[Knowledge of sickle cell disease and prevention methods in an urban district of Lomé, Togo]

Despite the important frequency of the gene "S" in Togo, essential information remains insufficient to elaborate a prevention campaign on this affection. In order to assess the knowledge on sickle cell diseases as well as the prevention practices in the Togo population in one of the five districts of the township of Lomé, a cross sectional study was conducted in the third district of the township of Lomé from January 21, 2004 to January 26, 2004 in 210 natives from Togo aged of 15 and over, through a semi-structured questionnaire. The variables studied were: - the socio-demographic features and the knowledge of sickle cell disease characteristics (symptoms, biological diagnosis, treatment and means). Data collected were analysed through software Statically Package for Social Science (SPSS) version 10.0 of Windows using the chi2 test with 5% significance in the comparison of some variables. 117 women and 93 men were interviewed. Sickle cell disease was known in almost all ethnic groups but incompletely: 79.5% of the individuals knew about premarital check up but only 12.4% knew about haemoglobin electrophoresis check up. 74,8% of the people had a good knowledge of the cause of sickle cell disease, 78.6% had a fairly good knowledge of its symptoms, 57.6% knew the factors inducing attacks, 64.3% the prognosis and 69.5% the prevention methods, but a poor knowledge of the complications (62.4%), biological diagnosis (71%) and treatment (97.2%). The prevention practices were poorly adopted: 12% had an haemoglobin electrophoresis check up and 15% of them had their husband to have one as well. Professional status influenced the level of knowledge of the biological diagnosis (p=0.001) and prevention means (p=0.018). The educational level influenced biological diagnosis knowledge (p = 0.000) and prevention means (p = 0.02). On the whole, sickle disease was linked to marital status (p = 0.00). Sickle cell disease remains quite unknown in spite of the gene "S" important frequency in Togo. These results are to be taken into account to implement information, education and communication program to struggle against sickle cell disease.

[Pediatric salmonellosis at the Tokoin's teaching hospital, Lomé (Togo)]

OBJECTIVE

The authors had for aim to describe the epidemiological, clinical, and bacteriological aspects and outcome of pediatric Salmonella enterica, Salmonella septicemia, over the last 10 years.

PATIENTS AND METHODS

We analyzed the case history of 132 patients hospitalized for Salmonellasepticemia (positive blood culture) between 1995 and 2004.

RESULTS

Salmonellosis accounted for 0.36% of all hospitalizations. The mean age of patients was 5.86 plus or minus 4.06 years, significantly higher in patients with S. ser. Typhi (7.14+/-4.04 years) than in patients with other serotypes (4.95+/-3.8 years). The clinical presentation was severe in many children (with dehydration (34.8%) and emaciation (55.3%)), so HIV was suspected and investigated in 51 patients (38.6%). Eight patients were HIV positive. Three serotypes of S. enterica were predominant: S. ser. Typhi, 55 cases (41.7%), S. ser. Enteritidis, 32 cases (24.2%), and S. ser. Typhimurium, 19 cases (14.4%). The bacterial susceptibility to antibiotics was good for ceftriaxone and ciprofloxacin (100%). But 78.8% of the serotypes were resistant to amoxicillin, 75.4% to chloramphenicol, and 69.4% to cotrimoxazole. The mean duration of hospitalization was 13.7 plus or minus 7.4 days (range 4-34 days). Complications occurred in 15.9% of cases, dominated by digestive bleeding (10.6%), and 6.1% of patients died.

[Priapism in sickle cell anaemia in Senegal: prevalence, attitudes and knowledge]

We interviewed 108 sickle cell anaemia patients aged 5 years older on priapism, and 113 healthy subjects in a control group. They were recruited in the out-patient consultation of the two sickle cell anemia care units of the Fann teaching hospital in Dakar. Ten cases of priapism were identified, all in the group of sickle cell patients (the difference is significant, p = 0.004). Prevalence of priapism was 9.3%. Actuarial probability of having priapism was 8.3% by 10 years of age, and 38.9% +/- 5.7 by 20 years of age. Before the interview, only 10.2% of the sickle cell patients and 8% in the control group knew about priapism, and most of them were unaware of its association with sickle cell disease (75% of sickle cell anaemia patients and 80% of control subjects). This lack of information should be improved by an educational program.

[Stuttering priapism in children with sickle cell anemia in Togo]

AIM

To describe clinical aspects and outcome of stuttering priapism (SP) in children with sickle cell anemia.

PATIENTS AND METHODS

We included the 8 children with sickle cell anemia suffering from SP between 1996 and 2004.

RESULTS

Age at onset of SP ranged from 5 to 14 years (mean 9.75+/-3.69 years). SP attacks occurred once a day for 6 patients, and 2 and 3 times by week for the others. It happened during deep sleep, especially in the night (all patients) and sometimes in the day (4 patients). The duration of attacks ranged from 10 min to 2 h in 6 patients and 4 to 5 h in 2 patients. Oral étilefrine was administered to all patients until the cessation of attacks, and continued during 1 month. A long remission was obtained in all patients after 7 days to 7 months treatment (follow-up 2 to 7 years) in spite of 1 or many relapses.

[Management of malaria in Togolese communities]

The objective of this study was to collect community basis data on prevention and home management of malaria for the future assessment of "Roll Back Malaria", the new world strategy of fighting against malaria. The study was carried out in 3 districts in Togo. Mothers were questioned about the quality of home management of uncomplicated malaria on 951 children aged under 5. Fathers were questioned about the use of mosquito bed nets in 597 households, and 246 women were interviewed about the prevention of malaria during pregnancy. Home management of children under treatment was correct in only 38.1% of cases and the drug observance was followed by only 35.4% of patients. Mosquito nets were used in 30.5% of households and only 16.5% were treated with insecticides. Only 22.7% of children under 5 slept under mosquito nets. 80% women made at least one antenatal visit and 74.4% received regular malaria chemoprophylaxis. Many efforts should be made in Togo to increase the quality of home management of malaria and the use of insecticide-treated bed nets.

[Evolution of severe pediatric malaria in Togo between 2000 and 2002]

The aim of this study was to analyse the clinical and evolutive aspects of severe malaria in hospitalised children in 2000, 2001, and 2002 in Togo. The study included 361 children in the pediatrics department of Lomé-Tokoin University hospital. All them received a 10% dextrose infusion, then an infusion of quinine or intramuscular artemether. Malaria accounted for 4.37% of all hospitalizations. Children aged 1 to 5 years were more affected (69.53%). The most frequent clinical forms were anaemia (55.7%) followed by cerebral manifestations. The frequency of hemoglobinuria increased (17.2%) as well as renal failure (3%) compared to previous years. Thirty-five children died (9.7%). Most of them presented with anaemia, neurological manifestations, or respiratory distress. Neurological sequels were present in 2.2% of patients.

[Treatment of cerebral malaria in African children by intravenous quinine: comparison of a loading dose regimen to a regimen without a loading dose]

OBJECTIVE

To compare in a randomized study the efficacy and the toxicity of the new WHO intravenous quinine treatment of cerebral malaria including a loading dose regimen to a regimen without loading dose.

PATIENTS AND METHODS

Seventy-two children eight months to 15 years of age with cerebral malaria were included. Quinine formiate was administered to a group of 35 patients in an initial loading dose of 20 mg salt/kg (equivalent to 17.5 mg/kg of the base) in 10 mL/kg of 5% glucose over four hours, followed eight hours later by a maintenance dose quinine of 10 mg salt/kg (equivalent to 8.7 mg/kg of the base) dissolved in 15 mL/kg of 5% glucose over and every 12 hours. The second group of 37 patients received intravenous quinine 15 mg salt/kg (13.1 mg of base) dissolved in 15 mL/kg of 5% glucose infused over 6 to 8 hours, every 12 hours. In both groups this treatment was continued until the patient could swallow, then quinine tablets were given to complete seven days treatment. The assessment of cardiovascular side effects was made by an ECG at admission, the 4th hour, the 24th hour and at the end of treatment for each patient.

RESULTS

Coma mean durations were similar in the two groups: 35.5 +/- 17.8 hours and 28.6 +/- 14.4 hours respectively for the loading dose group and the group without loading dose. The two groups were comparable also for the decrease evolution of parasitemia. Case-fatality rates were also similar: 95% of healing at the 72nd hour and a lethality rate between 5 and 6% in the two groups. But a significant increase of the body temperature was noted between the 51st and the 63rd hour in the group without loading dose. No significant cardiovascular toxicity was noticed in the two groups. The mean cost of the loading dose regimen was less than that of the second regimen.

CONCLUSION

The loading dose regimen of quinine is well tolerated and it seemed slightly more effective than the regimen without loading dose. In cases of contra-indications (patients who recently received quinine, mefloquine or halofantrine), regimens without loading dose, which remains effective, should be used.

[Acute osteomyelitis in the child with sickle cell disease in a tropical zone: value of oral fluoroquinolones]

AIM

This study was designed to assess the efficacy and the safety of fluoroquinolones in their compassionate use for acute osteomyelitis in children with sickle cell disease in a tropical country.

PATIENTS AND METHODS

This study was non comparative, including twelve children (eight SS, three SC and one SEzerothalassemia) treated for acute osteomyelitis with oral ciprofloxacin or ofloxacin because of the following reasons: financial inability to afford conventional parenteral beta-lactams therapy (nine patients), refusal of hospitalization (two patients), and failure of conventional treatment (one patient).

RESULTS

The mean age of patients was 9.5 +/- 2.6 years. The long bones were the predominantly site. Salmonella species were present in 75% of cases, followed by other enterobacteriaceae (16.7%), and Staphylococcus aureus (8.3%). Successful outcome occurred in all cases after three to four-weeks of treatment and 45 days of plaster immobilization. Transient bilateral Achilles tendon tendinitis was noted in a five-year-old patient.

CONCLUSION

In economically developing countries, oral fluoroquinolones may be a therapeutic alternative for acute osteomyelitis in patients with sickle cell disease particularly in cases of financial hardship or failure with conventional therapy.

Priapism in sickle cell anemia in Togo: prevalence and knowledge of this complication

Prevalence of priapism and knowledge on this disease was assessed by interviewing a group of 114 sickle cell anemia patients, 5 years and older, considered to be genotypically homogenous (Benin or #19 haplotype). Prevalence of priapism in homozygous sickle cell patients was 26.3% (30/114) and that of the control group of subjects with Hb AA was 2% (2/102) (the difference was very significant: p = 5.10-7). Actuarial probability of having priapism by 20 years of age was 69 +/- 8.5%. Few homozygous patients without a history of priapism (15.8%) have heard about priapism. This lack of knowledge, added to low accessibility of a health care system, may explain the high rate of impotence (31.6%). The results of this study led us to plan a large program of infonnation about priapism and sickle cell disease in the Togolese population.

Management of sickle cell priapism with etilefrine

Intracavernous injections of etilefrine were effective in seven children with acute sickle cell priapism, and stuttering priapism resolved in five children after one to seven months of oral etilefrine. Compared with our previous reports in adults, etilefrine appears to be more effective in childhood.

[Ambulatory management of sickle cell disease: evaluation of the first year follow up of patients in the pediatric department of Lomé (Togo)]

BACKGROUND

This study is an evaluation of the first year ambulatory follow up of patients from the sickle-cell care centre of the paediatric ward of the teaching hospital in Lomé-Tokoin.

PATIENTS AND METHODS

Togo is situated in the epicentre of the Benin haplotype. A total of 132 patients (109 SS, 22 SC and 1 S beta zero thal) followed up during one year from their admission date (period of 1st January 1996 to 31st December 1997). 132 patients were included in the study.

RESULTS

The patients' age varied, for the majority, between 2 months and 15 years, but a few adults (15%) were included in the study. Information was collected from the hospital files and health cards, which unfortunately did not have specific entrees for sickle cell disease. Clinical features revealed that the frequency of tooth decay and chronic persistent splenomegaly was low when compared to the rates in central Africa (Bantu haplotype). Laboratory findings lead to the conclusion that some analysis are relevant such as the dosage of the G6PD activity (24.1% of patients were deficient), parasitologic analysis of faeces (positive in 22.5%), retinal fluoro-angiography (32.2% of ocular lesions), and cardiologic check-up. On the other hand, scanning of biliary tracts and systematic X-rays of the hips seems to be secondary. Some positive results were noticed by the scanning of biliary tracts without any therapeutic decisions in non-symptomatic patients; no case of osteonecrosis was detected by the X-rays. The mean haemoglobin level was 7.4 +/- 1.4 g/dl for the SS and 10.7 +/- 2.4 g/dl for the SC. The mean MCV were 91.3 +/- 10.1 fl and 82.1 +/- 7.7 fl, respectively. Specific vaccinations were not well performed because of their high cost.

CONCLUSION

In order to carry on and improve the ambulatory management of patients with sickle cell disease, it is important in low income countries, such as Togo, to target the necessary laboratory tests for an initial and annual check-up. Solidarity networks for patients should be promoted and effective involvement of the health authorities ensured.

[Sexually transmitted diseases in young children in Lomé (Togo). Role of sexual abuse]

OBJECTIVE

The purpose of this study was to determine the importance of sexual abuse in young children with sexually transmitted diseases (STD) in Lomé (Togo).

METHODS

This transversal study consisted of documenting all cases of STD in young children (up to 11 years of age) diagnosed during 20 months (May 1997 to December 1998) in the dermatovenereology unit of the Lomé teaching hospital. Syphilitic (TPHA-VDRL) and HIV serologies were carried out in all children. These serologies were repeated two weeks and three months later in sexually abused children.

RESULTS

During this period, 33 cases of STD were diagnosed. There were 16 cases of anogenital warts (13 females, three males; mean age: 5.6 +/- 2.4 years); 13 cases of gonorrhoea (all were females; mean age: 7.2 +/- 1.8 years); and four cases of genital trichomoniasis (four females; mean age: 6.2 years). In 12 of 13 cases of gonorrhoea, sexual abuse was noted with identification of the alleged contaminators in ten cases. In eight of 16 cases of anogenital warts (all observed in females; mean age: 6.1 +/- 1.9 years), and two of four cases of genital trichomoniasis (mean age: six years) sexual abuse was observed. Syphilitic serology was negative in all children, but one ten-year-old girl had HIV infection with identification of the alleged contaminator.

CONCLUSION

The results of this study confirm that sexual abuse in children is not uncommon in black Africa and that the STD, like condylomata acuminata and gonorrhoea, are good indicators of this phenomenon. The classical consequences of such sexual abuses are aggravated in Africa by the high prevalence of HIV infection observed in the majority of countries, mainly in urban areas.

[The impact on families of sickle cell disease in Togo]

AIM

In order to master the difficulties due to sickle cell disease, this work aimed at assessing the effects on the families of the presence of a child with sickle cell disease in Togo.

POPULATION AND METHODS

From April 1 to November 31, 1998, 103 families with one or many sickle cell patients followed up in the Sickle Cell Care Unit of the pediatric department of the Lome Teaching Hospital were surveyed. Main care takers of patients with sickle cell disease, especially mothers (90.3% of cases), were surveyed.

RESULTS

Many parents were disturbed; the most common troubles were: compassion (pity) toward the child, 92.2%; insomnia, 82.5%; frustration, 76.7%; and fear of the death of the child, 73.5%. Less educated parents and those who lived alone (single parents, widows, separated) were more affected. Sickle cell disease caused the separation of seven couples out of 26 (26.9%), while in 11 couples of the 63 who still live together, relationships had deteriorated (17.5%). Most of the parents (83.3%) exaggerated the protection of their child and 65% mentioned financial problems.

CONCLUSION

There is no doubt about the unfortunate effects of the presence of children with sickle cell disease in a family in Lome. Many joint actions should be taken toward the sick children and their families in order to reduce their sufferings.

[Primary nephrotic syndrome in the black African child]

Idiopathic nephrotic syndrome (INS) in black African children differs from that of children in temperate areas. The main differences are the high rate of corticosteroid non-responders and the low rate of minimal change glomerulopathy in black African children, possibly related to a racial factor. The identification of a high corticosensibility in certain African regions (Togo and Ghana) can lead to the identification of an ethnic factor. Further genetic studies should be carried out in order to provide a better approach to INS in Africa.

[Home care of vaso-occlusive crisis in sickle cell disease in Togo]

BACKGROUND

Many people with sickle cell disease manage their pain crises at home. This study aims to describe the home management of sickle cell pain by Togolese patients.

PATIENTS AND METHODS

From July 1996 to April 1997, parents of children with sickle cell disease, and some adults with sickle cell disease living in rural and urban regions were interviewed about their home treatment habits during pain crises.

RESULTS

A total of 165 patients with sickle cell disease (82 from urban and 83 from rural areas) were selected. The techniques most frequently used for pain management included salicylates (61.8%), paracetamol (37%), non-steroidal anti-inflammatory drugs (15.1%), vasodilators and pentoxifylline (5.4%). Only 4.2% of the patients mentioned adequate hydration. None used other antalgics (weak or strong opium derivatives). No difference was noticed between the treatment habits of rural regions and those of urban regions.

CONCLUSION

In order to improve the quality of life of patients with sickle cell disease, information and awareness programs must be organized in order to establish a standard home pain management. Emphasis must be put on the use of salicylates and paracetamol at the correct dosage, the intake of abundant fluids, the easy use of analgesic of the second step of the Word Health Organization, and the systematic treatment of malaria which can induce pain crises.

[Intracavernous injections of etilefrin: its efficacy in the treatment of priapism in sickle cell patients]

OBJECTIVE

To date, the treatment of priapism in sickle-cell patients has relied on measures aimed at lowering blood viscosity and acidosis and reducing the level of circulating hemoglobin S (hyperhydration, alkalinization, or exsanguinotransfusion...) Surgical cavernous-venous shunt may be proposed if conservative treatment fails. We examined the efficacy of intracavernous etilefrin injections.

PATIENTS AND METHODS

From January 1996 through October 1997 (20 months) we performed 35 consecutive intracavernous injections of an alphastimulant, etilefrin in 7 sickle-cell patients (6 SS, 1 AS) who had experienced one or several episodes of low-flow priapism lasting 2 to 28 hours.

RESULTS

Involution of the tumefaction was rapidly achieved in all cases. Tolerance was satisfactory, although some post-injection undesirable effects were reported by certain patients: moderate transient pain (2-5 min) in the retrosternal area, or intense pain in the penis (more intense than the priapism) which lasted 10 to 30 minutes. This work confirmed the earlier reported efficacy of intracavernous injections of etilefrin and suggests that the autonomous nervous system plays an important role in the genesis of this condition in sickle-cell patients. Patients should be informed about the observed undesirable effects which have not been reported previously in the literature.

CONCLUSION

Etilefrin can be proposed as first line treatment for priapism in sickle-cell patients (at least in cases lasting less than 24 h). The pathogenic mechanism could involve neuromuscular dysfunction.

[Severe malaria in children in Togo]

BACKGROUND

The definition of severe malaria is no longer limited to cerebral malaria, but is as well extended to other clinical forms of the disease. This work analyses epidemiological, clinical and evolutive aspects of severe malaria in Togo.

PATIENTS AND METHODS

This study included 549 children, aged from 0 to 15 years, hospitalized in 1994-5 in the pediatric department of the Lome-Tokoin University Teaching Hospital for severe malaria as defined by World Health Organization (WHO) criteria.

RESULTS

The hospitalization frequency was 7.44%; the maximum frequency was from 1 to 5 years of age, but 6.56% of patients were more than 10 years old. The most frequent clinical form was that of severe anemia, followed by cerebral complications, as seen in many African countries. The death rate was 18.94% and the proportional mortality was 8.21%; 2.73% of the patients had neurological sequelae (behaviour disturbances in five cases, aphasia in four, hemiplegia in three, mumbling in one, oculomotor paralysis in one, and cerebellar ataxia in one). Hypoglycemia was fairly frequent (11.6%) and was associated with a poor prognosis.

CONCLUSION

It is possible to improve severe malaria prognosis in Africa by insisting not only on better equipment in intensive care wards, but also on improved and early management of hypoglycemia.

[Idiopathic thrombopenic purpura in a child in black Africa: a case report in Togo]

Idiopathic thrombocytopenic purpurea (ITP) is an autoimmune disease that occurs frequently in Europe and the US, but has rarely been described in Africa. Case report. An 8-year-old girl was admitted for cutaneous and mucosal bleeding. She had a low platelet count (11 x 10(9)/l). ITP was suspected and the diagnosis was confirmed by bone marrow examination. Corticosteroid treatment was effective.

DISCUSSION

This is the second case reported in Togo since 1982. The diagnosis of the disease is straightforward, so the lack of cases reported in central Africa suggests that the disease is rare in this region. The rarity of the disease may be due to genetic or environmental factors, or it may simply be that physicians overlook this disease when making their diagnosis. Corticosteroids are now the preferred treatment for ITP because of the risk of transmitting Creutzfeldt-Jacob's disease by intravenous administration of immunoglobulin. Splenectomy is the ultimate treatment for chronic forms.

CONCLUSION

Unlike other diseases, the diagnosis and treatment of which require methods unavailable in parts of Africa, ITP treatment, as currently practiced in countries of the northern hemisphere, is within the reach of most African countries. Further studies are required to determine the true frequency of the disease in central Africa.