[Rare cause of heart failure in an elderly woman in Djibouti: left ventricular non compaction]. / Une cause rare d'insuffisance cardiaque chez une djiboutienne. Non compaction ventricule guache (NCVG).

The purpose of this report is to describe the first case of left ventricular non compaction diagnosed in Djibouti. The patient was a 74-year-old Djiboutian woman with symptomatic heart failure. Echocardiography is the key tool for assessment of left ventricular non compaction. This rare cardiomyopathy is probably underdiagnosed in Africa.

[Ulceration of the heel in a woman from Djibouti: squamous cell carcinoma with carcinomatous lymphangitis]. / Ulcération du talon chez une Djiboutienne: carcinome epidermoïde avec lymphangite carcinomateuse.

The purpose of this report is to describe a case in which a heel ulcer with atypical features, i.e., large size and rapid progression, led to diagnosis of squamous cell carcinoma. Patient management was based on specialist advice obtained by "tele-dermatology" based on pictures and comments transmitted over the Internet. However, due to the risk of spreading and impossibility of providing other medical treatment (radiotherapy-chemotherapy), the lower limb was amputated at the top of the thigh.

[Comparative study of exercise-induced ischaemia in coronaropathy and aortic stenosis]. / Etude comparative de l'ischémie d'effort entre patients coronariens et patients atteints de rétrécissement aortique.

OBJECTIVE: To compare exercise and recovery data between a population of patients with proven CAD and patients with pure aortic stenosis (AS). PATIENTS AND METHODS: Exercise testing results (bicycle ergometry) of 45 patients with AS (34 men, 66+/-12 years, 56+/-20 mmHg peak-to-peak gradient and valve area 0.78+/-0.48cm2) were compared to exercise testing results of 50 patients with CAD (41 men, 65+/-9 years, greater or equal to 70% stenosis on one vessel in 62%, two vessels in 30%, three vessels in 8%). RESULTS: During exercise, 38% patients with AS and 82% patients with CAD had clinical symptoms. In the AS group, exercise duration was longer, heart rate (HR) was higher, maximal systolic and diastolic blood pressure were lower than in CAD group. The increase of systolic blood pressure was lower in the AS group (34+/-21 mmHg versus 47+/-27 mmHg, p<0.02). Maximal load achieved was not significantly different. Exercise ST depression appeared in 76% of AS group and 88% of CAD group (NS). No difference was found in ST depression, Detrano index and ST segment/HR slope. During recovery, no difference was found in HR variations. Clockwise rotation of the ST/HR recovery loop was more frequent in CAD group (35 patients versus 19 patients, p<0.001). CONCLUSION: Most of the exercise and recovery data are similar in patients with AS and CAD. Significant discriminating criteria were the increase of systolic blood pressure during exercise and ST/HR recovery loop.

[Transient left ventricular apical ballooning syndrome. Case report and review of the literature]. / Syndrome de ballonisation apicale transitoire du ventricule gauche. Revue de la littérature à propos d'un cas.

SUBJECT: Transient left ventricular apical ballooning syndrome, known as the japanese name of tako-tsubo was recently described and is characterised at the acute period by a large apical dyskinesia of the left ventricule apex. This syndrome usually mimics an acute coronary syndrome, sometime a cardiac failure or arrhythmias. We report a typical case of a seventy-seven years old women struck by a tako-tsubo syndrome revealed by an acute chest pain after an emotional stress. The diagnosis was proposed because angiography didn't shown any abnormality in spite of a large left ventricular dysfunction at the ventriculography. Actuality and strong points: Tako-tsubo syndrome is more and more published due to a better knowledge of this syndrome, specially in the acute coronary syndrome without coronary abnormality. His physiopathology is not well known but is clearly in relation with an acute stress. Several hypothesis are discussed, helped by some experimental animal model. With an excellent prognosis at a middle-course, his discovery allow an adapted take care especially of the complications. PROSPECT: The setting up of clinic and electrocardiographic reliable and well-tried criteria will allowed an early diagnosis to avoid harmful treatment. His specific treatment is not reached by consensus but will develop by a better knowledge of the physiopathology.

[Diagnosis difficulty in occult constrictive pericarditis]. / Difficulté diagnostique de la péricardite constrictive occulte. A propos d'un cas.

We report the case of a 42 years woman known to have a cardiac heart failure attributed to restrictive cardiomyopathy for want of any other plausible diagnosis. Evolution and repeted investigations finally permitted to rectify the diagnosis by revealing a constrictive pericarditis, remained occult 9 years during. The differentiation of restrictive cardiomyopathy and constrictive pericarditis has been a perennial problem in clinical cardiology. Diagnosis of constrictive pericarditis is based on associated signs sometimes too poor to go straight to thoracotomy. We discuss the mean to approach more precisely this uncommon pattern named occult constrictive pericarditis.

[Amebic lung abscess: an unexpected diagnosis]. / Amibiase pleuropulmonaire: un diagnostic inattendu.

Pleuropulmonary amebiasis is a very rare complication of amebiasis infection and direct pulmonary involvement is exceptional. The clinical diagnosis is difficult without any intestinal or extraintestinal manifestations. A percutaneous drainage is necessary to aspirate pus. We report herein the case of a 56-year-old man presenting with an amebic lung abscess in his right lower lung and pleural effusion. The diagnosis was suspected by our laboratory from a serological assay (antiamebic antibodies reaching 320 by IHA) and established from a direct examination of the pus in which rare trophozoites of Entamoeba were detected. We pointed out the importance of the communication between the clinician and the biologist. Protozoan infection should be suspected in pleuropulmonary infection when antibiotics failed even in France. This patient left endemic area a long time ago and the way of his amebiasis contamination is unknown: recurrence of amebic infection is rare and prevalence in industrialized countries reaches only 1%. Several hypothesis are exposed.

[Severity of aortic ring abscess complicated by cardiac conduction abnormalities]. / Sévérité des endocardites abcédées du manchon aortique compliquées d'anomalies de la conduction.

OBJECTIVE: To determine clinical features, management and prognosis of cardiac conduction abnormalities (CCA) complicating abscessed endocarditis. METHODS: We have analysed clinical, microbiologic and echocardiographic datas, therapies and outcome of cardiac abscesses complicated by CCA in patient hospitalized between 1995 and 2001 in our centre. RESULTS: Above 35 cardiac abscesses, six men (mean age 62 years) had CCA complicating six aortic ring abscesses (4 on native valve and 2 on prosthetic valve) with four cases of interventricular septal involvement and fistulization. Severe heart failure is present four times, a septic cerebral embolization twice. Streptococcus and Staphylococcus prevail. Complete atrioventricular block (AVB) reveals endocarditis twice and complicates the evolution three times. Trifascicular block (first degree AVB, left anterior fascicular block and complete right bundle branch block) revealed recurrence of endocarditis. Two patients were treated medically: one died quickly (complete AVB pre-mortem), and the other one had favourable issue (paroxystic complete AVB). Four patients had surgery with temporary pacemaker in three cases (one died) then definitive pacemaker in two cases. At 26.5 month (7-50), the four survivors had no recurrence of endocarditis. CONCLUSION: Severe CCA are classical in aortic ring abscessed endocarditis and associated with increased mortality. Immediate transfert in a dentre with cardiac surgery is necessary. Definitive cardiac pacing can be performed early without leads infection.

[Upper extremity deep venous thrombosis. 40 hospitalized patients]. / Thromboses veineuses profondes des membres supérieurs: à propos de 40 patients hospitalisés.

Deep venous thrombosis is 50 times less frequent in upper than in lower limbs. Data remain poor in the literature. Forty consecutive patients (24 males, 16 females, mean age: 54.5 years) were retrospectively analysed from 161 subjects who underwent venous explorations of the upper extremity for a 3.5 year period in the same center. Diagnosis of thrombosis was made by duplex ultrasonography (n =37) or phlebography (n =3). Main clinical manifestations were edema (n =36) and pain (n =29). Location of thrombosis was humeral (n =1), axillary (n =2), or sub-clavian (n =37, 2 bilateral). The majority of thrombosis (n =29) were secondary to cancer and venous catheter (n =19, 15 implanted ports), to central catheter alone (n =3) or cancer alone (n =7). The 11 others were associated with thoracic outlet syndrome (n =6) or apparent primary thrombosis (n =5). Thrombophilia was identified in 6 out of these 11. During follow up [mean of 9 months (0,5-36)], two patients developed pulmonary embolism, 14 a post-thrombotic syndrome and 16 patients died. Initial therapy included heparin (n =36) or fibrinolysis (n =4). Upper extremity deep venous thrombosis are mostly associated with cancers and venous catheters. Thrombophilia is frequent in the other cases. Heparin followed by oral anticoagulation is the optimal therapy whose duration depends upon underlying condition. Fibrinolysis has not been useful for preventing post-thrombotic syndrome in our study.

[Isolated pleural amebiasis: about one case in France]. / Amibiase pleurale isolée.

INTRODUCTION: Isolated pleural amebiasis is exceptional in the world and specially in France. CASE REPORT: We report a case of acute isolated pleural amebiasis in a 56 year old man who did not travelled in endemic countries for the 20 past years. Chocolate-colored pus from the pleural puncture suggested the diagnosis. Positive amebic serology and above all, trophozoites (Entamoeba histolytica) in the pleural liquid confirmed the diagnosis of pleural amebiasis. Drainage was required and metronidazole was introduced. Other antibiotics were necessary to treat bacterial co-infection, which is frequent. Of interest, a nurse developed an acute intestinal amebiasis probably infected by pleural pus, an indirect confirmation of diagnosis. CONCLUSION: This diagnosis should be suspected even in low endemic areas in case of infectious pleurisy resistant to traditional antimicrobial regimens.

[Exercise-induced left bundle branch block with chest pain related to antimalarial prophylaxis with chloroquine]. / Bloc de branche gauche douloureux d'effort associé à la chimioprophylaxie antipaludique par chloroquine.

Left bundle branch block (LBBB) during exercise can be associated with chest pain. Though this association is mostly correlated with an underlying coronary artery disease, painful LBBB has been described in patients with normal coronary arteries. We report a case of exercise-induced LBBB with typical angina pectoris related to antimalarial prophylaxis with chloroquine in a 66-year old woman with normal coronary arteries, which was reversed after treatment discontinuation. The effect of chloroquine on the electrophysiological properties of nodal cardiac tissue is responsible for this rate-dependent LBBB. Precautions for future antimalarial prophylaxis are also discussed.

[Atypical left ventricular hypertrophy revealing a rare cause of heart failure in a man from the Comoros Islands]. / Hypertrophie ventriculaire gauche atypique révélatrice d'une cause rare d'insuffisance cardiaque chez un Comorien.

In Africa, hypertension is a major public health problem, and hypertensive heart disease is a leading cause of heart failure. Left ventricular hypertrophy is a common consequence of hypertension. We present a case illustrating an unusual cause of such hypertrophy in a 73-year-old patient with heart failure living in the Comoros Islands, in whom we diagnosed cardiac amyloidosis. This disease has not previously been reported in the Comoros Islands and remains associated with a poor prognosis.

[Heart failure patterns in Djibouti: epidemiologic transition]. / Insuffisance cardiaque chez l'adulte à Djibouti : la perspective d'une transition épidémiologique.

BACKGROUND: The features of heart failure (HF) in Djibouti have not been well described. We sought to document the current patterns of HF here. METHODS: We prospectively included Djiboutian adults hospitalized for HF in the French Military Hospital (Djibouti) from August 2008 through December 2010. RESULTS: Of 1688 adults hospitalized in the medical department, 45 (2.7%) had symptomatic HF: 38 (84%) men, mean age 55.8 years (range 27-75). Twenty-five (56%) patients were initially hospitalized for acute pulmonary edema. The underlying diseases included coronary artery disease (CAD) (62%), hypertensive heart disease (18%), rheumatic valvular disease (13%), and primary dilated cardiomyopathy (7%). Their cardiovascular risk factors included tobacco use (53%), hypertension (69%), diabetes (47%), and hypercholesterolemia (51%). Patients in the CAD group were older, and had diabetes more often (p<0.01). All khat chewers (53%) were males and smokers. Mean left ventricular ejection fraction (LVEF) was 39 ± 14%. During follow-up (14.4 ± 9 months), 8 (18%) patients died, 9 (20%) were again hospitalized for HF, and 3 (7%) had ischemic strokes. One month after discharge, the New York Heart Association (NYHA) class was II for 40%, III for 44%, and IV for 16%. Higher NYHA classes and dilated cardiomyopathy were both associated with poorer outcomes (p<0.03). CONCLUSION: In hospitalized Djiboutians, most HF patterns are similar to those in industrialized countries. CAD is more prevalent than previously reported in African patients with HF.

LEOPARD syndrome.

LEOPARD syndrome (LS) is a rare hereditary disorder, characterised mainly by skin, facial and cardiac abnormalities. We report on the case of a six-year-old Djiboutian with typical features of LS. Multiple cardiovascular problems are described, including pulmonary infundibular, valvular and supra-valvular stenosis. A favourable course was observed after successful cardiac surgery. This is the first reported case of LS from the horn of Africa.

[Acute myocardial infarction in Djibouti: 2-year prospective study]. / Infarctus du myocarde en phase aiguë à Djibouti : étude prospective sur deux ans.

OBJECTIVES: Acute myocardial infarction (AMI) is a life-threatening emergency. In Africa, the increasing prevalence of cardiovascular risk factors is leading to an epidemiological transition. No data have yet been reported about AMI in Djibouti. PATIENTS AND METHODS: This study prospectively included all patients with acute coronary syndrome and persistent ST segment elevation admitted to the emergency department of Bouffard Military Hospital in Djibouti from January 2009 through December 2010. It analyzed their clinical data and management. RESULTS: The study included 35 patients. Their mean age was 52 ± 11 years [range: 29-76]. The sex ratio was 7.7 (men/women). Cardiovascular risk factors were: hypercholesterolemia (83%), tobacco use (60%), khat chewing (57%), diabetes (49%), hypertension (46%), and heredity (20%). AMI was anterior in 40% of cases. Fifteen patients (43%) arrived within 12 hours after the onset of symptoms (average 5 hours); thrombolysis was successful for 11 of them (73%). Seven patients (20%) died over the entire follow-up (11.3 ± 9 months), 5 within the first month. Mortality was significantly associated with diabetes (p<0.01), initial severe clinical complications (p<0.01) and initial low left ventricular ejection fraction (p<10(-6)). CONCLUSION: Patients with AMI in Djibouti are 10 to 15 years younger than in Western countries. Their high level of cardiovascular risk is remarkable. Khat use did not significantly affect prognosis. The high mortality rate was similar to rates reported before the percutaneous coronary angioplasty era.

[Whole-blood transfusion for hemorrhagic shock resuscitation: two cases in Djibouti]. / Transfusion de sang total pour la réanimation du choc hémorragique: à propos de deux cas à Djibouti.

Hemorrhagic shock requires early aggressive treatment, including transfusion of packed red blood cells and hemostatic resuscitation. In austere environments, when component therapy is not available, warm fresh whole-blood transfusion is a convenient treatment. It provides red blood cells, clotting factors, and functional platelets. Therefore it is commonly used in military practice to treat hemorrhagic shock in combat casualties. At Bouffard Hospital Center in Djibouti, the supply of packed red blood cells is limited, and apheresis platelets are unavailable. We used whole blood transfusion in two civilian patients with life-threatening non-traumatic hemorrhages. One had massive bleeding caused by disseminated intravascular coagulation due to septic shock; the second was a 39 year-old pregnant woman with uterine rupture. In both cases, whole blood transfusion (twelve and ten 500 mL bags respectively), combined with etiological treatment, enabled coagulopathy correction, hemorrhage control, and satisfactory recovery.

[Lethal aortic endocarditis due to Gemella morbillorum in a Djiboutian khat user]. / Endocardite aortique fatale due à Gemella morbillorum chez un consommateur de khat de Djibouti.

We report a 22-year-old man who presented in January 2009 in Djibouti for an aortic-abscessed endocarditis due to Gemella morbillorum (G. morbillorum). A voluminous aortic abscess that extended to the perimembranous ventricular septum was fistulized into the right atrium. Atrioventricular conduction abnormalities were observed. The portal of entry was dental with multiples caries and a periodontitis attributed to khat chewing. The patient died within few days. Diagnosis, severity and management of endocarditis due to this rare bacterium are discussed.