[Clinical and developmental aspects of care-related tetanus in the reference service of the teaching hospital of Abidjan]. / Aspects cliniques et évolutifs du tétanos lié aux soins dans le service de référence du CHU d'Abidjan.

A cross-sectional descriptive study was conducted from medical data of inpatients with tetanus in the Department of Infectious and Tropical Diseases of the University Hospital of Treichville in Abidjan from January 2003 to December 2007. In five years, 221 cases of tetanus have been hospitalized. The tetanus gateway was found in 188 patients (85%). Tetanus gateway linked to care was found in 22 patients (11.7%). Acts of care in question were intramuscular injections (10 cases) and operative procedures (12 cases). Concerning medical care by intramuscular injection, quinine (four cases), sulfadoxine-pyrimethamine (one case), and long-acting penicillin (one case) were the identified drugs. The operative procedures mainly involved were skin sutures (nine cases), cures of hernia (two cases), and flattening of Fournier's gangrene (one case). The average incubation period was 9.5 days. The invasion lasted for an average of 1.8 days. On admission, tetanus was immediately generalized for all patients with the presence of paroxysms in 20 patients (90.9%). The lethality of tetanus related care was 54.5%. The death rate in the first 48 hours of hospitalization was estimated at 83.3%. The average length of hospital stay was 14.6 days. Health workers should be involved in the prevention of tetanus in improving the quality of care and especially in reducing intramuscular injections. Also, any patient not immunized against tetanus should receive anti-tetanus serum and an update of its tetanus vaccine before any invasive procedures.

[Morbidity and mortality of military personnel at the Abidjan Military Hospital (AMH) in Côte d'Ivoire]. / Morbi-mortalité des militaires à l'hôpital militaire d'Abidjan, Côte d'Ivoire.

The purpose of this retrospective study was to document morbi-mortality in soldiers at the Abidjan Military Hospital (AMH). The medical files of soldiers treated at Abidjan Military Hospital from January 1 to December 31, 2004 were reviewed. During the study period, a total of 155 soldiers were treated for 259 pathologies including 208 infectious diseases (80.5%). The most common diseases were HIV infection (85 cases; 42%), pneumopathy (40 cases; 19%), cerebral toxoplasmosis (22 cases; 10.5%), malaria (18 cases; 9%) and tuberculosis (11 cases; 5%). Direct causes of death were cerebral toxoplasmosis (32%), pneumopathy (28%), tuberculosis (16%) and severe malaria (12%). The prevalence of HIV infection in soldiers who died was 76%. Morbi-mortality in military personnel at the AMH is due mainly to HIV infection and related complications. Specific prevention measures should be implemented for an effective control of this epidemic.

[Efavirenz versus indinavir among HIV-1 naive patients in Abidjan (Ivory Coast)]. / Efavirenz versus indinavir chez les patients naïfs infectés par le VIH-1 à Abidjan (Côte d'Ivoire).

OBJECTIVE: The authors had for aim to compare the therapeutic efficiency and tolerance of 2 NRTI+efavirenz (EFV) versus 2 NRTI+indinavir (IDV) in HIV infected adults in Abidjan. METHODS: A retrospective and multicentric study was made on 327 HIV-1 naive patients, 142 in the EFV group and 185 in the IDV group followed in Abidjan from November 1998 to December 2003. The analysis concerned clinical advents (opportunistic infections) and immunovirological parameters (CD4, viral load). Patients received 2 NRTI such as AZT+3TC or D4T+3TC combined either with EFV or IDV. The principal judgement criterion was therapeutic failure. We assessed the percentage of patients with undetectable viral load and the frequency of grade 3-4 adverse effects after 24 months of follow-up. RESULTS: Clinical improvement of patients' state and regression of opportunistic infections were identical in the two groups. The average gain of CD4 was superior to 177 in EFV versus +219 in IDV (p=0.004). The percentage of patients with undetectable viral load was 66% for EFV versus 59% for IDV (p=0.04). The frequency of adverse effects was more elevated with EFV than IDV, 39% versus 23% (p=0.002) initially, but seemed to decrease later. CONCLUSION: HAART with EFV is at least as efficient as with IDV in terms of reduction of viral load and increased CD4 count and is an excellent low-cost first line treatment.

[First case of Stevens-Johnson syndrome in a patient treated by Triomune in Abidjan, Côte d'lvoire]. / Premier cas de syndrome de Stevens-Johnson chez un patient traité par association de stavudine, lamivudine et névirapine à Abidjan, Côte d'Ivoire.

The authors report the first case of Stevens-Johnson syndrome which has occurred in a 45 year old patient treated by Triomune containing névirapine. Triomune is used within the context of the African antiretroviral initiative access. It was a mild form whose evolution was favourable when nevirapine was stopped. The prevalence of this affection should increase with the larger use of nevirapine in our countries and the attention of both prescriber and patient must be requested.

[Generalized tetanus complicating a traditional medicine applied for snakebite]. / Tétanos généralisé compliquant un traitement traditionnel instauré après une morsure de serpent.

In many of Africa's rural areas, snakebite victims often resort to traditional healers for first line treatment. This may be source of infectious complications. We report a case of generalized tetanus which occured after 15 days in a 13-years old boy who had applied a traditional, plant-based concoction on a snake bite. He presented with trismus, generalized contractures and fever extended musculo-aponevrotic necrosis of the right upper limb, without loss of consciousness. The only accompanying biological sign was an increased leukocyte count (11,200/mm3) with a predominance of neutrophils (84%). Platelets count, creatinin and AST/ALT titers and haemostasis were all normal, as was the radiogram of the right hand. The clinical outcome was favourable after 3 weeks hopital care (antibiotic, muscle relaxants, antitetanus serotherapy and local wounds care). This clinical observation shows that traditional care for snake bite wounds can be an entry point for tetanus. Appropriate treatment of snake bites in a hospital setting is of the utmost importance, in addition to vaccination against tetanus, in order to reduce the incidence of tetanus in African countries.

[Management of accidental exposure to blood in the Treichville teaching hospital, Abidjan (Côte-d'Ivoire)]. / Prise en charge des accidents d'exposition au sang au CHU de Treichville, Abidjan (Côte-d'Ivoire).

OBJECTIVE: The aim of this study was to assess care and preventive measures for accidental exposure to blood (AEB) in Abidjan. METHODS: A retrospective study of all AEB reported in the Infectious and Tropical Diseases Center of the Treichville University Hospital was made between January 2000 and December 2005. Epidemiology, management, clinical and biological post-exposure follow-up were analyzed. RESULTS: One hundred eighty-two AEB were managed over 6 years (151 needlesticks, 14 ocular projections of blood, 12 cuts, and 5 mucocutaneous exposure to blood). 94 men (51.6%) and 68 women (48.4%) were included [sex ratio 1.4] mean age 33.8 years+/-7.4 years. Physicians (29.1%), nurses (19.8%), assistant nurse (12.1%), and medical students (11.4%) were the professional categories which declared most accidents. Among them, only 51.1% was correctly vaccinated against hepatitis B. The average delay of consultation was 26.5 hours (1-240 hours), and 82.9% of victims consulted before the 48th hour. Antiretroviral prophylaxis was prescribed to 151 patients among whom 45% with bitherapy (Zidovudine and Lamivudine), and 55% with HAART including an antiprotease. Only 60 patients had one actual month of treatment. Despite the weak follow-up, no case of HIV seroconversion was reported 6 month after exposure. CONCLUSION: This work underlines once again the high frequency of AEB in Abidjan despite a under reporting, and calls for the implementation of a policy to train health care workers on AEB preventive measures.

[Medical emergencies related to HIV/AIDS in tropical zones: a prospective study in Cote d'Ivoire (1999-2000)]. / Urgences médicales liées au VIH/SIDA en zone tropicale: étude prospective en côte d'ivoire, 1999-2000.

At the beginning of the HIV epidemic, the incidence of the complications considered as emergencies was high in developed countries but with the advent of new therapeutic strategies the frequency of such complications and the associated need for emergency treatment decreased drastically. In developing countries where management resources remain limited, HIV/AIDS patients are still exposed to the risk of serious complications. However few studies have documented exact implication of HIV/AIDS in medical emergencies hospitals in developing countries. The purpose of this prospective study was to describe medical emergencies related to HIV infection in adult patients admitted at Treichvilie University Hospital Center. Evaluation of prevalence was carried out in the infections disease and internal medicine emergency units between May 1999 and January 2000. All patients over the age of 15 years were included after informed consent to undergo pre-testing and HIV serology. A total of 400 patients were recruited including 312 that were HIV positive (78%). Mean patient age of patients was 35 years. The male-to-female sex ratio was 1. The most frequent motives for emergency consultation were deterioration of general condition (62%), diarrhea (39.1%) and cough (20.5%). Illness was chronic in 54% of cases. Physical signs were severe weight lost (84%), fever (50%), pale conjunctivas (29%), respiratory signs (19.2%) and dehydration (19%). The most frequent organic involvement causing admission was digestive (39.7%), neurological (24.4%) and pulmonary (20.5%). No deaths were observed. Most medical emergencies related to the HIV infection in the adult involved opportunistic diseases. They pose a challenge for therapeutic management.

HIV status of female sex partners of men reactive to HIV-1, HIV-2 or both viruses in Abidjan, Côte d'Ivoire.

OBJECTIVES: To compare rates of serologic concordance in the female sex partners of men with HIV-1 and HIV-2 infections, and to determine the serologic status of sex partners of men who reacted serologically to both viruses. DESIGN: Cross-sectional study. SETTING: Infectious diseases service in a University Hospital in Abidjan, Côte d'Ivoire (West Africa). PARTICIPANTS: Hospitalized men reactive on synthetic peptide-based tests to HIV-1, HIV-2 or both viruses (dually reactive), and their spouses visiting them in hospital. OUTCOME MEASURES: Serologic status of female spouses of seropositive men. RESULTS: The serologic status of 540 spouses of 490 HIV-1- and/or HIV-2-positive, hospitalized men was studied. Similar proportions of spouses of HIV-1-infected men (49%) and HIV-2-infected men (44%) were concordantly seropositive. The overall prevalence of infection in spouses of dually reactive men (72%) was significantly higher than in spouses of other men; 44% of these spouses were infected with HIV-1, 8% with HIV-2, and 20% were themselves dually reactive. Considering only the seropositive female spouses of men monotypically reactive to HIV-1 or HIV-2, and the male spouses of women monotypically infected, rates of serologic discordance were significantly greater in men (24%) than women (7%). CONCLUSIONS: Men were likely to have been infected earlier than women because of their HIV-associated illness; also, men more frequently had serologic profiles indicative of infection outside of the union. Rates of serologic concordance in spouses of men with advanced HIV-1 or HIV-2 infection were similar (44-49%). Dually reactive hospitalized men frequently (72%) had seropositive sex partners, most of whom were HIV-1-positive. Dual reactivity was also frequent in these spouses, suggesting transmission of both HIV-1 and HIV-2, or of a cross-reactive strain, and a minority of partners were infected with HIV-2 alone. Prospective studies of discordant couples using quantitative molecular diagnostic techniques are required for better understanding of dual reactivity and transmission of HIV-1 and HIV-2.

Impact of the 1994 expanded World Health Organization AIDS case definition on AIDS surveillance in university hospitals and tuberculosis centers in Côte d'Ivoire.

OBJECTIVE: To assess the impact of the 1994 expanded World Health Organization (WHO) AIDS case definition on AIDS surveillance in Côte d'Ivoire. DESIGN: Prospective AIDS case surveillance. METHODS: From March 1994 through December 1996, passive AIDS case surveillance was conducted at the three university hospitals in Abidjan, and active AIDS case surveillance was conducted at the eight tuberculosis (TB) centers in Côte d'Ivoire. Standardized questionnaires were administered and blood samples for HIV serologic testing were collected from the patients evaluated. The numbers of persons who met the modified 1985 WHO clinical AIDS case definition (Bangui definition) and the 1994 expanded WHO AIDS case definition were determined, and the clinical characteristics of these patients were assessed. RESULTS: Of 8648 university hospital patients, 3658 (42.3%) met the clinical and/or the expanded case definition: 744 (20.3%) HIV-seropositive persons met only the expanded definition, 44 (1.2%) HIV-seropositive persons met only the clinical definition, 2334 (63.8%) HIV-seropositive persons met both definitions, and 536 (14.7%) HIV-seronegative persons met only the clinical definition. Of 18,661 TB center patients, 9664 (51.8%) met the clinical and/or the expanded definition: 5685 (58.8%) HIV-seropositive persons met only the expanded definition, none of the HIV-seropositive persons met only the clinical definition (by definition), 2625 (27.2%) HIV-seropositive persons met both definitions, and 1354 (14.0%) HIV-seronegative persons met only the clinical definition. CONCLUSIONS: Because of the inclusion of multiple severe HIV-related illnesses into the expanded definition, the number of reportable AIDS cases in HIV-seropositive patients increased 31.3% in the university hospitals, and 217% in the TB centers. The inclusion of HIV seropositivity as a criterion for the expanded definition also enhanced the specificity of AIDS case reporting, eliminating 536 cases in the university hospitals and 1354 cases in the TB centers in HIV-seronegative patients who had clinical signs of AIDS. The use of the 1994 expanded definition for surveillance purposes should be encouraged in areas of the developing world where HIV serologic testing is available.

Idiopathic CD4+ T-lymphocyte depletion in a west African population.

OBJECTIVE: To assess the frequency of CD4+ T-lymphocyte depletion in selected populations in West Africa and to determine whether an association exists between AIDS-like illnesses and CD4+ T-lymphocytopenia in HIV-negative individuals. DESIGN: Retrospective review of databases and prospective case-control study. SETTING: Project RETRO-CI, an AIDS research project in Abidjan, Côte d'Ivoire, a University Hospital and tuberculosis treatment and maternal and child health centres in Abidjan. METHODS: We conducted a retrospective review of CD4+ T-lymphocyte counts performed between 1991 and 1992 on hospitalized medical patients, outpatients with tuberculosis, and women participating in a study of HIV-1 and HIV-2 mother-to-child transmission. A prospective case-control study was conducted in 1992 to examine the relationship between HIV-negative CD4+ T-lymphocyte depletion and wasting syndrome (wasting and chronic diarrhoea and/or chronic fever). RESULTS: In the retrospective data review, CD4+ T-lymphocyte counts < 300 x 10(6)/l were found in 9.6% of 115 HIV-negative hospitalized patients, in 4.2% of 312 ambulatory tuberculosis patients, and in 0.4% of 263 healthy women after delivery. In the case-control study, no association was found between CD4+ T-lymphocyte depletion in HIV-negative individuals and the presence of wasting syndrome. Increased mortality in HIV-negative individuals was associated with wasting but not with reduced CD4+ T-lymphocyte counts. In contrast, a trend existed for increased mortality with increasingly severe CD4+ T-lymphocyte depletion in HIV-positive patients. Tuberculosis was the most frequently proven or suspected diagnosis in HIV-negative individuals with wasting and CD4+ T-lymphocytopenia. CONCLUSIONS: In the absence of HIV infection, CD4+ T-lymphocytopenia is uncommon (< 1%) in West African asymptomatic individuals but is more frequent in those with tuberculosis (4%) and hospitalized patients (10%). CD4+ T-lymphocytopenia in HIV-negative individuals was not associated with wasting syndrome or increased mortality. There was no evidence for frequent, clinically relevant immune deficiency other than that associated with HIV infection.

Profound immunosuppression across the spectrum of opportunistic disease among hospitalized HIV-infected adults in Abidjan, Côte d'Ivoire.

OBJECTIVES: To describe the spectrum of opportunistic disease in HIV-infected patients admitted to hospital in Abidjan, Côte d'Ivoire, and to describe the level of immunosuppression at which these diseases occur. DESIGN: Cross-sectional study. SETTING: In-patient wards of the University Hospital Infectious Diseases Unit. PATIENTS: A total of 250 adult patients recruited by systematic sampling at the point of hospital admission. MAIN MEASURES: HIV status; CD4 count; diagnoses, confirmed by microbiological/radiological investigations whenever possible; and outcome of hospitalization (death or discharge). RESULTS: Overall, 79% patients were HIV-positive. The most frequent diagnoses in HIV-positive patients were septicaemia (20%, with non-typhoid salmonellae, Escherichia coli and Streptococcus pneumoniae the most common organisms), HIV wasting (16%), meningitis (14%), tuberculosis (TB; 13%), isosporiasis (10%), cerebral toxoplasmosis (7%) and bacterial enteritis (7%). Most HIV-positive patients had evidence of severe immunosuppression: 39% had CD4 counts < 50 x 10(6)/l, 17% had 50-99 x 10(6)/l, and 20% had 100-199 x 10(6)/l. In-hospital mortality among HIV-positive patients was 38% compared with 27% among HIV-negative patients [age-adjusted odds ratio (OR), 1.5; 95% confidence interval (CI), 0.7-2.9]. Among HIV-positive patients, the highest case-fatality rates were among patients with meningitis, toxoplasmosis and TB: in a multivariate analysis the strongest independent risk factors for death were an abnormal level of consciousness (OR, 9.3; 95% CI, 3.5-24.6), a haemoglobin concentration below 8 g/dl (OR, 4.2; 95% CI, 1.4-12.8) and age > 40 years (OR, 3.9; 95% CI, 1.5-10.2). CONCLUSIONS: Our data show that, as in industrialized countries, most HIV-infected individuals admitted to and dying in hospital in Abidjan are profoundly immunosuppressed. Potentially preventable infections are the main causes of in-hospital morbidity and mortality among HIV-infected persons in Abidjan, and the evaluation of appropriate primary prophylactic regimes is a priority.

Treatment of acute bacterial diarrhea: a multicenter international trial comparing placebo with fleroxacin given as a single dose or once daily for 3 days.

This study was designed to test the efficacy of 400 mg fleroxacin given orally as a single dose or once daily for 3 days against acute bacterial diarrhea. A group of 508 adults with acute diarrhea were entered into a randomized, double-blind, placebo-controlled, multicenter trial. Patients were examined and asked about numbers of liquid stools daily for 3 days and at 5 days after start of treatment. Repeat stool samples were obtained for culture on days 3 and 5 after start of treatment. A total of 332 patients showed stool cultures positive for bacterial pathogens sensitive to fleroxacin and completed their treatments. Patients treated with fleroxacin, both single-dose and 3-day regimens, showed faster clinical improvement than did placebo-treated patients, as shown by earlier cessation of diarrhea (p < 0.001) and reduction in mean number of loose stools per day on days 2, 3, and 5 after start of therapy (p < 0.05). Bacteriologic efficacy was demonstrated by negative stool cultures for initial pathogens on days 3 and 5 after start of therapy in 94% of patients treated with single doses of fleroxacin and in 93% of patients treated with three doses of fleroxacin as compared with 57% of patients treated with placebo (p < 0.001). Patients with cholera, shigellosis, and infections due to Vibrio parahaemolyticus showed both clinical and bacteriologic responses to fleroxacin treatment, whereas patients with salmonellosis showed only bacteriologic responses. The good overall clinical and bacteriologic responses of most patients with acute bacterial diarrhea of fleroxacin indicate that this convenient single-dose therapy should be advantageous for empiric treatment of certain diarrheal illnesses.

Randomized comparative study of fleroxacin and chloramphenicol in typhoid fever.

This study compared fleroxacin, 400 mg daily for 7 or 14 days, with chloramphenicol, 50 mg/kg per day for 14 days, for the treatment of patients with typhoid fever in a multicenter study. A total of 184 patients were randomly assigned to the three treatment groups. Efficacy was determined by culture of blood and stool, overall clinical response, and time to defervescence. Safety was assessed by occurrence of adverse events and laboratory abnormalities. A total of 97 patients were evaluable for efficacy, 28 in the fleroxacin 7-day group, 35 in the fleroxacin 14-day group, and 34 in the chloramphenicol group. All showed rapid defervescence with high cure rates. Bacteriologic cure rates were 96% in the fleroxacin 7-day group, 97% in the fleroxacin 14-day group, and 85% in the chloramphenicol group. Clinical cure rates were 83-100% with fleroxacin and 82% with chloramphenicol. The time to defervescence was shorter for patients treated with fleroxacin than for those treated with chloramphenicol. All three treatment regimens were well tolerated. Fleroxacin, 400 mg daily for 7 days, appears to be satisfactory for the treatment of typhoid fever and compares favorably with the standard 14-day therapy with chloramphenicol.

Tuberculin skin testing to assess the occupational risk of Mycobacterium tuberculosis infection among health care workers in Abidjan, Côte d'Ivoire.

SETTING: Tuberculin skin test (TST) survey of health care workers (HCWs) in selected clinical services in Abidjan, Côte d'Ivoire. OBJECTIVE: To assess whether HCWs in Abidjan are at increased risk for occupationally acquired Mycobacterium tuberculosis infection. DESIGN: From October 1996 to January 1997, consenting HCWs from four services where tuberculosis (TB) prevalence among patients was high and two services where it was low were evaluated with a questionnaire, TST (including evaluation of anergy) and chest radiograph. RESULTS: Of the 512 participants, 405 (79%) had a TST reaction of > or =10 mm, eight (2%) were anergic, five (1%) had a radiograph compatible with TB, and two had confirmed TB. Using a cut-off of 10 mm, we found a higher prevalence of TST positivity in services with high TB prevalence than in those with low TB prevalence (92% vs 72%; odds ratio [OR] 4.3; 95% confidence interval [CI] 2.3-8.0]) and among HCWs with direct (87%; OR 2.9; 95%CI 1.6-5.1) and indirect patient contact (80%, OR 1.7; 95%CI 1.0-2.3) than among those with minimal patient contact (69%). CONCLUSION: These findings indicate that TST positivity among HCWs is related to level of exposure to TB patients, and suggest that HCWs in Abidjan are at risk for the nosocomial transmission of TB.

Nutritional status and dietary intakes in human immunodeficiency virus (HIV)-infected outpatients in Abidjan, Côte D'Ivoire, 1995.

OBJECTIVE: To evaluate nutritional status and dietary intakes in HIV-outpatients in Abidjan, Côte d'Ivoire. DESIGN: Cross-sectional study. SETTING: In the Outpatients and Counselling Unit in the University Hospital in Treichville, and in the follow-up Unit of Blood Donors. SUBJECTS: 100 HIV-infected patients at different stages of the infection recruited consecutively in the two consultation services. MAIN OUTCOME MEASURES: Clinical, biological and anthropometric data were collected: weight, baseline weight, height, triceps skinfold (TS), arm circumference (AC), body mass index (BMI), muscular circumference (MC) and weight loss (WL). Dietary intake was estimated by the 24 h recall method. RESULTS: The M:F sex ratio was 1.1:1. Mean age was 32.5 y (30.7-34.4); 64% of the patients were symptomatic (S+). Mean weight was 58.7 kg (56.8-60.6) and mean BMI, 20.9 k/m2 (20.7-21.1); 67% of the patients had a BMI < 21.5 kg/m2. S+ patients had mean weight, BMI, AC and MC significantly lower than asymptomatic patients (P < 0.0001 = 0.001, 0.0003 and 0.004 respectively) and had suffered a more important WL (P < 0.0001). Immunodepressed patients had mean weight, AC and MC significantly lower than patients with a CD4 count > or = 200/mm3 (P = 0.04, 0.005 and 0.04 respectively). WL was independent of CD4 count. Protein, carbohydrate and fat intakes were respectively 59 g/24 h (52-66), 266 g/24 h (240-292) and 59 g/24 h (51-66). Energy mean intake was 7.6 MJ/24 h (6.9-8.4) and lower than WHO recommended intakes. CONCLUSIONS: In Abidjan, anthropometric parameters and dietary intakes of HIV-infected patients are worsened by clinical events. Nutritional intakes are generally lower than recommendations. Further studies are needed to determine if, in the African context, a causal relationship could exist between dietary intakes and nutritional status in HIV-infected patients.

Effect of HIV infection on the incidence of lymphoma in Africa.

PIP: During a 9-month period in 1991, an autopsy was conducted on 247 cadavers of HIV-positive adult patients who died in a hospital in Abidjan, Ivory Coast. The most common cause of death among adults in Abidjan is AIDS. During 8 months in 1991-92, an autopsy was also conducted on 78 HIV-positive cadavers of children 2 months to 8 years old and on 78 HIV-negative cadavers of children 2 months to 12 years old located in a morgue in Abidjan. The pathologists aimed to determine the incidence of lymphoma among HIV-infected adults and children. Seven (2.8%) adult cadavers had B-cell lymphoma, each having been diagnosed with it in the postmortem. The types were visceral (4) and primary cerebral (3) lymphomas. The researchers estimated the non-Hodgkin's lymphoma crude incidence rate among adults in Abidjan to be 84/100,000 per year. This incidence is 10 times greater than expected among HIV-negative people. With 11% HIV prevalence, the incidence of non-Hodgkin's lymphoma is expected to double. None of the HIV-positive cadavers of children had B-cell lymphoma. Two HIV-negative children (ages 5 and 9) had B-cell lymphoma of Burkitt and lymphoblastic type lymphoma, respectively. In both child cases, the viscera was involved.^ieng

Contribution of tuberculosis to slim disease in Africa.

OBJECTIVES: To assess the contribution of tuberculosis to the aetiology of the HIV wasting syndrome (slim) in Africa, a condition usually considered an enteropathy. METHODS: Clinical examination and representative necropsy study of adult patients positive for HIV. SETTING: Hospital medical wards in Abidjan, Ivory Coast. SUBJECTS: Adults positive for HIV. MAIN OUTCOME MEASURES: CD4 T lymphocyte counts before death, clinical and anthropometric data, and gross and microscopic pathology. RESULTS: Necropsy was done on 212 HIV positive adults. Tuberculosis was found in 41 of 93 with the clinical HIV wasting syndrome and in 32 of 119 without (odds ratio 2.1, 95% confidence interval 1.2 to 4.0). A significant association existed between the prevalence of tuberculosis at necropsy and the degree of cadaveric wasting (no wasting 25% (15/59); moderate wasting 40% (23/58); skeletal wasting 44% (42/95); P = 0.02). Wasting was also associated with a history of chronic diarrhoea, but no association existed between diarrhoea and tuberculosis. Median CD4 T lymphocyte counts were lowest in wasted patients irrespective of findings at necropsy and in those with chronic diarrhoea (< 60 x 10(6)/l). CONCLUSION: Wasting and chronic diarrhoea are late stage manifestations of HIV disease in Africa. The importance of tuberculosis as a contributing factor in the pathogenesis of the slim syndrome has been underestimated. In nearly half of patients dying with severe wasting, tuberculosis was the dominant pathological finding.

PIP: The authors explore the contribution of tuberculosis (TB) to the etiology of HIV wasting syndrome in Africa, usually considered to be an enteropathy. Clinical examinations and necropsy were performed upon 212 HIV positive adults in the medical wards of the largest hospital in Abidjan, Cote d'Ivoire. TB was found in 41 of 93 patients with the clinical wasting syndrome and in 32 of 119 without. Significant associations were found between the prevalence of TB at necropsy and the degree of cadaveric wasting, moderate wasting, and skeletal wasting. Wasting was also associated with a history of chronic diarrhea, but no association existed between diarrhea and TB. Median CD4 counts were lowest in wasted patients irrespective of findings at necropsy and in those with chronic diarrhea. The authors note that wasting and chronic diarrhea are late stage manifestations of HIV disease in Africa and argue that researchers and practitioners have underestimated the importance of TB as a contributing factor in the pathogenesis of slim disease.

[The role of bacterial diarrhea in developing countries]. / Place des diarrhées bactériennes dans les pays en développement.

Bacterial diarrheas in developing countries remain a major public health problem. Cholera is endemo-endemic since 1970. Clusters of Shigella infections are commonly observed during the rainy season. Other enteropathogen cause nosocomial infections and foodborne diseases. The HIV epidemic determined the emergence of a new trend of enteric diseases caused by opportunistic bacteria such as Salmonella Enteritidis, S. Typhimurium. The risk factors associated with these infections remains almost unknown. Treatment failure is related to an incre of high level resistance strains.

[Problems produced by the use of antitubercular agents in a reference service for HIV/AIDS in Abidjan (Côte d'Ivoire)]. / Problèmes engendrés par l'utilisation des antituberculeux dans un service de référence pour VIH/SIDA à Abidjan (Côte d'Ivoire).

This study reports on the experience using antituberculosis drugs in a HIV/AIDS reference service in Abidjan during a 64 month period. Prevalence of tuberculosis is 1.9% out of a total of 23,957 patients. The annual incidence rate increased slowly from 0.9% in 1990 to 3.5% in 1995. Seropositivity to HIV is 90.8%. Predominant locations of tuberculosis are pulmonary (60.3%), extrapulmonary (19.7%) and multifocal or disseminated (20%). The average period of diagnosis (9.9 days) and average duration of antituberculosis treatment in hospital (11.8 days) are similar whatever the serological status and the location of the infection may be. However, the mortality rate is more important in HIV positive patients (39.7%) than in HIV negative (17.6%) p = 0.01. The decision to treat is taken by infectiologists only in 88% of the cases, by pneumologists only in 2.5%, and both by infectiologists and pneumologists in 9.5%. Side-effects due to antituberculosis drugs were noticed in 19 patients leading to an interruption of the treatment in 10 cases. The authors recommend that health personnel be trained for the management of tuberculosis.

[Adult non-viral lymphocytic meningitis in Abidjan (Côte d'Ivoire)]. / Méningites lymphocytaires non virales de l'adulte à Abidjan (Côte d'Ivoire).

Our prospective and longitudinal study aimed to analyse the aetiologies, clinical features and prognostic of non viral lymphocytes meningitis (NVLM). We recruited 131 patients, 77 males (59%) and 54 females (41%) sex-ratio 1.4. The mean age was 35 years [15-67]. 117 patients were HIV positive (89%) and 14 (11%) were HIV negative. Feverish meningoencephalitis was present in 85% of cases, with 7 days for mean delay of admission into hospital. 80 germs were found in the C.S.F. 70 Cryptococcus neoformans, 4 Mycobacterium tuberculosis, 3 Streptococcus pneumoniae, 1 Candida albicans, 1 Neisseria meningitis and 1 Trypanosoma gambiense. 63 aetiologies were linked to lymphocytes meningitis by indirect deduction: 41 cases of tuberculous meningitis with lung X-ray anomalies and M. tuberculosis in sputum (11 times), 11 cases of cerebral malaria with Plasmodium falciparum in blood, 11 cases of cerebral toxoplasmosis by significant features with cerebral tomodensitometry. Letality was 53%, 35% of patients improved and 12% were lost to follow-up. Our study shows the difficulties in the management of the NVLM, due to the delay of diagnosis, particularly for tuberculous meningitis.