African Journal of Neurological Sciences Pan African Association of Neurological Sciences ISSN: 1015-8618 Vol. 16, Num. 2, 1997

Andriantseheno L.M., Andrianasy T.F.

Department of Neuropsychiatry, University Hospital, Mahajanga, Madagascar.

Hospital-based data on neurological disorders from Mahajanga, the Northwestern province of Madagascar are reported.

Epilepsies (28.75% of cases), chronic headaches (20.95%), peripheral neuropathies (13.75%) and stroke (11.30%) are the commonest illnesses encountered. Unlike western series, degenerative diseases and multiple sclerosis are infrequent. The major risk factors (communicable diseases, malnutritions, poverty-induced stresses) and some aspects of the health care (lack of essential neurodiagnosis facilities and drugs) are shared with other developing tropical countries.

Les auteurs rapportent les donnees hospitalieres sur les troubles neurologiques rencontres a Mahajanga, province occupant la partie Nord-ouest de Madagascar. Les epilepsies (28,75% des cas), les cephalees chroniques (20,95%), les neuropathies peripheriques (11,30%) constituent les affections les plus frequemtes. Contrairement aux statistiques occidentales, les maladies degeneratives et la solerose en plaques sont rares.

Les principaux facteurs de risque (maladies transmissibles, manultrition, stress provoques par la pauvrete) et quelques aspects des realites sanitaires (manque d'equipments de diagnostic et de medicaments fondamentaux) sont partages avec d'autres pays tropicaux en voie de developpement.

Tropical countries share common climatic and biologic characteristics. They are thus expected to disclose similar patterns of diseases. However, the prevalence of these diseases vary because of the development and of the sociocultural peculiarities of each country. Population-based studies, the most appropriate ones to assess the magnitude of each health problem are unavailable in Madagascar. We report hospital data from Mahajanga, a Northwestem region of the island.

The study population was expected to be that of the whole province (1,379,000 inhabitants), but in fact, only the population of the city of Mahajanga and its nearest surroundings (up to 200,000 inhabitants) had access to the University hospital.

The population was young (44<15 years-old, only 3,2%>65 years-old), with an isosexual repartition expectancy (52 years vs 69 years for Mauritius) [1]. A considerable proportion of Mahajanga city dwellers have an Islamic influence, expressed in prohibitory eating behaviours (pork, alcoholic, drinks). The region has a hot and dry climate where malaria, schistosomiasis tuberculosis and syphilis are endemic.

The study itself consisted in a retrospective exam of registered inpatients and outpatients files in the department of Neuropsychiatry (University Hospital) between June 1, 1993 and December 31, 1995. Patients of both sexes, aged more than one year-old were included.

Electrical devices (EEG,EMG), cerebral imageries (CT scan, MRI), and sophisticated biological investigations were unavailable, so the diagnosis was built up on sole clinical and routine laboratory data. In fact, the most conclusive argument was the radical cure or alleviation of symptoms. The claSsification of the diseases was made according to internationally. recognised definitions (NINDS, IHS, ILAE, ICD 10).

1161 patients were registered during the study period: 741 had neurological disorders, 334 had psychiatric disorders, 86 had non neuropsychiatric diseases (table 1).

Epileptic seizures were listed in table .3: their classification, according to the 1981 ICE version was possible in spite of EEG data unavailability. Some authorities have admitted the validity of such classification (2,3). Like in most of tropical regions (3,4,5), partial seizures were predominant whereas absence seizures

Outpatients represented 68,42% of cases (n=507), and inpatients 31,58% of cases (n=234). Epilepsies were followed by chronic headaches, which were selectively recruited among outpatients..Cerebrovascular diseases occupied the second place among inpatients; the real magnitude of this affection might be underevaluated, because of parallel recruitment in other wards. Unlike series from industrialised countries, degenerative diseases were rare. Peripheral neuropathies were common, whereas spastic paraparesis were of a minor concern. Two per cent (2%) of neuropathies (15/741 ) were inclassifiable because of the lack of specific investigations.

were underrated (1% vs 10% for GASTAUT's [6]. Among the epilepsies which were deemed as secondary (56%=119/213), a putative aetiology was found in only 54% of them (64/119). Neurocystcercosis was the commonest pathology involved (42% of the aetiologies, i.e. 27/64).

Phenobarbital was the drug of first choice (94% of the prescriptions). The other antiepileptic drugs were either unavailable, or too expensive.

Chronic headaches were dominated by migraine (table 4); tension headaches were unexpectedly rare.' Many physicians were still unfamiliar with migraine, as judged by the non negligible rate of diagnosis wanderings (spasmophilia, ocular dsyfunctions, sinusitis), and maladjusted prescriptions (preventive treatment prescribed for one month.). Long term management of migraine suffered from the same bad compliance than that encountered in epilepsies; the main reasons were unavailability or cost inaccessibility (in percentage).

The aetiology investigations and the classification of neuropathies (table 5) were limited by the lack of diagnosis facilities (EMG, nerve conduction studies, specific biologic dosages). The main putative cause asserted was polyvitamins deficiency (26% of cases, ie 27/102) within the frame of global malnutrition or alcoholism.

Heavy deficiency sufferers (e.g prisoners) sometimes disclosed a proximal hindlimbs involvement. Three cases were associated with heart failure (wet beriberi). Radicular compressions (mainly of the sciatic type) were surprisingly overrepresented in our series, whereas facial nerve palsy was unfrequent (8,82% of cases). Unlike some African countries (7), no HIV-related palsies were encountered. Mahajanga has a leprosarium, so only a typical manifestations of this infectious disease were addressed in our department (2,94% of cases).

Table 5

Like in the majority of Caucasian (8) and African studies (9,10), strokes were dominated by the ischemic type (table 6).

Hypertensive encephalopathy was screened with accuracy because of its better therapeutic issue. Hypertension and syphilis were the main risk factors identified. The global fatality rate was high (58% of cases, i.e. 48/83). Neurosisticercosis was at the head of CNS infections (table 7), although the anatomical specimen prevalence of this Parasitosis (11) was among the lowest in Mahajanga(6% vs 40% for Antananarivo, 32% for Tulear, 15% for Fianarantsoa). Diagnosis was madeon sole clinical and serological basis (12); in fact,the therapeutic trial remained the most conclusiveargument. Bacterial infections of the cerebrum andits coverings were surely underestimated becauseof parallel recruitments.

Table 7 - Frequency of CNS infections

(in percentage)

Intrathecal antibiotics were often useful to palliate the dose inadequacy of parenteral drugs. Celebral malaria, like in the other underdeveloped countries (13), provided a high fatality-rate (26% of cases, ie 4/15), because of delayed chemotherapy. Neither HIV carriers nor proved quinine resistance was encountered among our fatal cases. Among degenerative affections, Parkinsoffs disease was the most frequent. Parkinsonism related to chronic use of neuroleptics was far commoner. Alzheimer-type dementia was not yet a public health problem.

The data from Mahajanga, globally display the same patterns of neurological diseases as those found in the majority of tropical regions. In spite of the lack of population-based studies, the leading position of epilepsies among our hospital-registered cases confirm their importance in public health. The predominance of partial seizure parallels the high rate of secondary epilepsies. However, their pattern is not homogenous in different tropical countries: Nigerian studies (4) emphasize the causative role of febrile convulsions to explain the higher rate of complex partial seizures; on the contrary, Indian studies (5) yield a higher rate of partial simple seizures (58% of cases) and credit the prominent role of CNS infections, amongst which neurocysticercosis is paramount. Our pattern is of the Indian type (table 3) and this parasitosis, really plays an important role. Additional studies on risk factors, appropriate drug supply (14/15) and pertinent education of the population, are the most adapted means to fight against epilepsies.

Concerning chronic headaches, post graduate training is needed to improve the diagnosis and the management of the main aetiologic forms, viz migraine and headaches of psychological origin. Drugs availability and cost must be taken into account in case of long term treatment; patients' compliance depend on these extramedical factors. Traditional pharmacopoeia (16) and alternative medicine (17) are optional or complementary issues for developing countries, but their use must be regulated. Peripheral neuropathies are probably underrated, for a bulk of patients to the hospital recruitment; the reasons may be a self management with vitamins and plants, geographical isolation and so on. The endowment of essential facilities (EMG, nerve conduction measurement, biological dosages) will enrich the knowledge about these diseases, common in tropical countries; certain aetiologies are likely different from those encountered in Western regions.

Massive polyvitamins deficiency is frequent among prisoners. Associated with a major protein calorie malnutrition it can provoke both axonal and segmental demyelination (18); this latter may explain the involvement of proximal hind-limbs in many patients. It is surprising to detect HTL V 1 among Malagasy patients, for the Seychelles, which share the same climatic, ecological, and even cultural characteristics with Madagascar, are considered as endemic areas (19).

The surprising high rate of nerve sciatic compression results likely on local inadequacy In professional training: indeed, Mahajanga is a port, and naive load handlers are recruited without any technical skill learning. However, lumbar disk prolapse is considered as a rather rare condition in Africans (20). Although the proportion of our stroke cases represent only one-third of those reported in the majority of African hospital-based studies (9, 10,21,22), they constitute a real human and economic burden; the laak of appropriate diagnosis and therapeutic supplies may explain the high mortality rate, and the worse functional prognosis.

Global campaign against hypertension, the main risk factor, has proved to be an efficient method to decrease the secular trend of strokes (23,24). The infection of the CNS are by far the most important causes of mortality and mobidity in many African countries (25). Our data, probably underestimate their real importance, because of parallel recruitments. The prognosis is often worsened by the delayed management and by the incapacity in identifying and treating adequately the infectious agent. Like in other African series, degenerative diseases are rare, independently of the low life expectancy (26). Before concluding on a case of Alzheimer's disease, tertiary syphilis and major depression must be ruled out.

The patterns of neurological diseases in Mahajanga (Madagascar) are globally similar to that of the majority of tropical countries. A descriptive epidemiological survey on general population and epidemiological research on risk factors are basic to build up an appropriate preventive policy. Without an endowment of essential diagnosis facilities (EEG, EMG, Echography) and drugs, curative care would be inefficatious; this failure will reinforce the negative attitude of the population towards Western medicine and favour the action of quacks.

1. ANDRIAMBAO DS and the << VC 101 >> study group, TEHINDRAZANARIVELO AD, ANDRIAMANTSIETIBENJA J J, TSANGANDRAZANA. Incidence and mortality of stroke in Antananarivo, Madagascar, XIIth Congress of the Pan African Association of Neurological Sciences, DURBAN, South Africa, May 1996.

3. BWALA SA. Stroke in a subsaharian Nigerian hospital: a retrospective study. TROP DOCT 1989;19:11-14.

4. CHELLI S., CHELLI M. Approche epidemiologique des accidents vasculaires cerebraux. MAGHREB MED 1985; 109:26-31.

5. CHOPRA JS, DHAD UK, METHA S et al. Effect of protein calorie malnutrition on peripheral nerves. BRAIN 1986; 109:3 07.

6. COMMISSION OF EPIDEMIOLOGY AND PROGNOSIS OF THE INTERNATIONAL LEAGUE AGAINST EPILEPSY. Relationship between Epilepsy and Tropical diseases. EPILEPSIA 1994;35(1):89-93.

7. COMMISSION ON EPIDEMIOLOGY AND PROGNOSIS OF THE INTERNATIONAL LEAGUE AGAINST EPILEPSY. Guidelines for epidemiologic studies on Epilepsy EPILEPSIA 1994; 34(4): 592-596.

8. COMMISSION ON CLASSIFICATION AND TERMINOLOGY OF THE INTERNATIONAL LEAGUE AGAINST EPILEPSY. Proposal for revised Classification and EEG. Classification of epileptic seizure. EPILEPSIA 1981;22:489-501.

9. COSNET JE, BILL PL. Parkinson's disease in Blacks. Observations on epidemiology in Natal. SOUTHAFR MED J. 1988.73:281-83.

10. DANESI MA. Classification of the Epilepsies: an investigation of 945 patients in a developing country. EPILEPSIA 1985 ;26(2): 131 - 136.

11. DUMAS M, GIRAND PL, N'DIAYE IP, COLLOMB H. Accidents vasculaires cerebraux au Senegal. BULL SOC MED A FR NOIRELANG FR 1973;18(3):265-277.

12. Editorial. In the shadow of epilepsy. THE LANCET June 28 1997; vol 349(9069):1851.

13. ENDESHAW Y, TEKLEMAINOT R. Altered rate of consciousness in adult Ethiopian. analysis of aetiological factors. J ROYAL SOC HEALTH 1988;5:173-175.

14. GASTAUT H, GASTAUT JL, CONCALVES C et al. Relative frequency of different types of epilepsy: a study employing the Classification of the International League against Epilepsy. EPILEPSIA 1975;16:457467.

15. GIORNADO C, PIQUEMAL M, N'DZANGA E. Factuers de rique et frequence des infractus cerebraux chez le Noir African de l'Ouest. MED & ARMEES 1979;7((4):3 5 5-3 5 8.

16. HADDOCK DRW. Cerebrovascular accidents in Ghana. TR/INS R. SOC TROP MED HYG. 1970;64:300-310.

17. JOSHI V, KATIYAR BC, MOHAN PK et al. Profile of epilepsy in a developing country: a study of 1,000 patients based on the International League against Epilepsy. EPILEPSIA 1977; 18:549-554.

18. LI S, SCHOENBERG BS, CHUNGCHENG W, et al. Epidemiology of epilepsy in urban areas of the People's Republic of China. EPILEPSI.41985;26:391-394.

19. NIKIFOROW. Headache in a random sample of 200 persons: a clinical study of a population in Northern Finland. CEPHALALGIA 1981;1:97-107.

20. OSUNTOKUN BO. Neurological disorders in Nigeria. In: SPILLANE TD ed: TROPICAL NEUROLOGY Oxford University Press, London 1973:161-190.

21. PLACENTA M., SANDER JWAS, ROMAN M et al. The characteristics of epilepsy in a largely untreated population in rural Ecuador. J NEUROL NEUROSURG PSYCHIATRY 1994;57:320-325.

22. PROJECT PNUD/OPS, MAG/89/018. Regions et developpement: MAHAJANGA, DIRASSET ed 1991.

23. RASMUSSEN BK, JENSEN R, SCHROLL M, OLESEN J. Epidemiology of headache in a general population: a prevalence study. J CLIN EPIDEMIOL 1991;44:1147-1157.

24. ROMAN GC, SCHOENBERG BS, MADDEN DL et al. Human-T lymphotropic virus type 1 antibodies in the serum of patients with tropical spastic paraparesis in the Seychelles. ARCH NEUROL 1987;44:605-607.

25. SENANAYAKE N. Classification of epileptic seizures: a hospital-based study of 1,250 patients in a developing country. EPILEPSIA 1993 ;34(5):812-818.

26. SCHOENBERG BS, KOKMEN E, OKAZAKI H. Alzheimer's disease and other dementing illnesses in a defined United States population: incidence rates and clinical features. ARCH NEUROL 1978;27-72.

27. SCHOENBERG BS, OSUNTOKUN BO, ADEUJA AO et al. Comparison of the prevalence of Parkinsoffs disease in Black population in the rural US and in rural Nigeria: door-to-door Community studies. NEUROLOGY 1988;38:645-646.

28. TEKLE-HAIMANOT R. Parkinsons disease in Ethiopia: a prospective study of 70 patients. EAST.AFR MED J. 1985;62:571-579.

29. VERNANT JC, MAURS L, GESSAINA et al. Endemic tropical spastic paraparesis associated with HTLV 1: a clinical and sero-epidemiological study of 25 cases.ANN NEUROL 1987; 21:123-130.

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