A. Niang

Tuberculose et diabète

Resume Introduction Du 1 er janvier 1999 au 31 aout 2004, nous avons mene a la Clinique de Pneumologie du Centre Hospitalier National de Fann, une etude retrospective comparative « Cas - Temoins » portant sur les aspects radiologiques de la tuberculose chez 100 diabetiques (cas), apparies en nombre, âge et sexe a des temoins ne presentant qu’une tuberculose pulmonaire bacillifere. Methodes et resultats Cette association a touche 4,7 % des 2 116 patients hospitalises pour tuberculose pulmonaire durant la periode d’etude et serait l’apanage de l’homme (60 %) avec un âge moyen de 51 ans (73 %). Le diabete de type II (non insulinodependant) etait le plus frequent (82 %). Sur le plan radiologique, l’association des differents types de lesions classiquement decrite dans la tuberculose a ete retrouvee dans des proportions quasi identiques dans les deux groupes de patients et l’atteinte parenchymateuse representait le type de lesion le plus frequemment rencontre aussi bien chez les diabetiques (n = 86) que chez les temoins (n = 88). La tendance a la cavitation etait significativement moindre chez les diabetiques (72 %) que chez les temoins (88 %) p = 0,04. Les images radiologiques lorsqu’elles etaient bilaterales, auraient une localisation plus a gauche chez les diabetiques (27 % versus 15 % chez les temoins). Les lesions basales etaient, de facon non significative, beaucoup plus le fait des cas (15 %) que des temoins (3 %) (p = 0,06). Conclusion Sur le plan evolutif, la mortalite serait plus elevee chez les diabetiques (18 %) que chez les temoins (6 %) et le deces survenait le plus souvent dans les 24 premieres heures de l’hospitalisation.

Étude préliminaire sur le tabagisme chez le personnel médical et paramedical du CHN de Fann

Resume Introduction Le tabagisme constitue un probleme actuel majeur de Sante Publique, responsable d’une morbidite et d’une mortalite tres importantes. Nous avons effectue cette etude afin de determiner la prevalence du tabagisme chez le personnel soignant du CHN de Fann, les habitudes tabagiques des sujets fumeurs, l’attitude du personnel face aux problemes lies au tabagisme et la conception de son role d’educateur face a des fumeurs. Materiels et methodes Il s’agit d’une etude prospective menee de fevrier a avril 2004 par un seul medecin, au sein du Centre Hospitalier National de Fann. Nous avons elabore un auto-questionnaire anonyme standardise et ecrit en francais, destine au personnel medical et paramedical du CHN de Fann. Resultats Nous avons eu un taux de participation de 95 %. Le service qui a le plus participe est le service des Maladies Infectieuses (24,5 %). Les paramedicaux ont participe a l’enquete dans une proportion de 63 %. L’etude montrait une predominance masculine (53,8 %). L’âge moyen des hommes etait de 39,2 ans contre 35,9 ans pour les femmes. Nous avons retrouve 11,6 % de fumeurs et 13,3 % d’ex-fumeurs. Chez les ex-fumeurs, l’âge moyen etait de 43,8 ans avec une nette predominance masculine (sex-ratio = 7,25). Parmi eux, 51,7 % avaient arrete de fumer depuis plus de 10 ans, avec des problemes de sante comme premiere raison d’arret du tabac (24,2 %), suivi de la culpabilite (21,2 %). L’etude des fumeurs montrait une moyenne d’âge de 38,6 ans avec un sex-ratio de 8,6. L’âge de debut du tabagisme etait de 14,3 ans pour les femmes et de 21 ans pour les hommes, avec une duree moyenne du tabagisme de 21 ans chez les femmes et 17 ans chez les hommes. La cigarette etait utilisee dans 96,6 % des cas avec une proportion de 31 % de gros fumeurs (> 20 cigarettes/jours). 75,9 % de nos fumeurs ont essaye d’arreter de fumer au moins trois fois. 86,2 % souhaitaient arreter de fumer, seuls 48,3 % pensaient avoir besoin de soutien medical et/ou psychologique. Le score de Fagerstrom montrait une forte dependance au tabac chez 27,6 % de nos sujets fumeurs. Plus de la moitie de la population totale (65,6 %) etudiee pensaient que le personnel de sante devrait aider les autres a arreter de fumer et 75,5 % pensaient avoir de l’influence pour cela. Conclusion Le personnel soignant senegalais doit prendre conscience de son role crucial d’educateur et de son devoir d’implication dans la lutte contre le tabagisme. La mise en place de mesures legislatives consensuelles et de centres de sevrage anti-tabac permettra d’entrevoir le bannissement effectif du tabagisme, surtout au sein des structures sanitaires.

Tuberculose du sujet âgé

OBJECTIVES The purpose of this study was to compare the epidemiology, clinical features and clinical course of primary presentations with pulmonary tuberculosis occurring in older and younger patients. PATIENTS AND METHODS We undertook a prospective, comparative study in the Pneumology clinic of the National University Hospital of Fann in Dakar, from April 1, 2005 to March 31, 2006, collecting data on all patients presenting with a first episode of bacterially confirmed pulmonary tuberculosis. RESULTS We studied 187 first presentations with confirmed pulmonary tuberculosis including 12.8% (n=24) elderly (>55 years) subjects (20 men and four women) and 87.2% (n=163) younger subjects (105 men and 58 women). In the older subjects, patients were more commonly men (sex-ratio: 5), without formal education, and working in the primary or informal sector. Comorbidities were more frequent in the older group, including smoking (P=0.002), alcohol consumption (P=0.01), diabetes (37.5%) (P<0.005) and obesity with BMI superior than 20 in 25%. Pulmonary shadowing was common (41.7% of the cases), P=0.008 and generally bilateral P=0.0001 with cavitation, but this observation was not statistically significant. COMPLICATIONS Complications were more frequent in the older patient (20.8%), as was mortality (29.3%, P=0.000) and rate of clinical improvement in response to treatment was less satisfactory (50%) there.

PILOT EXPERIENCE IN SENEGAL WITH PERITONEAL DIALYSIS FOR END-STAGE RENAL DISEASE

♦ Introduction: Peritoneal dialysis (PD) is occasionally used in western sub-Saharan Africa to treat patients with end-stage renal disease (ESRD). The present study is a retrospective review of the initial six years’ experience with PD for ESRD therapy in Senegal, a West African country with a population of over 12 million. ♦ Material and Methods: Single-center retrospective cohort study of patients treated with PD between March 2004 and December 2010. Basic demographic data were collected on all patients. Peritonitis rates, causes of death and reasons for transfer to hemodialysis (HD) were determined in all patients. ♦ Results: Sixty-two patients were included in the study. The median age was 47 ± 13 years with a male/female ratio of 1.21. Nephrosclerosis and diabetic nephropathy were the main causes of ESRD. The mean Charlson score was 3 ± 1 with a range of 2 to 7. Forty five peritonitis episodes were diagnosed in 36 patients (58%) for a peritonitis rate of 1 episode/20 patient-months (0.60 episodes per year). Staphylococcus aureus and Pseudomonas aeruginosa were the most commonly identified organisms. Touch contamination has been implicated in 26 cases (57.7%). In 23 episodes (51%), bacterial cultures were negative. Catheter removal was necessary in 12 cases (26.6%) due to mechanical dysfunction, fungal or refractory infection. Sixteen patients died during the study. ♦ Conclusion: Peritoneal dialysis is a suitable therapy which may be widely used for ESRD treatment in western sub-Saharan Africa. A good peritonitis rate can be achieved despite the difficult living conditions of patients. Challenges to the development of PD programs include training health care providers, developing an infrastructure to support the program, and developing a cost structure which permits expansion of the PD program.

Hypertension in Black Africans with Autosomal Polycystic Kidney Disease

Introduction: High blood pressure (HBP) that is a leading cause of end-stage renal disease (ESRD) in black African populations and is frequently associated to autosomal polycystic kidney disease (ADPKD). This study aimed to describe prevalence and severity of HBP in black Africans with ADPKD and to identify associated risk factors. Patients and methods: We performed a retrospective study of 65 ADPKD patients regularly followed in outpatient nephrology clinic between 1995 and 2009. ADPKD was diagnosed according to recent unified criteria (2009). Statistical analyses were done with SPSS 16.0. Results: We included 65 patients (36 males and 29 females) with a mean age of 47 ± 5 years. Hypertension was found in 73.8 % of patients and it preceded diagnosis of ADPKD in 23 patients (median delay of 28 months). Mean systolic/diastolic blood pressure was 168 ± 30 /96 ± 16 mm Hg respectively. All hypertensive patients presented retinopathy and left ventricular hypertrophy. Two patients presented stroke. Fifty one percent of patients were treated with angiotensin converting enzyme inhibitors alone and 29% received combinations of anti-hypertensive drugs. One third of them had their blood pressure normalized. Patients with HBP at diagnosis showed a similar proportion of ESRD in comparison with normotensive patients (p=0.12). At univariate analysis, HBP was correlated with age, gender, BMI, GFR and proteinuria. Multiple regression analysis identified age (OR=1.95, p=0.05) and glomerular filtration rate (OR=2.33, p=0.001) as independently associated to HBP. Conclusion: Hypertension with organ damage is frequent in Senegalese patients with ADPKD. Age and glomerular filtration rate at diagnosis were the main risk factors of HBP identified in our patients.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a rare but potentially lethal complication of peritoneal dialysis (PD). Peritoneal tuberculosis is considered an etiologic factor. We report a case of EPS in a 40-year-old man who was switched to hemodialysis because of peritoneal tuberculosis after 2 years of PD. Because of the persistence of gastrointestinal symptoms and cachexia, laparoscopic exploration was performed, which revealed an important thickening of the peritoneal membrane sheathing the intestinal loops. Accordingly, a diagnosis of EPS was made. Anti-tuberculosis treatment associated with a low dose of corticosteroids stabilized the disease.

Tuberculose familiale : dépistage parmi les sujets contacts autour d’un cas index contagieux

Resume Introduction Il s’agit d’une etude prospective portant sur 30 cas de tuberculose pulmonaire familiale a microscopie positive avec au moins deux membres de sa famille porteurs d’une tuberculose a microscopie positive colliges a la Clinique de Pneumologie de janvier 2003 a juin 2004 ; ils constituaient les cas index. Methodes Ces cas index representaient 3,5 % des tuberculoses pulmonaires bacilliferes (n = 850) et 2,9 % des hospitalisations (n = 1 034) durant la meme periode. Quatre patients avaient presente une serologie a VIH1 positive. Dans l’entourage familial, tous les sujets contacts avaient beneficie d’une intradermoreaction a la tuberculine 10 UI (IDRT) systematique et/ou d’une radiographie thoracique et/ou d’un examen direct des crachats a la recherche de BAAR. Resultats Sur les 601 sujets contacts, 359 (60 %) avaient une IDRT positive avec un diametre moyen de 13 mm. Une tuberculose pulmonaire bacillifere etait depistee chez 16 contacts, soit une prevalence de 2,7 % et une incidence de 4,5 % (16/359). Les adultes representaient 67 % des sujets contacts. Ils etaient âges de 16 a 87 ans avec un âge moyen de 35 ans. L’IDRT etait positive avec un diametre moyen de 12,3 mm. La radiographie thoracique etait anormale pour 40 adultes (16,7 %). La bacilloscopie confirmait une tuberculose pulmonaire dans 14 cas. Les enfants (n = 119) âges de 3 mois a 15 ans, representaient 33 % des contacts avec une preponderance de la tranche d’âge de 0 a 10 ans (85 %). L’IDRT etait positive avec un diametre moyen de 12 mm. La radiographie thoracique etait pathologique dans 22 cas (18,5 %). Deux enfants de 15 ans avaient presente une tuberculose pulmonaire bacillifere. Conclusion Ces contacts depistes avaient ete traites selon le protocole du PNT au Senegal (2 RHEZ/6 EH), la phase intensive etant seulement dispensee a l’hopital. Il est alors capital de developper des strategies efficaces d’information, d’education, de diagnostic et de prise en charge d’un cas de tuberculose pulmonaire contagieuse.

Problematic of Vascular Access for Hemodialysis in Sub-Saherienne Africa: Experience of Dakar

Aim: Vascular access is important for a good survive in hemodialysis. It can be temporary or permanent, and needs particular attention because of possible complications, especially infectious. We conducted a study to determine the type and the outcome of vascular access in two hemodialysis units in Dakar. Materials and Methods: A multicenter retrospective study was conducted from the 1st January 2005 to 10 September 2010 in two hemodialysis centers: Hospital Aristide Le Dantec and the MDTC (Multifunctional Diagnosis and Treatment Center) of Dakar. All the patients- regularly dialyzed since at least three months in these centers were included. Results: Sixty five patients were included. The mean age was 50.2 years with a sex ratio of 1.7. The mean duration in hemodialysis was 23.2 month. Only five patients (7.80%) had an AVF before starting in hemodialysis. Sixty patients (92.2%) started dialysis with a central venous catheter. Among them, 49 (81.6%) had a double lumen femoral catheter and 11 had a jugular one with 4 tunneled. Complications of vascular access were noted for 23 patients (39.7%) with 12 infections. Blood culture was positive for Staphylococcus Aureus in seven cases. Seven patients presented lower limb thrombophlebitis. Thrombosis of the catheter was noted in four patients. Radial arterio-venous fistula (AVF) was the first intention permanent access in 41 cases (64.1%) followed by cephalic AVF in 14 cases (21.9%) and basilic AVF in 9 (14%). AVF complications were presented in 56.9% of case (40 patients). Most of them was early defect in 18 cases (27.7%), thrombosis in 9 (13.8%) and stenosis in 5 (7.7%). Radial AVF infection to Staphylococcus Aureus was noted in 3 cases, and one pseudo aneurysm was noted. Conclusion: Vascular access for hemodialysis is a great problem in Senegal. More than two third of our patients start dialysis on venous catheters, this is far from the clinical practice guidelines.

Light Chain Deposition Disease in Black African, Report of Three Cases from Senegal

Background: Although there are numerous publications on multiple myeloma in black people, it seems sub-Saharan literature particularly Senegalese’ one is silent about Light chain deposition disease (LCDD) which is linked to immunoglobulin light chain deposition in glomerulus. The authors report the first three observations of LCDD collected in Nephrology department of Aristide Le Dantec hospital in Dakar, Senegal. Cases: we report three cases a man and two women of 61, 69 and 47 years old respectively, admitted to the Nephrology department of Aristide Le Dantec hospital for rapidly progressive renal failure in one case and a nephrotic syndrome in 2 other cases. The renal biopsy showed a nodular glomerulosclerosis and immunofluorescence microscopy, revealed deposition of IgG light chains suggesting LCDD. On the other hand, the diagnosis of multiple myeloma of IgG kappa type in 2 cases and IgG lambda type in the other one was done. A combination of chemotherapy (Mephalan Prednisone) and hemodialysis was instituted for all 3 cases. The evolution was marked by the appearance of an end stage renal disease in 2 cases and the third one was expired due to an infected bed sore secondary to a pathological fracture of the neck of the femur. Conclusion: Although the LCDD is rare, the prognosis of this syndrome seems to be poor as more than half of the patients die or progress to ESRD within 2 years.

La tuberculose dans le couple mère-enfant

Resume Introduction La tuberculose est un fleau de sante publique dans nos regions ; elle est particulierement dangereuse chez les jeunes enfants, surtout de meres tuberculeuses. L’objectif de ce travail est d’evaluer la prevalence de la tuberculose chez les enfants de mere tuberculeuse et de voir comment preserver leurs chances de survie de ces enfants pour un developpement harmonieux. Patients et methodes Du 1 er janvier au 31 juillet 2002, 45 femmes ont ete hospitalisees avec leur enfant en bas âge ( Resultats Quarante-cinq femmes (dont l’âge est compris entre 18-45 ans), ont ete hospitalisees pour une tuberculose pulmonaire bacillifere, une IDRT moyenne de 13 mm et une forte charge bacillifere (1 a plus de 10 bacilles/champ/OMS). Elles presentaient presque toutes (96 %), un syndrome parenchymateux excave (82 %). Nous n’avons note aucune seropositivite VIH. L’evolution etait favorable chez 43 meres sous SRHZ. On notait deux deces. Chez les enfants, de ces meres, systematiquement examines dont 82 % (n = 37) avaient moins de 20 mois, on denombrait 51 % (n = 23) de garcons et 26 enfants (58 %) etaient deja symptomatiques a la premiere consultation. Tous les enfants etaient nourris au sein, expliquant leur admission avec la mere ; on evitait ainsi, le sevrage brutal. La notion de contage tuberculeux quasi-constante, etait retrouvee egalement 6 fois chez le pere, 4 fois chez les grands-parents. Les signes cliniques les plus frequents etaient la fievre (92 %), la toux et l’amaigrissement (77 %), la malnutrition (69 %). L’IDRT etait positive chez 38/45 (84,5 %) et phlyctenulaire. Seize sur trente-huit (42 %). La radiographie thoracique normale chez 16/45 (35,6 %), revelait par ailleurs, des adenopathies mediastinale 19/29 (65,5 %), accompagnees de troubles de ventilation homo lateraux 11/29 (38 %) et de syndromes parenchymateux 3/29 (10,3 %). L’evolution a egalement ete favorable chez 44 enfants sous traitement antituberculeux (RHE). Nous avons deplore un deces sur terrain de malnutrition grave. Conclusion Traiter la tuberculose dans le couple mere-enfant est un gage de bonne observance, de guerison pour la mere et de developpement harmonieux pour l’enfant.