Systemic Diseases in Dakar ( Senegal ) : Spectrum , Epidemiological Aspect and Diagnostic Time-Limit

Introduction: Systemic diseases have been the subject of few studies in the African literature and have probably been under-estimated. The objective of our study was to specify their spectrum, their epidemiological aspects and diagnostic delay in Internal Medicine Departments of Dakar (Senegal). Material and Method: It was a multicentric retrospective and descriptive study regarding all systemic diseases during 119 months from 1st January 2005 to 30 November 2014 in 5 hospital centers down Dakar. Systemic diseases were retained according to their international consensus criteria. Results: During the studying period, 726 patients were included with 632 women and 94 men (sex ratio of 0.14). The average age was 43.76 years. Inflammatory rheumatoid family history was noted in 10.06% of cases. Rheumatoid arthritis (RA) was the predominant affection, recorded on 564 patients, isolated or associated with other systemic diseases. It was followed in a decreasing order, in the systemic auto-immune diseases sub-groupe, by systemic lupus (56 cases), Sjögren’s syndrome (32 cases), Systemic Sclerosis (26 cases), Idiopathic inflammatory myopathies (21 cases), Undifferentiated connective tissue diseases (20 cases), Anti Phospholipid’s syndrome (6 cases) and Mixed connective tissue disease (6 cases). A diagnosis of systemic vasculitis was recorded in 19 patients. The other systemic affections were represented by systemic sarcoidosis (8 cases), Adult-onset Still’s disease (03 cases), amyloidosis (02 cases) and 02 cases of systemic syndrome associated to immunodeficiency. The mean diagnostic delay duration before the diagnostic was 3.46 years. ConcluHow to cite this paper: Kane, B.S., Niasse, M., Ndiaye, A.A., Ndao, A.C., Djiba, B., Diack, N.D., Fall, B.C., Ndour, M.A., Dieng, M., Dia, D., Diagne, N., Faye, A., Leye, A., Gning, S.B., Ndongo, S. and Pouye, A. (2018) Systemic Diseases in Dakar (Senegal): Spectrum, Epidemiological Aspect and Diagnostic Time-Limit. Open Journal of Internal Medicine, 8, 196-206. https://doi.org/ 10.4236/ojim.2018.83019 Received: August 22, 2018 Accepted: September 22, 2018 Published: September 25, 2018 Copyright © 2018 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Introduction
Systemic diseases represent a heterogeneous group of diffuse auto-immune and/or auto-inflammatory diseases and syndromes, meaning that usually touches many organs [1].
The first studies have concluded for the rarity of these affections in Africa [2].
However, the frequency of the systemic auto-immune diseases was likely to be under-estimated in Africa [3].Indeed, In Africa, south of the Sahara, these affections are not a concern due to priority areas such as infectious and tropical diseases [4].
In our region, studies of inflammatory arthritis and autoimmune diseases have been reported.Forty-two (42) cases on connective tissue diseases were reported during 5 years at Ouagadougou [5].In this study, systemic sclerosis predominated, followed up by lupus disease [5].In Togo and Abidjan, it was about respectively 84 and 44 patients, with RA as predominant affection [2] [6].A more recent series in Togo helped to identify 626 cases of inflammatory rheumatism and connective tissue diseases in a period of 16 years [7].
We found it necessary to conduct a multicentric study about systemic disease in our country.
The aim of our study was to point out these diseases, the spectrum, their epidemiological aspects and the diagnostic delay in Internal Medicine Department of Dakar (Senegal) universities hospitals.

Type of Study
It was a retrospective and observational study carried out from 1 st January 2005 to 30th November 2014.It was carried out on all patient medical records received at external consultation or admitted for a systemic disease in the 5 Internal Medicine Units of Dakar Hospitals.

1) Inclusion Criterias
Were included all patients medical records diagnosed for affections named below, according to the international criterias as follow: The approval of the local ethics committee was required.

2) Exclusion criteria
All incomplete medical records that did not allow data exploitation were excluded.

3) Data collection and analysis
The following data were collected: age, sex, diagnosis delay, the presence of prior monitoring, past medical history and comorbidities, clinical, biological, immunological and histological signs lead to conclude to the diagnostic.The diagnosis delay was defined by the duration between the onset of the first clinical manifestation and the date of diagnosis.
The data were recorded through an Excel file.Then, with R software, the Excel database was imported for variable recoding and analysis.The results were presented in text, table and graphical forms.

Results
During the period of study, we gathered 962 medical records, 726 were included.
It was 632 females and 94 males, that to say a ratio of 0.14.The average age in our study was 43.76 years with extremes from 16 up to 86 years.
Around one third of our patients (32.23%) had a prior monitoring.It was exclusively about a medical monitoring in 83% of our patients.Two-third of these patients had received only a symptomatic treatment (steroidal and/or non-steroidal anti-inflammatory), without any core therapy in their prior medical monitoring.
5% of the patients saw only traditional healers and 12% of the patients combined traditional treatment with medical treatment.
The mean diagnostic delay duration was 41.52 months (3.46 years).Table 1 points out the distribution of systemic diseases during our study and Table 2 shows the diagnostic time-limit of each systemic condition.(4.6%).Tuberculosis and systemic diseases were associated on 10 patients (1.38%).Table 4 sums up the antecedents and comorbidities in our series.

Discussion
We reported series of 726 patients in a 10 years study period.This multicentric study allowed a complete recruitment, including all Internal Medicine Departments of Dakar hospitals.However, Internal Medicine units do not have the monopoly of systemic diseases recruitment.These affections may be seen, according to their clinical phenotypes in other medical departments.This was a limitation of our study.
Other series of systemic auto-immune diseases were reported in Sub-Saharan Africa.Forty two (42) patients were chosen during 5 years at Ouagadougou [5].
In this study, systemic sclerosis predominated, followed up by lupus disease [5].
Down Togo and Abidjan, it was about respectively 84 and 44 patients, with RA as predominant affection [2] [6].A more recent series in Togo helped to identify 626 cases of inflammatory rheumatism and connective tissue diseases in a period of 16years [7].
The average age in our study was 43.76 years and around two-third of our pa-tients (63.2%) were part of the 30 -60 years age group.Therefore, these affections would touch the more active populations, besides their functional impact, this would indicate their economic value by the direct and indirect costs of their management [4].
Belated diagnostic during systemic diseases would be linked to the lack of knowledge of these affections, the existence of particular way as the use of traditional medicine, the lack of specialists and the high cost of means of explorations in our areas.The association Tuberculosis-Systemic disease was recorded in 10 patients in our study (1.38%).It was rarely reported in African literature despite the endemicity of tuberculosis in our areas and the predisposing terrain of systemic diseases [35].However it should be taken as a matter of concern especially with the advent of biological therapies.

Conclusion
Systemic diseases in our study are characterized by their diversity, the predominance of rheumatoid arthritis and their belated diagnosis.Improving diagnostic procedures will help to cover systemic diseases in Africa.

Figure 2 .
Figure 2. Digital necrosis during vasculitis secondary to rheumatoid arthritis.
Kane et al.
o Absence of identifiable causes and/or mechanisms.

Table 1 .
Distribution of inflammatory systemic diseases in our study.

Table 2 .
Diagnostic delay of systemic diseases in our study.
Five hundred and sixty four (564) patients were suffering of rheumatoid arthritis (RA) with an average age of 45 years and a sex ratio of 0.13.In 84% of cases, the RA diagnostic was carried out at the disease later stage certified by the existence of articular erosions and deformities.Extra-articular manifestations of RA are summarized on Figure1.A disease high activity with a Disease activity score (DAS) 28 (>5.1) was noted on 43.23% of patients.Immunologically, rheumatoid factors were positive in 77.3% and anti-cyclic citrullinated peptide auto-antibodies (anti-CCP) in 96% of patients.tients in our study.It was an association of at least 02 connective tissue diseases (CTD) or "overlap CTD" on 31 patients.The entity of multiple auto-immune syndrome was retained on 07 patients.B. S. Kane et al.DOI: 10.4236/ojim.2018.83019201 Open Journal of Internal Medicine

Table 3 .
Distribution of sex-ratio and Mean age in our study.
The comorbidities in our patients are summarized on the Table4.High blood pressure was documented on 50 patients (6.9%) and diabetes on 34 patients

Table 4 .
Distribution of comorbidities in our patients.
Belated diagnostic during systemic diseases was confirmed in our study by 41.52 months (3.46 years) average diagnostic time-limit.RA is the condition for which the existence of an interest of an early and "open window" therapy was more documented.The average age of diagnosis of RA was 45.6 months (3.8 years) in our study, 54 months in Ngongo's study, 78 months according to [32]ndary vasculitis due to connective tissue diseases and Behçet disease predominated in our study.Only one case of PAN was reported in our series and the one from Ndongo and coll, that seems like to confirm the paradox between hepatitis Bendemicity in our regions and the rareness of reported cases of PAN associated with hepatitis B virus in African literature[32].