Creation of a therapeutic digestive endoscopy suite in Senegal: renovation, training and university certification. Results of a Belgian-Senegalese inter-university project.

Therapeutic digestive endoscopy did not exist in sub-Saharan Africa before 2005. However, the prevalence of digestive diseases that could potentially benefit from basic endoscopic treatment is very high in this region. Portal hypertension with variceal bleeding and severe dysphagia associated with benign or malignant upper gastrointestinal tract diseases are prominent in these countries. The aim of the Project described in this report was to create a digestive endoscopy facility in Dakar (Senegal, West Africa), that would also provide local training in therapeutic endoscopy to doctors and nurses and facilitate regional autonomy with the opening of a University Certification in Gastroenterology. It took about 10 years to achieve these targets - 5 years to prepare realistic aims that took into account local needs, available local resources, and funding, and 4 years for the Project itself (2005-2009). At the present time, Senegalese colleagues and nurses are autonomous for basic therapeutic procedures in the upper and lower gastrointestinal tract. Two years after the end of funding, the rate of therapeutic activity has increased from 0% in 2005 to 12 % of digestive endoscopic activity in 2011. Key points of success were preparation, confidence of medical personnel, university involvement, shared funding, local multidisciplinary training, and facilitation of autonomy. Belgian healthcare workers were present on-site in Dakar for a total of about 6 months over the 4-year Project period, with an annual budget of less than € 80000. The Project has enabled an efficient North-South collaboration with a minimal budget, which has changed the healthcare provision of digestive endoscopy in Senegal, and has also provided autonomy, and facilitated the development of South-South cooperation.

[Unusual presentation of mycetoma caused by Actinomadurella pelletieri on the scalp]. / Mycétome du cuir chevelu: forme tumorale à Actinomadurella pelletieri.

INTRODUCTION: Mycetoma is chronic inflammatory process characterized by areas of tumefaction with draining sinus tracts. It affects the foot in 80% of cases. The purpose of this report is to describe a case that posed a diagnostic challenge due to unusual scalp location and clinical presentation. OBSERVATION: A 23-year-old woman residing in a rural zone of Senegal consulted for indolent lesions ongoing on the scalp for 2 years. Physical examination showed two soft tumid lesions measuring about 3 cm in diameter on the vertex. The surface of the lesions was crusty but showed no sign of granules. Skull x-ray was normal. Skin biopsy demonstrated a polymorphous granulomatous infiltrate with foci of suppuration circumscribing small, irregular grains with radiating filaments. Mycological culture on Lowenstein medium demonstrated Actinomadurella pelletiere. Treatment with cotrimoxazole for 8 months led to significant regression of the lesions. DISCUSSION: The mycetoma described in this report posed a diagnostic challenge because of its unusual scalp location and especially its tumoral or pseudo-cystic presentation. This clinical form of mycetoma must be taken into account for diagnosis in any patient from endemic areas.

[Abdominal actinomycosis mimicking an abdominal tumor. Case report in Senegal]. / Actinomycose abdominale tumorale. Une observation au Sénégal.

The purpose of this report is to describe a case of abdominal actinomycosis (Actinomyces israelii) with a pseudo-tumoral appearance in a 57-year-old Senegalese woman.

[Adult-onset Still's disease: case report in Dakar, Senegal]. / Maladie de Still de l'adulte: une observation à Dakar (Sénégal).

Adult-onset Still's disease is a uncommon form of inflammatory rheumatism. It has rarely been reported in black Africa. The purpose of this report is to describe a case in a 49-year-old woman from Dakar, Senegal.

[Nocardiosis: 4 cases in Senegal]. / Nocardiose: 4 observations au Sénégal.

The purpose of this report is to describe four cases of nocardiosis observed over an eight-year period in medical units of Principal Hospital in Dakar, Senegal. It is a rare infection occurring mainly in people with weakened immune systems. Pulmonary forms are predominate and clinical and laboratory presentation can mimic pulmonary tuberculosis. Diagnosis should be suspected in patients presenting pulmonary infections and negative sputum bacilloscopy. Nocardia bacteria should be identified before starting antibiotic treatment. Patients require long-term antibiotic treatment with third generation cephalosporins or sulfamethoxazole-trimethoprim.

[Merkel cell carcinoma of the gingival mucosa in a black young adult]. / Carcinome à cellule de Merkel gingival chez un adulte jeune de race noire.

Merkel cell carcinoma (MCC) is a rare and aggressive primary neuroendocrine neoplasm of the skin with a poor prognosis. It occurs mainly in the skin of white elderly patients. Its occurrence in intraoral mucosal sites is rare. We report a rare case of MCC that arose in the gingival mucosa of young black adult.

[Dermatomyositis and polymyositis: 21 cases in Senegal]. / Dermatomyosites et polymyosites: 21 cas au Sénégal.

Dermatopolymyositis (DPM) is a term describing a group of disorders comprising multiple distinct entities depending on interactions between genetic and environmental factor. There is a paucity of studies on DPM in black Africa. The purpose of this report is to describe epidemiological, clinical, laboratory and therapeutic aspects of dermatomyositis (DM) and polymyositis (PM) observed at the Principal Hospital in Dakar, Senegal. A retrospective review as conducted of patients hospitalized for DM and PM in Medical Departments of Principal Hospital. Diagnosis of DRM was based on the criteria of Bohan and Peter's in all cases. A series of 21 black African patients was compiled including 15 with DM and 6 with PM. Mean age was 52 years and the M/F sex ratio was 0.6. The mean delay for diagnosis was 6 weeks (range, 3 to 12 weeks). Initial signs were dermatological in 12 patients, pulmonary in one and muscular in the remaining cases. The most common dermatological sign was erythema characterized by a zebra-like aspect on the extended limbs. Erythema was frequently pruriginous with a flagellate aspect on the back. Muscular signs were observed in 18 patients and included pharyngeal manifestations in 10 patients. Amyopathic DM was not observed. Cardiac abnormalities included tachycardia (4 cases), AVB (1), ischemic lesion (1), relaxation disturbances (4), pericardial effusion (3), myocarditis (2) and pulmonary hypertension (1). The most common pulmonary manifestation was interstitial lung disease observed in 6 patients. Gastrointestinal signs were noted in 9 patients including endoscopic evidence of superficial erosion in 4 cases. Electromyography (EMG) tracings revealed myogenic disease in 14 cases including 2 associated with reduced peripheral nervous conduction speed. Severe lymphopenia was observed in 3 patients but HIV serology was negative in all cases. Paraneoplasic DM was observed in 3 cases. Death occurred in 5 cases due to the cancer-related, pulmonary and infectious complications. Based on the findings of this study, the three main features of DM and PM in Senegal are flagellated and often pruriginous erythema, cardiac and interstitial lung disease, and peripheral neural involvement.

[Permanent deafness following typhoid fever: case report from Dakar, Senegal]. / Surdité définitive au décours d'une fièvre typhoïde une observation a Dakar (Sénégal).

Severe infections due to Salmonella typhi and Salmonella paratyphi are still common in sub-Saharan Africa where many patients are empirically treated for malaria. In addition to the usual clinical signs and complications of typhoid fever, clinicians practicing in high incidence areas must be aware of less common manifestations. The purpose of this report is to describe a case involving an 18-year-old boy who presented with quinine-resistant febrile coma. The final diagnosis was typhoid fever. After recovery the patient presented complete deafness. Discussion raises the question of whether deafness was secondary to typhoid fever or to drug therapy.

[Nocardia aroensis and lung infection: first case report in Africa ]. / Infection pulmonaire à Nocardia aroensis: première observation en Afrique.

Nocardiosis is a rare disease that is difficult to diagnose. Pulmonary forms are most common in association with a variety of nonspecific symptoms. Up to now isolation of the offending species, i.e., Nocardia aroensis, has been reported only once during the first description in Japan. The purpose of this article is to report the second world case of isolation of the Nocardia aroensis in a 50-year-old immunocompetent African woman.

[Shoulder pain revealing tuberculosis of the humerus]. / Une épaule douloureuse révélant une tuberculose osseuse inhabituelle.

Tuberculous spondylitis is the most common form of musculoskeletal tuberculosis. However, extraspinal manifestations have been described with tuberculosis of the wrist, femur, foot or shoulder, as in the patient presented. Because of an often-indolent clinical presentation, the diagnosis is delayed and antituberculous treatment is not able to prevent serious bone destruction.

[Poster presentations]. / La communication affichée.

Posters have become an essential tool for dissemination of study findings at medical meetings. By presenting a quick snapshot, posters can be an effective means of communicating the main findings of the research quickly and of stimulating rewarding exchanges with the people in attendance. Success depends on catching and holding the attention of passing attendees long enough to establish contact and share knowledge and experience. The purpose of this article is to provide a few guidelines and techniques for preparing and presenting effective and clear research posters at scientific meetings.

[Perception of nosocomial risk among healthcare workers at "Hopital Principal" in Dakar, Senegal (survey 2004)]. / Perception du risque nosocomial parmi le personnel hospitalier de l'Hôpital Principal de Dakar.

Nosocomial Infection (NI) is also observed in healthcare facilities in non-Western countries. The purpose of this report is to describe the findings of a survey undertaken to evaluate hygiene procedures implemented at the "Hopital Principal" in Dakar, Senegal and to assess perception and awareness of nosocomial risk among the hospital staff. A total of 264 healthcare workers were interviewed. Mean age was 39 years (range, 18-60) and the sex ratio was 1.3 (150 men/114 women). Sixty (22.7%) had university degrees, 106 (40.2%) had secondary school diplomas, 50 (18.9%) had attended middle school, and 13 (4.9%) had no schooling. Analysis of interview data showed that 56.1% (157/264) defined NI as infection acquired at the hospital but that only 9.8% (n=26) knew that a minimum 48-hour delay was necessary to distinguish nosocomial from community acquired infection. While understanding about NI was correlated with education level, data showed that 1 out of 3 physicians (13/39) failed to give the exact definition. Hand contact was cited as the second route of transmission. Isolation precautions were understood by 22.7% of personnel (60/264). Systematic handwashing was reported by 363% (96/264) but observation demonstrated that it was not performed properly regardless of the category of personnel. Care protocols were understood by 54.6% of persons interviewed (144/264). A hygiene-training course had been attended by 52.2% (n=138). Two thirds of the staff (69.7%: 54/264) was able to identify the hygiene nurse. Ninety-eight health care providers (37.1%) were familiar with the CLIN (Comités de Lutte contre les Infections Nosocomiales).

[Diffuse interstitial lung disease and connective tissue diseases: study of seven cases in Dakar]. / Les pneumopathies interstitielles diffuses non specifiques au cours des connectivites: à propos de 7 observations à Dakar.

INTRODUCTION: The diagnosis of diffuse interstitial lung disease non specific in connective tissue disease is difficult because of many differential diagnoses. Lung involvement can affect functional or vital prognosis. We report 7 cases. CASES: We collected data from 60 years old mean patients. Pulmonary localisation was diagnosed after 19 years of evolution of the auto-immune disease. Discovering circumstances were dyspnea and chronic cough. The radiographic and scannographic signs were diffuse because of long diagnosis delay. The underlying auto immune disease was scleroderma, rheumatoid arthritis, Sjögren's syndrome, ankylosing spondylitis, Sharp's syndrome, and multiple autoimmune syndrome. The main treatment was corticosteroids and respiratory physiotherapy. CONCLUSION: Throughout these 7 cases we discuss clinical, radiological and evolutive aspects and we focus on the need of early diagnosis for a better prognosis.

[Diabetes mellitus in sub-Saharan Africa: epidemiological aspects and management issues]. / Le diabète sucré en Afrique subsaharienne aspects épidémiologiques, difficultés de prise en charge.

In contradiction with long-standing conventional wisdom that it is a rich country's disease, diabetes mellitus is increasingly a major concern in developing countries, especially in sub-Saharan Africa. Care facilities have not kept pace with the sharp increase in diabetes mellitus. The WHO has predicted a worldwide rise in the prevalence of diabetes that is expected to affect 300 million people by 2025. This progression is more flagrant in developing countries particularly in sub-Saharan Africa. In these countries, the expansion of diabetes is part of a broader epidemiological transition from transmissible diseases to non-transmissible diseases. A number of factors are causing this transition including aging of the population, sedentary lifestyle, and obesity. Aside from obesity, arterial hypertension is the main cardiovascular risk factor associated with diabetes. Alone or in association with other risk factors, diabetes mellitus accounts for high morbidity especially due to cardiovascular and kidney complications. Management in sub-Saharan Africa faces a number of issues: poor understanding of the extent of the problem, high cost of medications, socio-economic setting that is poorly suited to maintaining a proper diabetic diet, and limitations in infrastructure and personnel. The rapid increase in the prevalence of diabetes mellitus in sub-Saharan Africa is a serious challenge. There is an urgent need to obtain accurate figures about the extent of the pandemia as a basis for training an adequate number of health care personnel and implementing sufficient resources to allow local management. Meeting this challenge will require enhancement of the awareness and participation of all players involved in public health.

[Lung cancer in Senegal]. / Le cancer bronchique au Sénégal.

In Africa the incidence of lung cancer is rising rapidly. The purpose of this prospective study was to analyze clinical, therapeutic, and prognostic features of lung cancer patients treated at the Principal Hospital in Dakar between 2002 and 2007. A total of 72 cases were compiled over the 5-year study period. In 88% of cases the patient was a male smoker with a mean age of 59.2 years. Histological samples were obtained in 79.1% of cases by bronchial fibroscopy (n=33), CT-guided transthoracic needle biopsy (n=17), or from a metastatic site (n=7). The histological diagnosis was squamous cell carcinoma in 23 cases, adenocarcinoma in 14, large-cell carcinoma in 17, small-cell lung cancer in 2, and bronchiolo-alveolar cancer in 1. Tumor staging demonstrated grades I-II in 6 cases, grade II in 17, and grade IV in 49. Symptomatic management was performed in 68% of patients. In the remaining cases management consisted of chemotherapy in 22 cases, radiotherapy for pain relief in 5, and surgery in 1. Ten patients were lost from follow-up. Median survival was 7 or 3 months depending on whether or not chemotherapy was performed. The much higher rate of histological diagnosis than in the sub-region is due mainly to the availability of trained personnel with access to bronchial endoscopy and CT-scan needle biopsy since September 2003. Administration of cytotoxins is feasible but the cost is excessive due to the lack of universal health care coverage: two-thirds of cases were abandoned whereas chemotherapy significantly improved median survival by 4 months (p < 0.0001). Prognosis of the disease is poor because management is undertaken at an advanced stage. Lung cancer is a health issue in Dakar, Senegal. It is urgent to develop therapeutic standards adapted to the African socio-economic setting as well as an anti-tobacco prevention policy.

[Important pericardial effusions: apport of echocardiography guided pericardocentensis: about 30 consecutive cases]. / Péricardites liquidiennes abondantes: apports de la péricardocentése echoguidée: a propos de 30 cas consécutifs.

INTRODUCTION: Western countries have good mastery of abundant pericardial effusion while in Africa this still raises some problems regarding diagnosis and therapy. The aim was to see to what extent echo guided pericardiocentesis could contribute in severe cases. METHODS: All patients with abundant pericardial effusion diagnosed by echocardiography with or without compression were considered in a prospective study. They experienced a pericardiocentesis. Some patients did undergo an additional surgical biopsy. The liquid was preliminarily submitted to chemical, bacteriological, cytological analysis. Tissues were observed through an anatomic pathology in biopsy. Heart tuberculosis was diagnosed through histology for following therapeutic testing. RESULTS: Thirty consecutive patients aged 37 in average were included. The sex ratio was 3.75. Prior to draining off, 3 neoplasies (2 of lung bronchitis, 1 of cervix ), 1 leukaemia, 2 extra pericardium tuberculosis and 1 amoebic abscess were diagnosed . Clinical occurrence: the most frequent case, besides the tampon (10 cases, i.e. 30%), was isolated pericardial effusion associated or not with an alteration of the global state (13 cases, i.e. 4%). The average quantity of liquid extracted was 600c c which provoked a kind of haemorrhage in 18 cases, i.e. 60%. Tuberculosis was the major aetiology: 15 cases e i 50% out of which 4 were HIV positive. Three additional surgical biopsies were carried out. Seven patients died. CCONCLUSION In addition to its diagnostic contribution, echo guided pericardiocentesis offers an alternative to endoscopy surgery.

[An unusual mediastinal opacity]. / Une opacité médiastinale inhabituelle.

A 36-year old immunocompetent male from Senegal with an uneventful history was admitted for exploration of a bullous collection in the posterior mediastinum. Multifocal tuberculosis was diagnosed. Computed tomography-guided drainage removed 600 cc of caseum. The diagnosis as rupture of intrathoracic Pott's abscess complicated by a probably esophageal fistula. The clinical course was rapidly favorable with later development of mediastinal fibrosis. This uncommon case illustrates the contribution of interventional radiology recently developed in the Principal Hospital in Dakar, Senegal.

[Leg ulcer due to hydroxyurea. A case report]. / Ulcère de jambe lié a l'hydroxyurée. A propos d'une observation.

Hydroxyurea is an antineoplasic agent usually used in myeloproliferative syndromes, but also in other benign pathological circumstances. Several dermatological manifestations have been recognized as being secondary to its prolonged use, of which the leg ulcer. We report an observation. Mrs. L.D, 47 years, were hospitalized on July 14, 2004 for an ulcer of left ankle in a feverish context. She was followed since 2001 for a chronic myelogenous leukaemia, and took hydroxyurea at a rate of 1500 mg per day, with a good clinical and hematologic answer. She presented a painful ulcer compared to the left external malleolus, with purulent bottom, without signs of vascular attack. The hemogram showed a hyperleucocytosis with 24.000 white elements/mm3 with neutrophilic polynucleosis. Pus sample on the ulcer showed Pseudomonas aeruginosa, and the blood culture was negative. The cure was obtained two months after stopping hydroxyurea. The ulcer of leg related to hydroxyurea is a seldom described pathology. Its occurrence imposes the final stop of the treatment.

[Hemorrhoids in Dakar: epidemiological, clinical and endoscopic aspects of 168 cases]. / Aspects epidemiologiques, cliniques et endoscopiques de la maladie hemorroidaire a Dakar. A propos de 168 cas.

INTRODUCTION: haemorrhoidal disease symptoms lead frequently to medical consultation. The aims of our study were to determine its epidemiological, clinical and endoscopic characteristics in Dakar. PATIENTS AND METHODS: we conducted a prospective multicentric study in the hospitals and in the private offices with endoscopic unit in Dakar from November 2nd 2003 to July 31 2004. A questionnaire with clinical and epidemiological features was applied to patients who presented haemorrhoid to the endoscopic exam. We included those who accepted the questionnaire. RESULTS: We recruited 168 patients. The mean age was 39.6 years. The sex ratio was 1.66 (male to female). The mean duration of symptoms was 6 years (range 1 month - 32 years). The symptoms that lead to medical visit were mainly: rectal haemorrhage (50.5%), anal pain (23.2%), constipation (13.1%) and anal tumefaction (9.5%). At the anamnesis the most frequently symptoms noted were constipation (80.4%), anal tumefaction (74.4%), anal pain (73.8%), rectal haemorrhage (64.9%) and anal pruritus (58.3%). The haemorrhoids were internal in 116 cases and external in 52 cases. According to the endoscopic classification, 35% of patients were at the first stage, 43% at stage II, 18% at stage III and 4% at the stage IV. An anitis was noted in 29.1% cases. We noted as associated lesions 18 fistulas and 15 anal fissures. CONCLUSION: The epidemiological, clinical and endoscopic characteristics of haemorrhoidal disease in Dakar are similar to those described in medical literature.