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We report a fortuitous discovery of primary pulmonary myxoid liposarcoma in an HIV-positive patient. Primary pulmonary localizations are uncommon. Generally, pulmonary localizations are metastatic. There is a male predominance and diagnosis is generally made around 40 years of age. The two main features of liposarcoma are the large tumor size and the complex histology that evolves over time. Pathology findings are rarely reproducible and vary from one pathologist to another. Macroscopically, liposarcomas can mimic benign tumors. The risk of recurrence is high after simple enucleation due to microscopic extracapsular extensions. Surgery remains the predominant treatment. Wide complete excision, if possible, provides long-term survival.

Objective: The purpose of this study was to determine the clinical, radiographic, and ultrasonographic aspects of mediastinal nodal tuberculosis and ascertain its clinical course in the era of HIV infection., Patients and Methods: We reviewed retrospectively 39 patients referred to the Ouédraogo Yalgado National Hospital Center and the National Anticancer Institute between February 1996 and December 1999 for mediastinal nodal tuberculosis. Endoscopic proof of tuberculosis was obtained in 30 cases (81.8%). HIV serology was positive in 26 of the 30 patients tested (86.6%)., Results: Nodal mediastinal tuberculosis accounted for 1.7% of the cases of tuberculosis recorded over the same period at the Anticancer Institute. Mean age of the patients was 32.8 years and the sex ratio was 1.05 in favor of men. Clinically, a past medical history was found in 18 cases (46%) including a herpes zoster in 6 (15.4%), cough in 38 (97.5%). Weight loss (95%), fever (100%) and peripheral node enlargement (20%) were found frequently, probably related to HIV infection more than tuberculosis. Radiographically, standard x-rays evidenced associated lesions in 22 cases, with 59% having predominant parenchymatous lesions. Other localizations of tuberculosis were very frequent (42.5%)., Discussion: Bronchial fibroscopy is most contributive to diagnosis of mediastinal nodal tuberculosis with an 81.8% yield in our series. HIV infection had a determining effect on the disease course since among the 16 patients who died, 14 were HIV-positive (52%).

Background: Neonatal and/or congenital tuberculosis is insufficiently understood., Case Reports: Case 1. A premature hypotrophic neonate presented at the age of 45 days, without any maternal contact, a bilateral bronchopneumopathy. Whilst the pregnancy and birth had not been affected by any noteworthy problem, the mother died from miliary tuberculosis despite rifampin, isoniazid and pyrazinamide treatment. Her baby also died on day 52 from multivisceral failure. Culture of tracheal secretions confirmed a few weeks later the diagnosis of tuberculosis. Case 2. A premature, hypotrophic neonate presented on day 22 signs of respiratory distress (miliary), icterus and hepatosplenomegaly. Whilst the pregnancy and birth had not been affected by any particular problem, the mother, 18 days after giving birth, presented miliary and pleural tuberculosis. Despite treatment with rifampin, isoniazid and pyrazinamid started on day 22, the baby died on day 27 from multivisceral failure. The post-mortem liver biopsy confirmed the diagnosis of tuberculosis. Case 3. A baby born at term was hospitalized on day 4 for jaundice. Whilst the pregnancy and birth had not presented any problem, the mother developed a pleural tuberculosis on day 10. Breast-feeding was stopped. Due to the presence of opacities at the top of the right lung, the child was given rifampin, isioniazid, and pyrazinamide. The course was marked by the appearance of hepatomegaly and poor weight gain up to day 25, followed by an improvement., Conclusion: The frequency of congenital tuberculosis is probably under-estimated. Its early diagnosis is essential but often difficult as the initial manifestations are delayed. Improved screening of women at risk and sensitization of the medical community are necessary.

One hundred years after Yersin discovered Yersinia pestis during the plague epidemic in Hong Kong in 1894, human plague still has not been eliminated. The epidemic in 1994 in India, a country where no cases had been observed since 1996, raised great concern. Plague is an epizootic bacterial infection caused by a Gram negative coccobacillus, Y. pestis, transmitted by the bite of infected fleas. Bubonic plague is the most common form. Other clinical presentations include asymptomatic plague, abortive plague, pharyngeal plague, septicemic plague, meningeal plague, and primary or secondary pneumonic plague which is observed in 5 to 20% of cases. Plague is a highly communicable disease between humans despite antibiotic therapy which has reduced mortality by 80%. The prognosis depends on early diagnosis. Streptomycin and cyclines are the gold standard treatment.

The indicators used in the struggle against tuberculosis, particularly in developing countries, can be separated into two groups. First, the variables, are indicators of the overall damage caused by the disease in the community. Secondly, the parameters, are the calculated indicators of the risk for tuberculosis faced by the individual. Their presentation here follows the pragmatic concerns of the coordinators of the programs: evaluating the scale of the tuberculosis problem; ensuring its surveillance and the supervision of a prevention program; and diffusing the information required to stir the program workers and the population into action to fight tuberculosis. Among the variables, the incidence of mortality lost significance. The emphasis is now on the incidence of the new cases of contagious pulmonary tuberculosis as well as the calculation of the Annual Risk of Infection (ARI). The ARI, despite serious criticisms, remains one of the best indicators for the study of tuberculosis. The data obtained from an active program must be standardized to allow comparisons of the declared cases as well as their follow-up after the initiation of the treatment. The parameters enable a mathematical representation of the different stages in the natural development of the disease: the risk to be infected; the risk of becoming ill; and the development of the illness. These parameters can be advantageously used to mobilize the people into action. The pandemic of HIV drastically changed the natural history of tuberculosis. HIV infection is the most important factor of the transition from tuberculosis infection to active tuberculosis. The HIV pandemic also modified the epidemiological estimations of tuberculosis. In particular, it reinforced the criticisms made against the ARI. The surveillance of the prevalence of HIV among tuberculosis patients is thus important data.

In 1980, a 32 years-old Madagascan female developed a pulmonary tuberculosis, bacteriologically confirmed. She cured with right apical cavitary sequellae. In 1989, she presented haemoptysis again. Antituberculous treatment was adopted without bacteriological confirmation and did not improve clinical symptoms. In 1991 and 1992 cultures from sputa and bronchi aspiration yielded acid-fast bacilli identified as Mycobacterium shimoïdei. M. tuberculosis could not be detected. The patient died during treatment. This case is the fourth one in the literature. Whereas previous cases have been reported in Europe, Australia, Asia, this new case shows M. shimoïdei is also present in Africa.

The genetic polymorphism of the mycobacteria of the tuberculosis complex in the city of Antananarivo was studied on 126 strains isolated from positive microscopy pulmonary tuberculosis patients. The genetic profiles established using the RFLP technic and the IS6110 marker yielded 83 clusters of 1 to 29 strains. There were 34 strains with a IS6110 unique band profile of which 29 had a band located at 1.4-1.5 kb. These strains could be differentiated using a second marker, the DR marker. 3 strains with an unique IS6110 band located at 1.8-1.9 kb were identified as M. bovis. In general, there was no evident epidemiological relationship between the patients presenting with identical profiles. In the prison of Antananarivo, the IS6110 typing of 36 strains yielded 28 clusters of 1 to 3 strains. Excepting 2 clusters showing an internal contamination, the absence of profiles specific to the jail suggests that the patients were probably contaminated before their entrance. This preliminary study shows that the RFLP profiles of M. tuberculosis, using the IS6110 and the DR markers, were polymorphic enough for using this method to study the transmission in Antananarivo.

A 56 months retrospective study, from October 1990 to May 1995, at the Centre Hospitalier de Soavinandriana in Antananarivo pointed out 29 tuberculous pericarditis among the 97 pericardial effusions discovered by the echocardiography of 5600 patients. The sex-ratio was 0,81 and the mean age 38,6 years old (+/- 14,3). Hospitalization was justified by dyspnea (18 cases), thoracic pain (18 cases), lower limbs edema (6 cases) and ascitis (3 cases). Moreover, electrocardiography showed microvoltage in 18 cases and thoracic radiography showed one heart enlargement. Even if for 15 cases a pleural effusion was associated, only 2 patients had a pulmonary image suggestive of tuberculosis. Tuberculous pericarditis has been proved by the following examinations: pericardium puncture (21 cases), pericardium and pleural biopsy (respectively 11 and 13 cases), ganglionic biopsy and search of alcohol-acid-fast bacilli in sputum: 1 case. Histologic proof has been obtained 8 times out of 9 pericardial biopsies and 6 times out of 7 pleural biopsies. Bacteriological proof has been obtained 11 times by pathological samples cultivation: twice from fresh caseous material taken from the pericardium, once from 13 pleural fluids, 5 times from 6 pericardial biopsies, 3 times from 3 pleural biopsies. The patients have been put under antituberculous treatment associated with prednisone. 20 patients have been declared cured at the end of the treatment, 5 were dead and 4 were lost out of sight. Tuberculous pericarditis has become rare in developed countries but it is still challenging in Madagascar. In spite of the antituberculous treatment associated with corticoids, prognosis is severe (evolution towards pericardial constriction death.

A survey was undertaken in April 1993 to compare the respective benefits of 2 regimens containing either streptomycin (SHRZ) or ethambutol (EHRZ) in the first two months of treatment of smear-positive pulmonary tuberculosis in Madagascar. This operational research was justified by the risks related to the use of parenteral streptomycin in a country where single use material is rare and its purpose was to provide arguments for an eventual recommendation to replace this drug by oral ethambutol which is also less expensive. 907 patients were included. The compliance was not significantly different between the 2 groups, although it was traditionally assumed to be better with streptomycin. The frequency of side effects was significantly lower with EHRZ. Overall treatment failure rates were not significantly different, but all of 6 patients who were negative at 5 months and were again positive at 8 months had received EHRZ. This point obliged to be careful before concluding, because 24% of patients were lost for follow-up. A 2 years surveillance will be necessary to compare the frequency of recurrences.

The experience of a 51 months continuous action of tuberculosis control in a pneumophysiology department of an important general hospital which works according to the principle of cost recovery, is reported. This centre, with an average of 345 annual cases, is the third in Madagascar. During the studied period (from September 1989 to December 1993), 1418 tubercular patients have been diagnosed, distributed into 57.7% of pulmonary tuberculosis and 42.3% of extrapulmonary tuberculosis. The number of extrapulmonary tuberculosis is obviously higher than in the rest of the country structure (16%); among them, pleurisies are distinctly prevailing (present in 29.6% of tubercular patients), other serositis take an important place, immediately after peripheric adenopathies (101 cases that is to say 7.1%); the high proportion of laryngitis shows the importance and oldness of bacilli infected pulmonary lesions. 13.7% of the patients have two or more tubercular localizations. Bacteriological proof has been done for 97.3% of the pulmonary tuberculosis and 7% of the extrapulmonary tuberculosis. A certitude proof has globally been acquired for 82.5% of the patients. 97.9% of the sick started a treatment. 7% of death were noted (95 cases), two thirds of them during the first month after diagnosis and two thirds due to pulmonary tuberculosis with positive microscopy. The average recovery rate within the studied period was 68.2% for all patients without distinction; 67.6% (456/674) for pulmonary tuberculosis with positive microscopy and 76% (265/349) for pulmonary tuberculosis with positive microscopy among civil servants and equivalent. It has been noted that private persons who pay their medical expenses showed a significantly less good compliance (60.9% of recovery rate) than civil servants whose medical expenses are entirely refunded.

A group of 122 observations of pediatric tuberculosis has been studied. Nurslings represented 34% of the group, children under 8 years old 75% and only 10% were above 12. The sex ratio was 1,1. In a statistically significant way, tuberculous children were less often immunized by BCG than reference children not infected by tuberculosis. Contact has been traced back to close family in 42% of cases. Weight loss was significant at diagnosis time and after treatment the difference with the reference group disappeared. Extrapulmonary localizations were less frequent with children under 2, pulmonary and extrapulmonary localizations associations could be observed with 14% of children under 2 and with 31% of the whole children developing a proved tuberculosis. The importance of bronchial fibroscopy has been pointed out, for it allowed to detect 30% of abnormalities and to prove the diagnosis of tuberculous in 25% of cases. It is regrettable that the National Tuberculosis Control Programme did not prescribe chemoprophylaxis of contact children in its routine instructions, yet it is well known that child tuberculosis is rarely contagious and is not considered a priority by a programme. Finally, the authors reported that the number of pediatric tuberculosis managed in the country showed an obvious underestimation of the problem and they hope this work would lead to think more frequently of that diagnosis in the future.

In 1991, the National Tuberculosis Control Program could start in Madagascar, thanks to the financial support of the French Cooperation. Within 3 years, this allocation of resources allowed the management, respecting the new standards, of 56% of the country's health structures and of more than 75% of the sick. The number of detected and treated patients increased of 80%. During the same period, the recovery rate increased from less than 35% to more than 65%. Those primary results were satisfactory in terms of working but they were not enough in epidemiological terms as the aims were still far: the detection rate of smear-positive pulmonary tuberculosis was 40% whereas it ought be 60%, and their recovery rate was 65% whereas it ought to be over 80%. The geographic extension of the Program and its progress depend on a structural strengthening needing an obvious political will and on the intervention of financial partners cooperating with France and willing to set up a long lasting partnership.

Ever since its establishment in Madagascar, the Lutheran Church has been very active in medical field. In 1983, the creation of a medical non governmental organization called SALFA (Sampanasa Loteriana momba ny Fahasalamana) gave a new impulse. Since 1987, the SALFA has been seriously involved in the management of tuberculous patients. This document is a synthesis of actions conducted by SALFA whose experience in tuberculosis control is widely recognized by the Health Department and specially by the National Tuberculosis Control Program (NTCP). With an annual average of 1250 tuberculosis taken in charge, this NGO assumes 10% of the whole of the Program work. The diagnosis work is good (more than 85% Of PMT+) and therapeutic follow up of patients is excellent (more than 80% of the cured); those two elements of screening-treatment, basis of all tuberculosis control program incited us to describe this exemplary program.

The setting up of a new nationwide tuberculosis control programme allowed the creation of a National Mycobacteria Reference Laboratory. This latter originated from the small bacteriology laboratory of the antitubercular dispensary of the Institut d'Hygiène Sociale (IHS) and its activities increased tenfold within three years. Extension of rooms, a more numerous staff and the acquisition of a modern equipment explained those results. However, to carry out the tasks of such a laboratory a rapid modification of structures and a new job distribution facilitated by a cooperation with the Institut Pasteur de Madagascar are necessary.

Because of the known epidemiological links between tuberculosis and HIV infection in developing countries, a systematic study of HIV infection prevalence among tuberculous patients has been conducted since 1989 in some centres of the capital and extended to other towns in 1992. HIV infection prevalence is still low (<200/100,000) with tuberculous patients. This result must incite to continue the surveillance of the ineluctable growth of HIV prevalence and to strengthen the tuberculosis Program in anticipation of subsequent problems.

A 33 months retrospective study (from September 1992 to May 1995) of 8525 patients indicated that the incidence of histologic extrapulmonary tuberculosis (EPT) was 7,7%. The 8341 malagasy native patients presented an incidence of 7.8%. Male are more frequently infected than female. Most samples came from Antananarivo, with a prevalence reaching 12,5% while it was only 2,9% in the provinces. Most pathologic EPT were pleural tuberculosis (55,6%) and ganglial tuberculosis (34%). Peritoneal tuberculosis were much less frequent. According to literature data in Madagascar, the incidence of histologic EPT is obviously increasing.

This study briefly reports the results of a survey conducted by the National Tuberculosis Control Programme (NTCP) to asses the Catholic Centres and particularly the leper colonies activities of tuberculosis control. Among the 34 Catholic Centres taking care of the lepers, 11 take part in the NTCP. Within less than 3 years, most of these centres have taken charge of twice more tuberculous patients: the number of cases increased from 540 to 1045. Leprosy prevalence is constantly decreasing, thus multibacillary leprosy cases declared by these centres decreased of 28% from 1992, to 1994. Centres which did not begin conversion would feel this necessity soon. Germs responsible for leprosy and for tuberculosis are "first cousins". Technical and operational approaches for the control of both affections are very much alike. Those considerations logically induce to propose the conversion of antileprosy centres for tuberculosis control. Other arguments are partially exposed in this work. The Central Division knows the existence of 28 Catholic Centres throughout the country, taking charge of tuberculous patients. In 1994, they put more than 1600 patients under treatment, thus 15% of the tubercular in Madagascar. Those Catholic Centres implementing tuberculosis control programme ought set up a "federation" as a privileged interlocutor for the NTCP and for the financial backers when allowing support. Responsibles of the Programme expect to convince Centres of the necessity of conversion and of the interest of tuberculosis control.

Within 42 months, from June 1990 to December 1993, 454 cases of tuberculosis have been recorded in the central remand home of Antananarivo. The tubercular prevalence observed was there eight times superior to that of the global population of Madagascar. Among the 360 pulmonary tuberculosis, only one did not have any bacteriological proof; among the 94 extrapulmonary tuberculosis, 37 have been proved by histology or bacteriology. Among the extrapulmonary tuberculosis, pleurisies were obviously preeminent (79/94). Association of tubercular localizations could be observed with 21% of the patients. New cases of smear-positive pulmonary tuberculosis (PMT+) represented 81% of all the PMT+, recurrences were 9% and revivals 10%. Since February 1991, the 8 months short course regimen was the standard applied; before, the lack of stock did not allowed any standardization. The PMT+ new cases recovery rate increased from 42.5% in 1990 to 74% in 1993, whereas lethality decreased from 23% in 1990 to 8% in 1993. Patient dropouts were noted only with released or escaped individuals. Treatment failure rate was 4%. The diminution of cases despite the constancy of prisoners number and the carrying out of activities by the same health team make questionable the explanatory factors of the burst of tuberculosis-diseases in a prison milieu. Because of the importance of prison tubercular foci in terms of public health and the satisfactory results obtained, the Programme proposes to apply the model of partnership developed between the Tonga soa NGO and the prison administration to other prisons in Madagascar.

From September 1989 to December 1992, 49 patients had been observed at the Centre Hospitalier de Soavinandriana and 31 cases at the prison infirmary of Antananarivo from April 1990 to December 1992. The 31 laryngeal tuberculosis observed in prison existed among 9.1% of tubercular patients, were associated to 10.9% of pulmonary tuberculosis and represented 24.2% of extrapulmonary tuberculosis. The 49 laryngeal tuberculosis of the CENHOSOA were present among 4.6% of tubercular patients, were associated to 7.9% of pulmonary tuberculosis and represented 8.4% of all the extrapulmonary tubercular localizations. Voice disorders, even if always present, rarely represented (<30%) a reason for tuberculosis discovery. Comparison with the whole of tuberculosis cases showed that laryngitis was not most frequent in retreatments and that there was no statistically significant difference in death risk. Laryngeal tuberculosis being mostly in the shadow of pulmonary tuberculosis, it develops in the same way under the same treatment, except when a very ancient laryngitis has given rise to irreversible fiber lesions. Recall of this very early known localization is made in a didactic perspective: in a developing country, all chronical voice disorders must induce to research of tuberculosis.

In Madagascar, the estimated incidence of tuberculosis is high (320 per 100,000) when human immunodeficiency virus (VIH) infection progress slowly. The authors have studied HIV seroprevalence in a group of tubercular patients and in two reference groups (general population and outpatients of the Clinical Biology Centre of Institut Pasteur). Circulation of HIV1 virus was observed with a low prevalence rate in all the 3 groups. There was no significant difference between tubercular patients and healthy population. Tubercular people ought to be a watch group for the epidemiological surveillance of HIV infection evolution in Madagascar.

The authors have conducted a retrospective study of 200 cases of tuberculous spondylitis, and wish to draw attention to the clinical and, chiefly, radiological aspects of the disease. Intrathoracic Pott's abscesses are principally observed in developing countries but they are not exceptional in France, and their varied semeiology deserves to be described.

The authors report a case of pulmonary tuberculosis appearing after an endobronchial fistula from a Pott's abscess. Such a clinical presentation is rare even in a developing country (PVD), where there is experience of more than 200 cases of tuberculous spondylodiscitis seen over a period of six years. The frequency of paravertebral abscess during the course of Pott's disease is around 52%, in the thoracic lesion their exteriorization by endobronchial fistula is around 4% (5 out of 114). The outcome is generally more simple and here a cure was achieved after six months of chemotherapy.

One hundred and fifty-nine cases of confirmed mediastinal tuberculous adenopathy were analysed retrospectively. This series, which is the first reported in French-speaking Africa, shows that the disease is not uncommon there, and not restricted to black Africans living in Europe. The clinical symptoms are not specific. Radiography is more interesting, and the extreme scarcity of bacillys-containing expectoration encourages endoscopy. The finding of a fistula at fibroscopy confirms the diagnosis. This easy examination is particularly useful since M. tuberculosis can be grown in cultures from ground bronchial fistula biopsies in 86% of the cases. Associated tuberculous lesions in other sites are very frequent (45%), as is extension of the disease from lymph nodes to lung tissue (79%). This clinical form of tuberculosis can be treated with modern short course chemotherapy which is remarkably effective.

In an 18-year old male patient a large cavity of the right upper lobe was occupied first by a tuberculous sequestration, then 2 years later, by a fungus ball. This case shows that the so-called "sleigh-bell" image is not pathognomic of aspergilloma and that this disease is far from being exceptional in Africa.

The authors report 3 cases of intrabronchial fistulisation of paravertebral abscesses due to tuberculous spondylitis of the thoracic spine. This complication is relatively rare (these 3 cases were in a series of 178 cases of Pott's disease) and is easy to diagnose due to its characteristic radio-clinical features. As mentioned in old publications, this type of fistulisation does not seem to have serious consequences. There are no particular aspects of treatment.

153 well documented records, gathered in one year in a Tuberculosis Center, were studied. Adenoid localization represents on fourth of all tuberculosis, and 95% of all etiologies of peripheral adenopathies. Value of bacteriological tests is studied and compared to the one of histology. The almost sole presence of Mycobacterium tuberculosis hominis is an uncommon datum, interesting in the field of epidemiology. The recorded outstanding efficacy of modern anti-tuberculosis drugs is less known, perhaps because of scarcity of recent works on such localizations. Some easy and reliable guidance is proposed within the context of a Communicable Diseases Program.

15 cases of human trypanosomiasis are reported. The patients did not travel previously through endemic areas, but all of them have stayed for a long duration in the Ouahigouya district lazaret. Never glossina were found in this district. This is suggesting a non conventional way of contamination, most likely mecanical transmission by hematophagous arthropodes. After COULM and FREZIL, the authors also raise the question of the importance of this possible mode of transmission in sleeping disease epidemiology.

The authors report 4 cases of round atelectasis seen over a period of 3 years. They review the very limited literature on this subject. In the light of their experience and according to the work of Hanke, they believe this to be a fairly common disease. This condition was first described during collapsotherapy, but now, it is essentially seen following pleurisy. For Hanke, round atelectasis may occur in almost one quarter of cases of pleural effusion. The authors also believe that this condition is common and that it is usually confused with or grouped together with "pleural sequelae". However, their original mechanism of formation, the reversible parenchymal involvement, and not pleural, and their radiological appearance clearly distinguish them. Round atelectasis is an interesting topic of discussion in terms of diagnosis, in the broad framework of round intrathoracic opacities (especially when the initial pleural episode has not been recognized) and also in terms of treatment, which consists of decortication when they are large.

The authors studied 198 strains of mycobacteriae from different sources, but mainly from bronchial secretion and adenoid pus or poundings. Because the preponderance of peripheral adenoid tuberculosis, we might fear a focus of Mycobacterium bovis. But this study gives leave to state positively that Mycobacterium tuberculosis hominis is almost exclusively the responsible and consequent by that there is an human reservoir almost exclusive. On the other hand, study of primary and secondary resistances to anti-bacillary drugs leads to express some concern particularly vis a vis modern treatments utilized as a matter of routine.

One case of unilateral pulmonary oedema a vacuo is reported and the 38 cases published in the literature are reviewed. Contributing factors are essential, the main ones being the duration and severity of lung collapse and the rate of reexpansion. The clinical signs and symptoms are described, together with the various possible courses of the disease, and the severity factors are deduced from 8 lethal cases. A therapeutic approach is proposed but not formalised, since pathophysiological data are still scarce.