[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.

[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.

[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.

Les tests de diagnostic rapide du paludisme en pratique quotidienne

Le paludisme reste un probleme de sante publique mondial; plus particulierement en Afrique. En 2010; le nombre des cas de paludisme a ete estime a 216 millions; dont 81en Afrique. Le nombre de deces lie paludisme s'est eleve a 655 000; dont 91en Afrique. Une confirmation parasitologique rapide par un examen parasitologique; en moins de 2 heures apres l'arrivee en consultation; est recommandee avant tout traitement antipaludique dans tous les cas suspects de paludisme. Alors qu'en 2009; seulement 20des cas de paludisme declare etaient confirmes par un examen parasitologique; dans les 21 pays sur 42 de la region Organisation Mondiale de la Sante (OMS) Afrique. Le test de diagnostic rapide (RDT) est un test immunochromato-graphique detectant la presence d'un antigene specifique de Plasmodium sp dans le sang en 10 a 15 mn. Il est un outil tres interessant et facile a utiliser pour ameliorer la prise en charge des cas de fievre et du paludisme et constitue un nouvel elan dans la marche vers l'elimination du paludisme. Il existe sur le marche plusieurs types de RDT en fonction du nombre d'antigenes specifiques de Plasmodium sp qu'ils detectent. Ils ont subi de tests d'evaluation de la performance sous l'egide de l'OMS. Depuis quelques annees; les RDT ont pris une place tres importante dans le diagnostic de paludisme. De plus; leurs sensibilites ont depasse largement celles exigees par l'OMS. Le respect de conditions de conservation et d'utilisation est indispensable pour leur fiabilite. L'accessibilite par les formations sanitaires publiques et prives reste a regler pour pouvoir tirer tous les benefices de RDT

[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.

[Discrimination of HIV infected persons in medical settings in Madagascar]. / Discrimination des personnes infectées par le VIH en milieu médical à Madagascar.

OBJECTIVE: The objective of our study was to describe the discrimination profile of healthcare personnel towards people living with HIV/AIDS (PLWHA) in medical settings in Madagascar. METHOD: A prospective, multicentric, descriptive, and analytic study was made with a questionnaire filled in anonymously, between February and August 2009, in 17 Madagascar hospitals (public and private). RESULTS: Thirty-six percent of PLWHA reported that they had been confronted with discrimination in the medical field. The age (30-40 years) and the level of education had an impact on discrimination in our study (p<0.05). Paramedics were the most responsible for discrimination (n=8/13) (61.5 %). Discrimination in the medical field was listed as: refusal of the patient to be managed in the hospital (n=5/27) (18.5 %) because of the fear of discrimination (n=4/5) (80 %) and sharing serological status with healthcare providers. Discrimination by the medical staff was listed as the unjustified use of some tools (stethoscope, tensiometer, thermometer) and by the refusal to manage PLWHA (p>0.05). Fifty-three percent of healthcare providers answered the question on HIV transmission mode correctly. Fifteen percent replied that HIV was transmitted by saliva, and 20 % by physical contact. CONCLUSION: As elsewhere, discrimination of PLWHA in the medical field is present in Madagascar. Fighting discrimination should be included in the strategy against propagation of HIV infection.

Maladie de Wegener : difficulte diagnostique et gravite

La granulomatose de Wegener est une vascularite granulomateuse systemique rare; surtout chez les sujets de race noire. Nous rapportons une observation d'une granulomatose de Wegener revelee par une fievre chronique et une insuffisance renale rapidement progressive. Il n'y avait pas d'atteintes oto-rhino-laryngees ou pulmonaires. La recherche des c-ANCA (specificite antiproteinase 3) etait fortement positive. L'evolution etait rapidement fatale malgre l'instauration d'une corticotherapie a forte dose associee a un bolus de cyclophosphamide. Sans les manifestations classiques oto-rhino-laryngees ou pulmonaires; le diagnostic d'une granulomatose de Wegener est difficile. Le pronostic est defavorable; s'il existe une atteinte renale ou a un taux des ANCA eleves