[Management of chromoblastomycosis, a challenge for limited-resource countries such as Madagascar]. / Prise en charge de la chromoblastomycose : un défi dans les pays à ressources limitées comme Madagascar.

INTRODUCTION: Chromoblastomycosis (CBM) is a chronic fungal infection of the skin and subcutaneous tissue caused by dematiaceous fungi. CBM lesions are recalcitrant and extremely difficult to eradicate. We report three cases of CBM with difficulties in therapeutic management. OBSERVATION: Three men aged 36, 50 and 67 years, all farmers, presented for between three and ten years with hyperkeratotic, scaly plaques with black dots on the right thigh and left leg, respectively. For all patients, mycological examination showed fumagoid cells, all of which were pathognomonic for CBM. PCR identified Fonsecaeanubica in one patient and Cladophialophoracarrionii in two patients. All patients received itraconazole 200mg/day for over 18 months. Two patients required combined therapy with terbinafine for seven months, which improved lesions; however, relapse occurred in one patient during the 5th month of this combined therapy and five months after the end of this treatment in the other. The patient on monotherapy (itraconazole) also presented recurrence of lesions five months after the end of treatment. DISCUSSION: Itraconazole is the standard therapy for CBM, with cure rates ranging from 15 to 80%. Success with itraconazole after eight to twelve months was reported by several authors. Fonsecaea and Cladophialophora are the most common species found in Madagascar, and while these organisms are susceptible to triazoles in vitro, clinical response is not so clear-cut. CONCLUSION: Although unavailable in Madagascar, posaconazole and isavoconazole appear to be effective in treating chromoblastomycosis.

Epidemiology and associated factors of atopic dermatitis in Malagasy children.

BACKGROUND: Little is known about the epidemiology and associated factors of childhood AD in the markedly different, low-income, tropical environment like Madagascar. METHODS: We aim to assess the epidemiology and associated factors of AD in individuals fewer than 15 years of age in Antananarivo Madagascar. It was a retrospective and descriptive study over a period of 7 years (2010 to 2016) in children 6 months to 14 years in the Department of Dermatology, Joseph Raseta Befelatanana Antananarivo Madagascar. The diagnosis of AD was based on clinical data. RESULTS: The prevalence of AD was 5.6% in children aged 6 months to 14 years. The details of 151 cases of atopic dermatitis were analyzed. The mean age of patients was 4 years. There was a female preponderance (sex ratio: 0.7). A family history of AD was noted in 56 cases (37%). No association between breast-feeding and AD was found. The age of onset of AD was before the age of 3 months in 7.5% and between 6 months to 5 years in 70%. Children born in March (dry season) had the highest risk of AD. Consultations for AD increased during the winter (from July to October; p = 0.005). However, the prevalence of AD was similar in urban and rural areas. CONCLUSION: Weather may have an impact on the prevalence of atopic dermatitis in Madagascar. No significant correlation was found between the duration of breastfeeding and AD, as well as urbanization.

Vitiligo Associated with Melanoma in a Malagasy Woman.

Malignant melanoma is the first fatal skin cancer. Vitiligo is a leukoderma or a multifactorial depigmentation acquired but especially of autoimmune origin. We report the first Malagasy case affected by both melanoma and Vitiligo. The appearance of Vitiligo during a melanoma could testify to an immunological response against melanocytes. Despite the association of melanoma and Vitiligo, the prognosis of melanoma is still fatal.

Position Statement on Atopic Dermatitis in Sub-Saharan Africa: current status and roadmap.

BACKGROUND: The first International Society of Atopic Dermatitis (ISAD) global meeting dedicated to atopic dermatitis (AD) in Sub-Saharan Africa (SSA) was held in Geneva, Switzerland in April 2019. A total of 30 participants were present at the meeting, including those from 17 SSA countries, representatives of the World Health Organization (WHO), the International Foundation for Dermatology (IFD) (a committee of the International League of Dermatological Societies, ILDS www.ilds.org), the Fondation pour la Dermatite Atopique, as well as specialists in telemedicine, artificial intelligence and therapeutic patient education (TPE). RESULTS: AD is one of the most prevalent chronic inflammatory skin diseases in SSA. Besides neglected tropical diseases (NTDs) with a dermatological presentation, AD requires closer attention from the WHO and national Departments of Health. CONCLUSIONS: A roadmap has been defined with top priorities such as access to essential medicines and devices for AD care, in particular emollients, better education of primary healthcare workers for adequate triage (e.g. better educational materials for skin diseases in pigmented skin generally and AD in particular, especially targeted to Africa), involvement of traditional healers and to a certain extent also patient education, bearing in mind the barriers to effective healthcare faced in SSA countries such as travel distances to health facilities, limited resources and the lack of dermatological expertise. In addition, several initiatives concerning AD research in SSA were discussed and should be implemented in close collaboration with the WHO and assessed at follow-up meetings, in particular, at the next ISAD meeting in Seoul, South Korea and African Society of Dermatology and Venereology (ASDV) meeting in Nairobi, Kenya, both in 2020.

Les urgences dermatologiques au service de dermatologie du Centre Hospitalier Universitaire Joseph Raseta Befelatanana

Introduction : L'urgence dermatologique constitue une face cachée de la dermatologie. Elle constitue une partie non négligeable en urgence médi-cale car sa méconnaissance entraînerait des conséquences désastreuses. Notre objectif était de décrire le profil épidémio-clinique et évolutif des situations d'urgences en dermatologie. Matériels et Méthodes : Une étude rétrospective, descriptive était menée dans les deux services de Dermato-logie du Centre Hospitalier Universitaire Joseph Raseta de Befelatanana, Antananarivo, de 2015 à 2017. Etaient inclus tous les patients hospitalisés présentant une urgence dermatologique vraie ou relative de tout âge. Résultats : Sur 634 patients hospitalisés, 113 patients présentaient une urgence dermatologique, soit 17,82%. Les pathologies observées étaient : les toxidermies (37%), les dermatoses infectieuses (20%), les maladies systé¬miques compliquées (11,7%), les dermatoses bulleuses auto-immunes (8%) et les réactions lépreuses (8%). Le taux de mortalité était de 7,8%. Con¬clusion : La toxidermie est la première pathologie grave en Dermatologie. La connaissance de ces principales urgences dermatologiques serait une aide précieuse pour les praticiens travaillant loin des centres hospitaliers de Dermatologie

Misuse of Topical Corticosteroids for Cosmetic Purpose in Antananarivo, Madagascar.

This cross-sectional study was conducted in Antananarivo, Madagascar, from June to September 2012. We aim to evaluate the misuse of TC on the face for cosmetic purpose and the adverse effects due to its application. A questionnaire-based analysis was done among females who use topical corticosteroids on the face for cosmetic purpose. Of the 770 women questioned, 384 (49,8%) used topical corticosteroids for cosmetic purpose whose mean age was 38 years (range 16-73 years). Two hundred and sixty-one females (68%) used TC combined with handcrafted cosmetics, and 123 (32%) used TC alone. "Pandalao," which contains salicylic acid, peppermint oil, lanolin, powder of Juanes de Vigo (mercury powder), and Vaseline, is the most handcrafted cosmetic combined with TC in our study (used by 29,4% respondents). Only one (0,26%) had obtained the TC by physician's prescription, 234 (61%) from cosmetic retailers, 92 (23%) directly from local pharmacies, 49 (12%) from beauticians, and 15 (4%) from unspecified sources. Lightening of skin color was the main reason for using TC in 44,8% of respondents in the absence of any primary dermatosis. Pigmentation disorders (63,2%) and cutaneous atrophy (52,1%) were the most adverse effects noted.

Chromoblastomycosis and sporotrichosis, two endemic but neglected fungal infections in Madagascar.

Chromoblastomycosis and sporotrichosis are endemic fungal infections of tropical and subtropical regions, including Madagascar. The causal fungi develop in the soil or on plants and infect humans through wounds, either directly (wounding by the plant, through thorns, for example), or through the contact of an existing wound with contaminated soil. For this reason, the lesions predominantly occur on the limbs, and these fungi principally infect people working outside with bare hands and/or feet. The subcutaneous lesions of chromoblastomycosis are initially nodular, subsequently becoming warty, tumoral, cauliflower-like and pruriginous, which promotes dissemination. The chronic nature of the infection and its progression over long periods lead to highly disabling lesions in essentially rural and agricultural populations. The lesions of sporotrichosis are also nodular, but more ulcerous, and they form an extended chain following the route of the lymph vessels. Pus, squamous or skin biopsy specimens are used for the mycological examination of these mycoses. Treatment depends on the severity and form of the lesions and is based on antifungal drugs sometimes combined with physical methods. There has been no study of these infections for more than two decades in Madagascar, despite the large numbers of cases seen by doctors in all parts of the island. The nature, diversity and distribution of the plants responsible for contamination have not been described in Madagascar. In this review, we described these two endemic mycoses in terms of their epidemiological, mycological, clinical and therapeutic characteristics, focusing particularly on Madagascar, which is one of the leading foci of these two infections worldwide.

Excellent response of infantile orbital hemangioma to propranolol.

Infantile hemangiomas are the most common vascular neoplasm that present in infancy, with more than half affecting the head and neck region. Periocularly, hemangiomas may be complicated by visual loss through induction of strabismal, deprivational, or anisometropic astigmatism. We report a case of a 5-year-old girl who presented with orbital hemangioma with potential risk of visual loss who had excellent response to propranolol.

Pulmonary Tuberculosis and Lepromatous Leprosy Coinfection.

Simultaneous occurrence of leprosy and pulmonary tuberculosis is reported infrequently in the modern era. We report a case of pulmonary tuberculosis diagnosed in patient being treated with glucocorticoids for complications of leprosy (type II reaction). Physicians should recognize that the leprosy patients treated with glucocorticoid may develop tuberculosis.

[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.

[Post-malaria neurological syndrome complicating a Plasmodium falciparum malaria in Madagascar]. / Syndrome neurologique postpaludisme compliquant un paludisme simple à Plasmodium falciparum à Madagascar.

Post-malaria neurological syndrome is a rare complication of malaria. Typically, it occurs in case of severe malaria. Here we report a case in a Malagasy patient presenting a non-severe Plasmodium falciparum malaria complicated by post-malaria neurological syndrome. The management of such a syndrome is radically different from non-severe malaria. No specific treatment is needed.

[Experience in the use of the malaria rapid diagnostic test in Madagascar]. / Test de diagnostic rapide du paludisme: l'expérience malgache.

Diagnosis of malaria cases depends on parasitological examination. Since 2006, the Department of Infectious Diseases at the Joseph Raseta Befelatanana University Hospital in Madagascar has been using the malaria rapid diagnostic test. The percentage of malaria cases (presumed or confirmed) in relation to the number of hospitalized patients has decreased. It was 23.4% in 2003, 10.3% in 2006 and 4.3% in 2008 (p<0.01532). To improve management of malaria cases and rationalize use of antimalarial agents, diagnosis should be confirmed by rapid diagnostic tests.

[Treatment's problem of osteoarticular infections in Madagascar]. / Difficulté de prise en charge des infections ost ostéoarticulaires à Madagascar.

The septic arthritis and osteitis treatment is based on germ(s) identification, which is not always obvious if we do not have at our disposal some proper technical platforms. Moreover, the population's low purchasing power compels us to prescribe the most affordable antibiotic. Regarding this context, this article is aimed at modelling a treatment strategy of osteoarticular infections for adult in developing countries, with international recommendations as our basis. It is a retrospective study, which concerned inpatients admitted in the rheumatology-dermatology department of the Antananarivo University Hospital for septic arthritis and osteitis over all clinical patterns. We considered 9 cases including 7 septic arthritis and 2 osteitis. Staphylococcus aureus was found in two patients who had an osteitis, no germ was isolated for the patients with septic arthritis. Ceftriaxone 2 g per day combined with ciprofloxacine 1 g per day by IV route, shifted by oxacilline 3 g per day and by ciprofloxacine 1 g per day peroral proved to be effective for all patients. The international epidemiological data and the medicines cost were used as reference for the choice of antibiotics treatment. Our approach is worth being taken into consideration as an adaptation of the European recommendations to the realities of developing countries. In absence of any particular risk factor for any specific infection, the combination of ceftriaxone Iciprofloxacine IV route, shifted by oxacilline/ciprofloxacine peroral is recommended.

[Unusual locations of tuberculosis: three case reports]. / Localisations inhabituelles de la tuberculose: à propos de trois observations.

We report three cases of tuberculosis of unusual location in Malagasy patients. The first patient presented with intracardiac tuberculoma during pulmonary tuberculosis. The second patient who had no significant musculoskeletal past medical history presented with tuberculous polymyositis. The remaining one presented with tuberculous epididymitis without involvement of the urinary tract. Diagnosis was histopathological. The outcome was favorable in the two last patients with antituberculous therapy. This report emphasizes the necessary awareness of tuberculosis even in the presence of unusual manifestations in hyper-endemic area of tuberculosis.

[Prevalence of urogenital mycoplasma infection in women infected with HIV in Bangui (Central African Republic)]. / Prévalence de l'infection par mycoplasmes urogénitaux chez la femme atteinte par le VIH à Bangui (République Centrafricaine).

Urogenital mycoplasma (UGM) infections have often been reported in HIV patients. Little is known about UGM colonization and infection. We assessed the level of UGM colonization and infection in a cohort of HIV-positive women living in Bangui, Central African Republic. We studied 146 women of child-bearing age, some of whom were pregnant. All were HIV-positive but asymptomatic and attended one of the urban health centers and the National Center for Sexually Transmitted Diseases in Bangui in April or May 1995. Colonization was defined as an endocervical mycoplasma concentration of less than 10(4) color change units per milliliter (CCU/ml) and infection was defined as an endocervical mycoplasma concentration of at least 10(4) CCU/ml. 58 of the 146 HIV-positive women were pregnant (group A). Group B comprised the other 88 women who were not pregnant. The mean age of the women in group A was 22.7 years (range: 15 to 41) and that for the women in group B was 25.8 years (range: 17 to 40). 134 of the 146 women were carrying one or both of the two types of UGM. There were 53 (91.4%) cases in group A and 81 (92%) in group B. Overall, 40% of the women were colonized and 51.4% were infected. UGM infections frequently affect HIV-positive pregnant women in Bangui. Our results suggest that women should be screened for UGM as well as for other sexually transmitted diseases, to improve the care of HIV-infected women attending antenatal clinics in developing countries.

[Localized granuloma annulare in children: outcome in 30 cases]. / Granulome annulaire localisé chez l'enfant: évolution de 30 cas.

BACKGROUND: The outcome of granuloma annulare in childhood is not well defined. POPULATION AND METHODS: A questionnaire was sent to the family of 40 children under 15 years of age examined for granuloma annulare from 1987 to 1992. Thirty of them answered, permitting a retrospective study. RESULTS: The sex-ratio F:M was 1.3:1. Ages ranged from 1 to 13 years (mean: 4.5 years). Lesions developed before the age of 5 years in 76.7% of cases. Involved sites were essentially the back of hands and feet; lesions were unique in half of the cases. No association with diabetes mellitus was found. Three familial cases were observed. Duration of lesions varied from 6 months to 7 years (mean: 2.5 years). Age at onset, sex, biopsy and treatment had no influence on outcome. CONCLUSION: Granuloma annulare in children is a benign disorder but its course may last up to several years.