Sporotrichosis in the Highlands of Madagascar, 2013-20171.

Sporotrichosis is a saprozoonotic fungal infection found mostly in tropical and subtropical areas. Few case reports in Madagascar have been published. To document sporotrichosis epidemiology in Madagascar, we conducted a cross-sectional study. During March 2013-June 2017, we recruited from select hospitals in Madagascar patients with chronic cutaneous lesions suggestive of dermatomycosis. Sporotrichosis was diagnosed for 63 (42.5%) of 148 patients. All but 1 patient came from the central highlands, where the prevalence was 0.21 cases/100,000 inhabitants. Frequency was high (64.7%) among patients <18 years of age. Sporotrichosis was diagnosed for 73.8% of patients with arm lesions, 32.3% with leg lesions, and 15.4% with lesions at other sites. Molecular identification identified 53 Sporothrix schenckii isolates. Among the 32 patients who were followed up, response to itraconazole was complete or major for 15 and minor for 17. Overall, endemicity of sporotrichosis in Madagascar was high, concentrated in the highlands.

Coinfection with Leprosy and Tuberculosis: A Case Series in Malagasy Patients.

Background: Leprosy and tuberculosis are two of the oldest and most common mycobacterial infections, caused by Mycobacterium leprae and Mycobacteium lepramatosis for leprosy and Mycobacterium tuberculosis for tuberculosis. Dual infections have been known since ancient times; however, cases remain rarely reported in the literature, even in countries where both diseases are endemic, such as Madagascar. Purpose: We report a case series of simultaneous occurrence of leprosy and tuberculosis. Patients and Methods: In this retrospective study, we reviewed the medical records of patients with leprosy registered at the Department of Dermatology, University Hospital Befelatanana, Antananarivo, Madagascar, between January 2012 and June 2021. Patients with leprosy and diagnosed as coinfected by tuberculosis were included in the study. Results: Of the 120 leprosy cases observed during the study period, coinfection with leprosy and tuberculosis was found in five patients. The mean age was 43.4 (SD 13.2) ranging, 21-59 years. Male gender was predominant (4/5). Four patients presented with lepromatous leprosy, and one with borderline lepromatous leprosy. Three patients experienced leprosy reaction. Four cases of pulmonary tuberculosis and one case of multifocal tuberculosis were observed. The diagnosis of leprosy preceded tuberculosis in four cases, and a coinfection diagnosis was made simultaneously in one case. The average time to develop tuberculosis was 38.8 (SD 10.2) months. HIV infection, malnutrition, alcohol consumption, and long-term corticosteroid therapy were the immunosuppressive factors reported in our patients. Three patients received concomitant multidrug therapy for leprosy and tuberculosis. Conclusion: Dermatologists should be aware of the importance of screening patients affected by leprosy for latent or active tuberculosis to prevent morbidity and mortality due to coinfection and to reduce the risk of acquired resistance to rifampicin, which is the greatest risk of this association.

Bullous Hemorrhagic Dermatosis Induced by Enoxaparin: About a Case in Madagascar.

Bullous hemorrhagic dermatosis is an adverse reaction occurring within 5 to 21 days after anticoagulation; the diagnosis is to be evoked in the presence of hemorrhagic bullous lesions at a distance from the injection site in the days following the introduction of anticoagulant; this is a diagnosis of exclusion. It is a rare pathology that mainly affects the elderly. A 54-year-old man presented with bullous hemorrhagic lesions on the left upper limb starting at the 4th day after enoxaparin injection, diagnosed as a bullous hemorrhagic dermatosis induced by enoxaparin. We report the first case of bullous hemorrhagic dermatosis induced by enoxaparin in Madagascar.

Clinicoepidemiology of Skin Diseases in Children Seen at the University Hospital Center Morafeno, Toamasina, Madagascar.

INTRODUCTION: The child's skin diseases are common and very diverse. Many studies concerning pediatric dermatoses have been carried out in Africa and the rest of the world. Few epidemioclinical data reflect these skin diseases in children, especially in the east coast of Madagascar. We aim to describe the pattern skin diseases among children seen at the University Hospital Center Morafeno, Toamasina, Madagascar. Patients and Methods. A retrospective study over a 3-year period from January 2017 to December 2019 was conducted in children seen in the Dermatology Department of University Hospital Center Morafeno, Toamasina, with skin diseases. RESULTS: During the study period, 347 children out of the 1584 new patients were retained with a sex ratio of 0.86. The mean age was 6.4 years old. The main diseases identified were skin infectious diseases (43, 23%), allergic dermatoses (24.21%), and autonomous dermatosis (15.56%). CONCLUSION: Our study revealed the importance of infectious and allergic dermatoses in Toamasina. It is necessary to carry out simple preventive actions such as hygiene.

Quality of life in lupus erythematosus female patients with cutaneous lesions in Antananarivo, Madagascar.

Background: Lupus erythematosus (LE) is a chronic autoimmune disease that affects more women than men. The quality of life (QoL) of patients with lupus erythematosus and skin manifestations is impaired, but little is known about Malagasy patients. Objective: This study aimed to assess the impact of cutaneous lesions on the QoL of patients who present with LE. Methods: A transversal study, during 3 months, was conducted in patients who presented with LE and cutaneous lesions at the University Hospital Antananarivo. QoL was assessed using the Dermatology Life Quality Index (DLQI) scales. Results: The impact of cutaneous lesions on the QoL was assessed in 37 patients with LE, of whom 34 were women. The mean age of patients was 37.32 years. The mean DLQI was 5.43 ± 4.67 (range, 0-21). Of the patients, 2.7% had a very important effect (DLQI >21), 18.9% reported a great effect of skin symptoms of LE in their QoL (DLQI: 11-20), 18.9% had a moderate effect (DLQI: 6-10), 40.4% had a small effect (DLQI: 2-5), and 18.9% had no effect of cutaneous lesions on their QoL. Daily activities, symptoms, and feelings were the most altered dimensions. The alteration in patients' QOL was influenced by high monthly income, severe medical history, and localization of the cutaneous lesions on the face and neckline. No correlation was found between sex and QoL. Conclusion: This study shows that significant impairment of QoL was found in patients with LE and cutaneous manifestations, which affected their sense of well-being.

Atopic dermatitis in adults: A cross-sectional study in the department of dermatology, Antananarivo, Madagascar.

BACKGROUND: Although atopic dermatitis (AD) is becoming a pressing public health concern in the world, Madagascar is underrepresented in the AD literature. OBJECTIVE: We aimed to study the demographic and clinical pattern of AD in adult dermatology outpatients. METHODS: A cross-sectional study was conducted in the Department of Dermatology, University Hospital, Antananarivo, Madagascar. Patients >15 years old with a registered diagnosis of AD, from January 2010 to February 2019, were included. AD was diagnosed by a dermatologist according to Hanifin and Rajka criteria. The severity of AD was assessed using scoring atopic dermatitis (SCORAD). RESULTS: Forty-two cases of AD were included. The prevalence was 0.5%. The median patient age was 37 years. The age of onset of AD was before the age of 15 years in 38% of the patients and after the age of 15 years in 61.9% of the patients. There was a female preponderance (female to male ratio, 2:1), but no correlation was found between sex and the severity of AD. People living in urban areas were the most affected. According to SCORAD, 37 cases presented moderate AD and 2 cases presented severe AD. CONCLUSION: The prevalence of AD in adult dermatology outpatients is still low, and moderate AD is the most frequent form, according to SCORAD.

Osteoarticular sporotrichosis in an immunocompetent patient.

Sporotrichosis is a frequent subcutaneous mycosis in Madagascar. Extracutaenous forms are exceptional and are usually seen in immunosuppressed hosts. We report a case of an aggressive clinical evolution of lymphocutaneous sporotrichosis with osteoarticular involvement in an immunocompetent patient. Therapy with oral itraconazole 200 mg twice daily for 12 months improved the lesion. Early diagnosis of Sporothrix schenkii infection is critical to prevent complications including osteoarticular involvement, disseminated forms and death.

Birth Month and Prevalence of Atopic Dermatitis in Children Under 3 Years in Antananarivo, Madagascar.

BACKGROUND: Several studies have been done to evaluate the relationship between month of birth and atopic diseases but the results are contradictory. OBJECTIVE: We aim to evaluate the correlation between the month of birth and the prevalence of AD in Malagasy children less than 3 years. METHODS: A case-control study was conducted based on patients' data of the department of Dermatology in the University Hospital Joseph Raseta Befelatanana (UH/JRB) Antananarivo. It included 438 children less than 3 years seen in this department between January 2010 and December 2019. For each atopic dermatitis (AD) patient, two age-and sex-matched controls without a history of AD were selected from the same period. RESULTS: This study included 146 AD cases and 292 non-AD controls. Our case-control study found that there is a statistically significant correlation between birth month and risk of AD in Malagasy children <3 years. Compared with people born in December, people born in April had the highest risk of AD (OR: 2.11, 95% CI 0.93-4.78), followed by people born in March (OR: 1.52, 95% CI 0.79-2,88). Asthma, allergic rhinitis and allergic conjunctivitis were significantly correlated with AD in our patients. CONCLUSION: Our case-control study found that being born in April and March (dry season) may be associated with an increased risk of AD.

Quality of Life in Patients with Psoriasis Seen in the Department of Dermatology, Antananarivo, Madagascar.

BACKGROUND: Psoriasis is a chronic, inflammatory, and multifactorial dermatosis that impairs quality of life (QoL). Health-related QoL has become an important element in medical decision-making along with the effectiveness and the harmlessness of the treatments. OBJECTIVE: To assess the impact of psoriasis in the QoL of patients with psoriasis by using the DLQI scales. METHODS: A cross-sectional study from January to June 2018 was conducted in the Department of Dermatology of the University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar, including patients more than 18 years old with mild to severe psoriasis. The severity of psoriasis was assessed using the "Psoriasis Area and Severity Index (PASI)". QoL of patients with psoriasis was evaluated by using the DLQI scales. RESULTS: 80 patients were included, their mean age was 36.5 years, and the male to female was 1.5 : 1. The mean DLQI score was 13.8. Symptoms, feelings, and psychic were the most altered dimensions. QoL was impaired in young patients, single, having medium level education. Even though patients with disease duration more than 5 years had higher DLQI score than other patients, the difference was not statistically significant (p = 0.36). Furthermore, the clinical presentation of psoriasis did not influence the patient's QoL (p = 0.73). Patients with nail involvement had QoL impaired but the difference with another localization was not statistically significant (p = 0.2). The quality of life was influenced by body area involved. The higher the body surface area involved, the more QoL is impaired (p = 0.002). Furthermore, the higher the PASI, the more QoL is altered (p = 0.002). CONCLUSION: Psoriasis has a negative impact in the quality of life in Malagasy patients with psoriasis, especially in younger and single patients. Worse quality of life is correlated to severity of psoriasis.

Clinical aspects of previously treated chromoblastomycosis: A case series from Madagascar.

OBJECTIVE: To describe the clinical aspects of chromoblastomycosis (CBM) presented by patients who had received incomplete antifungal treatment before consultation. METHODS: A prospective study of patients with clinically suspected CBM was performed between 2013 and 2018 in the Department of Dermatology at the University Hospital Antananarivo, and during consultation campaigns. RESULTS: Patients develop CBM over a period of more than 10 years, and many will have already received antifungals prescribed by general practitioners before consulting with a dermatologist. Such treatment obviously modifies the clinical presentation. From the 63 CBM patients in this large study, we describe 12 patients who received oral antifungals (terbinafine, griseofulvine, itraconazole, fluconazole) before consultation. The most frequent clinical aspect presented by these patients was cicatricial lesions, which are characteristically smooth and non-elevated, and enlarge by peripheral extension, with atrophic scarring at the center. CONCLUSION: Our study is the first to show that cicatricial lesions are a clinical aspect presented by CBM patients who received antifungals before presentation.

Treatment responses in patients with vitiligo to very potent topical corticosteroids combined with vitaminotherapy in Madagascar.

INTRODUCTION: Vitiligo is a refractory disease in which treatment modalities are not yet established. We aim to assess results obtained 10 years after the initiation of a therapeutic protocol which combines very potent topical corticosteroids (TCS), vitaminotherapy (B12 and C), and suppression of microtraumas in the management of nonsegmental vitiligo in Madagascar. METHODS: It was a prospective and descriptive study over a period of 6 years (2011-2016) in the Department of Dermatology, Joseph Raseta Befelatanana, Antananarivo, Madagascar. The diagnosis of vitiligo was based on clinical data. Patients who agreed to follow the treatment protocol, which combined very potent TCS (two applications/day for 10 days, and then one application/day for the following 10 days), oral vitamin C 500 mg/day for 20 days, and oral vitamin B12 100 mg/day for 20 days, were included in the study. Two successive courses of treatment were made 10 days apart. RESULTS: The details of 308 vitiligo patients were analyzed. The mean age of patients was 33.3 years. There was a female preponderance (sex ratio: 0.6). The duration of treatment in our patients varied from 3 to 18 months. Two hundred and thirty-nine patients had good therapeutic compliance and attended regular follow-up. Excellent repigmentation (more than 76% area repigmented) was noted in 50 patients (65.7%) less than 14 years of age. Lesions evolving in less than 1 year in 31 patients (36.9%) had excellent response to treatment. Localized lesions responded favorably to treatment with excellent repigmentation in 108 patients. CONCLUSION: These results show that therapeutic response is better in young people, lesions less than 1 year of evolution, and for localization of vitiligo in the face and neck.

Pemphigus vulgaris as the first manifestation of multiple myeloma: a case report.

BACKGROUND: The association between pemphigus and malignancy has been well documented for decades but an association between pemphigus vulgaris and multiple myeloma is unusual. We report a case of pemphigus vulgaris revealing multiple myeloma. CASE PRESENTATION: A 55-year-old Malagasy man, with no significant past medical history, presented with bullous and erosive skin lesions involving his trunk and scalp for the last 2 months. He had no mucous membrane involvement. A diagnosis of pemphigus vulgaris was made on skin biopsy and direct immunofluorescence of perilesional skin revealing immunoglobulin G deposition in the intercellular spaces in the epidermis. In an enzyme-linked immunosorbent assay, his serum autoantibody index against desmoglein-1 and 3 was found to be 112 RU/mL and 34 RU/mL respectively. Serum immunoelectrophoresis showed a monoclonal gammopathy with a markedly elevated immunoglobulin G level (2880 mg/dL) in association with a lambda free light chain. Bone marrow aspirate showed 6% plasma cell infiltration. Further investigations, including creatinine blood test and whole body radiographic examinations, showed that he had initially clinical stage I multiple myeloma of the immunoglobulin G-λ type. Six months later, bone tomography revealed vertebral compression fractures of the thoracic and lumbar spine that correlated with his back pain topographically. Anti-myeloma treatment including melphalan and prednisone led to an immediate decline in monoclonal immunoglobulin G concentration. Skin and hematologic remission were maintained for 12 months. CONCLUSIONS: Absence of mucosal involvement, lack of vacuolar degeneration at the interface, and absence of apoptotic, dyskeratotic keratinocytes ruled out paraneoplastic pemphigus in our case. Pemphigus vulgaris should be considered even if possible underlying disease for which paraneoplastic pemphigus is recognized is present.

Rosai-Dorfman Disease Involving Multiple Organs: An Unusual Case with Poor Prognosis.

Rosai-Dorfman disease is a rare, benign histiocytic proliferative disorder that usually affects the lymph nodes. Although extranodal involvement has been reported in diverse sites, manifestation in the cardiovascular system is extremely rare. Specifically, cardiac involvement in Rosai-Dorfman disease is an extraordinarily infrequent event. We describe a case of a 36-year-old female who presented Rosai-Dorfman disease of multiple organs including the heart, with poor prognosis.

A Case of Fluoroquinolone-Resistant Leprosy Discovered after 9 Years of Misdiagnosis.

We report a case of misdiagnosed leprosy in a 21-year-old Malagasy male, who, improperly treated, developed secondary mycobacterial resistance to fluoroquinolone. The patient contracted the infection 9 years prior to the current consultation, displaying on the right thigh a single papulonodular lesion, which progressively spread to the lower leg, back, and face. Initial administration of ciprofloxacin and prednisolone led to temporary and fluctuating improvement. Subsequent long-term self-medication with ciprofloxacin and corticosteroid did not heal the foul and nonhealing ulcers on the legs and under the right sole. Histopathological findings were compatible with lepromatous leprosy. Skin biopsy was positive for acid-fast bacilli and PCR assay confirmed the presence of a fluoroquinolone-resistant strain of Mycobacterium leprae (gyrA A91V). After 6 months of standard regimen with rifampicin, clofazimine, and dapsone, clinical outcome significantly improved. Clinical characteristics and possible epidemiological implications are discussed.