Clinical classification of diabetes in tropical west Africa.

The objective of this work was to classify and describe the different types of diabetic patients detected in West Africa. In four health centres (three in Ivory Coast, one in Niger) 310 new cases were detected and followed up over 1 year. Classification was based on age at diagnosis, BMI, ketonuria, basal and stimulated C-peptide levels at inclusion, and response to antidiabetic therapy. In this population, males were predominant (sex ratio = 2.40), and random blood glucose levels very high at screening (mean +/- SE, 18.6 +/- 0.4 mmol/l). Only one case of fibrocalculous pancreatic diabetes and one possible case of diabetes mellitus related to malnutrition were detected. IDDM was diagnosed in 11.3% of the patients, half of them above 35 years. Leanness was observed in 59% of the patients with NIDDM. A dramatic decrease of fasting blood glucose was observed in all groups after 2 months of treatment, especially in NIDDM. As IDDM and non-obese NIDDM presented great similarities before treatment, even for C-peptide levels, a point score system is proposed to classify these two groups at baseline. In conclusion, it is confirmed that the form of diabetes previously defined as related to malnutrition is a very rare entity in black African populations. In contrast, African diabetes is characterised by the high proportion of NIDDM patients with low BMI, and reduced beta-cell function, rarely associated to ketonuria. This form of diabetes seems to be adequately controlled with oral hypoglycaemic drugs and/or diet in the year following diagnosis.

Reliability of glucose measurement by glucose test strips in tropical conditions.

The reliability of glucose test strips and reflectance meters after storage in tropical conditions was assessed. In a first experiment, sealed bottles containing glucose test strips were stored for 1 month in closed sterilising ovens at 40 degrees C, one in dry (0% humidity) and the other in wet (75% humidity) conditions. Results were compared to measurements obtained with glucose test strips stored under standard Western conditions, in non-diabetic and diabetic patients, using the same standard reflectance meter. A second experiment was performed similarly, comparing the values obtained with reflectance meters stored in different conditions, using standard glucose test strips. Reproducibility was assessed on the basis of duplicate measurements for each condition of storage. We observed that temperature and humidity did not significantly affect the glucose test strips (1st experiment), while a slight underestimation of capillary blood glucose was found using reflectance meters stored at 50 degrees C, irrespective of the humidity (2nd experiment). All the correlation coefficients between duplicates were greater than 0.975 irrespective of the conditions of storage for glucose test strips and reflectance meters. Therefore, glucose test strips and reflectance meters appear fairly reliable at the grass-root level in the tropics, if used carefully.

Le diabete sucre intertropical

Longtemps considere comme une affection peu repandue en zone intertropicale; le diabete sucre (DS) suscite actuellement dans ces regions de nombreuses etudes. La repartition demographique permet de calculer que plus de 70 pour cent de la population diabetique mondiale se trouve maintenant dans les pays intertropicaux

[Imported malaria in Bordeaux: evaluation of the risk of infection with Plasmodium falciparum as a function of country visited]. / Paludisme d'importation à Bordeaux: évaluation du risque d'infestation par Plasmodium falciparum en fonction de la destination.

This study of imported cases of malaria, which was carried out in Bordeaux (France) in 1987-89, emphasizes the major part played by Plasmodium falciparum, especially in areas lying south of the Sahara in Africa, from where falciparum malaria is mainly imported to other countries. The study of these imported cases is strengthening our understanding of the epidemiology of malaria in relation to the country or area, whether the transmission occurs without interruptions or seasonally. The number of cases of P. falciparum per 1000 travellers (seen for vaccination against yellow fever at Bordeaux) gives an index for evaluating the risk of malaria. This risk changes with the epidemiological profile of falciparum malaria in the three major African ecosystems (rain forest, savannah, and sahelian belts), and is related to the progression of chloroquine resistance in Africa and influenced by the type of chemoprophylaxis proposed to travellers. The use of mefloquine for stays shorter than one month in Central Africa reduced the risk of malaria in 1988 and 1989, compared to 1987. [Editorial note. Recent data indicate some undesirable side-effects of mefloquine, e.g., its use during early pregnancy could lead to congenital defects.] Appropriate chemoprophylaxis and advice to travellers to areas lying south of the Sahara are therefore more and more necessary in order to arrest the increase in the number of imported falciparum malaria cases and reduce the number of serious cases, which are costly in terms of public health.

[Human malaria: dysglobulinemia-hypocholesterolemia syndrome]. / Paludisme. Le syndrome dysglobulinémie--hypocholestérolémie.

Comparative study of protein and lipid parameters within a homogenous sample of 144 non-immune subjects having stayed for four months in Central Africa, suggests a dysglobulinemia more significant in the infected group. This dysglobulinemia affects in particular the IgM which are negatively correlated with cholesterol, positively with apoproteins A2 and H.D.L. Such a peculiar profiling involving immunoglobulins, apoproteins and cholesterol is rapidly regressive after stopping exposure to parasitic risk. It appears as an adaptation syndrome--or resistance--to tropical environment.

[Imported malaria at hospitals in Bordeaux (France) in 1987 and 1988. Report of 185 cases]. / Le paludisme d'importation dans les hôpitaux de Bordeaux en 1987-1988. Etude de 185 cas.

100 cases of imported malaria were registered in Hospitals of Bordeaux in 1987 and 85 in 1988. Origin of infestation is Africa in 88 p.c. of the cases mainly from Central Africa (50 p.c.) in 1987 and western Africa (67 p.c.) in 1988. The most frequent species was Plasmodium falciparum 73 p.c. in 1987 and 82 p.c. in 1988. Admitted cases in Bordeaux were mainly French (81 p.c.) with a significant male prevailing and young adults. Mean age was 29 for Europeans and 19 for the others mainly Africans. Infestation risk is in close correlation with the duration of stay in endémic zones. It is maximum for stays between 2 and 11 months. Delay for first symptoms to appear following return from an endemic zone depends of species concerned during the first month, 83 p.c. of malaria fever at Plasmodium falciparum during the second quarter, 50 p.c. of fever at Plasmodium vivax, and after one year or more 40 p.c. at Plasmodium ovale. Only 1/4 of the cases were diagnosed during the first 48 hours. Delay in diagnosing may be prolonged and is in relationship with Plasmodium falciparum chemoresistance and self-medication. 21 strains of Plasmodium falciparum were chloroquinoresistant in vitro: 1 from French Guyana, 9 from Western Africa, and 11 from Central Africa. The strain from Guyana was also less sensible to quinine with a IC 50 = 480 nmol/l.

[Risk of AIDS for the occasional traveler in Africa]. / Le risque du S.I.D.A. pour le voyageur occasionnel en Afrique.

The authors first point out the importance of A.I.D.S. in Africa; then they appreciate the risk of contamination for occasional traveller in Africa. They recall some epidemic features of tropical A.I.D.S., its originality suggesting some risk factors different from the ones faced in temperate countries. Importance of risk of heterosexual transmission is emphasized, as well as possible parenteral contamination in connection with the frequent use of disposable needles and syringes again utilized without preliminary sterilization. Taking into consideration all these possibilities, the authors expose some prophylactic advises intended for people travelling briefly in endemic zones.

[Reflections on ankylosing spondylitis in Black Africa. Apropos of a juvenile-onset case]. / Réflexions sur la spondylarthrite ankylosante en Afrique noire. A propos d'un cas à début juvénile.

From the starting point of two cases of ankylosing spondylitis, one of which began in youth, observed in Abidjan, Ivory Coast, a review of the literature concerning the major cases amongst africans is carried out. This disease is unusual in tropical Africa: about thirty published cases, of varied origin. This low incidence of ankylosing spondylitis is correlated to the rarity of the HLA B27 group and of seronegative spondylitic joint diseases in general amongst the black population of Africa. Whereas the high incidence of forms with juvenile onset in North Africa suggests some connection with undetected Reiter's disease, the infrequency of this form of onset of the disease in sub-Saharan Africa and the lack of bacteriologic evidence make it impossible to reach any such conclusions.

[Osteoarticular manifestations of thalassemia]. / Manifestations ostéoarticulaires des thalassémies.

Thalassemia is a genetic illness which exists every where in the world. In Black Africa, intermediary thalassemia and beta-thalassemia minor are mainly observed. The osteoarthropatic signs are caused by erythroid hyperplasia and overload iron. We mention the roentgenographic skeletal survey of intermediary thalassemia and other less frequent bone abnormalities. We analyse the publications concerning osteoarticular manifestations in beta-thalassemia minor. We report a clinical and anatomical case of intermediary thalassemia with gout complications.

[The nutritional immunodeficiency syndrome]. / Le syndrome d'immunodéficit nutritionnel.

There is a strong relationship between nutritional status and resistance to infection. This relationship must receive attention more especially as human being is young. Newborns and infants have some immunological immaturity in regard to systemic immunity as well as local (particularly intestinal), immune defense. Malnutrition is an aggravating factor vis a vis such an immunodeficiency. It modifies the regulating activities of the different lymphocyte populations, of the macrophages, of the complementary system. These disorders are bound to energy, proteins, vitamins and mineral deficiencies. But many metabolic phenomenons have still to be explored, as well as the effect of such a dysimmunity on immunization. Bowel epithelial cells, cross-roads between immunity and nutrition, seem to be the point we ought to select in order to dislocate the infection--malnutrition couple.

[Survey of nutritional pathology in Mauritania]. / Aperçu de la pathologie nutritionnelle en Mauritanie.

A display of the different nutritional problems in Mauritania, such as they could be studied under the working medical conditions in this country. This study shows the coexistence, into a low life level country, of nutritional deficiency diseases, and obesity induced diseases, especially frequent among the mature women. This reality emphasizes the complexity of the mechanisms responsible for the nutritional diseases, and advocates for a global action to improve the nutritional status of a population. This supposes to integrate all the known data, including social and cultural knowledges.

[Tropical diabetes mellitus, a new nutritional indicator?]. / Le diabète sucré tropical, un nouvel indicateur nutritionnel?

Studies on diabetes mellitus in tropical zones indicate that its traditional link with overnutrition depends not only on the economic level, but also on some ethnic, social and cultural factors. At present, we insist on the unexpected relationship between diabetes mellitus and undernutrition either in some major infantile forms (described in India and Nigeria) with calcareous pancreatitis, or some less severe forms observed in Africa. This tropical diabetes mellitus occurs in some patients with normal weight or inferior to normal; it is not very ketogenic, responding to glucagon stimulation, and seems more frequent in the chronic malnutrition areas. So, it is tempting to utilize diabetes mellitus as an indicator of nutritional disorder or of dietary toxic factors. However, we ought to consider it within a multifactor surroundings associating genetic determinism and the other factors of tropical aggressiveness.