[Celiac disease: special features in Africa. Description of 8 cases in Djibouti (horn of Africa)]. / Maladie coeliaque: particularités africaines. A propos de 8 cas à Djibouti.

Celiac disease is poorly documented in intertropical Africa. The purpose of this retrospective report was to describe 8 cases observed at the Groupement Medico-Chirurgical of Bouffard Hospital in Djibouti (Horn of Africa) between January 2003 and January 2006. There were 5 females and 3 males ranging in age from 9 months to 17 years old (mean age: 48 months). Six patients were of Somali ethnic origin and two of Yemenite ethnic origin. Six were classified as middle class and 2 as lower class. All forms were symptomatic associating constant loss of weight with digestive manifestations (diarrhoea and vomiting). Diagnosis of celiac disease was based on the presence of anti-gliadin antibodies IgA and IgG associated with anti-endomysium or anti-transglutaminase antibodies that were measured in six and two cases respectively. Gastroduodenal endoscopy performed in three cases including two with duodenal biopsy demonstrated villous atrophy associated with gross of intra-epithelial lymphocytosis. A gluten-free diet initiated in five patients led to clinical improvement in four cases with a follow-up of 8.25 months. The findings of this study in Djibouti show that celiac disease exists in intertropical Africa. Its presentation is quite similar to elsewhere but diagnosis is more difficult due to poor knowledge about the disease and limited diagnostic facilities. Favourable response to presumptive treatment by a gluten-free diet is an alternative for diagnosis especially in Djibouti where eating habits differ from those in industrialized countries and this type of diet is easier to follow.

[Geographical distribution and pathogenesis of chronic calcifying pancreatitis in tropical zones. Results of a multicenter survey in French-speaking Black Africa]. / Distribution géographique et pathogénie des pancréatites chroniques calcifiantes en zones tropicales. Résultats d'une enquête multicentrique en Afrique Noire francophone.

Chronic calcifying pancreatitis (CCP) is rare in countries with low alcohol consumption except in some tropical countries where malnutrition is widespread (southwest India) and in which CCP occurs in young non-alcoholics. In Black Africa sporadic cases of CCP have been reported in English-speaking countries (Uganda, Nigeria). The purpose of this study was to: a) assess the geographical distribution of CCP in French-speaking Africa; b) estimate the relative proportion of alcoholic CCP (ACCP) and juvenile tropical pancreatitis (JCCP). A total of 92 cases were included in this study, conducted in 16 French-speaking African countries (including Madagascar). There were no cases in countries with partly desert to climates and Moslem populations. Of these 92 cases, 86 corresponded to ACCP due to over consumption of various types of alcoholic beverages depending on the region. All were males with a mean age at diagnosis of 40.7 yrs. The remaining 6 cases were JCCP which were observed in areas of malnutrition with low intakes of animal protein and lipids. In this group the male/female ratio was 1/1 and the mean age at discovery was 15 yrs. Manioc toxicity did not appear to play any role. The "mixed" form, i.e. associating current alcohol consumption with childhood malnutrition, which has been described in young moderate drinkers in Burundi, was a possibility in 4 of the 86 cases of ACCP.

[Cardiac manifestations of polymyositis. Apropos of 2 Senegalese cases]. / Manifestations cardiaques des polymyosites. A propos de deux cas sénégalais.

INTRODUCTION: Polymyositis cardiac involvement varies between 37% and 70%. EXEGENESIS: The authors report two cases of polymyositis with myocardial involvement observed in Senegal; the first case is a cardiac failure revealing an acute polymyositis occurring in a 44-year-old woman; the second case is a 34-year-old woman who had polymyositis with tachycardia and dyspnea: in the two cases echocardiography showed a left ventricular concentric hypertrophy with preserved systolic function and altered diastolic function; clinical and echocardiographic resolution were obtained by corticosteroid medication. CONCLUSION: Myocardial localization is the most common polymyositis cardiac involvement; clinical symptomatology is rare (3.3% to 6%). sometimes revealing polymyositis; electrocardiographic abnormalities are found in 18% to 81% cases and echographic abnormality in 42% cases; cardiac involvement is of bad prognosis.

[Lyme's disease, a possible cause of isolated acute myocarditis]. / Maladie de Lyme, cause possible de myocardite aiguë isolée.

The frequency of cardiac lesion in patients with other signs of Lyme disease has been estimated at 8 percent. The usual manifestation of myocardial involvement is a varying degree of atrioventricular block or more diffuse signs of myocarditis. Autopsy or intramyocardial biopsy provides a histological diagnosis of myocarditis. Microscopy shows a diffuse lympho-plasmocytic infiltrate with presence of macrophages in the myocardium, associated with a varying number of necrotic myocytes. Structures resembling spirochetes have been found in some cases. Exceptionally, the cardiac lesion may be isolated, presenting as an acute atrioventricular block and/or an acute myocarditis; in such cases the diagnosis of cardiac lesion caused by Lyme disease is made on serological grounds. We report the case of a 30-year old man admitted for acute myocarditis which turned out to be totally regressive. Intramyocardial biopsy showed interstitial congestion associated with inflammatory lympho-histiocytic infiltrates and eosinophilic polymorphonuclears; the myocardial fibres in contact with these infiltrates appeared to be altered. The diagnosis of Lyme disease was subsequently confirmed by serological tests. Patients with myocarditis caused by Lyme disease must be treated with antibiotics. Recent reports have demonstrated the presence of spirochetes in the myocardium of patients with dilated cardiomyopathy, suggesting that the spirochete Borrelia burgdorferi might be associated with, or play a part in, the subsequent occurrence of dilated cardiomyopathy.

[Management of Grave's disease in the tropics (experience at Bouffard Army Hospital Center in Djibouti]. / Prise en charge de la maladie de Basedow en milieu tropical (expérience du cha Bouffard de Djibouti).

Based on their experience in managing Grave's disease at the Bouffard Army Hospital Center within the local health care context in Djibouti, the authors advocate surgery as the first line treatment. Medical and economical factors supporting this preference are discussed so that readers can adapt them to his own local context.

[General surgery and closed mitral commissurotomy: when necessity makes the rules]. / Chirurgien généraliste et commissurotomie mitrale à coeur fermé: ou quand la nécessité fait loi.

Since emergency transfer of patients from Africa to European cardiovascular facilities is difficult, surgeons at the Principal Hospital in Dakar, Senegal, have reevaluated closed mitral commissurotomy. The purpose of this study was to ascertain patient selection criteria, optimal operative conditions, immediate and middle-term outcome, and cost of closed mitral commissurotomy. From June 1995 to March 1998, closed mitral commissurotomy was carried out on 21 patients (13 women and 8 men). Inclusion criteria were symptomatic mitral stenosis with a mitral surface less than 1.5 square centimeters. Exclusion criteria were associated valve disease, Wilkins score higher than 8, severe pulmonary artery hypertension, and evidence of mitral thrombus. One patient died on the fourth postoperative day and one patient developed transient hemiparesis. Twenty patients showed significant functional improvement. Mean mitral surface increased from 0.87 to 1.8 square centimeters. Follow-up at one-year confirmed stable results. Only one patient developed grade 3 mitral insufficiency but it was well tolerated and did not require valve replacement. The cost of the procedure was 1,000,000 F CFA in second category and 820,000 F CFA in third category. The findings of this study show that closed mitral commissurotomy can be performed without circulatory assistance equipment in African facilities such as the Principal Hospital in Dakar, that immediate and middle-term results are excellent, and that African surgeons should continue to learn the technique.

[Thyroid cardiac diseases in the African hospital milieu: experience of the Principal Hospital of Dakar, Senegal]. / Les cardiothyréoses en milieu hospitalier africain: expérience de l'Hopital Principal de Dakar, Sénégal.

The incidence of cardiomyopathy associated with hyperthyroidism in black Africa is unclear. A prospective study was carried out at the Principal Hospital in Dakar, Senegal to systematically screen for thyrocardiac disease using cardiologic examinations including electrocardiography and ultrasound in a series of 15 men and 35 women with hyperthyroidism. Cardiac manifestations were detected in 3 men and 8 women including right ventricular insufficiency in 9 cases, left ventricular insufficiency and angor in one. After treatment of hyperthyroidism, atrial fibrillation disappeared in two cases and angor in one. Isolated dilated hypokinetic cardiomyopathy observed in 6 patients was the most common ultrasound finding and disappeared after treatment of thyroid dysfunction in 5. Manifestations occurred in two patients with mitro-aortic valve disease and one patient with isolated aortic valve disease. Based on these findings, the incidence of cardiomyopathy in patients with hyperthyroidism in Senegal was estimated to be 22 per 100 cases. This is similar to the incidence reported in industrialized countries. However the age of occurrence is lower and rheumatic valve disease was the most common associated cardiopathy.

[Adults with sickle cell anemia in Senegal. Clinical study of 40 homozygote subjects]. / L'adulte drépanocytaire au Sénégal. Etude clinique de 40 sujets homozygotes.

While the well-documented life expectancy of patients with homozygous sickle cell anemia (SS) is 40 years in industrialized countries, this question remains unanswered in black Africa. The purpose of this prospective study was to establish the clinical phenotype for Senegal. A severity score based on 12 clinical, laboratory, radiological, and prognostic findings was calculated and correlated with age and hemoglobin F level. A total of 40 SS homozygotes over 15 years of age (mean age: 25 years) were hospitalized between January 1996 and January 1998 at the Principal Hospital in Dakar. The most common events requiring hospitalization were vasoocclusive phenomena (n = 26) but the incidence of these complications declined significantly with age (p < 0.05). The mean hemoglobin level was 4.4 mmol/l and the mean hemoglobin F level was 6.2 p. 100. The incidence of visceral involvement was low (lithiasic vesicules in 17 cases, necrosis of the head of the femur in 7, and abnormal cardiac ultrasound findings in 10). Only one patient died during the study. No correlation was found between severity score and either age or hemoglobin F level. These findings confirm that the phenotype is less severe in Senegal. However they also show that organ damage is common by the time that patients reach adulthood and thus underline the need for prevention and education to improve survival of SS homozygotes in Senegal.

[Etiopathogenic, ultrasonographic and prognostic features of postpartum cardiomyopathy]. / Particularités étiopathogéniques, échographiques et évolutives de la myocardiopathie du post-partum.

Peripartum cardiomyopathy is a classic but uncommon entity in African women about which there is little etiologic understanding. From January 1990 to March 1996 a series of 30 cases of peripartum cardiomyopathy was collected at the Principal Hospital in Dakar, Senegal. Peripartum cardiomyopathy was defined as the occurrence of cardiac insufficiency in a woman with no previous history of heart disease, during the period between the second and twentieth weeks after delivery confirmed by ultrasound evidence of dilated cardiomyopathy. The overall incidence of peripartum cardiomyopathy during the study period was 30 out of 1200 deliveries. The mean age of the women in the study was 34 years and mean parity was 5.2. In 13.3% of cases births involved twins. There were no predisposing socio-economic or climatic factors. The clinical picture was severe cardiac failure in 80.3% of cases and left ventricular insufficiency in 16.6%. In all cases ultrasound findings were typical of dilated cardiomyopathy. Serum selenium and vitamin B1 levels were normal. Measurements of T CD4 and CD8 in eight patients were normal. Conversion enzyme inhibitors were administered to twenty patients. Complete remission was achieved in 14 patients, three patients died, and thirteen patients presented ultrasonic evidence of persistent dilated cardiomyopathy. One patient relapsed after a subsequent delivery. These findings are in agreement with previous reports concerning the clinical and prognostic features of peripartum cardiomyopathy in Africa.

[Pulmonary manifestations of schistosomiasis]. / Les manifestations pulmonaires des schistosomiases.

Bilharziosis or schistosomiasis is the third leading endemic parasitic disease in the world, following malaria and ambiasis. More than 300 million individuals are infested. Schistomosomes are blood flukes which live in the perivisceral veins. Clinical signs result from ova migrations. Transmitted by urine and feces, the parasite cycle requires intermediary host, usually fresh water snails. Bilharsiosis is endemic in tropical zones where it is a major public health problem closely correlated with the socio-economic conditions. Liver, intestinal or urinary complications, depending on the species, lead to underestimated morbidity and mortality. Pulmonary lesions are attributed to 3 species: S. haematobium, S. mansoni and S. japonicum. Although the lung is mandatory step in the parasite cycle, pulmonary manifestations are limited. They can be acute or chronic depending on the phase of the cycle, but are the most frequent extradigestive localization for S. mansoni. Morbidity due to chronic manifestations is particularly severe and should be prevented whenever possible.

[Closed-heart mitral commissurotomy: our experience at the Main Hospital in Dakar]. / La commissurotomie mitrale à coeur fermé: notre expérience à l'Hôpital Principal de Dakar.

Confronted with difficulties of medical evacuation to cardiovascular surgical hospitals in Europe, the authors decided to bring up to date closed heart mitral commissurotomy. The aim of the study was to estimate possibility to select patients, to operate them safety to appreciate the results in medium and short time and the intervention's cost. 8 women and 7 men had a closed heart mitral commissurotomy from June 1995 to January 1997 in Dakar Principal Hospital; inclusion criteria were a symptomatic mitral stenosis with area less 1.5 cm2; exclusion criteria were an other valvulopathy, a Wilkin score above 8, a severe pulmonary arterial hypertension, an auricular thrombosis. One patient died on the forth day; a completely regressive hemiplegia was the only complication; 14 patients were clinically very improved: the average mitral area by planimetry form 0.89 cm2 +/- 0.15 became 1.64 cm2 +/- 0.33 and by Hatle formula from 0.82 cm2 +/- 0.12 to 1.71 cm2 +/- 0.37; the intervention cost was in second class 1,000,000 F CFA, in third class 820,000 F CFA. This study shows closed mitral commissurotomy can be realised in an african hospital as Dakar Principal Hospital; short and medium results are good; African surgeons must go on studying this surgical technic.

[Annulo-aortic ectasia syndrome apropos of 4 cases]. / La maladie annulo-ectasiante de l'aorte à propos de 4 cas.

The authors present four cases of annuloaortic ectasia recently observed in Dakar Principal Hospital; two cases are MARFAN's syndrome, one is complicated by aortic dissection. Third cause of aortic regurgitation, this disease must be diagnosed early on account of its bad prognosis with the risk of the dissection of the aorta and issue to cardiac insufficiency. The diagnosis is more often affirmed by transthoracic echocardiography. Treatment is surgical with low operative mortality and excellent long term result.