[Efficacy and tolerance of direct-acting antiviral drugs for the treatment of hepatitis C in Joseph Raseta Befelatanana Teaching Hospital in Antananarivo, Madagascar]. / Efficacité et tolérance des antiviraux à action directe dans le traitement de l'hépatite C au CHU Joseph Raseta Befelatanana d'Antananarivo, Madagascar.

Objective: Our work aimed to assess the efficacy and safety of direct-acting antiviral drugs in the treatment of hepatitis C in Madagascar. Methods: This retrospective clinical study was carried out from March 2018 to February 2020 in the hepato-gastro-enterology department of the University Hospital Center Joseph Raseta de Befelatanana. Results: A total of 35 patients were included, out of which 24 received sofosbuvir/ledipasvir ± ribavirin, 10 sofosbuvir/ribavirin and one sofosbuvir/velpatasvir. Thirty-three patients were naïve to the treatment and 2 patients were initially treated with the sofosbuvir/ledipasvir combination. The sustained virologic response was 94% (33/35) in the general population, 23/25 in cirrhotic patients and 10/10 in non-cirrhotic patients. The sustained virologic response was 22/24 for sofosbuvir/ledipasvir ± ribavirin, 10/10 for sofosbuvir/ribavirin and 1/1 for sofosbuvir/velpatasvir. Adverse effects were observed in 13 patients, mainly asthenia and insomnia. Discussion: The small number of patients with hepatitis C treatments and their limited financial resources are the main limits of this survey. Conclusion: Direct-acting antivirals are effective and characterized by good tolerance in these Malagasy hepatitis C patients.

[Acute cholangitis secondary to ascariasis and complicated by liver abscesses]. / Angiocholite aiguë d'origine ascaridienne compliquée d'abcès hépatiques.

Acute cholangitis secondary to ascariasis is rare and occurs mainly in areas of high endemicity. The clinical presentation is non-specific, sometimes complicated by liver abscess. Abdominal ultrasound plays an important role in diagnosis and therapeutic surveillance. We report the case of a 35-year-old Malagasy woman with an acute cholangitis secondary to ascariasis and complicated by liver abscesses and its course to full recovery under medical treatment.

[Helicobacter pylori: what eradication regimen in a tropical area after the failure of two separate lines of eradication including metronidazole and clarithromycin?]. / Helicobacter pylori : quel traitement d'éradication en cas d'échec de deux lignes de traitement comprenant le métronidazole et la clarithromycine en zone tropicale ?

Helicobacter pylori (H. pylori) resistance against antibiotics is a major challenge, particularly in developing countries. We report a case of H. pylori infection where eradication by two lines of treatment, one including metronidazole and the other clarithromycin, failed, and discuss the management of such a case in a tropical area. This 55-year-old man complained of epigastric pain dating back for three years. A stool antigen test for H. pylori was positive. First-line eradication therapy, which combined a proton pump inhibitor, amoxicillin and metronidazole, was unsuccessful, as was the second-line therapy, which replaced metronidazole by clarithromycin. Third-line treatment, which still included a proton pump inhibitor and amoxicillin but added levofloxacin was successful. A stool antigen test to verify eradication was finally negative. In developing countries, H. pylori eradication must be managed rationally. In particular, fluoroquinolones must be reserved for treatment failure. The stool antigen test appears to be a useful and economical alternative to the urea breath test for verifying eradication.

[A case of curable encephalomyelitis in a tropical area: pernicious anemia]. / Un cas d'encéphalomyélopathie reversible en milieu tropical: anemie de biermer.

Pernicious anemia is uncommon in Africa. The purpose of this report is to describe a case of pernicious anemia observed in Madagascar. The revealing manifestation was encephalomyelitis with combined medullar sclerosis that responded favorably to vitamin B12 replacement therapy. Clinical symptoms included paresthesia associated with allodynia of all four extremities and with tetrapyramidal syndrome, medullar ataxia and minor cognitive disturbances ongoing for 5 months. Hemogram testing revealed macrocytic anemia. Serum cobalamin level was low. Anti-intrinsic factor antibody was detected. Spinal cord magnetic resonance imaging showed diffuse high-signal intensity along the posterior spinal cord extending from C1 to C4. Vitamin B12 replacement therapy led to full regression of clinical signs after six weeks. Association of central nervous system involvement with macrocytic anemia suggests vitamin B12 deficiency and pernicious anemia should be suspected. This disease can be considered as a curable form of myelitis in Africa and Madagascar.

[Causes of death in a sample of cirrhotic patients from Madagascar]. / Les causes de mortalité dans une population de patients cirrhotiques malgaches.

OBJECTIVE: Cirrhotic patients have poorer life expectancy than the general population. The purpose of this study was to identify causes of death in a sample of cirrhotic patients from Madagascar. METHODS: A retrospective analytic and descriptive study was conducted on the files of cirrhotic inpatients admitted to the gastroenterology department of the Joseph Raseta Befelatanana University Hospital Center in Antananarivo, Madagascar from January 1, 2003 to June 30, 2007. RESULTS: The files of 117 patients were reviewed. Death occurred in 31 cases for a mortality rate of 26.5%. The main causes of death were disorders of consciousness (51.6%) and hypovolemic shock (25.8%). Jaundice, encephalopathy, and gastrointestinal bleeding were predictive factors for mortality. CONCLUSION: Cirrhotic patients in this study were hospitalized at a late stage of disease. Further prospective study in a larger sample will be needed to standardize the management protocol in Madagascar.

[Relation between Shistosoma mansoni and hepatosplenomegalies]. / Relation entre Schistosoma mansoni et hépatosplénomégalies à Madagascar.

INTRODUCTION: Although they remain a neglected transmissible disease, affecting mainly people in poor countries, the combined forms of schistosomiasis are second only to malaria as a major parasitic disease. Although both urinary and intestinal schistosomiasis are endemic in Madagascar, this study focuses only on the intestinal forms. The symptoms may remain unnoticed or be ignored, for the seriousness of intestinal schistosomiasis is due mainly to its hepatosplenic complications. OBJECTIVES: To estimate the etiological fraction of Schistosoma mansoni involved in hepatomegaly (HM), splenomegaly (SM) and hepatosplenomegaly (HSM), with or without signs of portal hypertension (PHT). METHODS: This file-based retrospective study includes patients admitted to the University Hospital of Antananarivo, Madagascar, between January 2005 and July 2008, who presented with HM, SM, HSM and/or PHT. The case was attributed to schistosomiasis if blood serology, tested with ELISA, was positive for this parasite. The statistical analysis used three approaches: a cross-sectional approach, a longitudinal approach (retrospective cohort), and a "case-control" approach. RESULTS: Of 7308 admissions during this period, 269 (4%) were diagnosed with a hepatosplenic complication and were retained. The average age (+/- standard deviation) was 47.8 (+/- 16.4) years. HM accounted for 55.4% of cases, SM 18.9%, HTP 18.6% and HSM 18.6%. Serology was positive for schistosomiasis in 21.6% of cases. The sex ratio (men:women) for these cases was 1.9, and 67.3% of the patients were aged 30 years or older. The main schistosomiasis complications were SM (n=22) and HTP (n=22). The age group most affected depended on the specific complication: for HM, 28.6% of patients were aged between 40 and 49 years; for HSM, 57.1% were aged between 30 and 40 years. The prevalence of SM was lower in subjects between 50 and 59 years of age (4.5%) than the other complications. Patients with positive serology results were significantly younger than those with negative results, or whose serology was not checked (37.8 years vs. 50.5 years, p < 0.001). Stratification according to complication showed that the etiological fraction of schistosomiasis was 76% for patients with SM, 79% for HTP, 58% for HSM and 4.9% for HM. The retrospective cohort and the case-control analyses both showed that a history of dysentery and frequent contact with water were the main factors associated with complicated schistosomiasis. It is important to note that urban and rural residents had the same risk of developing schistosomiasis with complications (OR: 0.9 [0.4; 1.9]). CONCLUSION: This study showed that schistosomiasis infection is strongly associated with hepatosplenic pathologies. One of the shortcomings of the study is the absence of any analysis of the course and outcome in the study patients. Nevertheless, the course of oesophageal varices, SM or HSM in patients with HTP indicates that schistosomiasis was often fatal.

[Portopulmonary hypertension due to schistosomiasis in two Malagasy patients]. / Hypertension porto-pulmonaire d'origine bilharzienne chez deux patients malgaches.

Portopulmonary hypertension is characterized by a chronic liver disease associated with a mean pulmonary artery pressure >25 mmHg at rest, an increased pulmonary vascular resistance and a capillary pulmonary pressure <15 mmHg with portal hypertension. Schistosomiasis may be an aetiology of this syndrome, however, few cases have been reported. We describe the first cases of portopulmonary hypertension with schistosomiasis in Malagasy patients. There were 2 men aged of 18 and 20 from hyperendemic area of schistosomiasis in Madagascar Both had a history of repeated water contact. They presented a dyspnea associated with ascites and oedema. Clinical examination showed portal and pulmonary hypertension with right ventricular heart failure. Cardiac examination revealed a systolic murmur and splint of the second heart pulmonary Pulmonary hypertension was confirmed by cardiac ultrasonogaphy Serology of bilharzias was positive. Parasitological examination showed eggs of S. mansoni. The treatment based on salt-free diet, spironolactone and praziquantel led to a better evolution of symptoms (case 1). Symptoms of right heart failure remained for the second patient even though improvement was noted. In tropical countries, schistosomiasis may be one of the cause of portopulmonary hypertension and may appear in early age. Its treatment remains difficult as the drugs recommended are not affordable.

[Seroprevalence of Helicobacter pylori infection in Malagasy population]. / Séroprévalence de l'infection due à Helicobacter pylori dans un échantillon de population malgache.

Helicobacter pylori is a worldwide infection. However very few data are actually available on H. pylori seroprevalence in the Malagasy population. We carried out a transversal study in a sample of persons who met the following criteria: older than 15 years old, presence in the medicine internal unit 2 (University Hospital Center of Antananarivo) during the period of the study whatever the reason. H. pylori infection was identified serologically by using ELISA (G.A.P IgG H. pylori ELISA, Bio-Rad, France). Several factors were evaluated including serological status, demographic information, the reason of the presence in the unit, factors influencing H. pylori infection: socio-economic status, siblings, promiscuity consumption of alcohol, use of tobacco, water source and history of gastroscopy. The presence of clinical symptoms, such as dyspepsia and abdominal pain, was determined. Forty-five men and 45 women were included (mean age: 41.8 +/- 3.4 years). The seroprevalence of H. pylori infection was 82%. H. pylori infection was higher in men than in women (p < 0.02). Promiscuity constituted the principal factor influencing H. pylori infection. The seroprevalence of the H. pylori infection appears to be comparable to the rate encountered in developing countries. Considering this high rate of the H. pylori infection, eradication of H. pylori should be commonly recommended when facing gastrointestinal pathologies potentially induced by H. pylori.

[Portal vein thrombosis in HIV-infected patients: report of four cases]. / Thrombose portale chez des patients infectés par le virus de l'immunodéficience humaine: à propos de quatre observations.

Portal vein thrombosis (PVT) seems rare among HIV infected patients. Even though, the report of such cases is of great interest because it may help to determine the factors of occurrence. We describe cases of PVT in 4 HIV-infected men, aged 32 - 64. Two of them were co-infected with hepatitis C virus (HCV). The four patients had a history of disseminated mycobacterial infection (one case of tuberculosis, 3 cases of mycobacterium avium complex infection) with abdominal lymphadenitis. Despite HAART, their immunodeficiency was profound (CD4: 65 to 216/mm(3)). At the time of diagnosis, two patients were treated with protease-inhibitor containing regimen: indinavir (one case), ritonavir-saquinavir (one case). PVT was revealed by haematemesis (one case), abdominal pain (ome case), anasarca (2 cases). In three patients, the diagnosis of PVT was confirmed by imagery (echo-doppler or angio- RMI), and for the last patient, PVT was found during the transjugular intrahepatic portosystemic shunt setup. A low level of C protein was diagnosed in one case. Cirrhosis was not found in HIV-HCV co-infected patients. Two patients died early after diagnosis, one patient died 3 years after the onset of symptoms. Various factors may cause the development of a PVT in HIV infected patient. Serious immunodeficiency, opportunistic infections such as tuberculosis and mycobacterium avium complex related infection with abdominal lymphadenitis can further the development of PVT. Protease-inhibitor might have facilitated the process. Due to the severe prognosis of advanced cases, early evocation of diagnosis is needed.