Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs.

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper.

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

[A rare case of huge aspergilloma developed within a lesion of pulmonary fibrosis secondary with a systemic scleroderma in an immunocompetent patient in Madagascar]. / Un cas rare d'aspergillome volumineux développé au sein d'une lésion de fibrose pulmonaire secondaire à une sclérodermie systémique chez une malade immunocompétente à Madagascar.

We report a rare case of a huge aspergilloma developed within a bronchiectasis due to pulling by a pulmonary fibrosis of systemic scleroderma. The patient is a 58-year-old woman presenting a deterioration of the general state associated with repeating hemoptysis, dyspnea, dysphagia, sclérodactylia, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no antecedent pulmonary tuberculosis. The patient had a pulmonary arterial hypertension complicated by a chronic pulmonary heart at the stage of right cardiac decompensation. Aspergillosis serology was positive and the immunological assessment confirmed scleroderma. The computed tomography showed a huge oblong opacity in a small round bell shape ("signe du grelot", Monad's sign) in the left upper lobe developed within a bronchiectasis, and a bilateral pulmonary fibrosis. Although surgery remains the recommended treatment of an aspergilloma, the management of our patient was medical in front of contra-indication for surgery. The evolution was marked by repeating hemoptysis and stability of the pulmonary lesions 2 years later. The management of this entity remains difficult and complicated; the prognosis is in general unfavourable and depends at the same time on the evolution of scleroderma and the aspergilloma infection.

[Pulmonary abscess: a 111-case series in Madagascar]. / Abcès pulmonaires: 111 observations a Madagascar.

The purpose of this report is to present a series of 111 cases of pulmonary abscess observed over a 4-year period in Madagascar. There were 75 men (67.6%) and 36 women (32.4%) with a mean age of 38 years. Alcohol and tobacco use was found in 32.2% of cases. Thirteen patients (11.7%) used chewing tobacco and all patients were exposed to passive smoking. Eighty-eight patients (79.2%) had a history of bronchopulmonary disorders. Onset was progressive in 63% of cases. The main symptoms were fever (81.9%), pulmonary condensation (74.7%) and pleurisy (9.9%). Coughing was productive in 91.8% cases including 54% of patients having muco-purulent expectorations. In 49 patients (44.1%), chest radiography showed an opacity with a hydroaeric level. The abscess was solitary in 40 cases, multiple in 9, and bilateral in 5. In-hospital antibiotherapy was performed on a presumptive basis: tritherapy in 92 patients (82.9%), bitherapy in 18 (16.2%) and monotherapy in one (0.9%). Other treatment modalities inculuded respiratory kinesitherapy in 57 cases (51.3%), surgical drainage in four (3.6%) and pneumonectomy in one (0.9%). Outcome was favorable in 93 cases (8,7%) but there were 18 deaths (16.2%). This study emphasizes the value of achieving early diagnosis, identifying supporting factors and starting appropriate treatment promptly.

[Acute community acquired pneumonia: 96 cases in Madagascar]. / Pneumonie aiguë communautaire: 96 observations à Madagascar.

The purpose of this report is to describe a study on acute community-acquired pneumonia (CAP) carried out in the Pneumology Department of the Antananarivo University Hospital Center. This prospective one-year study included patients presenting symptoms of acute CAP. Patients with chronic lung disease and tuberculosis were excluded. Study parameters included epidemiological, clinical and laboratory findings as well as data on the efficacy of the therapeutic treatments used. A total of 96 patient charts were analyzed. Males were predominant with a sex ratio of 1.5. Mean age was 41.8 years. A history of pulmonary tuberculosis was noted in 7.2% of cases. Clinical examination showed pulmonary condensation in 93.7% of cases. Radiological examination depicted alveolar syndrome in 97.6%. Betalactamines were the most frequent class of antibiotic agents used for treatment (90.6%). The most frequently prescribed agent was amoxicillin (60.4%) at a dose of 3 g/day. Single-agent therapy was used more often than double-agent therapy (93.7% vs. 6.3%). The oral route was used more frequently than the intravenous route (62.5% vs. 37.5%). The outcome was favorable in 97.9% of cases and lethal in 2.1%. The prevalence of acute CAP in patients hospitalized in our department was low in comparison with that tuberculosis. Since single-agent therapy using amoxicillin at a dose of 3 g/day was effective, this antibiotic can be recommended as the first-line treatment after ruling out tuberculosis.

[Hemoptysis in Madagascar: etiologies of 114 cases]. / Hémoptysie à Madagascar: étiologies de 114 observations.

A prospective study of patients presenting hemoptysis was carried out over a 12-month period in Madagascar. A total of 114 cases were recorded during the study period. Mean patient age was 37 years. Patients were predominantly male. Pulmonary tuberculosis with positive bacilloscopy was the most common etiology (66.66%). Bronchopulmonary cancer accounted for only a small number of cases (1.75%). Etiology was undetermined in a significant number of cases (15.78%).

[Madagascar: public health situation on the "Big Island" at the beginning of the 21st century]. / Madagascar: la situation sanitaire dans la Grande ile au début du XXIe siècle.

The main public health issue in Madagascar at the beginning of the 21st century still involves transmissible infectious diseases including re-emerging diseases such as bubonic plague and emerging diseases such as HIV/AIDS, dengue fever and Chikungunya virus infection. Health and hygiene especially access to clean water is still poor especially in rural areas. No improvement in the public health situation with regard to malaria, schistomosomiais or cysticercosis as well as non-infectious diseases such as protein-energy malnutrition is expected within the next decade.

[Disseminated pulmonary actinomycosis with hepatic injury: a misleading form mimicking a polymetastatic picture]. / Actinomycose pulmonaire disséminée avec atteinte hépatique: une forme trompeuse mimant un tableau polymétastatique.

INTRODUCTION: Thoracic actinomycosis, caused by bacteria of the Actinomyces genus, is a rare infection, with poor prognosis if untreated, whose clinical and radiological picture is misleading, which can simulate a tumoral or tuberculous disease. CLINICAL CASE: This is a case of generalised pseudotumoral pulmonary actinomycosis in a non-smoking, non-drinking 48-year-old man, who for one month has been presenting a cough with haemoptoic sputum, dyspnoea associated with fever and a deterioration in general condition. The clinical examination discovered weight loss, diffuse crackling rales and multiple dental caries. Biologically, he presented an inflammatory syndrome. The radiological imaging and lung and liver CT-scans discovered a peripheral lung mass right side associated with multiple nodular cannon-ball opacities, multiple liver lesions of metastatic appearance. The bacteriological examination of the bronchoalveolar lavage fluid (Gram stain and culture) and the transparietal biopsy of the lung mass confirmed the presence of Actinomyces. Progress under treatment with 10 million international units of parenteral penicillin G daily over a period of six weeks substituted by three grams of amoxicillin/clavulanic acid daily over a period of 12 months and following an oral preparatory procedure was favourable. The thoraco-abdominal scan carried out three months after the treatment showed that the lesions had completely disappeared. CONCLUSION: Our case illustrates the diagnostic difficulty of actinomycosis particularly faced with a picture of multiple lung and liver metastasis. Hence, the importance of a histological and bacteriological examination of samples. The prognosis of this complaint is generally good following well-managed, prolonged treatment; and the prognosis peculiar to disseminated forms is less certain.

[Hemophagocytic syndrome secondary to cavitary pulmonary tuberculosis]. / Syndrome d'activation macrophagique secondaire à une tuberculose pulmonaire cavitaire.

Hemophagocytic syndrome is due to the activation and nonmalignant proliferation of macrophages and T lymphocytes. The purpose of this report is to describe a 25-year-old man who presented with fever, coughing, and weight loss over the past month. Laboratory findings demonstrated pancytopenia, hyperferritinemia, and cytolysis. The myelogram showed a hemophagocytic syndrome, and tuberculosis bacilli were found in the sputum. Chest radiography and thoracic computed tomography depicted a cavitary lesion suggestive of pulmonary tuberculosis. Treatment of tuberculosis alone, without an immunosuppressant agent, was effective and led to improvement. In a country where tuberculosis is highly endemic, hemophagocytic syndrome should be considered in the differential diagnosis of patients with active tuberculosis complicated by pancytopenia.

[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.

[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.

[Huge dorsolumbar cold abscess associated with Pott's disease]. / Volumineux abcès froid péripottique dorsolombaire.

Pott's disease, or tuberculosis of the spine, is the most common osteoarticular tuberculosis. Among them, dorsolumbar impairment is predominant. The authors report the case of a patient with a huge cold lumbar abscess associated with Pott's disease. The patient is a 32-year-old man presenting dorsolumbar tumefaction associated with an alteration in his general condition and fever for three months. Treatment by "traditional healers" did not provide any improvement. He consulted for mild lumbar pain triggered by fatigue appearing one week before and after the failure of the traditional practitioner. The clinical examination found a temperature of 38.5°C, cachexia, mild lumber kyphosis and impressive, soft, painless and non inflammatory dorsolumbar bruised tumefaction, 40 cm high, 15 cm wide and 7 cm deep. He did not present any neurological signs. The dorsolumbar X-ray of the spine revealed a lesion associated with Pott's disease in the first and second lumbar vertebrae with pinching of the disc, punched-out lesions and osteocondensation. The ultrasound examination of the soft tissue revealed the presence of a laterovertebral collection of fluid diffusing in the subcutaneous region. The psoas major and the paravertebral muscles were not affected. A scan or MRI of the spine was not carried out. Examination of the tissue sample and drainage of the abscess confirmed the tubercular origin. Treatment with tuberculostatic drugs for 12 months associated with immobilisation resulted in a cure with sequelae of mild kyphoscoliosis vertebral statics.

[Severe systemic lupus erythematosus induced by isoniazide]. / Lupus érythémateux systémique grave induit par l'isoniazide.

The authors report a rare case of low register systemic lupus erythematosus with renal attack and neurological armature by isoniazid. The patient was a 23-year-old woman presenting a lupus induced by isoniazid 1 month after the treatment of pleural tuberculosis. Antinuclear antibodies, anti-native DNA, anti-ENA, anti-Sm, anti-SSa, anti-SSb and antihistone were present. The symptoms included arthralgia, fever, anaemia, pleural effusion, pericarditis and anasarca. She presented a renal and neurological attack, accounting for the gravity of the disease. The treatment consisted of the interruption of the isoniazid and a bolus of methyl-prednisolone during 3 days relayed by an oral corticosteroid. The evolution was favourable after 8 months of corticosteroids.

Primary health care centres in Madagascar.

PIP: In 1976, Madagascar promised to establish 1500 primary health care centers to be run by a community health agent. The communities selected sites for the centers, nominated health agent candidates, built and maintained the centers and accommodation for the health agents, supplied the centers, and undertook their operation. The government organized the recruitment and training of the agents, paid their wages, and provided equipment and drugs. The candidates were 18-28 years old and had completed two years of secondary education. Training lasted 14 months and enabled the new agents to provide basic health care in the curative, preventive, and educational fields. The health agents can deal with normal births, family planning, vaccination, and health education. In 1991 the country had 1935 facilities that were providing primary care. Some 85% of the health agents have remained in the primary health care centers for over 10 years; 50 agents have moved out to become nurses or midwives. Financial support for the program comes from the state and external donors. Of the 1500 planned primary health care centers, 461 stopped functioning, mostly because the communities concerned have not adequately built and maintained premises for the health agents. The primary health care centers are less frequently attended than formerly because equipment is aging and drugs are in short supply. Cost recovery should be widely adopted in the national health system. More in-service training should be provided for health agents, and more tours of inspection should be carried out. Community health workers should be managed entirely by the community, and the Ministry of Health should take charge of their training. Primary health care in Madagascar has largely proved its worth; if the economic handicaps can be overcome, the program is likely to contribute to the achievement of the health-for-all goals.^ieng