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.

Cutaneous disseminated sporotrichosis in an immunocompetent farmer.

Sporotrichosis is an implantation mycosis due to the genus Sporothrix. Cutaneous disseminated sporotrichosis is an unusual clinical form that often affects immunocompromised patients. We report a case of cutaneous disseminated sporotrichosis in an immunocompetent famer from a rural region of Madagascar, treated successfully with Itraconazole 200mg twice a day. This case highlights the role of multiple inoculation affecting different parts of the body as a risk factor of cutaneous disseminated sporotrichosis in an immunocompetent individually.

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.

Mucocutaneous Manifestations Among HIV-Infected Patients in Madagascar: Cross-Sectional Study.

BACKGROUND: More than 90% of HIV-infected patients present with at least one mucocutaneous manifestation during the course of their disease. Insufficient data are available regarding dermatologic findings among HIV-infected patients in Madagascar. OBJECTIVE: This study aimed at evaluating the spectrum of mucocutaneous manifestations and their relationship with CD4 cell counts in HIV-infected patients in Madagascar. METHODS: A cross-sectional study on HIV-positive patients attending the Department of Infectious Diseases in the University Hospital of Antananarivo in Madagascar was conducted from January 2013 to March 2020. HIV-positive patients older than 18 years and receiving antiretroviral therapy as well as those awaiting antiretroviral therapy commencement were included. RESULTS: Among 328 patients enrolled in this study, 167 (51%) presented with at least one type of mucocutaneous lesion. Oral candidiasis was the most common presentation, followed by seborrheic dermatitis and Kaposi sarcoma. Decreases in CD4 cell counts were substantially correlated with oral candidiasis, syphilis, and condyloma acuminatum. CONCLUSIONS: According to our findings, oral candidiasis, syphilis, and condyloma acuminatum may serve as clinical indicators for predicting the immune status of patients. As HIV infection progressed and immune function declined, an increase in cutaneous manifestations was observed.

Idiopathic Granulomatous Mastitis as an Unusual Cause of Erythema Nodosum in a Malagasy Woman.

Introduction: Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease. Neoplastic and infectious etiologies must be ruled out. IGM is a diagnostic challenge for countries with high tuberculosis endemicity like Madagascar since it may clinically and radiologically mimic breast tuberculosis. We report a case of IGM associated with erythema nodosum in a Malagasy. Case Report: A 29-year-old primiparous woman came to a dermatological consultation for typical erythema nodosum lesions that appeared one month after a breast swelling. She had no particular medical history. Examination revealed typical erythema nodosum lesions on the legs, voluminous tender mass in the right breast. Bacteriological samples and tuberculosis test were negative. Imaging showed mastitis on the right breast with no evidence of malignancy. Histology revealed a non-caseating granulomas on the lobule of the right breast. As part of an etiological work-up, COVID-19 serology was performed with a positive IgG antibody. The diagnosis of IGM associated with erythema nodosum was evocated. The evolution was favorable under systemic corticosteroid therapy. Discussion: The cause of this uncommon lesion remains obscure. The extramammary localizations such as erythema nodosum and arthralgia suggest an autoimmune origin. This pathogenesis is also reinforced by a good response to systemic immunosuppression. In our patient, the etiological assessment of the mastitis revealed a chronic infection with SARS-CoV-2. Histopathology is the gold standard for the IGM diagnosis which demonstrates a lobulocentric granulomas without caseous necrosis. Oral corticosteroid therapy is the initial choice of treatment. Conclusion: Now, with several cases of concomitant IGM and EN reported, dermatologists should be aware that erythema nodosum can be one of the presenting signs of IGM, since the two conditions appear to be associated. The particularity of our case lies in the incidental discovery of SARS-CoV-2 infection. Is a chronic granulomatous disease associated with SARS-CoV-2 infection, a coincidence?

Treatment responses in patients with chromoblastomycosis to itraconazole in Madagascar.

INTRODUCTION: Chromoblastomycosis (CBM) is a chronic fungal infection of the skin and subcutaneous tissue caused by several pigmented fungi. It is frequently found in tropical and subtropical areas like Madagascar. This study primarily discusses the effects of antifungal therapy while also describing the epidemiological, clinical, and pathological features of CBM in our patients. METHODS: From March 2013 to January 2019, a descriptive prospective study on CBM patients was undertaken. The study included patients with CBM who had received antifungal treatment for at least 3 months. Itraconazole 200 mg was given to patients every day for ˃3 months. Results were assessed at the 6th and 12th months and classified as major responses, minor responses to treatment, or failure. RESULTS: A total of 29 cases of CBM were included. The mean age of patients was 42.02 years. They primarily worked in rural areas. Infected men were more prevalent. At the end of the 12th month of itraconazole therapy, 3 patients presented major responses, 14 patients had minor responses to treatment, and 12 had been lost to follow-up. The clinical response of CBM to treatment was correlated to the severity and the long course of CBM. When compared with CBM caused by Cladophialophora, CBM caused by Fonsecaea showed a greater clinical response. CONCLUSION: These findings demonstrated that CBM lesions are recalcitrant and difficult to treat.

Chromoblastomycosis (CBM) is a chronic fungal infection of the skin and subcutaneous tissue commonly seen in tropical and subtropical areas. This study mainly discusses the therapeutic while also describing the epidemiological, clinical, and pathological features of CBM in Madagascar.

[Clinical aspects of Neurofibromatosis type 1 seen in the Department of Dermatology at University Hospital Antananarivo, Madagascar]. / Aspects cliniques de la Neurofibromatose de type 1 vue au service de Dermatologie Du Centre Hospitalier Universitaire Antananarivo, Madagascar.

Introduction: Neurofibromatosis 1 (NF1) is an inherited disease, in an autosomal dominant manner, with complex multi-system involvements. Prevalence varies from one country to another. However, little is known about neurofibromatosis in African countries, particularly in Madagascar. Methodology: A descriptive retrospective study from 2014 to 2019 was conducted at the service of dermatology at University Hospital Joseph Raseta Befelatanana in Antananarivo, including all patients with neurofibromatosis according to National Institutes of Health Consensus Conference criteria for whom genealogical investigation could be made. Results: Among 32 cases of NF1 seen during 6 years, 28 cases were included with a sex ratio M/F of 0.87. The mean age was 24 years ranging from 11 to 54 years. Seventeen patients presented sporadic forms. All patients had "café au lait" spots and cutaneous neurofibromatosis. Three cases presented plexiform neurofibromas which cause significant cosmetic and functional problems by their size and their displayed topography. Fifteen patients had Lisch nodules but no case of optic glioma was identified. Neurological symptoms such as learning difficulties, epilepsy and headache were frequent in our case series. However, access to medical imaging was very limited. Scoliosis was the most common orthopedic complication. Conclusion: The clinical manifestations of NF1 are extremely variable. Although the possibility of systemic complications seems to be low, patients must be followed up.

A Large Parotid Hemangioma Managed Successfully with Propranolol.

The treatment of parotid hemangiomas has posed a challenge. A male infant presented with large hemangioma of the right parotid gland diagnosed at the age of 3 months. Starting at the age of 4 months, he was treated with oral propranolol for 10 months, which led to a marked reduction in tumor size and strawberry hemangioma. Our case shows that propranolol is effective and safe in treating large parotid infantile hemangioma.

Adverse Effects of Long-Term Oral Corticosteroids in the Department of Dermatology, Antananarivo, Madagascar.

BACKGROUND: Long-term oral corticosteroids have an important role in dermatological care in Madagascar. However, significant adverse effects have been associated with continuous exposure to oral corticosteroids. OBJECTIVE: We aim to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology at the University Hospital Joseph Raseta Befelatanana Antananarivo (UH/JRB), Madagascar, and to identify the risk factors associated with these adverse effects. METHODS: A cross-sectional study was conducted during 4 months to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology. Patients treated with oral corticosteroids for more than 3 months were included in our study. RESULTS: The prevalence of long-term use of oral corticosteroids in the Department of Dermatology of UH/JRB was 34.28%. A total of 51 patients were included and adverse effects occurred in 64.70% of this population. Repetitive infections and cutaneous adverse reactions were the most frequent adverse effects, in 23.52% and 11.76% of cases, respectively. There were no correlations between age, gender, type of disease treated, the molecule used or daily dose and the risk of adverse effects. Patients who received a corticosteroid dose of more than 40 mg daily (longer than 3 months) or a high cumulative dose of corticosteroids had a high risk of adverse effects. CONCLUSION: Repetitive infections and cutaneous adverse reactions are the most frequent adverse effects of long-term oral corticosteroid use. Prescribing the lowest effective dose may reduce the risk of these adverse effects. Furthermore, prevention of the adverse effects of corticosteroids through diet, calcium and vitamin D supplementation is strongly recommended during long-term oral corticosteroid therapy.

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.

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.

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.

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.

Population Genomics of Mycobacterium leprae Reveals a New Genotype in Madagascar and the Comoros.

Human settlement of Madagascar traces back to the beginning of the first millennium with the arrival of Austronesians from Southeast Asia, followed by migrations from Africa and the Middle East. Remains of these different cultural, genetic, and linguistic legacies are still present in Madagascar and other islands of the Indian Ocean. The close relationship between human migration and the introduction and spread of infectious diseases, a well-documented phenomenon, is particularly evident for the causative agent of leprosy, Mycobacterium leprae. In this study, we used whole-genome sequencing (WGS) and molecular dating to characterize the genetic background and retrace the origin of the M. leprae strains circulating in Madagascar (n = 30) and the Comoros (n = 3), two islands where leprosy is still considered a public health problem and monitored as part of a drug resistance surveillance program. Most M. leprae strains (97%) from Madagascar and Comoros belonged to a new genotype as part of branch 1, closely related to single nucleotide polymorphism (SNP) type 1D, named 1D-Malagasy. Other strains belonged to the genotype 1A (3%). We sequenced 39 strains from nine other countries, which, together with previously published genomes, amounted to 242 genomes that were used for molecular dating. Specific SNP markers for the new 1D-Malagasy genotype were used to screen samples from 11 countries and revealed this genotype to be restricted to Madagascar, with the sole exception being a strain from Malawi. The overall analysis thus ruled out a possible introduction of leprosy by the Austronesian settlers and suggests a later origin from East Africa, the Middle East, or South Asia.

The Diagnosis of Fungal Neglected Tropical Diseases (Fungal NTDs) and the Role of Investigation and Laboratory Tests: An Expert Consensus Report.

The diagnosis of fungal Neglected Tropical Diseases (NTD) is primarily based on initial visual recognition of a suspected case followed by confirmatory laboratory testing, which is often limited to specialized facilities. Although molecular and serodiagnostic tools have advanced, a substantial gap remains between the desirable and the practical in endemic settings. To explore this issue further, we conducted a survey of subject matter experts on the optimal diagnostic methods sufficient to initiate treatment in well-equipped versus basic healthcare settings, as well as optimal sampling methods, for three fungal NTDs: mycetoma, chromoblastomycosis, and sporotrichosis. A survey of 23 centres found consensus on the key role of semi-invasive sampling methods such as biopsy diagnosis as compared with swabs or impression smears, and on the importance of histopathology, direct microscopy, and culture for mycetoma and chromoblastomycosis confirmation in well-equipped laboratories. In basic healthcare settings, direct microscopy combined with clinical signs were reported to be the most useful diagnostic indicators to prompt referral for treatment. The survey identified that the diagnosis of sporotrichosis is the most problematic with poor sensitivity across the most widely available laboratory tests except fungal culture, highlighting the need to improve mycological diagnostic capacity and to develop innovative diagnostic solutions. Fungal microscopy and culture are now recognized as WHO essential diagnostic tests and better training in their application will help improve the situation. For mycetoma and sporotrichosis, in particular, advances in identifying specific marker antigens or genomic sequences may pave the way for new laboratory-based or point-of-care tests, although this is a formidable task given the large number of different organisms that can cause fungal NTDs.

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.