[Susceptibility to neuro-malaria and HLA-DR alleles in Senegal]. / Susceptibilité au neuropaludisme et allèles HLA-DR au Sénégal.

A prospective study was carried out in 46 patients suffering from severe malaria. The control group included 220 persons of which the HLA-DR distribution was known. The HLA-DRB1 alleles were typed by PCR-SSP (Sequence Specific Primers). The most frequent HLA-DR alleles found in patients group were: DR52 (82.8%), DR13 (57.1%), DR10 (28.6%), DR53 (25.7%), DR3 (20%), DR18 (20%). A significant difference was observed between patients with severe malaria and control group for the following alleles: DR3, DR10, DR13 (p < 0.001; Chi square with Yates' correction) and their relative risk were respectively 14.67; 6.29; 2.84. HLA-DR3 was considered as the major marker associated to severe malaria.

[Prognostic value of cytokines and HLA markers in patients with cerebral malaria in Senegal]. / Valeurs pronostiques des cytokines et marqueurs HLA chez des patients atteints de neuropaludisme au Sénégal.

41 patients senegalese patients suffering from clinically defined severe malaria were studied in the intensive medical care unit of the Hôpital Principal in Dakar, Senegal. All of these individuals lived in Dakar, an area of low and seasonal Plasmodium falciparum transmission. In this study, we aim to determine in one hand, the cytokine levels of TNF-alpha, TNF-alpha sRI, TNF-alpha sRII, IL-2 sR, IL-6, IL-6 sR, and IL-10 to evaluate their prognostic value in the course of the disease; in the other hand, the influence of the HLA-DR alleles in the susceptibility to get severe malaria. At the day of admission (day 0) and 3 days later, one or two blood samples were collected for each patient to assess different biological parameters. Plasma samples were tested for cytokines cited above by ELISA (Medegenix EASIA kits) and DNA samples for HLA-DR by PCR-SSP genotyping. The concentrations of all the cytokines and/or their receptors were significantly increased at day 0 in the patients who died (TNF-alpha = 455 +/- 480 pg/ml, IL6 = 511 +/- 396 pg/ml) and decreased rapidly in the patients who survived from the disease (TNF-alpha = 354 +/- 629 pg/ml, IL6 = 453 +/- 706 pg/ml). A fatal issue seems likely related to the age of patients (20 +/- 12 years for surviving patients and 31 +/- 16 years for patients who died) and the kinetic of the cytokines. Significant differences were observed (pc < 0.001) between patients with severe malaria and a control group for the following HLA alleles: DR3, DR10 and DR13. The HLA-DR13 allele was found positively and highly associated with severe malaria.

Prognostic value of anti-Plasmodium falciparum-specific immunoglobulin G3, cytokines, and their soluble receptors in West African patients with severe malaria.

Forty-one African patients suffering from clinically defined severe malaria were studied in the intensive medical care unit of the main hospital in Dakar, Senegal, West Africa. All of these individuals lived in Greater Dakar, an area of low and seasonal Plasmodium falciparum endemicity. Twenty-seven patients (mean age +/- 1 standard deviation, 19.2 +/- 12.7 years) survived this life-threatening episode, but 14 (30.8 +/- 16.2 years old) died despite initiation of adequate treatment. On the day of admission (day 0) and 3 days later, one to two blood samples (i.e., approximately 10 to 15 ml) were obtained from each subject, and different biological parameters were evaluated in the two groups. Plasma samples were tested for their content in tumor necrosis factor alpha (TNF-alpha), soluble receptors I and II for TNF-alpha (TNF-alpha sRI and TNF-alpha sRII), interleukin-6 (IL-6), IL-6 sR, IL-10, and IL-2 sR. The concentrations of all these cytokines and/or their receptors was significantly elevated in patient plasma samples on day 0, and it rapidly decreased in the group of individuals who survived. By comparison, the mean concentration of the same parameters decreased slowly in the group of patients who died (except for IL-10, which dramatically fell in all patient plasma samples soon after initiation of antimalarial treatment). The TNF-alpha sRI level remained significantly elevated among the patients who died, and the highest levels of soluble TNF-alpha sRI receptor were found among the older patients. Parasite-specific immunoglobulin M (IgM), total IgG, IgG1, IgG2, IgG3, and IgG4 were evaluated by enzyme-linked immunosorbent assay using a crude extract of a local P. falciparum isolate as antigen and human class- and subclass-specific monoclonal antibodies. Parasite-specific IgM, total IgG, and IgG1 were detectable in the plasma samples of most of these African patients, whereas IgG2 and IgG4 mean values were low. The mean level of parasite-specific IgG3 was different (P = 0.024) at day 0, i.e., before initiation of intensive medical care, between the group of the 27 surviving subjects and the group of 14 patients dying of severe malaria. As a consequence, most of the African patients who died had only trace amounts or almost no detectable level of parasite-specific IgG3 at the time of admission. In contrast, the presence of even limited IgG3 activity at day 0 was found to be associated with a significantly increased probability of recovering from severe malaria. Therefore, in our study, both an elevated level of TNF-alpha sRI and absence of IgG3 activity were of bleak prognostic significance, whereas a favorable outcome was usually observed when parasite-specific IgG3 activity was detectable. This finding was strongly suggestive of a prime role for these parasite-specific immunoglobulins in the capacity to help recovery from severe malaria.

[Re-expansion pulmonary edema after excision of an intrathoracic tumor]. / Oedème pulmonaire de réexpansion après exérèse d'une tumeur intrathoracique.

We report an acute respiratory insufficiency following the removal of a large intrathoracic fibroma (3.1 kg) in a 6 year-old child, caused by a re-expansion pulmonary oedema (unilateral oedema occurring within one hour after expansion). This oedema improved rapidly and was followed by a well-tolerated pleural effusion. This complication is due to discrepancy between a small lung and a large thoracic cavity, due to the prolonged time course of the tumor growth. These oedemas are caused by rapid lung re-expansion, the volume of the removed tumor and the depth of postoperative pleural suction. The value of positive-end expiratory pressure is discussed.

[Multiple organ failure syndrome after ovarian hyperstimulation]. / Syndrome de défaillance multiviscerale après hyperstimulation ovarienne.

Ovarian stimulation is used to treat female infertility, especially in Black Africa where infertility is considered as shameful. Ovarian stimulation can lead not only to multiple pregnancies but also to severe systemic complications such as the one described in this report. Ovarian stimulation using human menopausal gonadotropin led to ovarian hyperstimulation and multiple organ failure in a 28-year-old Senegalese woman. Symptomatic treatment using corticosteroids, abdominal paracentesis to relieve ascites, and fluid expansion failed. Bilateral ovariectomy was performed resulting in permanent sterility. Ovarian stimulation requires close monitoring by ultrasound visualization and measurement of 17 beta-estradiol to allow early detection of complications.

[Prognostic value of nutritional indices for digestive tract cancer surgery in the African environment]. / Valeur pronostique des indices nutritionnels dans la chirurgie des cancers digestifs in milieu africain.

Malnutrition occurs in all patients digestive tract cancer and its effects on perioperative mortality have been well documented. However no study has assessed the predictive value of nutritional status within the context of facilities available in Africa. The purpose of this study was to determine the prognostic value of nutritional status for perioperative mortality in patients with digestive tract cancer i Dakar, Senegal. All patients that underwent surgery for digestive tract cancer were included. Preoperative assessment included physical examination (weight, mid-upper arm circumference, triceps skinfold thickness, and theoretical and real weight loss) and laboratory tests (serum albumin and creatinine/height index). The only evaluation criteria that was correlated was mortality at 14 days. Of the 40 patients included, 18 died (45%). In these 40 patients, 240 malnutrition tests were performed revealing 101 criteria of malnutrition. The results of laboratory tests were not correlated with mortality of clinical factors nor with each other. Physical findings were well correlated with each other but only real weight loss was correlated with postoperative mortality which ranged from 10% when weight loss was less than 10% to 100% when weight loss was 40% or higher. These findings emphasize the value of simply assessing real weight loss, which is difficult in Africa, for predicting perioperative mortality in patients with digestive tract cancer. Use of other physical criteria and especially more elaborate laboratory tests was not of further clinical value.

[A comparative study of recovery following maintenance of anesthesia with propofol or isoflurane. An attempt to synthesize current data]. / Etude comparée du réveil après entretien de l'anesthésie par propofol ou isoflurane. Essai de synthèse des données actuelles.

Quality of recovery is a means to improve anaesthetic safety during postoperative time, in post-anaesthesia recovery room and especially when the patient returns to his unity. The comparison of recovery after maintenance of anaesthesia with propofol or isoflurane shows that, for 50 to 60 min surgical procedures, results are significantly better with isoflurane. Review of literature shows that, for less than 30 min operations, propofol seems to give best recovery. For more than 30 min operations, isoflurane enables better quality recovery.

[Fatal poisoning caused by African viper's bite (Echis carinatus)]. / Envenimation mortelle par une morsure de vipère africaine (Echis carinatus).

The case is reported of a 44-year-old European who was bitten on the foot in Djibouti, probably by an African viper. Unusually, there wasn't any pain, nor any cardiovascular collapse nor any local swelling. An oedema of the lower limb started the day afterwards. Two days after the bite, the patient presented a generalized haemorrhagic syndrome, which led to his admission. There was a consumption of fibrinogen and prothrombin, without any decrease in the platelet count. Heparin was started (100 IU.kg-1.day-1), as well as fluid replacement (albumin, fresh frozen plasma, packed red cells). This allowed him to be transferred to France, where he arrived in anuria, with hyperpyrexia, and severe lower limb oedema and a haemorrhagic syndrome. There was a major extensive retroperitoneal haematoma spreading to the perineum. The four limbs were ischaemic. The patient's condition continued to worsen, developing hypoxic pulmonary oedema. He died on the seventh day after the bite, during a session of haemodialysis, from cardiovascular failure resistant to all the usual drugs. The principles of anti-venom therapy are recalled. Indeed, this should be started early enough and relies on large amounts of serum (greater than 50 ml).

[A deep skin burn caused by the local application of a traditional oily ointment of Senegal (Carapa procera)]. / Une brûlure cutanée profonde provoquée par l'application locale d'unonguent huileux traditionnel du Senegal (Carapa procera).

Many traditional ointments are utilized in Senegal because of their local effects. We report the case of a new born girl deeply burned by the application of "Touloucouna" (Carapa Procera) on her skin. The berries of the tree contain cyclic terpens (Meliacine) well known for inducing inflammation by contact with the skin. They are most likely responsible for that burn until now, such injuries have never been described with Touloucouna.

[Vaginal hysterectomy: its place in surgical practice overseas as related to the experience of the Principal Hospital of Dakar]. / L'hystérectomie vaginale: sa place en pratique chirurgicale outre-mer à propos de l'expérience de l'Hôpital Principal de Dakar.

The authors report on their surgical practice of vaginal hysterectomy at the Principal Hospital of Dakar. First, they assign a place to the frequency of this technic. Then, they recall the major technical details, underlining advantages and limits. They conclude in favour of better knowledge and performing this technic more often, while recognizing some limits related to the pathologic context overseas.

[Human immunodeficiency virus infections (HIV-1 and HIV-2) in Dakar. Epidemiologic and clinical aspects]. / Infections par les virus de l'immunodéficience humaine (VIH1 et VIH2) à Dakar. Aspects épidémiologiques et cliniques.

The authors report on the results of an investigation carried out on 109 HIV seropositives ascertained by the Dakar Central Hospital between February 20, 1987 and May 31, 1988. These seropositives affected 44 patients with AIDS (0.78% of admitted patients) and 65 seropositive people of which 43 blood donors (1.35% of donors). Both viruses are present in about equal number: 50 HIV1 seropositives, 44 HIV2 seropositives, and 15 composite seropositives. Sex-ratio is 3,9 in favour of males; this figure is nearer to the one observed in Europe and North American than the one observed in Central Africa where there is equality between both sex. Clinical patterns are dominated by a bad general status: lost of weight, fever, diarrhea, polyadenopathiae, pneumopathiae, meningoencephalitis. Kaposi's sarcoma and cryptococcal meningitis have been observed only four times. Development of the infection lead to death for 12 patients during the 16 months of the investigation. Both viruses are responsible for an equal immunodepression, leading to the same potential severity. Immunodepression might be acquired more slowly with HIV2, so strongly suggesting an incubation apparently lasting more.

PIP: Between February 1987-May 1988, 109 patients at the Dakar Central Hospital were diagnosed by the ELISA method and confirmed by Western Blot as seropositive for HIV infections. 44 had AIDS, including 2 blood donors and 1 child. 39 asymptomatic but seropositive subjects included 15 blood donors, 7 spouses and 2 children of seropositive individuals, 2 subjects who had spent time in Central Africa where HIV is endemic, 2 patients receiving blood transfusions in Benin and the Ivory Coast, 2 patients with a positive treponemic serology, 4 pregnant women, and 5 patients with disorders unrelated to AIDS. The remaining 26 seropositive blood donors were not examined and their risk factors and health status were unknown. Among the 109 cases there were 50 seropositivities to HIV 1, 44 to HIV 2, and 15 for both HIV 1 and 2. 83 men and 26 women were seropositive, for a sex ratio of 3.9. The average ages of AIDS patients were 33.2 for HIV 1, 41.1 for HIV 2, and 42.3 for HIV 1 and 2. Average ages of asymptomatic carriers were 30.1 for HIV 1, 29.5 for HIV 2, and 26.1 for HIV 1 and 2. Risk factors were difficult to study, but 78 records including information indicated 3 open homosexuals, 4 drug users, 25 who frequented prostitutes, 11 patients who had received transfusions, and 30 who had received injections. 21 of 35 seropositive for HIV 1, 5 of 33 seropositive for HIV 2, and 5 of 10 seropositive for both HIV 1 and 2 had lived outside Senegal and its neighboring countries in the past 10 years. Clinical signs in the 44 AIDS patients were highly varied. The most frequently noted were poor general state with weight loss, fever, diarrhea, polyadenopathic syndrome, pneumopathy, and meningoencephalitis. 9 men and 3 women died during the study period. In all cases the clinical status at hospital admission was very poor. There has as yet been no epidemic of AIDS in Senegal following observation of the 1st case in 1987. The 44 AIDS patients represented .78% of hospital admissions during the study period, while the 43 seropositive blood donors represented 1.35% of all donors. The HIV 1 and HIV 2 viruses both cause profound immunodepression. Some evidence suggests that the HIV 2 virus has a longer incubation period. The study indicates that the epidemiology of HIV is not the same in West Africa as in Central Africa.

[Acute staphylococcal epidural inflammation. Apropos of 2 cases]. / Les épidurites staphylococciques aiguës. A propos de deux cas.

Two cases of staphylococcal infection of the epidural space are presented and on this purpose a review of literature is done to remind of this pathology and to plead for early diagnosis.