[Long-term results of plantar skin grafts versus skin grafts of hairy areas for covering loss of skin substances on the palmar surface of the fingers, palm of the hand and sole of the foot in patients with black skin. Prospective cohort study of 123 total skin grafts]

CONTEXT

Despite the use of total skin grafting in the treatment of loss of skin substances on the palmar surface of the fingers, the palm of the hand and the sole of the foot, the data published in the literature on long-term results in black-skinned patients are non-existent.

METHODS

The present study, filling this gap, used data from a prospective cohort of 123 total skin grafts performed on 93 black African patients who benefited from plantar skin grafts versus skin grafts from hairy areas to cover loss of skin substances. of the palmar surface of the fingers, the palm of the hand and the sole of the foot. This study covers a period of 163 months.

RESULTS

Sixty-four grafts of hairy areas were carried out in 52 patients, 29 of whom were male and 23 female, for a M/F sex ratio of 1.3; and 59 plantar skin grafts in 41 patients including 21 males and 20 females, M/F sex ratio of 1. The digital palmar surface was the most recipient of the plantar graft, i.e. 35.5% of cases. After a post-operative follow-up of at least 12 months, patients or their entourage judged the functional and aesthetic results of plantar skin grafts to be better and acceptable, unlike the results of hairy area grafts. The texture and color are even better if the total skin graft is taken from an identical histological area.

CONCLUSION

In view of these results, we recommend a plantar skin graft for black-skinned patients to cover losses of skin substances on the palmar surface of the fingers, the palm of the hand and the sole of the foot, if indicated.

[Second ear piercing for aesthetic purposes and appearance of pathological scars in negroids: About 172 observations in an endemic area of keloids]

This is a transverse and retrospective descriptive study carried out on a quantitative and qualitative component on pathological scars after a second ear piercing for aesthetic purposes in a Negroid female population from an endemic area of keloids. For a period of 10 years (from January 1, 2010 to December 31, 2019), we observed 172 patients with pathological ear scars after a second piercing for aesthetic purposes including 65.7% of female students and 22.1% of students. Clinically, we had 143 (83.1%) patients with keloids and 29 (16.9%) with hypertrophic scars. The average age of the second piercing was 22.62 years; 98 (57%) patients had single lesions on the pierced ear and 74 (43%) multiple lesions; 168 (97.7%) had no family history of pathological scars. Our patients from an endemic area of keloids did not develop pathological scars during the first piercing but all develop pathological scars after the second piercing. Several risk factors could be accused: heredity, environment, race, age, gender, wearing of poor-quality jewelry, infection, disruption of the healing process caused by the first piercing, mechanical tension caused by the new ornamental object. However, none of these assumptions has been verified. In the meantime, we do not recommend that at risk negroid subjects, originating from areas with high endemicity of keloids, a second ear piercing for aesthetic purposes.

Silicone infusion tubing instead of Hunter rods for two-stage zone 2 flexor tendon reconstruction in a resource-limited surgical environment

The authors describe their experience using silicone infusion tubing in place of Hunter rods for two-stage zone 2 flexor tendon reconstruction in a resource-limited surgical environment. This case report features a 47-year-old, right-handed man who had no active PIP and DIP joint flexion in four fingers of the right hand 5 months after an injury. During the first repair stage, the A2 and A4 pulleys were reconstructed using an extensor retinaculum graft. An infusion tube was inserted instead of Hunter rods. During the second stage, formation of a digital neo-canal around the infusion tubing was observed. The infusion tubing was removed and replaced with a palmaris longus tendon graft according to the conventional technique. Physiotherapy and rehabilitation followed surgery. At 6 months, very significant progress had been made with complete recovery of PIP and DIP flexion in the four fingers.

[Stab wounds of the hand and forearm due to Kuluna in Kinshasa (Democratic Republic of Congo): types of injuries and treatment]

Democratic Republic of Congo (DRC), a particular form of juvenile delinquency and insecurity intensifies in the city of Kinshasa. This is the phenomenon Kuluna. It is organized gangs equipped with machetes and other weapons. The main objective of this study is to know the phenomenon Kuluna and describe the upper limb injuries caused by machetes, while insisting on the specifics of the management of these lesions in our communities. This retrospective descriptive study examines 14 cases of wounds of the hand and forearm due to stab phenomenon Kuluna, in Kinshasa. It covers the period from 1 November 2010 to 1 November 2013. Among the 14 patients with lesions in the hand and forearm admitted and treated at the Unit of Plastic Reconstructive and Aesthetic Surgery, Hand Surgery and Burns, University Clinics of Kinshasa to attacks due to the phenomenon Kuluna. We have 11 men and 3 women. The average age was 33, 5 years (extremes of 21 and 56 years). The right upper limb is reached that the left upper limb, respectively 12 patients and 2 patients. The lesions are localized to the wrist in the majority of cases (10 patients) in the palm of hand and in 3 patients in the fingers in 1 patient. The palmar surface is reached (10 cases) and the dorsal (4 cases). Zone 5 of the International Classification of flexor and Zone 8 topographic classification extensors at hand are the predilection sites of lesions respectively the palmar surface (6 out of 10) and the dorsal (2 case 4). The median nerve at the wrist is cut in half the cases. On bone lesions localized to the forearm, we observed a high incidence of fracture of the ulna (62.5%). The treatment begins with the stabilization of bone pieces, gestures revascularization and nerve sutures and suture tendon and finally skin coverage. Rehabilitation was mandatory, she supervises the actions of repair and it continues until the recovery of function.

[Not Available]

Burn injuries to the hand are still common in low-income countries. Between December 1st 2010 and May 1st 2014, 32 patients, representing 38 hands, were admitted and treated at the University Clinics of Kinshasa in the Democratic Republic of Congo (DRC). We observed 22 patients (69%) in the juvenile age group (under 18 years old) and 10 patients (31%) in the adult age group (18-59 years). We did not observe any patients in the senior age group (60 years and over). In the juvenile age group, those aged from 1 to 5 years old were the most affected, comprising 13 patients (40%). Accidents occurred mainly at home (72%). The most common burn etiologies were thermal injuries caused by flame (51%) and scalds (34%). Contractures were the most frequently occurring lesions (84%). Overall dorsal retraction, known as "claw hand", was found in 40% of patients, and was associated with keloid and hypertrophic scars in 84% of cases. Excision and grafting were performed in 43.7%, local flaps in 43.7% and distant flaps in 12.5% of cases. On discharge from hospital, 84% "good" results were observed. Follow-up lasted 18 months. This study demonstrates the feasibility of reconstructive surgery in sequelae of hand burns, despite limited resources. However, the challenges in low income countries with limited resources are numerous: poor access to current techniques of plastic surgery, inadequate initial burns management, and poverty.

Response to treatment in a prospective cohort of patients with large ulcerated lesions suspected to be Buruli Ulcer (Mycobacterium ulcerans disease)

Background

The World Health Organization (WHO) advises treatment of Mycobacterium ulcerans disease, also called “Buruli ulcer” (BU), with a combination of the antibiotics rifampicin and streptomycin (R+S), whether followed by surgery or not. In endemic areas, a clinical case definition is recommended. We evaluated the effectiveness of this strategy in a series of patients with large ulcers of ≥10 cm in longest diameter in a rural health zone of the Democratic Republic of Congo (DRC).

Methods

A cohort of 92 patients with large ulcerated lesions suspected to be BU was enrolled between October 2006 and September 2007 and treated according to WHO recommendations. The following microbiologic data were obtained: Ziehl-Neelsen (ZN) stained smear, culture and PCR. Histopathology was performed on a sub-sample. Directly observed treatment with R+S was administered daily for 12 weeks and surgery was performed after 4 weeks. Patients were followed up for two years after treatment.

Findings

Out of 92 treated patients, 61 tested positive for M. ulcerans by PCR. PCR negative patients had better clinical improvement than PCR positive patients after 4 weeks of antibiotics (54.8% versus 14.8%). For PCR positive patients, the outcome after 4 weeks of antibiotic treatment was related to the ZN positivity at the start. Deterioration of the ulcers was observed in 87.8% (36/41) of the ZN positive and in 12.2% (5/41) of the ZN negative patients. Deterioration due to paradoxical reaction seemed unlikely. After surgery and an additional 8 weeks of antibiotics, 98.4% of PCR positive patients and 83.3% of PCR negative patients were considered cured. The overall recurrence rate was very low (1.1%).

Interpretation

Positive predictive value of the WHO clinical case definition was low. Low relapse rate confirms the efficacy of antibiotics. However, the need for and the best time for surgery for large Buruli ulcers requires clarification. We recommend confirmation by ZN stain at the rural health centers, since surgical intervention without delay may be necessary on the ZN positive cases to avoid progression of the disease. PCR negative patients were most likely not BU cases. Correct diagnosis and specific management of these non-BU ulcers cases are urgently needed.

Buruli ulcer (BU) disease, a neglected devastating infection caused by Mycobacterium ulcerans, has a huge impact because of the massive necrotizing, disfiguring ulcers that may result if not treated. Therapeutic options are surgery, antibiotics or combinations of both. Since 2004, the World Health Organization has recommended the use of antibiotics (rifampicin and streptomycin) for the management of the disease. The effectiveness of this antibiotic treatment on advanced lesions is, however, not well documented. We evaluated this strategy on large ulcers clinically suspected to be BU, in a rural zone of the Democratic Republic of Congo, and also assessed the outcome of treatment based only on clinical diagnosis. All patients were treated with antibiotics for 12 weeks and surgery was performed after 4 weeks. BU was confirmed by laboratory tests in 67% of the patients indicating that the clinical diagnosis of ulcerated forms of BU may be more difficult than usually reported. Although delayed surgery seemed detrimental in some confirmed cases, it was possible to treat 92% of patients successfully with low recurrence rates (1.1%) by combining antibiotic treatment with surgery in a rural zone. However, the need for and the best time for surgery for large Buruli ulcers requires clarification.

[Relapse after surgical treatment of mycobacterium ulcerans infection (buruli ulcer): study of risk factors in 84 patients in the Democratic Republic of the Congo]

OBJECTIVE

To identify risk factors for relapse after exclusively surgical treatment of Mycobacterium ulcerans infection (Buruli ulcer).

METHODS

Study was carried out in 102 patients treated exclusively by surgery for Buruli ulcer at various care facilities in the Congo from January 1, 2000 to January 1, 2005.

RESULTS

Outcomes included relapse in 22 patients (21.5%), cure in 62 (60.7%), and unknown in 18 (17.6%). Statistical analysis identified the following variables as independent risk factors for relapse after exclusively surgical treatment: incomplete surgical excision (OR = 91.83; P = 0.0000; IC to 95%), age under 16 years (OR = 14.80; P = 0.0000; IC to 95%) and pre-ulcerative Buruli lesions (edema and plaque) (OR = 3.18; P = 0.0215; IC to 95%).

CONCLUSION

Quality of excision, patient age, and clinical form of lesion are the main predictors of relapse after isolated surgical treatment of Buruli ulcer.

New foci of Buruli ulcer, Angola and Democratic Republic of Congo

We report 3 patients with laboratory-confirmed Buruli ulcer in Kafufu/Luremo, Angola, and Kasongo-Lunda, Democratic Republic of Congo. These villages are near the Kwango/Cuango River, which flows through both countries. Further investigation of artisanal alluvial mining as a risk factor for Buruli ulcer is recommended.

[Follow-up of the first case of Mycobacterium ulcerans infection documented by PCR, genotyping and culture in the Republic of Congo-Brazzaville]

This article presents follow-up data from the first patient in whom Mycobacterium ulcerans infection (MUI) was documented by PCR, genotyping and culture in the Republic of Congo-Brazzaville. Findings show the importance of regular clinical and microbiological evaluation for the disseminated form of the disease. The patient was probably infected in Pointe Noire where MUI has been described but never documented. Culture of specimens collected before antibiotic treatment showed that the bacterium was sensitive to the antibiotics being administered (streptomycin and rifampin) and was identical to isolates from Atlantic-coast regions of West Africa where MUI is endemic. The patient was treated with streptomycin and rifampin for 12 weeks in association with surgery. During treatment clinical examination was performed every day and microbiological analysis every two weeks. The duration of follow-up from the end of specific antibiotic treatment was 26 months. Medical treatment failed to prevent bone involvement and fistulae that were treated by surgery. However medical treatment may have limited dissemination of the disease. Serial microbiological evaluation was useful to detect bone involvement in this patient, but persistent positive gene amplification is not a proof of active disease. This study confirms that MUI is still endemic in the region of Pointe Noire. This finding underlines the need to optimize epidemiologic surveillance, laboratory diagnostic capabilities, and therapeutic management in the Republic of Congo-Brazzaville.

[Mycobacterium ulcerans infection treated by Rifater, pyrazynamide, Myambutol, and surgery: a case report with a 6-year follow-up]

The author reports a case of pleuritis associated with a large homolateral Buruli thorax ulcer in a nine-year old female patient, in the Democratic Republic of Congo. Smears on Ziehl-Neelsen revealed acid-alcohol-resistant bacilli. The pathological histology confirmed a Mycobacterium ulcerans infection (Buruli ulcer). The treatment was surgical (excision-dressing-grafting) associated to antibiotic therapy (Rifater, Pyrazynamide, and Myambutol). After six years of follow up, no relapse was observed.

[Study of names and folklore associated with Mycobacterium ulcerans infection in various endemic countries in Africa]

The purpose of this article is to present names used for Mycobacterium ulcerans infection (Buruli ulcer) and explain their meanings in various African languages. Representations associated with the disease were also studied. The study approach involved qualitative analysis of information from interviews and literature. Interviews were conducted with the directors of various programs and management centers. Findings from 9 African countries where Buruli ulcer is known to be endemic, i.e., Benin, Cameroon, Congo-Brazzaville, Côte d'Ivoire, Ghana, Uganda, Democratic Republic of Congo, Southern Sudan and Togo, showed that the names used for the disease could be classified into three categories based on the geographical origin of infection, the features of the observed lesions, and aspects of ost often associated with belief in witch-craft, i.e., bad luck, fetishes, and curses. Representation of the disease in different African languages were similar and appear to demonstrate a good understanding of the disease in the countries where Buruli ulcer is prevalent. The impact of the representations of the disease on therapeutic choices and itineraries is also discussed.

[Mycobacterium ulcerans disease (Buruli ulcer): surgical treatment of 102 cases in the Democratic Republic of Congo]

This report describes the preliminary results of surgical treatment of 102 patients presenting Buruli ulcer (BU) over the 5-year period from January 1, 2000 to January 1, 2005. The overall purpose is to improve therapeutic management of BU in the Democratic Republic of Congo. The main disease features were the same as those described in the literature. Diffuse mixed ulcerative forms were the most common in the hospital and at the health care center. Infection by Mycobacterium ulcerans was confirmed by microbacteriological analysis and histological study. Surgical removal of the BU was performed with primary suture, protective dressing, or skin grafting. Local care consisted of application of an aqueous solution of chloramine-metronidazole-nitrofurandoine daily after debridement. Skin grafting was performed with or without protective dressing. Preliminary results with a follow-up of 12 months showed healing in 62 cases, recurrece in 22, and unknown outcome in 18. Although surgical treatment was feasible in poor rural facilities, the cost depending on clinical form is high and recurrence is frequent. These findings undersscore the importance of early detection and treatment with antimycobacterials.

[Buruli ulcer in Angolese refugees in the Kimpese area, Lower Congo, D.R. Congo]

Many epidemiological studies on Buruli ulcer have established the endemic zones in the Congolese Democratic Republic. But the situation about the areas where the refugees are located in high endemicity zones has not yet been studied. The present study describes the presence of the Mycobacterium ulcerans infection in the angolese refugee populationat Kimpese. The data obtained reveal that 50% of patients in the region are angolese refugees. All patients were infected two years before their insertion. The group most affected are children under 15 with a predominance of masculine patients. The legs were the most affected. The most frequent form is the ulcerative form.

Late ophthalmologic manifestations in survivors of the 1995 Ebola virus epidemic in Kikwit, Democratic Republic of the Congo

Three (15%) of 20 survivors of the 1995 Ebola outbreak in the Democratic Republic of the Congo enrolled in a follow-up study and 1 other survivor developed ocular manifestations after being asymptomatic for 1 month. Patients complained of ocular pain, photophobia, hyperlacrimation, and loss of visual acuity. Ocular examination revealed uveitis in all 4 patients. All patients improved with a topical treatment of 1% atropine and steroids.

Organization of patient care during the Ebola hemorrhagic fever epidemic in Kikwit, Democratic Republic of the Congo, 1995

In contrast with procedures in previous Ebola outbreaks, patient care during the 1995 outbreak in Kikwit, Democratic Republic of the Congo, was centralized for a large number of patients. On 4 May, before the diagnosis of Ebola hemorrhagic fever (EHF) was confirmed by the Centers for Disease Control and Prevention, an isolation ward was created at Kikwit General Hospital. On 11 May, an international scientific and technical committee established as a priority the improvement of hygienic conditions in the hospital and the protection of health care workers and family members; to this end, protective equipment was distributed and barrier-nursing techniques were implemented. For patients living far from Kikwit, home care was organized. Initially, hospitalized patients were given only oral treatments; however, toward the end of the epidemic, infusions and better nutritional support were given, and 8 patients received blood from convalescent EHF patients. Only 1 of the transfusion patients died (12.5%). It is expected that with improved medical care, the case fatality rate of EHF could be reduced.

Ebola hemorrhagic fever and pregnancy

Fifteen (14%) of 105 women with Ebola hemorrhagic fever hospitalized in the isolation unit of the Kikwit General Hospital (Democratic Republic of the Congo) were pregnant. In 10 women (66%) the pregnancy ended with an abortion. In 3 of them, a curettage was performed, and all 3 received a blood transfusion from an apparently healthy person. One woman was prematurely delivered of a stillbirth. Four pregnant women died during the third trimester of their pregnancy. All women presented with severe bleeding. Only 1 survived; she had a curettage because of an incomplete abortion after 8 months of amenorrhea. The mortality among pregnant women with Ebola hemorrhagic fever (95.5%) was slightly but not significantly higher than the overall mortality observed during the Ebola epidemic in Kikwit (77%; 245/316 infected persons).

Ebola hemorrhagic fever in Kikwit, Democratic Republic of the Congo: clinical observations in 103 patients

During the 1995 outbreak of Ebola hemorrhagic fever in the Democratic Republic of the Congo, a series of 103 cases (one-third of the total number of cases) had clinical symptoms and signs accurately recorded by medical workers, mainly in the setting of the urban hospital in Kikwit. Clinical diagnosis was confirmed retrospectively in cases for which serum samples were available (n = 63, 61% of the cases). The disease began unspecifically with fever, asthenia, diarrhea, headaches, myalgia, arthralgia, vomiting, and abdominal pain. Early inconsistent signs and symptoms included conjunctival injection, sore throat, and rash. Overall, bleeding signs were observed in <45% of the cases. Typically, terminally ill patients presented with obtundation, anuria, shock, tachypnea, and normothermia. Late manifestations, most frequently arthralgia and ocular diseases, occurred in convalescent patients. This series is the most extensive number of cases of Ebola hemorrhagic fever observed during an outbreak.

Treatment of Ebola hemorrhagic fever with blood transfusions from convalescent patients. International Scientific and Technical Committee

Between 6 and 22 June 1995, 8 patients in Kikwit, Democratic Republic of the Congo, who met the case definition used in Kikwit for Ebola (EBO) hemorrhagic fever, were transfused with blood donated by 5 convalescent patients. The donated blood contained IgG EBO antibodies but no EBO antigen. EBO antigens were detected in all the transfusion recipients just before transfusion. The 8 transfused patients had clinical symptoms similar to those of other EBO patients seen during the epidemic. All were seriously ill with severe asthenia, 4 presented with hemorrhagic manifestations, and 2 became comatose as their disease progressed. Only 1 transfused patient (12.5%) died; this number is significantly lower than the overall case fatality rate (80%) for the EBO epidemic in Kikwit and than the rates for other EBO epidemics. The reason for this low fatality rate remains to be explained. The transfused patients did receive better care than those in the initial phase of the epidemic. Plans should be made to prepare for a more thorough evaluation of passive immune therapy during a new EBO outbreak.