[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.

Evaluation of the Xpert MTB/RIF assay for the diagnosis of smear-negative pulmonary and extrapulmonary tuberculosis in Madagascar.

OBJECTIVE: To evaluate the feasibility of the implementation of a commercial rapid molecular diagnostic test (Xpert MTB/RIF) for the routine diagnosis of smear-negative or extrapulmonary tuberculosis (TB) and its diagnostic accuracy, and to assess HIV prevalence in a real-life setting in Madagascar. This study was set in a tertiary care hospital in Madagascar. METHODS: A prospective cohort study was conducted of all consecutive cases with suspected smear-negative and/or extrapulmonary TB over a 2-year period. Cases were classified as proven, probable, or possible TB cases, or as having an alternative diagnosis. RESULTS: Of the 363 patients included, 183 (50.4%) had suspected smear-negative pulmonary TB and 180 (49.6%) had suspected extrapulmonary TB. For proven cases, the sensitivity, specificity, positive and negative predictive values of Xpert MTB/RIF were 82.4%, 98.8%, 98.3%, and 86.6%, respectively; for proven and probable cases grouped together, these values were 65%, 98.8%, 98.5%, and 64%, respectively. The diagnostic accuracy was slightly lower for extrapulmonary TB compared to smear-negative pulmonary TB. The prevalence of HIV infection was 12.1%, but almost half of these cases did not have TB (alternative diagnosis group). CONCLUSIONS: The implementation of a rapid diagnosis programme for TB in a resource-poor setting is feasible. The performance of the Xpert-MTB/RIF was remarkable in this difficult-to-diagnose population. HIV prevalence in this study was much higher than the prevalence reported in the general population in Madagascar, in patients with TB and patients with conditions other than TB.

[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.

[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.

[Post-malaria neurological syndrome complicating a Plasmodium falciparum malaria in Madagascar]. / Syndrome neurologique postpaludisme compliquant un paludisme simple à Plasmodium falciparum à Madagascar.

Post-malaria neurological syndrome is a rare complication of malaria. Typically, it occurs in case of severe malaria. Here we report a case in a Malagasy patient presenting a non-severe Plasmodium falciparum malaria complicated by post-malaria neurological syndrome. The management of such a syndrome is radically different from non-severe malaria. No specific treatment is needed.

[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.

[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.

[Organizing pneumonia secondary to a hiatal hernia]. / Pneumopathie organisée secondaire à une hernie hiatale.

Organizing pneumonia secondary to a hiatal hernia is a specific kind of inflammatory and fibroproliferative lung reaction due to a pulmonary aggression involving micro-inhalation of the digestive contents. The authors report the case of a 74-year-old woman presenting pneumonia of infectious speed, resistant to a triple antibiotic treatment. Clinically, her general condition changed and associated cough, fever, dirty sputum and dyspnoea. The bacteriological and immunological tests were normal. The respiratory functional explorations showed a moderate restrictive syndrome and hypoxemia. The broncho-alveolar wash found a mixed alveolite of predominantly lymphocyte and polynuclear neutrophiles. The thoracic scanner detected pleural alveolar opaqueness with the characteristic of organizing pneumonia as well as a voluminous hiatal hernia discovered by chance. No lung samples were taken because of a precarious general state of the patient and the respiratory instability. The strong corticosensitivity to the corticosteroid therapy backed up the authors' diagnostic hypothesis. The clinical and radiological evolution was good after six months of treatment. The patient benefited from a medical and then surgical treatment with a good evolution and without any recurrence.

[Severe presentations of Rift Valley Fever in Madagascar]. / Les formes graves de la fièvre de la vallée de Rift pendant l'épidémie à Madagascar.

OBJECTIVE: The authors describe clinical and epidemiologic characteristics of severe presentations of Rift valley fever (RVF) during the 2008 epidemic in Madagascar. METHODOLOGY: The diagnosis was confirmed by RVF virus polymerase chain reaction (PCR), or detection of specifics antibodies by Elisa. RESULTS: Sixteen cases of severe RVF were recorded. The sex-ratio was 7/1 and median age was 32 years (20/59 years). The risk factors of infection were: contact with infected animals or their meat (n=8), and travelling to a risk area (n=2). Hemorrhagic, neurological, and ocular manifestations were observed respectively in 87.5%, 43.8% and 6.3% of cases. All patients who died (n=4) presented with a hemorrhagic form of the disease. CONCLUSION: The hemorrhagic form was the most frequent presentation of RVF and was responsible for a high level of mortality. Epidemiologic surveillance must be implemented.

[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.

[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.

[Experience in the use of the malaria rapid diagnostic test in Madagascar]. / Test de diagnostic rapide du paludisme: l'expérience malgache.

Diagnosis of malaria cases depends on parasitological examination. Since 2006, the Department of Infectious Diseases at the Joseph Raseta Befelatanana University Hospital in Madagascar has been using the malaria rapid diagnostic test. The percentage of malaria cases (presumed or confirmed) in relation to the number of hospitalized patients has decreased. It was 23.4% in 2003, 10.3% in 2006 and 4.3% in 2008 (p<0.01532). To improve management of malaria cases and rationalize use of antimalarial agents, diagnosis should be confirmed by rapid diagnostic tests.

[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.

[Epidemiological, clinical and therapeutic aspects of severe malaria in adults in hospital in Antananarivo, Madagascar]. / Aspects cliniques et thérapeutiques du paludisme grave de l'adulte en milieu hospitalier a Antanana- rivo, Madagascar.

Few data are available about severe malaria in Madagascar. Our aims were to describe epidemiological, clinical and therapeutic aspects of severe malaria in patients in Antananarivo. We conducted a retrospective study from 1 March 2006 to 31 March 2008 at the infectious disease department. We recorded 61 cases of severe malaria among 1,803 in patients. Sex ratio was 2 and average age was 35.3 years old. Three pregnant women were recorded among women (15.8%). Self-medication was registered in 23%. Among 35 patients who received first medical care, no one had parasitological examination. The treatment was inadequate for all patients (n = 19). Conscience impairment (65.6%), jaundice (24.6%), seizure (18%) and prostration (14.8%) were the major severe signs. Diagnosis was made 6.54 days after the onset of the disease. Mortality rate was 11.5%. Self-medication, inappropriate primary care and delayed diagnosis represented risk factors for severe malaria in our cohort.