the spine was not carried out. Examination of the tissue sample and drainage of the abscess confirmed the tubercular origin. Treatment with tuberculostatic drugs for 12 months associated with immobilisation resulted in a cure with sequelae of mild kyphoscoliosis vertebral statics.

[Acute community acquired pneumonia: 96 cases in Madagascar]. / Pneumonie aiguë communautaire: 96 observations à Madagascar.

The purpose of this report is to describe a study on acute community-acquired pneumonia (CAP) carried out in the Pneumology Department of the Antananarivo University Hospital Center. This prospective one-year study included patients presenting symptoms of acute CAP. Patients with chronic lung disease and tuberculosis were excluded. Study parameters included epidemiological, clinical and laboratory findings as well as data on the efficacy of the therapeutic treatments used. A total of 96 patient charts were analyzed. Males were predominant with a sex ratio of 1.5. Mean age was 41.8 years. A history of pulmonary tuberculosis was noted in 7.2% of cases. Clinical examination showed pulmonary condensation in 93.7% of cases. Radiological examination depicted alveolar syndrome in 97.6%. Betalactamines were the most frequent class of antibiotic agents used for treatment (90.6%). The most frequently prescribed agent was amoxicillin (60.4%) at a dose of 3 g/day. Single-agent therapy was used more often than double-agent therapy (93.7% vs. 6.3%). The oral route was used more frequently than the intravenous route (62.5% vs. 37.5%). The outcome was favorable in 97.9% of cases and lethal in 2.1%. The prevalence of acute CAP in patients hospitalized in our department was low in comparison with that tuberculosis. Since single-agent therapy using amoxicillin at a dose of 3 g/day was effective, this antibiotic can be recommended as the first-line treatment after ruling out tuberculosis.

[Hemoptysis in Madagascar: etiologies of 114 cases]. / Hémoptysie à Madagascar: étiologies de 114 observations.

A prospective study of patients presenting hemoptysis was carried out over a 12-month period in Madagascar. A total of 114 cases were recorded during the study period. Mean patient age was 37 years. Patients were predominantly male. Pulmonary tuberculosis with positive bacilloscopy was the most common etiology (66.66%). Bronchopulmonary cancer accounted for only a small number of cases (1.75%). Etiology was undetermined in a significant number of cases (15.78%).

[Severe systemic lupus erythematosus induced by isoniazide]. / Lupus érythémateux systémique grave induit par l'isoniazide.

The authors report a rare case of low register systemic lupus erythematosus with renal attack and neurological armature by isoniazid. The patient was a 23-year-old woman presenting a lupus induced by isoniazid 1 month after the treatment of pleural tuberculosis. Antinuclear antibodies, anti-native DNA, anti-ENA, anti-Sm, anti-SSa, anti-SSb and antihistone were present. The symptoms included arthralgia, fever, anaemia, pleural effusion, pericarditis and anasarca. She presented a renal and neurological attack, accounting for the gravity of the disease. The treatment consisted of the interruption of the isoniazid and a bolus of methyl-prednisolone during 3 days relayed by an oral corticosteroid. The evolution was favourable after 8 months of corticosteroids.

[Madagascar: public health situation on the "Big Island" at the beginning of the 21st century]. / Madagascar: la situation sanitaire dans la Grande ile au début du XXIe siècle.

The main public health issue in Madagascar at the beginning of the 21st century still involves transmissible infectious diseases including re-emerging diseases such as bubonic plague and emerging diseases such as HIV/AIDS, dengue fever and Chikungunya virus infection. Health and hygiene especially access to clean water is still poor especially in rural areas. No improvement in the public health situation with regard to malaria, schistomosomiais or cysticercosis as well as non-infectious diseases such as protein-energy malnutrition is expected within the next decade.

[Malaria in the central highlands of Madagascar: control strategies]. / Paludisme sur les hautes terres centrales de Madagascar: stratégies de lutte.

The purpose of this article is to present data on malaria in the central highland plateaux of Madagascar and strategies to improve the national malaria control program. Use of rapid diagnosis strips, early home-based fever management with pre-packaged chloroquine treatment kits and proposed new therapeutic combination based on artemisinine are discussed for management of patients with high suspicion of malaria attack. Preventive measures including alternated targeted and full-house indoor spraying for vector control, use of insecticide-impregnated bednets, implementation of intermittent preventive treatment in risk groups, optimization of the epidemic early detection and warning system using the Lot Quality Assurance Sampling method for epidemiological investigation if the alert threshold is exceeded, and provision of rapid diagnosis strips are presented.

Paludisme sur les Hautes Terres Centrales de Madagascar : strategies de lutte

Le present article presente le paludisme sur les Hautes Terres Centrales de Madagascar et les strategies pour ameliorer les composantes du programme national de lutte contre le paludisme. Pour la prise en charge du patient suspect d'acces palustre; l'utilisation des bandelettes de diagnostic rapide; la prise en charge precoce a domicile par la chloroquine pre-emballee et les reflexions sur les nouvelles combinaisons therapeutiques a base d'artemisinine sont discutees. Pour les mesures de prevention; l'alternance des pulverisations intra domiciliaires ciblees et generalisees dans la lutte antivectorielle; l' utilisation de moustiquaires impregnees d'insecticides; le passage au traitement preventif intermittent pour les groupes a risque; l'amelioration du systeme de surveillance et d'alerte epidemique par l'utilisation de la methode de Lot Quality Assurance Sampling pour l'investigation epidemiologique en cas de depassement du seuil d'alerte et la mise a disposition des bandelettes de diagnostic rapide sont etudies

[Assessment of sulfadoxine-pyriméthamine (Fansidar, Paludar) efficacy in patients with uncomplicated malaria in Madagascar: preliminary study to propose a simplified study protocol]. / Surveillance de l'efficacité de sulfadoxine-pyriméthamine (Fansidar, Paludar) pour le traitement de l'accès palustre à Madagascar: proposition d'un protocole simplifié.

To alleviate the insufficient number of experienced medical teams invited to and accepting to monitor the effectiveness of drugs prescribed to patients with a diagnosis of uncomplicated malaria and to insure the surveillance of the susceptibility of P. falciparum to current antimalarials used in Madagascar, there is a need to draw a feasible study protocol carefully discussed with them. We carried out a preliminary study in two rural areas and assessed the efficacy of sulfadoxine-pyrimethamine (SP) for curing uncomplicated P. falciparum malaria, with a simplified protocol based on the principle of observational study. A single dose of SP was given on day 0 with paracetamol. The persons to whom the drugs were administered accepted two other interventions of one member of the medical teams on day 14 and day 28. Nineteen patients, 3-63 years old, fulfilled the follow-up. The efficacy of this combination was noted for the 19 persons. Our results show that P. falciparum strains are susceptible to SP. Since SP will be used in intermittent preventive treatment in pregnant women in Madagascar, one way to delay the occurrence of SP resistant parasites will be (a) to avoid massive use of SP for the non pregnant persons and (b) to monitor susceptibility of P. falciparum to SP as part of pilot studies using standard WHO protocol (which is not really easy for most of the peripheral health facilities--with the follow-up procedures with clinical examination and parasitological control at Days 0, 1, 2, 3, 7, 14, 21 and 28), and routinely with simplified protocol such as the analytical observational study illustrated in this present study. Limit and advantage of observational study are discussed.

Alkaloids from Galipea officinalis.

Galipea officinalis Hancock is a shrubby tree reputed in folk medicine for its many properties which may be related to its alkaloid composition. We present in this paper the structural elucidation of five quinoline alkaloids: cuspareine, cusparine, and galipine, that have been previously described, demethoxycusparine, newly isolated in this species of Galipea and a new quinoline alkaloid named galipinine which is the 3',4'-methylenedioxycuspareine.