P. Pitché

Syndrome de Stevens-Johnson et nécrolyse épidermique toxique à Lomé (Togo): Profil évolutif et étiologique de 40 cas

INTRODUCTIONnStevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe cutaneous drug reactions, the prognosis of which largely depends on the quality of their treatment. The purpose of this study was to determine the evolutional and etiological profiles of SJS/TEN in a teaching hospital in Lome (Togo).nnnMETHODSnThe medical records of patients hospitalized in the departments of dermatology and intensive care of the university hospital center of Lome for SJS/TEN from 1992 to 2001 were reviewed retrospectively. The records of patients retained corresponded to the international classification criteria of SJS/TEN.nnnRESULTSnWe collected 40 cases of SJS/TEN (27 cases of SJS, 12 cases of TEN and one overlap SJS/TEN). Patients mean age was of 30 +/- 7 years. The sex ratio (male/female) was of 1.5 and the mean follow-up after hospitalization was of 2 months (range: 4 weeks to 8 months). The HIV serology was known in 20 cases (13 cases of SJS and 7 cases of TEN). It was positive in 10 cases (5 during TEN and 5 during SJS). Five of the 12 patients (41.7 p.cent) exhibiting NET died (all were HIV-infected) versus 2 of the 27 patients (7.4 p.cent) exhibiting SJS (2 patients were also HIV-infected). The principle drugs incriminated were: antibacterial sulphonamides (16 cases; 40 p.cent), rifampicin-isoniazid combination (7 cases; 17.9 p.cent), anti-epileptics (5 cases; 12.5 p.cent); amino-penicillin (4 cases; 10 p.cent) and non-steroidal anti-inflammatories (2 cases; 5 p.cent). Chinese drugs of undetermined nature were incriminated in 3 cases of SJS. No drug was formally identified in 3 cases of SJS.nnnDISCUSSIONnThis study confirms the rareness of SJS/NET. These affections are of poor prognosis, particularly in developing countries. The results of this study suggest that the concomitance of an opportunist infection due to HIV-immunodepression is of poor prognosis in the evolution of SJS/NET. Antibacterial sulphonamides and the rifampicin-isoniazid combination are frequently incriminated in Togo.

Profile of Buruli ulcer treated at the National Reference Centre of Togo: a study of 119 cases

The purpose of this study was to describe the epidemiological, clinical, therapeutic profile and the outcome of Buruli ulcer (BU) in the National Reference Center for Buruli ulcer treatment (NRCBUT) in Togo. It was a retrospective and descriptive study of records of patients treated for BU in the NRCBUT between June 2007 and December 2010. During the study period, 119 patients (56.3% males) were treated in the NRCBUT for BU. The median age of patients was 14 years. The proportion of children (< 15 years) was 56.3%. On admission, 85 patients were at ulcer stage and 34 patients at the pre-ulcer stage. BU wounds were mainly located on lower limbs (50.4%), followed by upper limbs (32.6%) and trunk (13.3%). The location of the wounds on the lower limbs were more frequent in patients older than 15 years (P < 0.001), while those on the upper limbs (P = 0.002) and trunk (P = 0.03) were more frequent in patients aged less than 15 years. All patients had received medical treatment which was based on rifampicin-streptomycin combination for eight weeks. This treatment was coupled to surgery in 30 cases. The outcome was punctuated by complications in 7 patients, limb amputation in 3 patients, and sequels in 10 patients. This study confirmed that the BU is the prerogative of young subjects and the exposed areas in the skin facilitates transmission. Apart from these classic features, some unique aspects including the age-dependent distribution are related to the pathogenesis of this disease.

Basidiobolomycose probable chez un jeune rural togolais traitée avec succès par du kétoconazole

Basidiobolomycosis is a deep mycosis which preferentially affects rural young people in tropical countries. We report a case of basidiobolomycosis successfully treated with ketoconazole. It was a 9-year-old boy of rural origin in whom the diagnosis of basidiobolomycosis was suspected due to a deep skin infiltration involving the chest and neck. Histology revealed hypodermic granulomatous inflammation with predominantly macrophage and eosinophils. The child was treated successfully with ketoconazole in eight weeks. Treatment of basidiobolomycosis is based on azole derivatives which are particularly effective. Histopathology is very important in the diagnosis of this affection, especially in tropical countries where it may simulate Mycobacterium ulcerans infection.

Loss of HIV-infected patients on potent antiretroviral therapy programs in Togo: risk factors and the fate of these patients

Introduction National programs are facing challenges of loss to follow-up of people living with HIV/AIDS (PLWHA) on antiretroviral therapy (ART). We sought to identify risk factors associated with early loss to follow-up among HIV-infected patients on ART in Togo and the outcome of such patients. Methods This was a retrospective cross-sectional study using medical records of all patients older than age 15 years enrolled at 28 treatment centers who were on ART programs and who were lost to follow-up from 2008 to 2011. Results Of the 16,617 patients on ART, 1,216 (7.3%) were lost to follow-up. Most (94.1%) were infected with HIV-1 and 32.6% were in WHO stage III or IV. The median CD4 count was 118/mm3 (IQR: 58-178 cells/mm3). No telephone number was mentioned in the medical records of 212 patients. Of the 1004 patients whose phone number was listed, 802 patients (79.9%) were not reachable on the recorded number, 114 patients (11.4%) were alive and 88 patients (8.8%) had died. In multivariate analysis, factors associated with loss to follow-up during the first 6 months of ART were: age below 35 years (OR = 1.6; 95%CI: 1.2-2.2), female sex (OR = 1.8; 95%CI: 1.3-2.5), WHO stage III or IV (OR = 1.7; 95%CI: 1.3-2.2), existence of an opportunistic infection (OR = 2.3; 95%CI: 1.5-3.1), and follow-up in a public centre (OR = 1.9; 95%CI: 1.2-3.3). Conclusion This study identified several factors associated with lost to follow-up during the first 6 months of ART, and confirmed high mortality among these patients. The National AIDS Program should strengthen medical support of PLWHA in Togo including active case follow-up.

Causes of mortality associated with HIV/AIDS in health-care facilities in Togo: a six-month prospective study

In order to determine the rate and the different causes of mortality associated with HIV/AIDS in health-care facilities we conducted a prospective study between 1 April and 30 September 2010 in the six health regions of Togo. We rationalized the choice of the healthcare facilities in order to cover the entire national territory. During the study period, 24,054 patients were hospitalized. HIV serology was positive in 1065 (18.2%) of the 5865 tested patients. Of the 24,054 patients, we recorded 2551 deaths (10.6%), including 309 HIV-infected patients (5.2%). The mortality rate associated with HIV/AIDS was 1.3% of the total number of inpatients and 5.3% of the number of patients tested for HIV. The mortality rate among HIV-infected patients was 29%. The causes of death in patients infected with HIV/AIDS were mainly anaemia and cerebral toxoplasmosis. This study shows that mortality associated with HIV/AIDS in health-care facilities in Togo remains relatively high.

Facteurs de risque associés à l’érysipèle de jambe en Afrique subsaharienne : étude multicentrique cas-témoins

BACKGROUNDnAcute bacterial cellulitis of the leg (erysipelas) is a common problem involving considerable morbidity in dermatology practice in Africa. Previous studies conducted in Europe and North Africa have highlighted lymphoedema and toe-web intertrigo as independent factors associated with leg erysipelas. The aim of this case-control study was to identify risk factors associated with leg erysipelas in sub-Saharan Africa, within a different socio-economic and culture context.nnnPATIENTS AND METHODSnWe conducted a prospective case-control study in hospital dermatology departments in 8 sub-Saharan African countries over a 12-month period (October 2013 to September 2014). Each case of acute leg cellulitis was matched with 2 controls for age (±5 years) and sex. We analysed the general and local factors.nnnRESULTSnDuring the study period, 364 cases (223 female, 141 male) were matched with 728 controls. The mean age was 42.15±15.15 years for patients and 42.11±36 years for controls. Multivariate analysis showed the following to be independent risk factors associated with leg erysipelas in our study: obesity (odds ratio [OR]=2.82 ; 95% confidence interval: 2.11-3.76), lymphoedema (OR=3.87, 95%CI: 2.17-6.89), voluntary cosmetic depigmentation (OR=4.29, 95%CI: 2.35-7.83), neglected traumatic wound (OR=37.2, 95%CI: 24.9-57.72) and toe-web intertrigo (OR=37.86, 95%CI: 22.27-64.5).nnnCONCLUSIONnThe results of this study confirms the major role of local risk factors (toe-web intertrigo, lymphoedema) previously identified in other geographical settings. However, the originality of our study consists of the identification of voluntary cosmetic depigmentation as a risk factor for leg erysipelas in sub-Saharan Africa.

Profil de l’ulcère de Buruli pris en charge au Centre national de référence du Togo: étude de 119 cas

The purpose of this study was to describe the epidemiological, clinical, therapeutic profile and the outcome of Buruli ulcer (BU) in the National Reference Center for Buruli ulcer treatment (NRCBUT) in Togo. It was a retrospective and descriptive study of records of patients treated for BU in the NRCBUT between June 2007 and December 2010. During the study period, 119 patients (56.3% males) were treated in the NRCBUT for BU. The median age of patients was 14 years. The proportion of children (< 15 years) was 56.3%. On admission, 85 patients were at ulcer stage and 34 patients at the pre-ulcer stage. BU wounds were mainly located on lower limbs (50.4%), followed by upper limbs (32.6%) and trunk (13.3%). The location of the wounds on the lower limbs were more frequent in patients older than 15 years (P < 0.001), while those on the upper limbs (P = 0.002) and trunk (P = 0.03) were more frequent in patients aged less than 15 years. All patients had received medical treatment which was based on rifampicin-streptomycin combination for eight weeks. This treatment was coupled to surgery in 30 cases. The outcome was punctuated by complications in 7 patients, limb amputation in 3 patients, and sequels in 10 patients. This study confirmed that the BU is the prerogative of young subjects and the exposed areas in the skin facilitates transmission. Apart from these classic features, some unique aspects including the age-dependent distribution are related to the pathogenesis of this disease.

Cas cliniqueLeucodermie en gouttes précoce au cours de la maladie de Darier chez un sujet à peau noireEarly guttate leukoderma in Darier's disease in a patient with black skin

BACKGROUNDnThe clinical manifestations of Dariers disease are polymorphic and diverse. Guttate leukoderma has been described in around twenty patients with genetically pigmented skin. We report a case of widespread guttate leukoderma several years before the classic signs of Dariers disease in a patient with black skin.nnnCASE REPORTnA 19-year-old woman consulted for characteristic signs of Dariers disease evolving for the previous four years. Examination revealed perifollicular, non-confluent hypopigmented macules and papules in small drop size (1-5mm in diameter) scattered on the trunk, limbs and the jaw and chin. These hypopigmented lesions had been present since the age of six years. Histology of the keratotic papules confirmed the diagnosis of Dariers disease. Histological inspection of a hypopigmented lesion showed hyperkeratosis, acantholysis and a considerable reduction of epidermal melanin pigment.nnnDISCUSSIONnOur observation suggests that a guttate leukoderma could be an early sign, readily accessible to dermatologists, in the diagnosis of Dariers disease in black-skinned patients.

Leucodermie en gouttes précoce au cours de la maladie de Darier chez un sujet à peau noire

BACKGROUNDnThe clinical manifestations of Dariers disease are polymorphic and diverse. Guttate leukoderma has been described in around twenty patients with genetically pigmented skin. We report a case of widespread guttate leukoderma several years before the classic signs of Dariers disease in a patient with black skin.nnnCASE REPORTnA 19-year-old woman consulted for characteristic signs of Dariers disease evolving for the previous four years. Examination revealed perifollicular, non-confluent hypopigmented macules and papules in small drop size (1-5mm in diameter) scattered on the trunk, limbs and the jaw and chin. These hypopigmented lesions had been present since the age of six years. Histology of the keratotic papules confirmed the diagnosis of Dariers disease. Histological inspection of a hypopigmented lesion showed hyperkeratosis, acantholysis and a considerable reduction of epidermal melanin pigment.nnnDISCUSSIONnOur observation suggests that a guttate leukoderma could be an early sign, readily accessible to dermatologists, in the diagnosis of Dariers disease in black-skinned patients.

Traitement du lichen cutané étendu par le dipropionate et phosphate disodique de bétaméthasone : étude ouverte de 73 cas

Resume Objectif Le but de cette etude etait d’evaluer l’efficacite du traitement du lichen plan cutane etendu par le dipropionate et phosphate disodique de betamethasone injectable. Malades et methode Une etude prospective a ete menee, entre septembre 2003 et aout 2005, chez les malades souffrant de lichen plan cutane etendu consultant en dermatologie au CHU de Lome (Togo). Chaque malade inclus dans l’etude a eu trois injections de dipropionate et phosphate disodique de betamethasone espacees de 15 jours. L’evaluation a ete effectuee a 6 semaines, a 3 mois et 6 mois. Resultats Soixante-treize cas de lichen plan cutane etendu ont ete inclus dans notre etude. Le sex-ratio (H/F) etait de 0,7. L’âge moyen des malades etait de 29,5 ± 11,9 ans. A 6 semaines, nous avons obtenu 83,6 p. 100 de remission complete 8,2 p. 100 de remission partielle et 8,2 p. 100 d’echec. A 3 mois, la remission complete persistait chez 58,9 p. 100 des malades contre 23,3 p. 100 de rechute. A 6 mois, le taux de recidive etait de 31,5 p. 100. Aucun effet secondaire majeur n’a ete rapporte chez les malades durant toute la periode de l’etude. Discussion Les resultats de cette etude montrent que le dipropionate et phosphate disodique de betamethasone constituent une bonne alternative therapeutique au cours du lichen plan cutane etendu. Mais ces resultats meritent d’etre confirmes par une etude randomisee avec un recul plus long.