[Bilharzian meningomyeloradiculopathy in children]. / La méningo-myélo-radiculite bilharzienne chez l'enfant.

Child meningomyeloradiculitis is a rare complication form of schistosomiasis, even in hyperendemic area. Its diagnosis is very difficult, especially if there are not history or signs of Schistosoma mansoni or hematobium infections. It must be evocated in case of acute flask paralysis occurring in children living in Schistosoma infections endemic area. The authors report a 14-year-old boy's case and suggest etiopathogeny of the disease.

[Acute flaccid paralysis after drug injection: a case report in the pediatric service of the Befelatanana Hospital Center in Antananarivo]. / Paralysie flasque aiguë post-injectionnelle de médicament chez l'enfant: à propos d'un cas observé au Service de Pédiatrie du Centre Hospitalier de Befelatanana-Antananarivo.

In the framework of the poliomyelitis program eradication, the World Health Organization suggests two markers to survey the circulation of the poliovirus: notification of all cases of acute flask paralysis (AFP) and etiological research of these AFP from two stool samples. The authors reported the case of a AFP, occurring after a polio vaccination in a 5-year-old boy who had later an acute rhinopharyngitis treated by antibiotics and quinine intramuscular injections. A left lower limb AFP justified his hospitalisation. The isolation of a Sabin type 3 poliovirus was a pitfall because clinical and complementary investigations demonstrate a peripheral neuromuscular paralysis. This demonstrative case shows the need for health staff to be trained to perform correctly an usual act like intramuscular drug injections.

[Diagnostic pitfalls in childhood acute obstructive dyspnea]. / Pièges diagnostiques d'une dyspnée aiguë obstructive de l'enfant.

Diagnosis of an acute obstructive dyspnea is very difficult because there are many possible causes. The authors reported the case of a 3.5-year-old boy with an atopic status who presented iterative asthma attacks which evolute to severity in spite of an appropriate therapy. Then suffocation occurred with a serious infectious context. The cause of the disease was diagnosed by respiratory tract endoscopic exam which allowed to detect a laryngeal papillomatis. The surgical extraction of this tumour cured the patient. Physiopathology of acute obstructive dyspnea in child was discussed. Upper airway obstructions are separated from lower pulmonary diseases. Two syndromes are very difficult to separate among upper airway obstructions: spasmodic laryngitis and subglottal laryngitis. They are considered in fact as different outward signs of the same disease: subglottal laryngitis is the infectious evolutive form of a spasmodic laryngitis in which atopic status exists. Laryngeal papillomatosis would be a favourising factor of infection. The authors conclude that respiratory tract endoscopic exam is very important to diagnose childhood acute obstructive dyspnea.

[Neonatal bacterial infections: a public health problem at the maternity hospital of Befelatanana (1997-1998)]. / Les infections bactériennes néonatales précoces: un problème de santé publique à la maternité de Befelatanana (1997-1998).

Neonatal infections represented the second cause of morbidity at the neonatalogy service of the Maternity Hospital of Befelatanana, and they were the first cause of the perinatal mortality (81%). This prospective study was carried out from May 1997 and December 1998 and had concerned neonatal infections suspicions among newborns. Its purpose was to identify problems with regard to the management of those newborns and to assess the impact of the prevention. Over 14,009 births, 1,877 neonates had infections recorded during the first week of life. Were noticed as main pathogen germs isolated: Escherichia coli, groups B, A, G, D Streptococci and Staphylococcus aureus. The authors conclude that screening and early treatment of materno-fetal infections constitute with asepsis, prevention basis of neonatal infections.

[Evaluation of the management of tuberculosis in children in Madagascar. Results of a multicentric study]. / Evaluation de la prise en charge de la tuberculose infantile à Madagascar. Résultats d'une étude multicentrique.

In Madagascar, tuberculosis remains an important cause of morbidity and letality with a Risk of Annual Tubercular Infection about 1% in 1996 in spite of a vaccination rate of 82.6% and tubercular drugs free of charge. In 1995, the National Tubercular Control Program detected 7,000 cases of pulmonary tuberculosis and expected more than 12,000 cases per year. This study was carried out in order to review the management and the treatment of the child tuberculosis in Madagascar. This retrospective study was conducted in four pediatric units of the General hospital of Befelatanana (A and B), Ambohimiandra Hospital and Regional Hospital Centre of Toliara for a twenty four months period from January 1997 to December 1998. All the less than 15-year-old children medical files were consulted. 214 cases were suspected of tuberculosis. 133 of them were treated upon clinical presumption basis and/or radiological exams (33 bacteriological and/or histopathological exams were only realized). 56% of the cases were vaccinated by BCG vaccine. Respiratory diseases with fever motive 46% of hospitalization. The majority of these children are living in poor conditions and 38% of them had malnutrition. Were found as clinical manifestations: 47% of pulmonary tuberculosis (among them 20% were smear-positive pulmonary tuberculosis), 12% had ganglionar tuberculosis, 10% peritoneal tuberculosis, 8% a tubercular meningitis, 5% a Pott-disease and 2% a miliary-disease. Mortality increases with suffocation. 18% of cases died, especially infants and in tubercular meningitis. The authors conclude that management and treatment of tuberculosis need an early diagnosis. But the diagnosis is difficult in front of non specific clinical manifestations in children and due to lack of means and national agreement which settle up diagnosis and therapy. A scoring system based upon clinical signs in agreement with complementary medical tests is desirable.

[Premature deliveries at the maternity hospital of Befelatanana, Antananarivo in 1997]. / Les accouchements prématurés à la Maternité de Befelatanana, Centre Hospitalier Universitaire d'Antananarivo en 1997.

Preterm deliveries (PT) produce new-borns whose prognosis is generally very dark. Prematurity is the first cause of neonatal death. A retrospective study was carried out at the Maternity Hospital of Befelatanana, Antananarivo in order to specify causes and difficulties of PT and to draw up strategy for their better management so that premature infants have chance to survive. The survey concerned 1394 patients: all pregnancies whose gestational age are between 22 and 36 weeks and those who delivery viable infants discharged home whose weights are between 500 and 2,500 grams. PT occur frequently among teenagers and more than 35-year old women. Risk factors and determinative causes of PT are mothers' toxic habits, gyneco-obstetrical history as PT, abortion, cicatricial uterus, urogenital infections. 12 maternal deaths were noted. Infant perinatal mortality rate was of 47.3 per cent. The authors conclude that difficulties were in labor and both antepartum and intrapartum periods. Preventive measures must surpass curative therapy. They will be based on the improvement of standard of living, the reinforcement of planning family and a strict pregnancy surveillance.

[Premature rupture of membranes seen at the Befelatanana maternity, Antananarivo University Hospital Center]. / Les ruptures prématurées des membranes vues à la Maternité de Befelatanana, Centre Hospitalier Universitaire d'Antananarivo en 1998.

Generally preterm ruptures of membranes (PRM) are harmless, but they become serious if the labor doesn't occur in the following 24 hours. Then, they might generate neonatal infections which provoke heavy fetal and maternal mortality. A retrospective study was carried out in 1998 at the Maternity Hospital of Befelatanana, Antananarivo in order to sum up knowledges on epidemiology and fetal prognosis of this disease, and to draw up measures to aim to reduce causes of PRM. 4232 cases of PRM were registered for the study period. The average age of parturient women was of 27 years old. PRM occur frequently among primiparas and high level multiparas. Risk factors and determinative causes are gyneco-obstetrical history as abortion, preterm delivery, cicatricial uterus, urogenital infections; uterine malformation; placenta praevia; hydramnios; dystocic labor presentation; uterine distension due to either multiple pregnancy or disproportion of fetus and birth canal; irregular and poor prenatal visits quality; low standard of living. Numerous premature infants of PRM outcomes had infections: 1,619 out of 4315 new-borns. Infant perinatal mortality rate was of 11.7 per cent. Maternal complications were infections, uterine rupture, hemorrhages. 5 deaths were noted. The reduction of PRM rate might be obtained by improvement of standard of living and hygiene, correct cares during pregnancy and intergenesic periods.

[Study of idiopathic thrombopenic purpura in two pediatric services of Antananarivo city]. / Etude du purpura thrombopénique idiopathique dans deux services pédiatriques de la ville d'Antananarivo.

Idiopathic thrombocytopenic purpura (ITP), haematologic disease affecting the only blood platelets, is an acquired disease. It appears as cutaneous and mucosal bleedings preceded by a feverish syndrome. Cerebral haemorrhage is possible but very rare. If the disease occurs frequently in Europe and in the United States of America, there is a lack of data in Africa and in Madagascar. In order to fill this gap, the authors carried out retrospective and prospective studies in two paediatric units of Antananarivo for 32 months. They reported 4 cases of PTI of which clinical signs were moderate. As therapy, corticosteroids were used and were efficiency. It is desirable to settle a program allowing to survey sick children.

[Value of C-Reactive Protein (CRP) in childhood fever conditions]. / Intérêt de la C-Reactive Protein (CRP) dans les affections fébriles de l'enfant.

C-Reactive Protein (CRP) measurement is used to orientate the diagnosis of an inflammation especially in childhood febrish diseases. A retrospective study was carried out at the pediatric service of the General hospital of Befelatanana in Antananarivo for 48 months (1997-1998). The population of this study was continued of 361 patients taken from 714 febrish children. 384 CRP were performed. The initial CRP measurement allowed to differentiate 152 presumed bacterial infections: 49 respiratory tract infections, 62 in neurological pathology, 10 in digestive pathology, 19 in otorhinolaryngology pathology, 12 in urinary pathology, and 153 presumed viral infections: 86 respiratory tract infections, 29 in neurological pathology, 12 in digestive pathology, 26 in otorhinolaryngology pathology. There was a right correlation of CRP values and leukocyte levels in presumed bacterial infections. Specificity and sensibility of the test applied in different child febrish diseases were satisfactory. CRP measurement is easy and rapid to perform. It is useful and seems to be the appropriate method to diagnose childhood febrish diseases in countries where facilities are insufficient and financial possibilities limited.

[Congenital afibrinogenemia complicated by spontaneous cerebral hemorrhages: a case report]. / Afibrinogénémie congénitale compliquée d'hémorrhagies cérébrales spontanées: à propos d'un cas.

Congenital afibrinogenemia is a rare autosomal recessive disease caused by markedly reduced or absent synthesis of fibrinogen. Consanguinity is common in affected family. Clinical manifestations range to minimal or moderate bleeding to catastrophic haemorrhage. Bleedings are often post-traumatic, sometimes spontaneous. Diagnosis is established by laboratory tests presenting trace or absence of fibrinogen. Substitutive treatment with fibrinogen concentrates or fresh frozen plasma is used. The authors reported the case of a 41-year-old male with congenital afibrinogenemia with fatal spontaneous cerebral haemorrhage. Diagnosis was made upon history, bleeding history, clinical examination, blood coagulation tests and radiography. Cerebral haemorrhage must be suspected in any patient presenting blood coagulation disorders with bleeding history. Drug therapy must be installed immediately and continued before obtention of specific radiology images which are often late in relation to clinical signs.

[Evaluation of the use of antibiotics in the hospital pediatric milieu]. / Evaluation de l'utilisation des antibiotiques en milieu hospitalier pédiatrique.

Excessive and inappropriate use of antibiotics is a world-wide serious problem because it contributes to the development and the spreading of antibiotic resistance. The authors carried out a study for one year by 1998, in order to evaluate antibiotic prescriptions in three childhood diseases: respiratory, digestive and neurological diseases. Patients hospitalized at the unit paediatric of the General hospital of Befelatanana are 0 month to 15 years old. Three antibiotic families were frequently used: cotrimoxazole, penicillins derivatives and aminoglycosides. Results of this study noted that antibiotic precriptions were irrational. Some factors may give explanations to these facts: the insufficiency of biological labs, but also expensive costs of exams. It is desirable that all paediatricians can gather in order to draw up clinical protocols and to assess them by a multicentric survey. Further results may be used as reference for empirical or probabilist antibiotic prescriptions of which efficacy will be checked by an experienced lab.

[Costs directly related to acute lower respiratory tract infections in the pediatric hospital milieu]. / Coût direct lié aux infections respiratoires aiguës basses en milieu hospitalier pédiatrique.

The purpose of this retrospective study carried out by 1997 in two paediatric units of Antananarivo: paediatric unit of the General hospital of Befelatanana (Marfan) and paediatric unit of the Hospital Center of Soavinandriana (CI), was to evaluate direct service costs for an hospitalization of a child affected by lower acute airway diseases. In the first unit, there is partial charge, in the second, there is full charge. Direct services were continued by complementary tests, therapy and meals. The length of the hospitalization changes according to the cause and the severity of diseases. Average direct service costs were of 19 and 38 US$ respectively. Maximum direct service costs were of 77 and 154 US$ respectively. Amounts of direct service costs were crippled especially by inappropriate use of antibiotics.

Les accouchements prematures a la Maternite de Befelatanana; Centre Hospitalier Universitaire d'Antananarivo en 1997

L'accouchement prématuré donne naissance à des enfants dont le pronostic est généralement très sombre : la prématurité étant la première cause de décès néonatal. Une étude rétrospective portant sur les accouchements prématurés, répertoriés entre le 1er janvier et le 31 décembre 1997, à la Maternité de Befelatanana a été entreprise afin de préciser leurs causes et les problèmes qu'ils posent, et de dégager une ligne de conduite pour une prise en charge de qualité pour assurer la survie des prématurés. Toutes les femmes en travail, porteuses d'une grossesse d'âge gestationnel compris entre 22 et 36 SA révolues, et les femmes admises, après un accouchement prématuré à domicile, dont les enfants pesaient entre 500g et 2 500g ont été incluses. 1 394 accouchements prématurés ont été enregistrés pendant la période d'étude. Les adolescentes et les femmes âgées de plus de 35 ans sont les plus exposées à l'accouchement prématuré. Les facteurs de risque et les facteurs déterminants d'un accouchement prématuré sont les habitudes toxiques de la mère, des antécédents d'avortement ou d'accouchement prématuré, un utérus cicatriciel, et des infections uro-génitales. 12 décès maternels ont été enregistrés. Le taux de mortalité périnatale a été de 47,3% (660 cas). Il ressort de cette étude que les facteurs péjoratifs se situent aussi bien en amont qu'en aval des accouchements prématurés. Les mesures préventives doivent l'emporter sur les traitements curatifs. Elles reposent notamment sur l'amélioration de la qualité de la vie, le renforcement de la planification familiale et la surveillance stricte de la grossesse

Les ruptures prematurees des membranes vues a la Maternite de Befelatanana; Centre Hospitalier Universitaire d'Antananarivo en 1998

La Rupture Prématurée des Membranes (RPM) reste le plus souvent anodine, mais elle devient grave lorsque le travail ne se déclenche pas dans les 24 heures qui suivent. Elle peut être alors à l'origine d'une infection néonatale qui engendre de lourdes morbidité et mortalité materno-foetales. Une étude rétrospective menée pendant l'année 1998 a eu pour cadre la Maternité de Befelatanana afin de faire le point sur l'épidémiologie et le pronostic foetal consécutifs à la RPM et de dégager des stratégies visant à diminuer les causes de ces RPM. Il y eut 4 232 cas de RPM, soit une incidence de 50,5%. L'âge moyen des parturientes a été de 27 ans. Les primipares et les grandes multipares ont été les plus touchées et ont représenté 59,8% de la population d'étude. Les facteurs de risque et les facteurs déterminants ont été des antécédents gynéco-ostétricaux : avortement ou accouchement prématuré ou utérus cicatriciel, une malformation utérine, un placenta praevia, un hydramnios, une présentation dystocique, une surdistension utérine provoquée par une grossesse multiple ou une disproportion foetopelvienne,des infections uro-génitales, des notions de massage sur la région abdominale, une mauvaise consultation prénatale et un bas niveau de vie. Sur 4 315 naissances issues de RPM, 1 619 nouveau-nés (39,2%) présentaient des signes d'infection. Par ailleurs, nous avons enregistré 504 cas de mortalité périnatale, soit 11,7%. Les complications ayant survenu chez la mère ont été des infections, des ruptures utérines, des hémorragies. 5 décès ont été notifiés. La réduction du nombre de RPM repose d'une part sur l'amélioration de la vie et de l'hygiène de la population et d'autre part sur la qualité des soins offerts, depuis la période intergénésique, jusqu'à la période post-natale