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Mendrika Fifaliana Rakotoarisaona,1,* Tsiory Iarintsoa Razafimaharo,2,* Fandresena Arilala Sendrasoa,2,* Malalaniaina Andrianarison,1,* Naina Harinjara Razanakoto,3,* Volatantely Tobiniaina Ratovonjanahary,2,* Onivola Raharolahy,2,* Irina Mamisoa Ranaivo,4 Lala Soavina Ramarozatovo,1 Fahafahantsoa Rapelanoro Rabenja1 1Department of Dermatology, University Hospital of Analakely, Antananarivo, Madagascar; 2Department of Dermatology, University of Befelatanana, Antananarivo, Madagascar; 3Department of Dermatology, University Hospital of Mahavoky Antsimo, Mahajanga, Madagascar; 4Department of Dermatology, University Hospital of Morafeno, Tamatavy, Madagascar*These authors contributed equally to this workCorrespondence: Mendrika Fifaliana Rakotoarisaona, Department of Dermatology, University Hospital of Analakely, Antananarivo, 101, Madagascar, Tel +261 34 61 947 34, Email lulubslj@gmail.comBackground: Leprosy and tuberculosis are two of the oldest and most common mycobacterial infections, caused by Mycobacterium leprae and Mycobacteium lepramatosis for leprosy and Mycobacterium tuberculosis for tuberculosis. Dual infections have been known since ancient times; however, cases remain rarely reported in the literature, even in countries where both diseases are endemic, such as Madagascar.Purpose: We report a case series of simultaneous occurrence of leprosy and tuberculosis.Patients and Methods: In this retrospective study, we reviewed the medical records of patients with leprosy registered at the Department of Dermatology, University Hospital Befelatanana, Antananarivo, Madagascar, between January 2012 and June 2021. Patients with leprosy and diagnosed as coinfected by tuberculosis were included in the study.Results: Of the 120 leprosy cases observed during the study period, coinfection with leprosy and tuberculosis was found in five patients. The mean age was 43.4 (SD 13.2) ranging, 21– 59 years. Male gender was predominant (4/5). Four patients presented with lepromatous leprosy, and one with borderline lepromatous leprosy. Three patients experienced leprosy reaction. Four cases of pulmonary tuberculosis and one case of multifocal tuberculosis were observed. The diagnosis of leprosy preceded tuberculosis in four cases, and a coinfection diagnosis was made simultaneously in one case. The average time to develop tuberculosis was 38.8 (SD 10.2) months. HIV infection, malnutrition, alcohol consumption, and long-term corticosteroid therapy were the immunosuppressive factors reported in our patients. Three patients received concomitant multidrug therapy for leprosy and tuberculosis.Conclusion: Dermatologists should be aware of the importance of screening patients affected by leprosy for latent or active tuberculosis to prevent morbidity and mortality due to coinfection and to reduce the risk of acquired resistance to rifampicin, which is the greatest risk of this association.Keywords: Madagascar, Mycobacterium leprae, rifampicin

Mendrika Fifaliana Rakotoarisaona,1 Tsiory Irintsoa Razafimaharo,1 Naina Harinjara Razanakoto,1 Fandresena Arilala Sendrasoa,1 Anne Ducournau,2 Christine Devalland,3 Anne-Sophie Dupond,2 Irina Mamisoa Ranaivo,4 Lala Soavina Ramarozatovo,1 Fahafahantsoa Rapelanoro Rabenja1 1Department of Dermatology, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar; 2Department of Dermatology, Nord Franche-Comté Hospital, Trevenans, France; 3Department of Pathology, Nord Franche-Comté Hospital, Trevenans, France; 4Department of Dermatology, University Hospital Morafeno, Toamasina, MadagascarCorrespondence: Mendrika Fifaliana Rakotoarisaona, Department of Dermatology, University Hospital Joseph Raseta Befelatanana, Rue Dr Davioud Jacques, Antananarivo, 101, Madagascar, Tel/Fax +261 34 61947 34, Email lulubslj@gmail.comIntroduction: Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease. Neoplastic and infectious etiologies must be ruled out. IGM is a diagnostic challenge for countries with high tuberculosis endemicity like Madagascar since it may clinically and radiologically mimic breast tuberculosis. We report a case of IGM associated with erythema nodosum in a Malagasy.Case Report: A 29-year-old primiparous woman came to a dermatological consultation for typical erythema nodosum lesions that appeared one month after a breast swelling. She had no particular medical history. Examination revealed typical erythema nodosum lesions on the legs, voluminous tender mass in the right breast. Bacteriological samples and tuberculosis test were negative. Imaging showed mastitis on the right breast with no evidence of malignancy. Histology revealed a non-caseating granulomas on the lobule of the right breast. As part of an etiological work-up, COVID-19 serology was performed with a positive IgG antibody. The diagnosis of IGM associated with erythema nodosum was evocated. The evolution was favorable under systemic corticosteroid therapy.Discussion: The cause of this uncommon lesion remains obscure. The extramammary localizations such as erythema nodosum and arthralgia suggest an autoimmune origin. This pathogenesis is also reinforced by a good response to systemic immunosuppression. In our patient, the etiological assessment of the mastitis revealed a chronic infection with SARS-CoV-2. Histopathology is the gold standard for the IGM diagnosis which demonstrates a lobulocentric granulomas without caseous necrosis. Oral corticosteroid therapy is the initial choice of treatment.Conclusion: Now, with several cases of concomitant IGM and EN reported, dermatologists should be aware that erythema nodosum can be one of the presenting signs of IGM, since the two conditions appear to be associated. The particularity of our case lies in the incidental discovery of SARS-CoV-2 infection. Is a chronic granulomatous disease associated with SARS-CoV-2 infection, a coincidence?Keywords: corticosteroid, erythema nodosum, granulomatous mastitis, Madagascar

Fandresena Arilala Sendrasoa, Tsiory Iarintsoa Razafimaharo, Samson Leophonte Ramily, Lala Soavina Ramarozatovo, Fahafahantsoa Rapelanoro Rabenja Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, 101, MadagascarCorrespondence: Fandresena Arilala SendrasoaDepartment of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, 101, Madagascar, Email nasendrefa@yahoo.frAbstract: The treatment of parotid hemangiomas has posed a challenge. A male infant presented with large hemangioma of the right parotid gland diagnosed at the age of 3 months. Starting at the age of 4 months, he was treated with oral propranolol for 10 months, which led to a marked reduction in tumor size and strawberry hemangioma. Our case shows that propranolol is effective and safe in treating large parotid infantile hemangioma.Keywords: large parotid hemangioma, propranolol, infantile

Fandresena Arilala Sendrasoa, Irina Mamisoa Ranaivo, Arifetraniaina Julia Raherivelo, Fahafahantsoa Rapelanoro Rabenja, Lala Soavina Ramarozatovo Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, MadagascarCorrespondence: Fandresena Arilala SendrasoaDepartment of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, MadagascarEmail nasendrefa@yahoo.frBackground: Long-term oral corticosteroids have an important role in dermatological care in Madagascar. However, significant adverse effects have been associated with continuous exposure to oral corticosteroids.Objective: We aim to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology at the University Hospital Joseph Raseta Befelatanana Antananarivo (UH/JRB), Madagascar, and to identify the risk factors associated with these adverse effects.Methods: A cross-sectional study was conducted during 4 months to assess the adverse effects of long-term corticosteroid therapy in patients seen in the Department of Dermatology. Patients treated with oral corticosteroids for more than 3 months were included in our study.Results: The prevalence of long-term use of oral corticosteroids in the Department of Dermatology of UH/JRB was 34.28%. A total of 51 patients were included and adverse effects occurred in 64.70% of this population. Repetitive infections and cutaneous adverse reactions were the most frequent adverse effects, in 23.52% and 11.76% of cases, respectively. There were no correlations between age, gender, type of disease treated, the molecule used or daily dose and the risk of adverse effects. Patients who received a corticosteroid dose of more than 40 mg daily (longer than 3 months) or a high cumulative dose of corticosteroids had a high risk of adverse effects.Conclusion: Repetitive infections and cutaneous adverse reactions are the most frequent adverse effects of long-term oral corticosteroid use. Prescribing the lowest effective dose may reduce the risk of these adverse effects. Furthermore, prevention of the adverse effects of corticosteroids through diet, calcium and vitamin D supplementation is strongly recommended during long-term oral corticosteroid therapy.Keywords: oral corticosteroids, repetitive infections, cutaneous adverse reactions, high dose

Fandresena Arilala Sendrasoa, Volatantely Tobiniaina Ratovonjanahary, Naina Harinjara Razanakoto, Mendrika Fifaliana Rakotoarisaona, Onivola Raharolahy, Malalaniaina Andrianarison, Irina Mamisoa Ranaivo, Viviane Estelle Mbotinirina, Moril Sata, Lala Soavina Ramarozatovo, Fahafahantsoa Rapelanoro Rabenja Department of Dermatology, Faculty of Medicine, University of Antananarivo, Antananarivo, MadagascarCorrespondence: Fandresena Arilala SendrasoaDepartment of Dermatology, Faculty of Medicine Antananarivo, Antananarivo 101, MadagascarTel +261 341420496Email nasendrefa@yahoo.frBackground: Several studies have been done to evaluate the relationship between month of birth and atopic diseases but the results are contradictory.Objective: We aim to evaluate the correlation between the month of birth and the prevalence of AD in Malagasy children less than 3 years.Methods: A case-control study was conducted based on patients’ data of the department of Dermatology in the University Hospital Joseph Raseta Befelatanana (UH/JRB) Antananarivo. It included 438 children less than 3 years seen in this department between January 2010 and December 2019. For each atopic dermatitis (AD) patient, two age-and sex-matched controls without a history of AD were selected from the same period.Results: This study included 146 AD cases and 292 non-AD controls. Our case-control study found that there is a statistically significant correlation between birth month and risk of AD in Malagasy children < 3 years. Compared with people born in December, people born in April had the highest risk of AD (OR: 2.11, 95% CI 0.93– 4.78), followed by people born in March (OR: 1.52, 95% CI 0.79– 2,88). Asthma, allergic rhinitis and allergic conjunctivitis were significantly correlated with AD in our patients.Conclusion: Our case-control study found that being born in April and March (dry season) may be associated with an increased risk of AD.Keywords: birth month, atopic dermatitis, children, Madagascar

Fandresena A Sendrasoa, Irina M Ranaivo, Naina H Razanakoto, Malalaniaina Andrianarison, Lala S Ramarozatovo, F Rapelanoro Rabenja Department of Dermatology, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar Abstract: Infantile hemangiomas are the most common vascular neoplasm that present in infancy, with more than half affecting the head and neck region. Periocularly, hemangiomas may be complicated by visual loss through induction of strabismal, deprivational, or anisometropic astigmatism. We report a case of a 5-year-old girl who presented with orbital hemangioma with potential risk of visual loss who had excellent response to propranolol. Keywords: hemangioma, orbital, propranolol

Chromoblastomycosis is an implantation fungal infection. Twenty years ago, Madagascar was recognized as the leading focus of this disease. We recruited patients in Madagascar who had chronic subcutaneous lesions suggestive of dermatomycosis during March 2013-June 2017. Chromoblastomycosis was diagnosed in 50 (33.8%) of 148 patients. The highest prevalence was in northeastern (1.47 cases/100,000 persons) and southern (0.8 cases/100,000 persons) Madagascar. Patients with chromoblastomycosis were older (47.9 years) than those without (37.5 years) (p = 0.0005). Chromoblastomycosis was 3 times more likely to consist of leg lesions (p = 0.003). Molecular analysis identified Fonsecaea nubica in 23 cases and Cladophialophora carrionii in 7 cases. Of 27 patients who underwent follow-up testing, none were completely cured. We highlight the persistence of a high level of chromoblastomycosis endemicity, which was even greater at some locations than 20 years ago. We used molecular tools to identify the Fonsecaea sp. strains isolated from patients as F. nubica.

Human settlement of Madagascar traces back to the beginning of the first millennium with the arrival of Austronesians from Southeast Asia, followed by migrations from Africa and the Middle East. Remains of these different cultural, genetic, and linguistic legacies are still present in Madagascar and other islands of the Indian Ocean. The close relationship between human migration and the introduction and spread of infectious diseases, a well-documented phenomenon, is particularly evident for the causative agent of leprosy, Mycobacterium leprae . In this study, we used whole-genome sequencing (WGS) and molecular dating to characterize the genetic background and retrace the origin of the M. leprae strains circulating in Madagascar ( n = 30) and the Comoros ( n = 3), two islands where leprosy is still considered a public health problem and monitored as part of a drug resistance surveillance program. Most M. leprae strains (97%) from Madagascar and Comoros belonged to a new genotype as part of branch 1, closely related to single nucleotide polymorphism (SNP) type 1D, named 1D-Malagasy. Other strains belonged to the genotype 1A (3%). We sequenced 39 strains from nine other countries, which, together with previously published genomes, amounted to 242 genomes that were used for molecular dating. Specific SNP markers for the new 1D-Malagasy genotype were used to screen samples from 11 countries and revealed this genotype to be restricted to Madagascar, with the sole exception being a strain from Malawi. The overall analysis thus ruled out a possible introduction of leprosy by the Austronesian settlers and suggests a later origin from East Africa, the Middle East, or South Asia., (Copyright © 2020 Avanzi, Lécorché, Rakotomalala, Benjak, Rapelanoro Rabenja, Ramarozatovo, Cauchoix, Rakoto-Andrianarivelo, Tió-Coma, Leal-Calvo, Busso, Boy-Röttger, Chauffour, Rasamoelina, Andrianarison, Sendrasoa, Spencer, Singh, Dashatwar, Narang, Berland, Jarlier, Salgado, Moraes, Geluk, Randrianantoandro, Cambau and Cole.)

Sporotrichosis is a saprozoonotic fungal infection found mostly in tropical and subtropical areas. Few case reports in Madagascar have been published. To document sporotrichosis epidemiology in Madagascar, we conducted a cross-sectional study. During March 2013-June 2017, we recruited from select hospitals in Madagascar patients with chronic cutaneous lesions suggestive of dermatomycosis. Sporotrichosis was diagnosed for 63 (42.5%) of 148 patients. All but 1 patient came from the central highlands, where the prevalence was 0.21 cases/100,000 inhabitants. Frequency was high (64.7%) among patients <18 years of age. Sporotrichosis was diagnosed for 73.8% of patients with arm lesions, 32.3% with leg lesions, and 15.4% with lesions at other sites. Molecular identification identified 53 Sporothrix schenckii isolates. Among the 32 patients who were followed up, response to itraconazole was complete or major for 15 and minor for 17. Overall, endemicity of sporotrichosis in Madagascar was high, concentrated in the highlands.