[Discharge of children against medical advice at CHU of Brazzaville (Congo)]. / Les sorties contre avis médical en pédiatrie au CHU de Brazzaville (Congo).

In a prospective study conducted from January to December 2010 in the Teaching Hospital of Brazzaville (Congo), we compared the discharge of hospitalized children against medical advice at the parents' request (group 1 - cases) with those admitted during same period with routine discharge (group 2 - controls). Two hundred and seven (7.7%) hospitalized children, 117 boys and 90 girls, were discharged at the parents request. The mean age was 18.0 ± 13.5 months (range: 1 month-5 years). Among these patients, 150 (72.5%) children were from biparental families, and 30.9% of children were the first and/or only child of the household. Among the parents of Congolese nationality, 147 (71%) had a secondary school level education, including 66.7% of mothers and 58% of the fathers 59.9% of children were admitted between 15 and 7 hours, and 75.4% were hospitalized during working days. The duration of hospitalization did not exceed 3 days in 147 cases (71%). The main reasons for hospitalization were digestive disorders (27%), fever (16.4%), convulsions (11.1%) and anaemia (11.1%). Among patients discharged against medical advice, 34.8% left on the first day of hospitalization (72 cases), 36.7% before the start of treatment (76 cases of which 36 during check-up) and 63.3% during treatment (131 cases). The main reasons for discharge request were improvement in the clinical condition improvement (30.9% of cases), lack of money (28% of cases), supposed insufficient medical care (7.7% of cases), unsatisfactory hospitalization conditions (6.3% of cases), care of other children at home (6.3% of cases), traditional and/or religious beliefs (5.8% of cases) and disagreements with nurses (5.3%). Patients discharge against medical advice was correlated strongly with the educational level of parents, age of the child, delay of consultation, time of admission, rank of the child in family and nationality of parents. Discharge against medical advice is associated to the distrust between the patients and nurses. Improvement of hospitalization conditions in our hospitals, improvement of the socioeconomic status of Congolese and establishment of national social security seem to be the main determinants of reduction of discharge against medical advice.

[Orphans in Brazzaville orphanages]. / Situation des enfants orphelins dans les orphelinats de Brazzaville.

UNLABELLED: Children are orphaned everywhere, but their situation is particularly acute in developing countries. OBJECTIVES: To assess the epidemiologic situation of orphans in Brazzaville and to identify the social and medical determinants of their placement in institutions. MATERIAL AND METHODS: This exploratory cross-sectional study was conducted from March 3, 2003, through January 30, 2004 (11 months). Direct interviews based on a standardized questionnaire collected information from the orphans old enough to answer questions, their parental substitutes or guardians, and the orphanage directors. The evaluation of the conditions in the orphanages was based on observable, quantifiable indicators. ON THE WHOLE: We identified 12 orphanages and 162 children: 92 boys (56.8%) and 70 girls (43.2%). Their average age was 10.5 years +/- 3.5 (range: 3 months to 15 years). Overall, 38 (23.5%) had lost only their mother, 22 (13.6%) their father, and 102 (63%) both parents. The child was placed at the orphanage by the family in 97 cases (60%), the social services department in 50 cases (30.9%), and by the police or the Red Cross in 15 cases (9.3%). The reasons for placement were: lack of financial support (137 cases, 84.5%), other social reasons (8 cases, 4.9%), abandonment (3 cases, 2%) and unspecified causes (14 case, 8.6%). The principal causes of parents' deaths were: pregnancy and childbirth 73 cases (45%), war, 45 cases (28%), HIV infection, 26 cases (16%), malaria, 6 cases (4%), accidents, 8 cases (5%) and unknown, 4 cases (2.5%). CONCLUSION: Orphanages are one alternative for the survival of children without parents able to care for them. Attention to them, support of their activities, and improvement of the living conditions there are all important.

[Pulmonary tuberculosis in infants in Brazzaville, Congo. A review of 117 cases]. / Tuberculose pulmonaire du nourrisson à Brazzaville (congo). A propos de 117 cas.

Little information is available on pulmonary tuberculosis in infants in sub-Saharan Africa. This retrospective study was conducted in infants ranging in age from 1 to 23 months admitted to the Paediatric Departments of the University Hospital Centre in Brazzaville, Congo for pulmonary tuberculosis between January 1, 1999 and July 1, 2004. Tuberculosis was diagnosed on the basis of epidemiological, clinical, radiological, and follow-up data. All children over 12 months old underwent HIV testing. In case of positive test results, children between the ages of 12 and 18 months were retested after the age of 18 months. Of a total of 803 children admitted for tuberculosis during the study period, 117 (14.6%) were under the age of 24 months (53% males). Mean age was 17.5 months. The BCG test was mentioned in 75.2% of cases. Determination of the contagion in 50.4% of cases indicated that transmission was intrafamilial in 69.3% of cases. The mean delay for hospitalization was 2.6 months (range, 21 days to 16 months). Eighty-one patients (69.2%) presented severe malnutrition. Intrathoracic forms accounted for most cases with bronchopneumopathy (72.6%) and mediastinal adenopathy (40.2%). The incidence of bronchopneumonopathy and isolated forms was significantly higher in children over one year old than in children under one year old: 78.3% versus 21.7 % (p<0.01) and 62.8% versus 37.2% (p<0.001) respectively. A total of 35 children (43.8%) over the age of 12 months presented HIV infection. In comparison with HIV-negative children, HIV-positive children were more likely to present malnutrition and presented a statistically higher incidence of mediastinal adenopathy and multifocal forms. All associated extrathoracic lesions (21.4% of cases) occurred in HIV-positive children. Outcome was favourable in all HIV-negative children while 7 HIV-positive children (20%) died during treatment. Pulmonary tuberculosis in infants in Brazzaville is characterized by frequent association with HIV infection and prognosis is more severe in case of HIV co-infection.

[Nephrotic syndrome complicated by chylous ascites in a girl of 2 years and 8 months old]. / Syndrome néphrotique compliqué d'ascite chyleuse chez une fillette de 2 ans et 8 mois.

We report on a case of nephrotic syndrome with focal and segmental hyalinosis complicated by chylous ascites in a girl of 2 years and 8 months old. This pure nephrotic syndrome in its early stage was initially treated with intensive steroid treatment at 2mg/kg/day orally for 2 months, followed by a bolus of methylprednisolone. The persistence of proteinuria meant corticosteroid resistance. Renal biopsy then revealed focal and segmental hyalinosis. A recurrence of the edema-ascites syndrome was associated with macroscopic hematuria. Blood pressure and serum creatinine remained normal. Protidemia decreased to 28g/L, with severe hypoalbuminemia at 7g/L. The ascites puncture brought 1 L of aseptic and milky fluid, containing 0.22g/L of proteins, 20 IU/L of amylase, and 331g/L of total lipids. The treatment protocol included a hyperprotein diet, prednisone at 0.5mg/kg/day, cyclophosphamide at 2.5mg/kg/day for 1 month, then once every 2 days for 3 months, and repeated ascites punctures. After 12 ascites punctures performed every 15 days, a polyuric episode occurred and the ascites disappeared. Proteinuria persisted at a nephrotic rate up to the 14th month, without impairment in kidney filtration function, and completely disappeared at the 20th month. After 5 years of follow-up, proteinuria remains undetectable and the physical exam is normal. The occurrence of chylous ascites during the nephrotic syndrome is a rare event. The formation of bowel lymphangiectasia, caused by a slowdown in venous return due to the pressure exerted by ascites, is probably the predominant mechanism.

[African histoplamosis. A report of three pediatric cases]. / Trois cas pédiatriques d'histoplasmose africaine à Brazzaville.

Histoplasmosis duboisii (Histoplasma capsulatum var duboisii) is uncommon disease especially in children. It is observed in Africa where the incidence is unknown. The authors report a series of three pediatric cases. The report concerned 2 girls and one boy who were 3, 9 and 4 year-old, respectively. Symptoms evolved for more than two months in each case. At admission, we found fever and poor general condition. Observed lesions were lymphnodes localisation disseminated (cases 1 and 2), subcutaneous (cold abscess) and cutaneous simulating molluscum contagiosum (case 2), osteoarticular (cases 2 and 3), abdominal including peritoneal and hepatosplenic (case 1). In all cases, a mild leukocytosis was found and an accelerated erythrocyte sedimentation rate (ESR) greater than 70mm. The HIV serology was negative. The treatment consisted of itraconazole in 2 cases and ketoconazole in one case. The evolution was insidious, leading to the discharge against medical advice. The death occurred at home in all cases. CONCLUSION: Histoplasmosis duboisii can realize two main clinical presentations (localized or disseminated), affecting the skin, lymph nodes, bones, sometimes the intra-abdominal organs. HIV serology is not always positive in disseminated forms. The evolution is unpredictable and capricious under antifungal treatment. The disease should be well explained to prevent a possible discharge against medical advice, often pejorative.

[Early diagnosis of leukaemia in the trisomic child. Congolese experience based on two cases]. / Diagnostic précoce de la leucémie chez l'enfant trisomique. Expérience congolaise de deux cas.

We are reporting here two cases of acute leukemia in Congolese children with Down syndrome. They were aged 27 and 30 months. The two cases were revealed by anemia, hyperthermia with enlargement of the liver and the spleen. Clinical course was unfavorable. Therefore, the early diagnosis of leukemia remains very important in patient with Down syndrome presenting hyperthermia with hepatosplenomegaly.

[Severe malaria associated with acute renal insufficiency: apropos of a case]. / Paludisme grave associé à une insuffisance rénale aiguë: à propos d'une observation.

Renal insufficiency as a complication of severe malaria is a rare pathology. A case was observed in young girl aged 10.5 years following Plasmodium malaria fever. Clinical features included severe anemia, oligo-anuria, and creatinemia of 80 mg/l. The haemoglobin electrophoresis was standard. Under furosemide, the resumption of diuresis was effective nine days later. Renal functions of the child affected by severe Plasmodium malarial fever must always be checked.

[Kawasaki syndrome: apropos of 2 cases observed in Brazzaville]. / Le syndrome de Kawasaki: à propos de deux cas observés à Brazzaville.

The authors report for first time in Congo two cases of Kawasaki syndrome. One case from a five years boy carried out a typical form of an adeno-mucocutaneous syndrome; the other from a six month little girl was an incomplete form. In both cases, the immediate development has been excellent. The scarceness of this syndrome among the blacks and the diagnostic difficulties have been the background of the interest of this work.

[Early isosexual precocious pseudopuberty revealing a juvenile granulosa cell tumor in a 3-year-old Congolese girl]. / Pseudo-puberté précoce isosexuelle révélatrice d'une tumeur de la granulosa juvénile chez une fillette congolaise de 3 ans.

We describe a juvenile granulosa cell tumor expressed by an early pseudopuberty occurring in a 3-year-old black child. Clinically, an endocrine syndrome was associated with a pelvic mass and ascites. Hyperoestrogenia and serum alphafetoprotein level were biologically detected. Histological examination showed typical microscopic features of a granulosa cell tumor. The patient is well four years after surgery. Growth and mental development are normal.