Pregnancy in autoimmune diseases in the sub-Saharan zone: the experience of the University Hospital of Libreville Department of Internal Medicine.

Autoimmune diseases are a group of heterogeneous conditions responsible for polymorphic clinical and biological manifestations. Because pregnancy activates them and promotes gestational complications, it is difficult for women with these diseases. Pregnancy and autoimmune diseases have rarely been studied in sub-Saharan Africa. We report the experience of the Internal Medicine Department of the University Hospital of Libreville. Conducted retrospectively for 2008 through 2011, and prospectively from 2012 through August 31, 2018, this descriptive and analytical study examined the records at the Department of Internal Medicine of the University Hospital Center of Libreville of women with a known autoimmune disease, receiving regular care there, and who became pregnant after the diagnosis. During pregnancy, women were monitored and manÂged simultaneously in the departments of obstetrics and internal medicine. Data considered for this study were demographic data (Âge, sex, social status), type of autoimmune disease, including the diagnosis, the therapies used, extent of disease control, and time from diagnosis to each pregnancy. Obstetric data include the number of fetuses, obstetric complications, gestational Âge at and route of delivery, fetal sex, and Apgar score to 5 minutes (normal ≥ 7). Women had the following autoimmune diseases : systemic lupus erythematosus (SLE) (n = 16), Sjögren's disease (n = 3), inflammatory myopathy (n = 2), rheumatoid arthritis (n = 1), primary antiphospholipid syndrome (APS) (n = 1), and Still disease (n = 1).The overall averÂge Âge at diagnosis was 26.6 years (range : 13-40). The 24 women had 32 pregnancies. The mean interval from diagnosis to first pregnancy was 3.3 years, to the second pregnancy also 3.3 years (n = 6), and to the third (n = 2), 5 years. Disease was controlled for at least 2 years (n = 23) except for one woman with primary APS. Therapeutically, corticosteroids were used alone (n = 2) or combined with other immunomodulatory therapies (n = 32). Gestational complications included spontaneous abortions in the first trimester (n =2), in utero deaths (n = 2), perinatal death on day 12 (n = 1), and eclampsia (n = 2), one of which was complicated by a pulmonary embolism in the first pregnancy. The mean gestational Âge at delivery was 37 weeks. Intrauterine growth restriction affected 11 fetuses, and preterm delivery 18. There were 11 cesarean deliveries and 16 vaginal. Mean birth weight was 2353.3 grams, Apgar was ≥ 7 for all neonates except in one case of dermatomyositis complicating a neonatal death. The sex ratio was 13 male infants per 17 females. Women with optimal disease control can become pregnant and have positive pregnancy outcomes. This possibility has been little explored in sub-Saharan Africa; mystical-religious notions of conceptions persist and can prevent women from attempting to become prégnant . This experience with a short series of viable fetuses of women with autoimmune diseases is therefore encouraging and deserves to be continued.

[About a Case of Febrile Gastroenteritis Due to Strongyloidiasis in a Gabonese Patient Treated for Lupus]. / A propos d'un cas de gastro-entérite fébrile due à une anguillulose chez une patiente gabonaise traitée pour un lupus.

Srongyloidiasis can sometimes be a source of diagnostic wandering in a patient with an autoimmune disease living in a tropical environment, despite systematic deworming with albendazole (400 mg/day/3 days), prior to the starting of a corticotherapy. We report an observation of a febrile gastroenteritis complicated by signs of intra and extracellular dehydration, in a 37-year-old lupus patient, including duodenal biopsies, and stool parasitology, which led to the diagnosis of strongyloidiasis effectively treated by ivermectin per os (two doses) of 200 micrograms/kg, once every 2 weeks apart), following failure of a first 5-days course of albendazole (400 mg/day).

L'anguillulose peut parfois être source d'errance diagnostique chez un patient porteur d'une maladie auto-immune vivant en milieu tropical, et ce malgré un déparasitage systématique par l'albendazole (40 mg/jour / 3 jours), avant la mise en route d'une corticothérapie. Nous rapportons une observation de gastroentérite fébrile, compliquée de signes de déshydratation intra et extracellulaire, chez une patiente lupique de 37 ans, dont les biopsies duodénales, et la parasitologie des selles ont conduit au diagnostic d'anguillulose traitée efficacement par ivermectine per os (2 doses de 200 microgrammes/kg, en prise unique à 2 semaines d'intervalle l'une de l'autre). Ce traitement faisait suite à l'échec d'un premier traitement par 5 jours d'albendazole (400 mg/jour).

Myeloblasts and atypical bone marrow: Fortuitous discovery of the filiarial nematode loa loa in the bone marrow during a work-up for prolymphocytic T-cell leukemia.

Loiasis is a chronic cutaneous disease caused by a filarial nematode for whom humans are the only definitive host: Loa loa, an African eyeworm transmitted by Chrysops flies. The parasite is seen on blood smears, in the skin, or during its ocular migration, but rarely on a bone marrow smear. We report the case of a 57-year-old Gabonese woman whose bone marrow aspiration during a work-up for T-cell leukemia fortuitously found Loa loa filariae.

[Behavior and attitudes towards smoking among student midwives in Libreville]. / Comportements et attitudes des élèves sages-femmes de Libreville vis-à-vis du tabagisme.

BACKGROUND: The midwife, in taking on a public health role, is one of the most important resources for the prevention of smoking and in helping smoking cessation among women of childbearing age thanks to their numerous contacts with pregnant women. With this in mind, we conducted a study among student midwives to examine their smoking behavior, their attitudes towards smoking, and their participation in prevention. METHOD: This was a descriptive cross-sectional study conducted from 15 January to 15 February 2018 using a self-administered questionnaire and included the student midwives of the University of Health Science at Libreville (Gabon). RESULTS: A total of 188 student midwives completed the questionnaires (70.7% of students of the 1st year, 15.0% of students of the 2nd year and 14.3% of students of the 3rd year). Gaps exist in the knowledge of student midwives regarding the risks of cigarette smoking in pregnancy and its role in the development of complications for the mother and foetus. Overall, 17.1% of student midwives think that smoking is responsible for the occurrence of ectopic pregnancies, 20.3% believe it is responsible for retro-placental haematoma, 17.6% for premature rupture of the membranes. The prevalence of smoking was 11.1% and was most frequent in 2nd year students (25.0%) and 3rd year students (14.8%) (P<0.023). The mean age of beginning smoking was 19.0±4.4 years. The main initiating factors were peer influence (28.6%), pleasure (19.0%) and stress (14.3%). Nicotine dependence was weak to moderate among 48.8% of smokers and absent in 52.2%. CONCLUSION: Gaps exist in the knowledge of student midwives regarding the risks of cigarette smoking to complications of pregnancy. There is need therefore to include formal training on tobacco control strategies at an early stage in the medical curriculum.

Lupus: evidence of environmental degradation? Assessment from 60 patients followed up in the Internal Medicine Department at the Libreville University Hospital, Gabon.

Lupus is an autoimmune disease of the connective tissue that occurs predominantly in women and blacks and whose expression is influenced by environmental factors, especially ultraviolet rays. The rising temperature in Gabon for nearly two decades led us to look for correlations between the onset of lupus, the patients' regions of origin, and environmental temperatures before and at diagnosis. retrospective, descriptive, and analytic study conducted in the Department of Internal Medicine of the CHU of Libreville (Gabon), from 01/01/2016 to 31/05/2016, based on the files of patients with diagnosed lupus receiving care in the department since 01/2002. Data collection forms listed for each patients age, sex, occupation, date and season of diagnosis, and place of residence (during childhood, adolescence, and adulthood). We looked for correlations between these data and temperatures, based on meteorological data from the country's seven main weather stations over a period from 1996 to 2015. The study included 53 women and 7 men (sex ratio 0.13), with a mean age of 32.7 +/- 8.9 years. The population included students (n = 25), civil servants (n = 15), the unemployed (n = 8), private-sector employees (n = 6), and shopkeepers (n=6). Diagnoses varied according to season, with 56.6% of the cases in the dry season and 43.4% in the rainy season. From 1 to 4 cases of lupus were diagnosed annually before 2011, 7 each year from 2011 to 2014, and at least 14 per year since 2015. Most patients (62.5%) had spent their childhood, adolescence, and adulthood in the country's capital (industrial zone par excellence), 17.8% in mining regions, and 12.5% in oil-drilling areas. The increase in the number of cases of lupus appears to be correlated with their greater prevalence in regions with higher temperature exposures, that is, in industrial, mining and petroleum regions, which are the regions of greatest exposure among our lupus patients.

Treatment of chronic inflammatory rheumatism by biotherapy in Gabon : eligibility and follow-up of the first 8 patients in sub-Saharan Africa.

OBJECTIVE: to clarify the eligibility criteria for biotherapies in patients with chronic inflammatory rheumatism (CIR) in sub-Saharan Africa and to describe the characteristics of the first 8 patients treated with biotherapy in Gabon. MATERIALS AND METHODS: Patients who responded inadequately to treatments by cDMARDs (EULAR criteria) had a face-to-face interview to inform them about and obtain their consent to biotherapy for at least 3 months, with details of the cost and side effects of each available biotherapy and a certificate of "necessity of biotherapy". The inclusion and follow-up of patients took place in the outpatient rheumatology consultations at the University Hospital of Libreville (Gabon) between January 2010 and December 2016. RESULTS: Of the 30 patients who failed cDMARDs and required biologic treatment, 8 (26.6%) were able to start a biotherapy: 4 men and 4 women with rheumatoid arthritis (n = 4.50%), spondyloarthritis or psoriatic rheumatism (n = 2.25% each). The biotherapy was etanercept (n = 4, 50%), adalimumab, golimumab, infliximab and rituximab (n = 1, 12.5% each). The average duration of the biotherapy was 27.4 months (9-54). Biotherapy was stopped in 4 cases (50%), one each (12.5%) for multifocal tuberculosis, pregnancy, financial reasons, and remission. CONCLUSION: Our study shows that biotherapies, which are currently very expensive, can be prescribed in Africa provided that the usual recommendations are followed strictly. Here, access to biotherapies is only possible through private insurance and the rheumatologist must play the role of facilitator for needy and consenting patients.

Sickle-cell disease with an eruptive appearance? What is your diagnosis?

Lupus is an autoimmune disease of the connective tissues, relatively frequent in the black population, and with a marked female prevalence. Clinical polymorphisms explain the diverse and varied nature of the clinical forms that are sources of diagnostic aberrations. This disease can be associated with various diseases. Here we report an unusual association with AS hemoglobinopathy.

Patients' Families' Perceptions of Lupus in Sub-Saharan Africa.

Lupus is an autoimmune disease affecting the connective tissue. Its clinical and biological polymorphism is often misunderstood by patients and families and can lead to treatment interruption and a decision to turn to alternative medicine. We used a questionnaire to assess the degree of knowledge of this disease of family members living with lupus patients. Of the 56 lupus patients receiving regular follow-up at our hospital, 123 members of 30 of their families (53.5%) participated. Overall, among these families, 81.5% of the participants perceived the disease as predominantly non-mystical, 72.3% as hereditary, 87.9% as non-contagious, and 60.9% as curable ; 90.2% considered it compatible with pregnancy, another 90.2% with work, and 73.9% with sports activity. The principal clinical signs mentioned involved joint (22.7%), skin (13%), and finger-related (11.3%) disorders, with renal disease (9.7%), heart disease (8.1%), and general signs (8.1%) mentioned most frequently as the main complications. The best-known medications for disease control were corticosteroids (20.3%) and hydroxychloroquine (17%). Family members considered non-adherence (53.6%) the most frequent factor in disease flares. More than half were unaware of the life expectancy associated with this disease, but 30.1 % thought it was lower than that of the national population of Gabon - 70 years. Only 64 (52%) of the respondents had seen documentation about lupus, mostly through the Internet (65.6%). Lupus is not a disease that families know and understand well.

Non-adherence to antiretroviral therapy in patients infected with HIV and cryptococcal meningitis: two cases at the Lambaréné Hospital Center in Gabon.

Cryptococcal meningitis is a serious infection occurring mainly in immunodepressed patients, especially those with AIDS. Its incidence is growing among people living with HIV/AIDS who interrupt their antiretroviral treatment. We report two cases that occurred in this situation and had lethal outcomes in the short term. Testing for cryptococcal antigen in serum (serum CRAG test) enables a reliable and early diagnosis, and its use should be promoted in rural areas of sub-Saharan Africa.

[Copper deficiency and peripheral neuropathy as an outcome of gastrectomy]. / Déficit en cuivre et neuropathie périphérique compliquant une gastrectomie.

INTRODUCTION: Bariatric surgery may be indicated in patients with morbid obesity. Peripheral and central neurological complications can occur after bariatric surgery. OBSERVATION: We report a 47-year-old woman who presented with a tetraparesis related to copper deficiency after sleeve gastrectomy for morbid obesity. CONCLUSION: Neurological complications related to copper deficiency can occur after bariatric surgery.

[Socioeconomic aspects and management of chronic hepatitis B and C in Libreville, Gabon]. / Aspects socioéconomiques de la prise en charge des hépatites chroniques B et C à Libreville (Gabon).

INTRODUCTION: Viral hepatitis remains a major public health problem in the sub-Saharan region. Diagnosis is often made at an advanced stage after a long period with few or no symptoms. Late diagnosis impedes optimal management. MATERIALS AND METHODS: All patients treated for documented chronic hepatitis B or C from January 2001 to December 2009 were identified and the cost of their treatment was estimated. Data examined included socioeconomic information, circumstances surrounding diagnosis, cost of work-up, cost of curative treatment (pegylated interferon + ribavirin for hepatitis C and lamivudine for hepatitis B), and overall cost of support. RESULTS: The study included 146 patients (65 women, 81 men) with a mean age of 34 years. Hepatitis was type B in 89 patients, type C in 51, and type B/C coinfection in 6 patients. The estimated cost of work-up was 483 USD for type B and 507 USD for type C. The cost of curative treatment was 1569 USD for type B and 7842 USD for type C. The estimated cost of support was 407 USD. The total cost of management was 2459 USD for type B and 8757 USD for type C. Only 9 patients received optimal treatment, and it resulted in curing 3 of the 4 with hepatitis B and 4 of the 5 with hepatitis C. During treatment, progression to cirrhosis occurred in two patients, one with hepatitis B and one with hepatitis C. CONCLUSION: Financial constraints frequently prevent patients in Gabon with hepatitis B and C from receiving optimal care. The creation of a national healthcare system in 2008 may lead to cost reductions and improve management of this disease in a predominantly young population.

[Centrilobular nodules with ground-glass opacities in the lungs]. / Un lâcher de ballon curable.

We report the case of a 56 year-old Gabonese man under treatment by candesartan-hydrochlorothiazide for essential hypertension. After 2 months of treatment, he presented with pneumonia and severe respiratory failure. The chest radiography showed centrilobular nodules resembling tumor metastases, but no evidence of a primary tumor. Laboratory and imaging found no evidence of infectious or autoimmune disease. The computed tomography findings led to a diagnosis of diffuse alveolitis. The candesartan treatment was stopped and oral corticosteroid therapy (50 mg/day) initiated. The rapid favorable outcome supports the diagnosis of a drug-induced infiltrative lung disease.

[Purple extremities in black-skinned patients: blue toe syndrome as presenting sign of antiphospholipid antibody syndrome]. / Extrémités violettes sur peau noire: orteils pourpres révélateurs d'un syndrome des antiphospholipides.

Although acral ischemia can involve several underlying mechanisms, suspicion of lupus warrants testing for antiphospholipid antibodies in patients with blue toe syndrome.

[Castleman's disease: first case in Gabon]. / Maladie de Castleman: première observation au Gabon.

Castleman's disease is an atypical lymphoproliferative disorder characterized by hyperplasia of lymphoid structures with vascular proliferation. It has rarely been diagnosed in black African populations. The purpose of this report is to describe the first case in Gabon. The patient was a 47-year-old black African man. Outcome was fatal.

[Association myositis and hepatocellular carcinoma: one case and review of literature]. / Association myopathie inflammatoire et hépatocarcinome : à propos d'une observation et revue de la littérature.

Association inflammatory myopathies and tumors are not fortuitous but association with hepatocellular carcinoma is rarely reported in literature. We described a case of association polymyositis hepatocellular carcinoma in 37-year-old black African patient, with fatal issue.

[Kikuchi-Fujimoto disease in Gabon. Description of first 2 cases in Gabon]. / Maladie de Kikuchi-Fujimoto: 2 premiers cas au Gabon.

Kikuchi-Fujimoto disease is a rare disorder sometimes associated with systemic lupus. It has rarely been reported in the black African population. The purpose of this report is to describe the first two cases in Gabon. In patients presenting enlarged cervical lymph nodes, it is first necessary to rule out infectious disease. Histology can allow diagnosis by demonstrating necrotizing histiocyte lymphadenitis.

[Lupus, corticosteroid treatment and opportunistic infection: 26 cases in Gabon]. / Corticothérapie et infections opportunistes dans une cohorte de 26 lupus au Gabon.

Opportunistic infection is frequent in lupus patients. Susceptibility is inherent in the lymphopeniant nature of the disease and enhanced by the use of immune-suppressing agents (alone or in combination) for optimal disease control. The purpose of this retrospective series of lupus patients diagnosed based on the criteria of the American College of Rheumatology (ACR) was to assess the frequency of opportunistic infection in a high-risk epidemiological area. A total of 26 patients (24 women, 2 men) with a mean age of 28.8 years were identified. Systematic review carried infectious before the steroid and in light of the local endemicity (HBs Ag, hepatitis C serology, HIV + Rx Thorax IDR) coupled with blood cultures was non-contributory, without waking the tank or during the introduction treatment. With a mean follow-up of 3.6 years (range, 0.83 to 9.91), only one case of tuberculosis was observed with fatal outcome. Our study indicates that the prevalence of opportunistic infections in the Lupus under treatment in a high-risk area for infectious diseases was low. This finding suggests that the risk of infectious complications secondary to corticosteroid therapy in sub-Saharan zone is acceptable provided that surveillance is performed on a regular basis.

[Elevated C reactive protein rate in 23 black African patients with systemic lupus erythematosus and without opportunistic infectious disease]. / Valeur prédictive de l'augmentation de la protéine C réactive dans le lupus systémique en l'absence d'infection intercurrente chez le patient noir africain à travers une série de 23 lupus systémiques.

INTRODUCTION: CRP rarely increases during systemic lupus exacerbations. MATERIALS AND METHODS: This retrospective study of patients with systemic lupus diagnosed according to ACR criteria examined all patients with no intercurrent infectious disease and responding to corticosteroid treatment and compared the patients with normal and with significantly elevated (> or = 30 mg/l) CRP. RESULTS: 23 black patients (22 women, 1 man) were selected and classified in two groups: group I with CRP > 30 mg/l (n = 12) and the controls, group II, with normal CRP (n =11). In group I, mean CRP was 279 mg/l. Four patients had isolated pericarditis, and one pericarditis associated with pleurisy. Nine patients had no cardiovascular risk factors or abnormal liver function enzymes. Antinuclear antibodies were specific for anti-DNA (n= 8), anti-Sm (n = 2), anti-RNP (n = 1), and anti-SSA (n = 1). In group II, seven patients had pericarditis, and nine had no cardiovascular risk factors or liver function results. Antinuclear antibodies were specific for anti-DNA (n = 9), anti-Sm (n = 1) and unknown (n = 1). DISCUSSION: The paucity of data about black Africans in the literature makes it difficult to interpret these results in terms of their specificity for this population or as a typical profile of elevated CRP without infectious disease. CONCLUSION: In absence of a specific profile for patients with elevated CRP without intercurrent infectious disease, we consider the possibility of a subgroup of the black population that may be particularly vulnerable and express CRP more easily.

[Dermatomyositis and pregnancy: a case in Gabon]. / Dermatomyosite et grossesse: une observation au Gabon.

The purpose of this report is to describe a case of successful pregnancy involving a 30-year-old Afican woman presenting dermatomyositis, without use of immunosuppressive treatment. The child was delivered prematurely by caesarean section at 32 weeks of gestation.

[Two cases of probable immune restoration syndrome under antiretroviral treatment in patients treated for tuberculosis in Gabon]. / Probables syndromes de restauration immunitaire lors de la mise sous traitement antirétroviral chez des patients traités pour tuberculose: à propos de deux observations au Gabon.

Tuberculosis can be reactivated under specific treatment, as immune reconstitution inflammatory syndrome (IRIS), in HIV patients under antiretroviral treatment. We report two observations of tuberculosis exacerbation with extension to other territories (lymph node and pericarditis) occurring 3 weeks and 4 months after administration of tuberculosis treatment, with a favourable development, in absence of rehabilitation or addition of complementary therapy These observations show the necessity of increased surveillance on the short, medium and long term in patients with both treatment for tuberculosis and antiretroviral treatment.