Tropical Doctor recent issues

Health leadership in sub-Saharan Africa

2009-09-17

How long could we wait for the delivery of the second twin?

Nkwabong, E, Kamgaing Noubi, N, Dadje, C, Mbu, R — 2009-09-17

There is no consensus about the safe time interval between the deliveries of twins. This retrospective study, conducted from 1 January 2000 to 31 December 2004 at the University Teaching Hospital of Yaoundé, Cameroon, was designed to evaluate the safe time interval between deliveries of twins. We analysed 268 twin deliveries. The mean time interval between twin deliveries was 10.0 ± 7.9 minutes. The mean fetal weight of the first twin was 2416 ± 565 g and that of the second was 2395 ± 558 g. However, in 47.7% cases, the second twin was bigger than the first. When the second twin was delivered more than 30 minutes after the first, the mean 5 minute Apgar score was low. Therefore, efforts should be made to deliver the second twin within 30 minutes after the delivery of the first baby.

Does a preference for symphysiotomy over caesarean section reduce the operative delivery rate?

Nkwo, P. O, Onah, H. E — 2009-09-17

We analysed the data from a hospital that had practiced symphysiotomy and caesarean section (c/s) for many years and where symphysiotomy was acceptable to the parturient women, in order to determine the effects of symphysiotomy on c/s and on the overall operative delivery rates. Regression analysis revealed significant negative correlation between symphysiotomy and c/s (R = –0.610, P = 0.03 at 95% confidence interval [CI]) and a non-significant negative correlation between symphysiotomy and combined operative deliveries (R = –0.108, P = 0.383 at 5% CI). This study has confirmed that, in our environment, the practice of symphysiotomy significantly reduces the c/s rate and may save some women from operative deliveries in subsequent pregnancies. With the widespread aversion for c/s in the developing countries and a preference for symphysiotomy in some communities, symphysiotomy should be offered as an alternative to c/s whenever possible. Urgent revival of the dying skill of symphysiotomy is recommended in developing countries.

Effectiveness of vaginal hysterectomy for benign conditions in semi-urban hospital: report from Maroua-Cameroon

2009-09-17

We assessed the effectiveness of vaginal hysterectomy for benign uterine conditions in Northern Cameroon. This is a case series study of 29 elective vaginal hysterectomies carried out between February 2005 and June 2007 in Maroua, Cameroon. Hysterocele was found as the only or associated indication in 17 (58.6%) patients, symptomatic uterine fibroids in 4 (13.8%) and other indications in 8 (27.6%) patients. The mean duration of the operation was 132 minutes and the mean blood loss at surgery was 150 ml. Twenty-five of the 28 (89.3%) women had less than seven days of hospitalisation. There was a negative correlation (r = –0.45, P = 0.015) between duration of the surgery and the order of operation. One urinary tract and one wound infection were observed. Two patients had conversion to laparotomy. This study has shown that vaginal hysterectomy is a safe and feasible method of hysterectomy in a semi-urban hospital.

Co-existence of TB and adult haematological cancers in Benin City, Nigeria

Omoti, C. E., Olu-Eddo, A. N., Nwannadi, A. I. — 2009-09-17

Tuberculosis is an ancient human scourge that continues to be an important public health problem worldwide. As impaired immunity is closely associated with the pathogenesis of TB, an increase in the incidence of the disease among patients with cancer is anticipated. A total of 20 cases of haematological cancers co-existing with TB in a tertiary hospital in an African setting between January 2005 and September 2008 were analysed. Clinico-pathologic profiles, types of TB infection and outcome were noted. The incidence of TB in patients with haematological malignancies was 3.4%. Lymphoma and leukaemia were the most common malignancies associated with TB. With the high incidence of such cases we recommend the exclusion of an active disease prior to the initiation of cancer therapy. Chemoprophylaxis might be indicated in TB endemic areas.

A comparative trial of three therapeutic regimens: ciprofloxacin-rifampin, ciprofloxacin-doxycycline and doxycycline-rifampin in the treatment of brucellosis

Keramat, F., Ranjbar, M., Mamani, M., Hashemi, S. H., Zeraati, F. — 2009-09-17

This study was designed to compare the efficacy of ciprofloxacin plus rifampin (CR) and ciprofloxacin plus doxycycline (CD) versus doxycycline plus rifampin (DR) in the treatment of brucellosis. A total of 178 patients with brucellosis who were referred to the Sina Hospital, Hamedan, Iran, were included. The responses to therapy were observed in 166 cases (93.7%) – 59 were in the DR group, 59 in the CR group and 48 in the CD group. No significant differences in the therapeutic responses were observed (P = 0.09). Relapse was observed in 11.7% (DR 7.7%, CR 8.3% and CD 17.5%) after a six-month follow-up. No significant differences were also observed in relapse rates among the three groups (P = 0.35). We concluded that DR is still the first choice regimen and CR or CD may be used as alternatives for treatment of brucellosis in adults.

Prevalence of anaemia in the postpartum period: a study of a North Indian village

Somdatta, P., Reddaiah, V P, Singh, B. — 2009-09-17

Anaemia is a common public health problem but there is a paucity of studies regarding anaemia in the postpartum period. The objective of this study was to investigate the prevalence of anaemia in the postpartum period and factors associated with it. This prospective community-based study was carried out in a village of Haryana, India. Blood samples were collected for haemoglobin estimation at the end of six weeks postpartum. A total of 211 women were recruited and 168 women were included in the final analysis. It was found that 70% of the study participants were anaemic (Hb < 11 g/dL). Only 37% of the population had consumed ≥90 iron folic acid (IFA) tablets. The mean haemoglobin level of women who had consumed ≥90 IFA tablets in the antepartum period was higher (10.43 g/dL) than those who consumed <90 IFA (9.9 g/dL). Multicentric studies are recommended to get the true picture for the whole country.

Hepatic cystic echinococcosis: clinical characteristics and outcomes in Pakistan

Mumtaz, K., Kamani, L., Chawla, T., Hamid, S., Jafri, W. — 2009-09-17

Hepatic cystic echinococcosis (HCE) is an emerging disease in central Asia, particularly in Pakistan, due to the migration of infected people. Medical records of patients with HCE admitted between 1995 and 2006 to a tertiary care hospital were reviewed. A total of 106 patients were admitted with a mean age of 34±17 years; 60 (56.6%) were men, 72 (67.9%) were residing in rural areas of Pakistan and 21 (19.8%) were Afghan refugees. Twenty-seven (25.4%) had extra hepatic cysts and liver cysts. All patients received albendazole. Percutaneous aspiration, instillation and reaspirarion was done in 14 (13.2%) patients and 71 (66.9%) underwent surgery. Three (2.8%) died and 14 (13.2%) had morbidity. This is one of the largest series of HCE reported from Pakistan. HCE is mostly prevalent in rural areas and among Afghan refugees with low mortality and recurrence, but with significant morbidity.

Postoperative analgesia following caesarean deliveries in a rural health district of South Africa

Khan, M F, Omole, O B, Marincowitz, G J O — 2009-09-17

The under-treatment of postoperative pain is prevalent worldwide. This cross-sectional study examined general practitioners' (GPs) knowledge and practices regarding postoperative analgesia in Caesarean deliveries. Postoperative analgesia was said to ensure that patients were pain-free (38.7%), achieved early mobilization (19.4%) and enabled early breast feeding (16%). Pethidine was the opioid of choice; normally prescribed eight hourly (69%) and was combined with non-steroidal anti-inflammatory drugs (NSAID) by 48.6% of doctors and used solely by 51.6%. The prescription of analgesics was mainly influenced by drug availability (45.2%) and potency (19.4%). Most doctors (93.5%) had never attended a pain management course or used pain scores. Doctors at level 1 hospitals were less likely to use pethidine in combination with NSAID (odds ratio: 0.11; confidence interval: 0.02–0.59) compared to those in the specialized hospital. The GPs recognized the importance of postoperative analgesia, but their practices made patients vulnerable to pain after caesarean section.

What is the fate of the missing intrauterine contraceptive device?

Ibitoye, B. O, Aremu, A. A, Onuwaje, M. A, Ayoola, O. O — 2009-09-17

An intrauterine contraceptive device (IUCD) is one of the most common forms of contraception in use worldwide today. It is associated with a myriad of problems and complications, one of which is the missing IUCD. It is a known fact that IUCDs can perforate the uterus resulting in its subsequent relocation in other organs within the pelvis and the abdomen. This study showed that more than 50% of clinically diagnosed cases of a missing IUCD are still located within the endometrial cavity. It is therefore being proposed that a clinical diagnosis of ‘missing string’ be made until adequate radiological investigations, such as ultrasonography, plain X-rays and computerized tomography, have been carried out.

Clinical features of patients with typhoid fever and drug resistance of the causative isolates in western Iran

2009-09-17

Typhoid fever is an important infectious disease in developing countries, including Iran. In this survey, all patients hospitalized in teaching hospitals of Hamedan during 1995–2005 were investigated. A total of 162 patients with typhoid fever were studied. Of all patients, 106 were male (65.4%). The most prevalent symptoms were fever (93.2%), chills (76.5%), anorexia (72.2%) and headache (71%). Splenomegaly and hepatomegaly were present in 43.8% and 13.6%, respectively. Salmonella typhi strains were identified in 144 patients (88.9%) and S. paratyphi A strains were found in 12 (7.4%). In others, S. paratyphi B and C were detected. Serum glutamic oxalo-acetic transaminase values were higher than normal in 77.5% of cases and serum glutamic pyruvic transaminase values were higher than normal in 62.5%. The highest sensitivity rate was for ceftizoxime, 91.4% and the lowest rate was for ampicillin, 16.3%.

'Frozen finger' in anal fissures

Chintamani, , Tandon, M., Khandelwal, R. — 2009-09-17

Acute anal fissures are usually managed by various invasive and non-invasive modalities ranging from simple lifestyle changes to chemical and surgical sphincterotomies. Frozen finger, prepared using a water-filled ordinary rubber glove, was successfully used in one hundred patients, thus providing a cost-effective and simple solution to the problem.

A novel short-course regimen of intramuscular iron therapy for anaemic pregnant women

Thirunavukkarasu, S., Bhandary, A. — 2009-09-17

This study was conducted in anaemic pregnant women to investigate the efficacy and feasibility of intramuscular iron therapy as a short-course regimen and also to show the usefulness of such a regimen in women intolerable or non-compliant to oral iron.

The incidence, clustering and characteristics of Burkitt lymphoma in the Northwest province of Cameroon

Wright, N J, Hesseling, P B, McCormick, P, Tchintseme, F — 2009-09-17

The epidemiology of Burkitt lymphoma (BL) has never been documented in Cameroon. Data were collected from 16 hospitals, the Delegation of Public Health and the regional pathologist in the Northwest province of Cameroon on all BL cases. The incidence of BL in this region is 5.9/100,000 children aged <15 years/year – the second highest incidence documented to date. Significant clustering was also identified in Ndop, a low-lying region with a high malaria endemicity, at 21.5 cases/100,000 children aged <15 year/year (P < 0.001).

Investigation of two outbreaks of suspected oral transmission of acute Chagas disease in the Amazon region, Para State, Brazil, in 2007

2009-09-17

Acute Chagas disease (ACD) is caused by Trypanosoma cruzi. ACD outbreaks due to probable oral transmission occur regularly in small family gatherings that are exposed to contaminated foods. We studied two cohorts of residents on islands in the Breves and Bagre municipalities, in July and August 2007, to identify risk factors of transmission and to recommend preventative measures. Of the 25 cases identified in both cohorts, 13 (52%) were men, and the most frequent symptoms were fever (96%),asthenia (80%), myalgia (76%), abdominal pain (64%), retro-orbital pain, headaches and asthma (52%). We recommend detailed investigation of future outbreaks and other studies to better understand and control oral transmission of T. cruzi.

Neurobrucellosis: an evaluation of a rare presentation of brucellosis from a tertiary care centre in Central Anatolia, Turkey

2009-09-17

Nervous system involvement is a rare manifestation of brucellosis. We describe our experience of the diagnosis, treatment and final outcome of patients with neurobrucellosis at the Erciyes University Gevher Nesibe Hospital, a tertiary referral centre in Central Anatolia, Turkey. Thirty-six adult patients were diagnosed with neurobrucellosis from January 1997 to December 2006. Headache and fever were the most common symptoms. Neck stiffness was present in 25 patients. Brucella spp was isolated from the blood of nine patients and from the cerebrospinal fluid of 11. Doxycycline (by mouth) plus rifampin (by mouth) with ceftriaxone (intravenously) were the most common treatment choices. Three patients died as a result of problems other than neurobrucellosis and relapse occurred in one patient. Neurobrucellosis presents with hetoregenous clinical signs.

Prevalence of acanthosis nigricans and its correlates in a cross-section of Nigerians with type 2 diabetes mellitus

Ogbera, A O, Akinlade, A, Ajose, O, Awobusuyi, J — 2009-09-17

Acanthosis nigricans (AN) is a dermatological condition that is often associated with obesity and may be a physical marker of insulin resistance. Studies have documented a high prevalence rate of AN in people with diabetes mellitus (DM). However, there have been no Nigerian reports on AN and DM. This report bridges the information gap and documents the prevalence of AN in Nigerians with type 2 DM as well as its clinical correlates. Three hundred and forty consecutive subjects with type 2 DM were examined for the presence of AN and its associated clinical features. The prevalence of AN in type 2 DM in this report is 17%. Factors associated with AN include obesity, a family history of DM, female gender, the presence of hypertension and poor glycaemic control.

Clinical and therapeutic aspects of childhood kerosene poisoning in Djibouti

Benois, A., Petitjeans, F., Raynaud, L., Dardare, E., Sergent, H. — 2009-09-17

We report a prospective and descriptive study about childhood acute poisoning with kerosene in Djibouti. Acute poisoning is a common and stable occurrence in low socioeconomic groups in Africa, where negligence is the main cause of poisoning. The respiratory system was the main target, with 41% of patients having pneumonia, which may become life-threatening, but with low mortality rate. Asymptomatic patients (35%) can be discharged, while those with pulmonary or neurological signs must be admitted for observation and supportive treatment based on oxygen administration. Our study suggests management and provides a discussion for therapeutic options and emphasizes the importance of prevention.

High maternal mortality and stillbirth in the Wad Medani Hospital, Central Sudan, 2003-2007

Elhassan, E. M, Mirghani, O. A, Adam, I. — 2009-09-17

The aim of this study was to investigate the incidence and causes of maternal deaths and stillbirths at the Hospital of Obstetrics and Gynecology at Wad Medani, Sudan, from 1 January 2003 through 31 December 2007. All maternal deaths and stillbirths during this period were reviewed and classified retrospectively. There were 146 maternal deaths and 33034 live births, giving a maternal mortality ratio of 442/100,000 live births. The age range was 18–42 years with a mean (standard deviation) of 30.57 (5.26) years. The most common cause of death was septicaemia following obstructed labour or abortion-related sepsis, followed by haemorrhage, pre-eclampsia/ecalampsia, viral hepatitis and malaria. The stillbirth rate was 29/1000 births; the majority of which (8/1000) were macerated stillbirths.

Altered consciousness in Ugandan hospital admissions

Rwebembera, J., Wilson, T. — 2009-09-17

An awareness of diseases causing altered mental status (AMS) in particular localities could greatly facilitate patient management. This cross-sectional study evaluated 100 consecutive patients with AMS admitted to a hospital in Uganda. Patients were assessed by the Confusion Assessment Method. History, examination, available laboratory tests and patients' response to treatment were used to identify aetiologies. Our study included 58 males and 42 females: 82% were 16–50 years old and 38% were HIV-infected. The most common cause of AMS was infection (51.3%), with cerebral malaria and meningitis predominating. The aetiology was unidentified in 12%. The in-hospital mortality rate was 44%, with HIV infection being positively associated.

As infections and metabolic derangements, the most common causes of AMS in our setting, are mostly treatable with a relatively favourable outcome, critical evaluation, early intervention and improved investigative capacity would greatly improve patient outcome.

Primary amoebic meningoencephalitis: two new cases from Pakistan

Saleem, T., Rabbani, M., Jamil, B. — 2009-09-17

Naegleria fowleri causes a fatal infection of the central nervous system. Only one case of N. fowleri meningoencephalitis has previously been reported from Pakistan. We describe two cases of primary amoebic meningoencephalitis. A 24-year-old man presented with a two-day history of high grade fever, headaches and vomiting. He was put on intrathecal amphotericin B, fluconazole and rifampicin when motile trophozoites were identified on a wet mount of cerebrospinal fluid. The patient did not improve and died on the sixth day of admission. The second case was a 30-year-old man who presented with a three-day history of high grade fever, vomiting and agitation. His clinical course was marked by a rapid deterioration. He received intrathecal amphotericin B, fluconazole and broad spectrum antibiotics when motile trophozoites on wet mount were observed. Again, the patient's condition did not improve and he died on the eighth day of admission.

Mid-trimester spontaneous uterine rupture

Halder, A., Halder, S. — 2009-09-17

The rupture of a uterus is still an enigmatic episode in obstetrics. Obstetricians may have to face it unexpectedly if it occurs spontaneously. Here, we report a case of a 20-year-old woman who presented to our out-patients department with abdominal pain and vaginal bleeding, and was diagnosed with a ruptured uterus.

Ileosigmoid knotting- a rare variant of bowel volvulus

Alvi, A R., Bibi, S., Effendi, S., Khan, S. — 2009-09-17

Two patients with acute intestinal obstruction underwent exploratory laparotomy after adequate fluid resuscitation and radiological imaging. A preoperative diagnosis of sigmoid volvulus and an operative diagnosis of ileosigmoid knotting or compound volvulus were established.

Disseminated histoplasmosis in an AIDS patient: a rare case from southern India

2009-09-17

We present a case of disseminated histoplasmosis with acquired immunodeficiency syndrome (AIDS). A 38-year-old woman presented with fever, cough, dysphagia, significant weight loss and a loss of appetite. She also suffered from anaemia and cervical lymphadenopathy. A lymph node biopsy and a bone marrow aspirate showed intracellular yeast forms of Histoplasma capsulatum. She improved with parenteral amphotericin B and oral itraconazole. Even though histoplasmosis is not endemic in South East Asia and India, it should be kept in mind when evaluating AIDS patients in view of the current scenario of the pandemic.

Giant hydatid cyst of spleen: a case report

Cabadak, H., Erbay, A., Aypak, A., Tekce, A. Y. T., Sen, S. — 2009-09-17

Hydatidosis is endemic in many Mediterranean countries, the Middle East, South America, Australia, New Zealand and Africa. It is caused by an infection from the Echinococcus granulosus larvae which can lead to the development of cysts. The most frequently affected organ is the liver. Splenic involvement alone is very rare. In this article, a case of an isolated giant splenic hydatid cyst is reported. The patient underwent splenectomy. The diagnosis of a hydatid cyst was confirmed by histopathology. This case suggests that hydatid disease should be considered as a differential diagnosis in every patient with a cystic mass of the spleen in endemic areas.

Adenomyosis and uterine rupture during labour in a primigravida: an unusual obstetric emergency in Nigeria

Dim, C. C, Agu, P. U, Dim, N. R, Ikeme, A. C — 2009-09-17

The primigravid uterus is believed to be immune to rupture during labour. This may not be true for those who have had prior adenomyomectomy, hence this report. The patient was a 28-year-old nullipara who became pregnant 11 months after an adenomyomectomy. Twelve hours after vaginal delivery at term, she developed haemoperitoneum of unclear cause. Emergency laparotomy and subsequent histology showed a fundal complete uterine rupture through the adenomyomectomy site, which was repaired. It is concluded that adenomyomectomy predisposes a pregnant uterus to rupture during labour. Therefore, such women should be offered elective caesarean delivery at term.

A case of Brucella endocarditis in association with superficial femoral artery thrombus

Caylan, R, Keske, S, Durmaz, T, Keles, T, Tasyaran, M A — 2009-09-17

We report here a case of Brucella endocarditis associated with superficial femoral artery thrombus. The patient was treated only with medical treatment. The clinical significance of the case was the presence of two rare complications of brucellosis:endocarditis and arterial thrombus.

Invading plant material appearing as a colonic tumoural mass in a four-year-old girl

Mahjoub, F., Kalantari, M., Tabarzan, N., Moradi, B. — 2009-09-17

In this article, we report the invasive behaviour of a plant, not described before, which elicited a severe inflammatory response in the colonic wall, and was clinically diagnosed as a mass lesion in a four-year-old girl. Although rectal bezoars are the most frequent complications of ingested dried seeds, this plant behaviour should also be borne in mind in rare occassions.

Abdominal cocoon in an adolescent male patient

Ibrahim, N A, Oludara, M A — 2009-09-17

Abdominal cocoon is a rare cause of bowel obstruction. The condition was first described three decades ago and is found mainly among adolescent females in tropical and sub-tropical countries. It is characterized by a thick fibrous membrane encapsulating the small intestines partially or completely. Patients present with features of intestinal obstruction and diagnosis is usually made intraoperatively. Surgical excision of the membrane and adhesiolysis result in complete recovery. We report on an adolescent male patient who had acute intestinal obstruction due to abdominal cocoon detected at surgery.

Amputation surgery in children: an analysis of frequency and cause of early wound problems

Banza, L N, Mkandawire, N C, Harrison, W J — 2009-06-17

Amputation surgery in children is a relatively uncommon procedure. The objective of our study was to determine the incidence of complications in this type of surgery as well as any related factors. The results of our retrospective study of children aged between one and 18 years, over a five-year period were collected and analysed. The most frequent indications for amputation were congenital limb deformities (60%). Trauma, tumours, infection and other rare conditions were less common.

Results also revealed that in our hospital the wound infection rate was 38 %, the wound breakdown rate was 11 % and the general wound sepsis rate was around 1%. More complications were observed following through-knee amputation. We had noticed fewer complications (25%) when the surgery was performed by a consultant than when it was performed by a junior trainee (66%).

Clinical neuropathy in HIV/AIDS: an eight-year review of hospitalized patients in Sokoto, northwestern Nigeria

Isezuo, S A, Sani, A Z, Ezunu, E, Maiyaki, S, Njoku, C H, Obembe, A — 2009-06-17

HIV/AIDS is a multi-systemic disease that targets mainly the immune and nervous systems. Although about 4.4% of Nigerians are infected with HIV, data on the spectrum of HIV-related nervous disease in this population is rare. This study describes the neurological manifestations of HIV/AIDS in northern Nigeria. We undertook retrospective and descriptive analyses of the demographic, clinical, neurologic and laboratory data of all hospitalized HIV/AIDS adults in a referral hospital in northwestern Nigeria. The study period covered 2000 to 2007. We studied 322 HIV/AIDS patients (218 men, 104 women) aged 33.4 ± 11.4 years (range: 18–65 years) who constituted 3.5% of the total medical admissions. HIV transmission was exclusively by heterosexual intercourse involving multiple partners. The majority (70.2%) was married and 78.9% were in stage III/IV HIV/AIDS disease. Fifty-two (16.2%) had CD4+ T-cell count determination, the mean value being 220 ± 147.2 cells/m³, and 58 (18.0%) were on highly active antiretroviral therapy. Fifty-one (15.8%) had neurological complications dominated by central nervous diseases including encephalitis (17.6%), dementia (16.2%) and stroke (14.9%). Peripheral nerve involvements were relatively infrequent. Compared with HIV/AIDS patients without neurological complications, a significantly higher proportion of those with HIV-associated neuropathy had a stage IV disease (30% versus 9.4%, ² = 19.5, P < 0.001). Neurological complications, particularly central nervous diseases, are an important cause of morbidity in the HIV/AIDS population.

Neonatal tetanus in the babies of Nigerian mothers immunised against Tetanus

Fetuga, B. M., Ogunlesi, T. A., Adekanmbi, F., Olanrewaju, D. — 2009-06-17

The objective of this study was to describe the clinical characteristics of babies with neonatal tetanus (NNT) whose mothers were immunised against tetanus and determine the outcome of their hospitalisation. The hospital records of babies affected by NNT whose mothers received at least two doses of anti-tetanus vaccine during pregnancy were identified and compared with similarly affected babies whose mothers were not immunised against tetanus during pregnancy in a Nigerian hospital. Out of 175 cases of NNT, the mothers of 24 (13.7%) babies were immunised against tetanus during pregnancy while the mothers of 151 (86.3%) were not. The proportions of babies of immunised mothers and unimmunised mothers who presented within the first three days of life, within a day of the onset of symptoms and with spasms were similar. Nevertheless, the survival rate was higher (62.5% vs. 26.5%; P = 0.0004) among babies of immunised mothers. Despite similarities in clinical presentation of babies of mothers with and without anti-tetanus vaccination, the survival rate was higher for the former.

Limitations in the role of ulcer edge biopsy in establishing the aetiology of nontraumatic small bowel perforation

Sharma, S., Kotru, M., Batra, M., Gupta, A., Rai, P., Sharma, R. — 2009-06-17

Spontaneous small intestinal perforations are common in India. Surgeons operating on patients with an obscure peritonitis should be aware of the diverse aetiologies of small intestinal perforations in order to be able to provide the appropriate management. We reviewed the pathology records of 165 patients operated on for nontraumatic perforations of the small intestines in our hospital between 2005 and 2007. Perforation edge biopsy was diagnostic in 53 cases, with typhoid being the most common aetiology, followed by TB. The majority of cases, however, revealed only a non-specific inflammatory granulation tissue. However, the sensitivity of biopsy diagnosis could be increased by taking additional biopsy material from the mesenteric lymph nodes, tubercles or omental nodules. We conclude that perforation edge biopsy is useful in a third of cases, but the diagnostic rate could be improved by taking additional biopsy material.

Impact of day care cataract surgery on inpatient services in a tertiary care ophthalmic setup

Prakash, G., Sharma, N., Jhanji, V., Agarwal, T., Titiyal, J. S — 2009-06-17

We retrospectively reviewed the admission patterns for one year before and one year after the introduction of day care cataract surgery at our cornea services and noted that the number of cataract surgeries per month improved from year 2003 to 2005 (P < 0.001), with a higher number of admissions for non-emergency corneal pathology seen in 2005 (P < 0.001). There was a 69.1% more chance of admission for a corneal pathology patient after the introduction of day care services cataract surgery. Day care cataract surgery decongests non-cataract pathology related inpatient services and is therefore a viable alternative in the developing world.

Delivery room logbook - fact or fiction?

Duffy, S., Crangle, M. — 2009-06-17

The delivery room logbook entries of Gimbie Adventist Hospital for a period of one month were monitored and compared with the actual number of births recorded on a separate worksheet for that period. The implications of the missing data were reviewed. This data was compared to a previous audit of the same design. Eighty per cent of births were recorded during this one month period which reflected an improvement from 72% reported in a previous study. Underreporting resulted in discrepencies when calculating the number of births and signal functions such as caesarean section rates, blood transfusion, administration of parenteral anticonvulsants and removal of retained products. In turn, these discrepencies impact the calculation of process indicators of safe motherhood projects. The reliability of the delivery room logbook as the sole source of information to create health policy and to monitor and evaluate health programs is questionable.

Stroke at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria

Onwuchewa, A., BellGam, H., Asekomeh, G. — 2009-06-17

The case records of 202 consecutive adult Nigerian in-patients with stroke at the University of Port Harcourt Teaching Hospital (UPTH) were retrospectively reviewed. The mean age at presentation was 62.62 ± 14.2 years. The male to female ratio was 1:1.2. The commonest risk factors were hypertension, diabetes mellitus, hypercholesterolaemia, older age and a previous history of stroke. Clinically, 67.3% had cerebral infarction (CI), while 27.7% had intracerebral haemorrhage (ICH). The peak age of events for both sub-types was the 7th decade. The case fatality was 55.4% for ICH and 23.5% for CI. Thus, stroke is associated with high mortality at the UPTH. Improved emergency care of stroke patients is needed while the setting up of dedicated stroke centres is advocated. A community-based study is necessary to provide more insight into the problem and also highlight the basis for appropriate intervention and policy.

Prevalence of transfusion transmitted infections in blood donors: an Indian experience

Chandra, T., Kumar, A., Gupta, A. — 2009-06-17

A retrospective study was done on blood units collected from replacement and voluntary donors from 2001 to 2007. Seropositivity of transfusion transmitted disease in replacement donors was 1.96% in hepatitis B surface antigen, 0.85% in hepatitis C virus, 0.23% in HIV and 0.01% in syphilis. Voluntary donors had an almost negligible infectivity rate.

The frequency of hepatitis D virus in patients with hepatitis B in Iran: an increasing rate?

Somi, M. H, Farhang, S., Miri, S. M., Pouri, A. A, Mjidi, G., Alavian, S. M. — 2009-06-17

This study sought to determine the seroprevalence of the hepatitis D virus (HDV), the risk factors and its association with the severity of liver disease. Continuous patients at Tabriz and Tehran Hepatitis Clinics were enrolled during 2007–2008 in a cross-sectional study. Demographic data and possible risk factors for infection were recorded for all hepatitis B surface antigen positive patients. The blood samples of 847 patients infected with the hepatitis B virus were evaluated. The seroprevalence of HDV was 9.3%. This rate was significantly higher after reaching 40 years of age. The rate was 12.7% in patients with chronic hepatitis B and 4.7% in patients with in-active hepatitis B; the difference was statistically significant. A history of dental interventions and several trips abroad were good predictors of HDV infection in logistic regression. No significant difference in liver function tests was found. The seroprevalence of HDV was higher than in some other studies from Iran but a decrease was noted in younger age.

The incidence of selected congenital malformations during a two-year period in Tehran, Iran

2009-06-17

In this descriptive cross-sectional study carried out from March 2005 to March 2007, 410 congenital malformations were recorded among 61,112 live births in six general hospitals in different districts of Tehran. The overall incidence was 0.6% (0.69% in males and 0.62% in females) and the most affected system was the digestive system (40%), followed by the musculoskeletal system (20.5%), central nervous system (19.5%), genitourinary system (12.2%) and cardiovascular system (3%). It is essential that government organizations educate the population through scheduled preconceptional primary care visits on interventions like diet supplementation and avoidance of teratogenic agents, in order to decrease the rate of congenital malformations.

Risk factors for fatality in patients with Crimean-Congo haemorrhagic fever

Fisgin, N. T., Tanyel, E., Doganci, L., Tulek, N. — 2009-06-17

Crimean-Congo haemorrhagic fever (CCHF) is a potentially fatal viral disease. In this study, the aim was to investigate the prognostic factors affecting the patient's survival and risk factors to fatality. At Ondokuz Mayis University Faculty of Medicine, a tertiary referral centre near the CCHF epidemic region, patients with typical clinical findings and indicative microbiological results for IgM and/or reverse transcriptase-polymerase chain reaction of CCHF virus were enrolled in the study, from 2004 to 2007. Patients were divided into two subgroups according to their survival outcomes; group I (n = 44) survived patients and group II (n = 6) consisted of fatal cases.

The median platelet count was significantly lower in the fatal group (11000/mm³) when compared to the survived group (49500/mm³). Aspartate transferase and alanine transferase (ALT) levels were significantly higher in group II, when compared to group I. Also, the median range of serum lactic dehydrogenase (LDH) and creatinine phosphokinase (CPK) levels were much more elevated, and prothrombin time (PT) and activated partial thromboplastin time (aPTT) were prolonged in fatal cases. There was also a significant difference in median age of these two groups. Advanced age, late admission, low platelet count, increased AST, ALT, CPK and LDH levels, and prolonged PT and aPTT could be an early indicator of poor prognosis in patients with CCHF.

Serological immunity to diphtheria and tetanus in healthy adults in Delhi, India

Saxena, S., Jais, M., Dutta, R., Dutta, A K — 2009-06-17

Widespread childhood immunization with DPT (diphtheria, pertussis and tetanus) has largely eradicated diphtheria and tetanus from many countries. The reduction in the circulation of toxigenic strains has resulted in less natural boosting of adult immunity. As a result, the adult population in countries with high childhood immunization coverage have become susceptible to the disease. The duration of immunity after primary immunization to diphtheria and tetanus is limited and a reduction in immunity is common in adults. With this perspective, the present study was carried out on a random serum sample of 255 healthy individuals aged 20-50 years. The serum samples were tested for immunoglobulin G levels against diphtheria and tetanus by enzyme immuno assays. Fifty-three per cent of adults were unprotected; 22 % were seen to have only a basic protection against diphtheria; 25% were protected against both diseases; and 47% were susceptible to tetanus. The susceptibility was seen to increase with age. To avoid epidemics in the future, immunity must be improved. It is important to treat even the most trivial wound with care and tetanus toxoid immunization. Also, it is necessary to monitor the community for immunity to diphtheria using standard techniques in order to undertake epidemiological surveillances of, and prevention from, these dreadful diseases.

Pulmonary nocardiosis from a tertiary care hospital in Southern India

Chawla, K., Mukhopadhyay, C., Payyanur, P., Bairy, I. — 2009-06-17

The present study highlights eight cases of pulmonary nocardiosis diagnosed during the time period of January 2006–March 2008. Nocardia otitidiscaviarum, N. asteroides and N. brasiliensis were isolated from these cases. Whereas six patients were treated successfully, one showed partial response and one case expired before the institution of treatment. Early and correct microbiological diagnosis can help to decrease the disease-related morbidity and mortality.

Tuberculosis in systemic lupus erythematosus in Chinese patients

Wang, J., Pan, H.-F., Su, H., Li, X.-P., Xu, J.-H., Ye, D.-Q. — 2009-06-17

This study investigates the prevalence and clinical and laboratory features of patients with systemic lupus erythematosus (SLE) associated with TB in Chinese patients, as well as its similarities to and differences from patients without TB. Our results show that SLE patients with TB (SLE-TB) might be a subgroup of patients with distinct clinical and laboratory features. Therefore, specific treatment should be given in order to provide a better outcome for SLE-TB patients.

Incidence and outcome of peripartum cardiomyopathy from a tertiary hospital in South India

Pandit, V., Shetty, S., Kumar, A., Sagir, A. — 2009-06-17

There is very little literature regarding peripartum cardiomyopathy (PCM) from Asian countries. A study of PCM was conducted at Kasturba Medical College Hospital, Manipal, with special reference to incidence and outcome. The incidence of PCM was 1 case per 1374 live births. Major risk factors for the development of PCM were multiparity and advanced maternal age. Echocardiography is useful in early diagnosis and for follow-up assessment of left ventricular function. Most of the patients noticed good symptomatic improvement at time of discharge and during the follow-up with standard therapy. Clinical improvement was well correlated with improvement of LV function by echocardiography. Significant thrombotic complications were noticed. None of the patients died during the study and follow-up period.

The use of hospital medical records for child injury surveillance in northern Malawi

2009-06-17

Our study evaluates the usefulness and the limitations of using the medical records of a central referral hospital to develop a child injury surveillance system in northern Malawi. The most prevalent types of injury were falls (29.6%), road traffic injuries (22.0%), burns (21.4%) and poisoning (15.1%). Older children (aged 5–14 years), in the cool-dry season (May to August) and the hot-dry season (September to October), were significant predictors for total injury admissions. Our study indicated that hospital medical records are a valuable component of a child injury surveillance system and can illustrate the trends and patterns of moderate to severe injuries as well as suggest potential prevention strategies for local settings. Combined with a specially designed trauma registry form, it is possible for developing countries at local level to combat the emerging public health issues.

Rare primary extrahepatic intra-abdominal hydatid cysts

De, U. — 2009-06-17

Hydatid disease is an endemic parasitic disease prevalent in sheep-rearing countries. Although liver and lung are the commonly involved organs, hydatid disease can occur in any organ or tissue. In this case series, we share our experience of some rare primary extrahepatic intra-abdominal hydatid cysts.

Idiopathic CD4+ T-lymphocytopenia with cryptococcal meningitis: first case report from Cambodia

Augusto, E., Raguenaud, M.-E., Kim, C., Mony, M., Isaakidis, P. — 2009-06-17

We report on a patient with cryptococcal meningitis with CD4+ T-lymphocytopenia and no evidence of HIV infection.

Amoebic liver abscesses complicated by inferior vena cava and right atrium thrombus

Khan, S., Ameen Rauf, M. — 2009-06-17

Amoebiasis is a common protozoal infection that is endemic in South Asia. Hepatic involvement that manifests as abscess formation occurs in approximately 10% of all patients. Identified expeditiously, this can be treated with metronidazole. We present a case of multiple, large amoebic liver abscesses, that were complicated by thrombus formation in the inferior vena cava extending to the right atrium, requiring surgical removal.

Severe adverse reactions to meglumine antimoniate in the treatment of visceral leishmaniasis: a report of 13 cases in the southwestern region of Brazil

2009-06-17

Antimony-based medications continue to be the chosen drug for visceral leishmaniasis treatment in most countries. Pentavalent antimony compounds are highly effective but frequently have adverse reactions. Although toxic effects are almost always reversible, some of them can be severe. Clinical and laboratory data of 13 patients who developed severe adverse reactions to meglumine antimoniate in a teaching hospital in southwestern Brazil in 2004–2005 were analysed. Most patients were adults (10/13), mainly at the age of 50 or older (4/13). The main severe adverse reactions were renal failure (eight episodes), pancreatitis (six episodes) and hepatic failure/hepatitis (five episodes). Six patients died in the period; all presented acute renal failure and four presented hepatic failure. Meglumine antimoniate can cause severe reactions, which can lead to death if not promptly identified. Further studies are warrented on the effect of less toxic drugs.

Unusual presentation of tuberculosis

Singh, S., Pandey, D., Ahmad, Z., Bhargava, R., Hameed, I., Mehfooz, N. — 2009-06-17

Mediastinal mass is not an unusual entity. It occurs mostly due to lymphoma, thymoma, germ cell tumours, granulomatous diseases, and so on. Tuberculosis is an uncommon cause of mediastinal mass. It is rarely suspected when it is presented in such an unusual way. We report here a case of a 35-year-old male who presented with mediastinal mass, which was later confirmed as a case of tuberculosis on histopathological examination. He was successfully treated with anti-tubercular drugs.

Pulmonary nocardiosis presenting with cardiac tamponade and bilateral pleural effusion in a HIV patient

Chandrashekar, U K, Acharya, V., Gnanadev, N C, Varghese, G. K, Chawla, K. — 2009-06-17

Nocardiosis induces a high mortality rate in those infected with HIV. It is now being increasingly described in patients with AIDS. Nocardia infection usually involves the lungs. In immunocompromised individuals it tends to disseminate. It mimics pulmonary TB both clinically and radiologically and many a time is wrongly treated with anti-tubercular drugs. Involvement of the pericardium is uncommon, having only been reported infrequently in the past. We describe a patient who presented with a cardiac tamponade and was confirmed as having pulmonary parenchymal and pleural disease.

Acute glomerulonephritis in hepatitis A virus infection: a rare presentation

Aggarwal, A., Kumar, D., Kumar, R. — 2009-06-17

An eight-year-old boy presenting with features of acute glomerulonephritis (AGN), developed jaundice. He was positive for hepatitis A immunoglobulin M. AGN is a rare complication of hepatitis A. Here, we describe a temporal association of hepatitis A infection complicated by AGN.

Death due to chikungunya

2009-06-17

After its first appearance in Kolkata (Calcutta) during 1963–1965, chikungunya occurred in epidemic form in India in 17 states and union territories. There were 13,90,322 cases suspected to be suffering from chikungunya in 2006, 59,535 in 2007 and 11,222 in 2008; in 2006, 2007 and 2008 there were 15,961, 7,837 and 262 samples, respectively, sent to the National Institute of Virology, Pune, and the National Institute of Communicable Disease, Delhi, for serological diagnosis. Of these, 2001, 1826 and 44, respectively, were confirmed as chikungunya. There were no deaths (data from the National Vector Borne Disease Control Programme, Government of India).

Cutaneous dirofilariasis presenting as an eyelid swelling

Shenoi, S. D, Kumar, P., Johnston, S. P, Khadilkar, U. N — 2009-06-17

Dirofilariasis is a common filarial infection occurring in domestic and wild animals as a result of arthropod bites. However, it can be transmitted to humans after mosquito bites. Here, we report a case of a 54-year-old lady who developed an unilateral eyelid swelling secondary to Dirofilaria repens.

Scurvy-a forgotten disease with an unusual presentation

Kumar, V., Choudhury, P. — 2009-06-17

We report an unusual case of scurvy where a six-year-old female presented with clinical and radiological features suggestive of juvenile idiopathic arthritis. However, follow-up radiological examination, carried out in view of refractory arthritis, was diagnostic for scurvy and the patient later responded well only with vitamin C therapy.

Help with overseas surgical training

2009-03-18

Managing mycetomas

Ameen, M. — 2009-03-18

Mycetomas are chronic, granulomatous, subcutaneous infections caused by traumatic inoculation into the skin of either the actinomycetes bacteria or the eumycetes fungi, giving rise to actinomycetomas and eumycetomas, respectively. They are endemic in the tropics afflicting mainly those of low socio-economic status and men working in agriculture. The disease is slowly progressive and can cause bone involvement, which can result in considerable disability. Late presentation is not uncommon making them notoriously difficult to manage. This article highlights the important aspects of their management and developments in drug therapy.

Office haemorrhoidectomy with local anaesthesia: a feasible day-case procedure

Zafar, A., Ahmad, S., Ansari, J. A. — 2009-03-18

We report on 100 patients (88 men and 12 women) who underwent ligation-excision haemorrhoidectomy for prolapsing haemorrhoids in an outpatient office setting under local anaesthesia. Operating time, complications during procedure, postoperative complications and patient satisfaction with the procedure were analysed. The mean operating time was 55 (40–90) minutes. Ninety-seven were discharged three to five hours after surgery. Three patients were directly admitted to the hospital after surgery. One patient was readmitted after discharge. Severe postoperative pain occurred in eight; three suffered urinary retention; 88% were satisfied with the surgery but 12% were not. This study shows that, in selected patients, performing ligation-excision haemorrhoidectomy under local anaesthesia in the outpatient office setting is safe and viable.

Decline in hospital mortality rate after the use of the World Health Organization protocol for management of severe malnutrition

2009-03-18

We studied the implementation of the World Health Organization protocol for the treatment of malnourished children at the largest maternal and infant hospital in the northeast of Brazil. The implementation of the protocol resulted in a reduction in the mortality rate from 38.0% to 16.2%.

Do patients in rural Malawi benefit from upper gastrointestinal endoscopy?

2009-03-18

The aim of this study was to evaluate the benefits of upper gastrointestinal endoscopy at central hospital level in Malawi and to draw conclusions from its use in the treatment of patients presenting with dysphagia and dyspepsia to health institutions in rural Africa.

This retrospective study was carried out in order to investigate the endoscopic findings in 455 patients who presented to Zomba Central Hospital, Malawi, with upper gastrointestinal symptoms.

Fifty-six percent of patients presenting with dysphagia were found to have oesophageal carcinoma. In 50% of patients with epigastric pain and 44% with abdominal pain, an endoscopy did not reveal any pathological findings. The intended treatment was frequently altered as a result of performing the endoscopy. We were able to treat patients according to their specific diagnosis in a significantly higher number than before: 51% versus 18% of those presenting with dysphagia, 96% versus 24% of those with epigastric pain and 90% versus 39% of those with abdominal pain.

Upper gastrointestinal endoscopy is a feasible diagnostic tool in developing countries which improves the detection and treatment of diseases of the gastrointestinal tract.

Atypical cerebrospinal fluid profile in tuberculous meningitis

Pinto, V. L., Lima, M. A., Rolla, V. C., Rebelo, M. C., Boia, M. N. — 2009-03-18

The aim of this study was to describe atypical cerebrospinal fluid (CSF) alterations in tuberculous meningitis (TBM) and to analyse the differences in outcome between patients with typical and atypical profiles. We did a retrospective study during the period of 2000 to 2005 including the cases of TBM assisted in a referral centre for infectious diseases in Rio de Janeiro State, Brazil. Neutrophilic plecytosis at the first spinal tap was found in 32.4% of TBM patients, who had a worse outcome when compared with those patients with typical CSF profiles. One factor that might have a major impact was the delay in starting empirical treatment (27.5 versus 11.6 days). We conclude that, in cases with clinical and epidemiological data compatible with TBM but with an atypical CSF profile, empirical treatment should be considered if CSF culture and direct examination for bacteria are negative.

Peripheral neuropathy in HIV-positive patients at an antiretroviral clinic in Lilongwe, Malawi

Beadles, W I, Jahn, A, Weigel, R, Clutterbuck, D — 2009-03-18

Peripheral neuropathy (PN) is common in the setting of antiretroviral (ARV) programmes in resource-limited settings and poses significant challenges in assessment and management. A retrospective analysis was undertaken of prevalence and management of PN in a cohort of 3341 patients on highly active antiretroviral therapy. A first line ARV regimen containing stavudine (D4T) is used for clinically eligible patients. Amitriptyline is prescribed for symptom relief and in cases of persistent or escalating symptoms zidovudine (AZT) is substituted for D4T. Leg pain or numbness was reported in 1173 patients (35%). However, only 428 (13%) were given a diagnosis of PN, 228 (7%) were prescribed amitriptyline and 200 (6%) were switched to AZT. A recent pharmokinetic study in this population showed a high C_max of D4T with the generic combination triomune (D4T 40 mg). This could account for the high prevalence of PN. The optimum time for switch to a non-D4T containing regimen is unknown.

Presentation of trauma at the National Orthopaedic Hospital Enugu: a pilot study

Onah, I I, Okwesili, I C — 2009-03-18

This prospective study spanning three months was undertaken to provide insight to trauma care including intervention times in this centre. Improved organization of trauma care is needed urgently for improved outcomes.

Iron, folate and vitamin B12 parameters in HIV-1 infected patients with anaemia in southern Brazil

Castro, L., Goldani, L. Z — 2009-03-18

We conducted a study to determine the role of iron, folate and vitamin B12 in HIV-infected patients with anaemia attending a tertiary-care hospital in southern Brazil. Low serum folate levels were found in 14 (41%) HIV-infected patients; parameters of iron deficiency such as low transferring saturation index and ferritin in 10 (30%); and combined folate and iron deficiency in five (14%). Vitamin B12 deficiency was found in only two (6%) patients who presented with mean corpuscular volumes within the normal range. Our study has shown that folate and iron deficiency were frequently detected in HIV-infected patients at our institution, and should be considered in the differential diagnosis of anaemia in all HIV-infected patients independent of their HIV stage of progression.

Clinical characteristics and outcome of Brucella endocarditis

2009-03-18

Brucella endocarditis, a rare complication of brucellosis, is the main cause of death attributable to this disease. There are difficulties in the diagnosis and uncertainty regarding many aspects of the treatment of Brucella endocarditis. We retrospectively examined the clinical characteristics and outcome of patients diagnosed with Brucella endocarditis. Of the six patients diagnosed as having Brucella endocarditis, four had valvular disease, one had aortic and mitral mechanic valve prosthesis (AVR + MVR) and one had secundum type atrial septal defect. Transesophageal echocardiography showed vegetations in four patients. Blood culture grew Brucella mellitensis only in two patients. Standard agglutination tests were elevated in all patients (range 1/320–1/10240). Four patients were managed with combined antibiotherapy and surgery. One refused further treatment and one refused an operation and follow-up was lost for that patient. Two patients died during follow-up; one having had a previous AVR + MVR operation refused further treatment and the other suffering renal failure. Due to the fulminant course of the disease, treatment should be initiated when there is a clinical suspicion, even if the culture results are unknown or negative. Agglutination titres aid in the diagnosis. A combination of antibiotherapy and surgery seems to be preferable treatment modality.

False negative serological tests may lead to misdiagnosis and mismanagement in osteoarticular brucellosis

Janmohammadi, N., Roushan, M. R. H. — 2009-03-18

Non-specific clinical presentations and paraclinical findings in osteoarticular brucellosis may mimic many other diseases and other causes of arthritis which could lead to misdiagnosis and mismanagement. We studied retrospectively the records of 232 patients with osteoarticular brucellosis who were admitted to the three teaching hospitals of Babol Medical Sciences University from April 2001 to September 2006. The distribution of osteoarticular involvement and their management were evaluated to determine if any cases had been misdiagnosed because of false negative serologic tests and who had, as a result, undergone inappropriate surgical interventions. Of 232 patients, 138 (59%) were male and 94 (41%) were female. Polyarthritis, monoarthritis, spondylitis and sacroilitis were seen in 91 (39%), 60 (26%), 43 (18.5%) and 38 (16.5%) patients, respectively. Two hundred and twenty-nine (98.7%) patients were diagnosed correctly and treated successfully; three (1.3%) were misdiagnosed and had been given inappropriate surgical interventions. Of these three patients, two (3.3%) were suffering from monoarthritis (hip joint) and one (2.3%) had spondylitis.

Diagnosis of malaria in children's outpatient departments in Abuja, Nigeria

Nomhwange, T. I, Whitty, C. J. — 2009-03-18

Over-diagnosis of malaria has previously been described, especially in East Africa. Abuja is the capital of the most populous country in Africa. Over-prescription of artemisinin-based combination therapy (ACT) antimalarials in Nigeria on the scale reported from other countries will result in substantial unnecessary use of this class of drug.

In a study of 1000 children seen in the outpatient paediatric clinics of four district hospitals in Abuja, 669 had history of fever, of whom 616 (92%) were diagnosed with malaria. Only 24 (3.8%) where confirmed by positive malaria slides. Of 82 malaria tests requested, 32 (40%) were not available when clinicians wrote their prescriptions. Of 256 children prescribed an ACT, 11 (4.4%) were test negative, eight (3.1%) test positive, in 11 (4.3%) the test was not available and the test was not requested for 219 (86%). The proportion of available negative slides for patients treated with an antimalarial was 23/26 (88%), which was similar to the 22/24 (91%) treated with an antimalarial who were test positive. Testing for malaria made almost no impact on ACT prescription or on all other antimalarials and antibiotics. Based on these findings there is high possibility of massive over prescription of antimalarials.

Surgical training in resource-limited countries: moving from the body to the bench - experiences from the basic surgical skills workshop in Enugu, Nigeria

Ezeome, E R, Ekenze, S O, Ugwumba, F, Nwajiobi, C E, Coker, O — 2009-03-18

Increasingly, many institutions and surgical groups are resorting to laboratory simulations when teaching surgical skills. The Association of Surgeons of Great Britain and Ireland partnered with the West African College of Surgeons and Johnson and Johnson Corporation to introduce basic surgical skills (BSS) training into West Africa. The local faculty at the University of Nigeria Teaching Hospital, Enugu, was able to use the opportunity of this partnership to establish a regular basic surgical skills training programme. The achievement in Enugu shows that, with a dedicated team of local faculties, giving the local medical trainers a short introduction to the practicalities of organizing and conducting BSS is enough to jump start the programme in resource-poor countries. The Enugu example is a model that should be emulated by centres in other resource-poor countries to make the course a regular feature of their surgical training.

The use of Foley's catheter in the removal of a coin in the oesophagus

Bowa, K, Bvulani, B, Mukonge, L — 2009-03-18

A coin in the oesophagus is a common paediatric emergency in Zambia. There are very few specialist surgeons and hospitals where endoscopic removal can be carried out in many resource-limited countries. The technique described here allows the removal of an ingested coin using an ordinary Foley's catheter. The use of this technique under fluoroscopic guidance has been described in literature. However, fluoroscopic facilities and trained radiologists are not commonly available in many parts of Africa. This technique is simple, safe and has a success rate close to that achieved by endoscopic removal.

Kawasaki disease: a clinical and epidemiological study of 70 children in Brazil

2009-03-18

This is a prospective study of a cohort of 70 children with Kawasaki disease (KD) admitted from April 2002 to April 2007 to a tertiary hospital in Brasilia, Brazil. Of the 70 children, only 32 (45.7%) were referred during the acute phase of the disease and only 15 (21.4%) were referred with the correct diagnosis. Coronary aneurysms were detected in 13 (18.5%). A high suspicion index is essential in order to detect new cases as KD is probably underdiagnosed in Brazil and other developing countries, and an early diagnosis will dramatically decrease its life-threatening complications.

Acalculous cholecystitis in a patient with Plasmodium falciparum infection after a trip to the Dominican Republic

Salinas, A, Puerta, A, Olmedo, J, Martinez, E, Blanch, J., Mateos, F, Tarraga, I — 2009-03-18

Acalculous cholecystitis has been associated with several infectious agents, but its relation with Plasmodium falciparum infection has not been clearly defined. This is the first case of acalculous cholecystitis produced by Plasmodium falciparum infection that is directly documented and should be included among the differential diagnoses of acalculous cholecystitis.

Neurological disorders in rural Africa: a systematic approach

Winkler, A. S., Mosser, P., Schmutzhard, E. — 2009-03-18

Empirical knowledge suggests that neurological disorders are common in sub-Saharan Africa. The aims of our study were to assess the hospital-based prevalence of neurological disorders in a rural African setting and to suggest a systematic approach to disease classification. Of 8676 admissions (over a period of eight months) 740 patients (8.5%) were given a neurological diagnosis; cases were grouped according to diagnostic certainty. We suggest three major categories for neurological disorders (group 1 = no diagnostic uncertainties; group 2 = minor diagnostic uncertainties; group 3 = major diagnostic uncertainties) with clinical implications.

Complications of paediatric elbow trauma treatment by traditional bonesetters

Butt, M. F., Dhar, S. A., Gani, N. U., Kawoosa, A. A — 2009-03-18

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.

Brucellosis in central Anatolia: evaluation of complications and relapse

Naz, H., Aykin, N., Cevik, F., Bal, C. — 2009-03-18

Brucellosis is an infectious disease involving many organs and tissues. We investigated retrospectively the brucellosis cases at our hospital, in order to study the relationship between clinical, laboratory and therapy findings, and relapse rates. We found that relapse was related to a positive family history, living in a rural area and the presence of complications.

Atypical bacterial pathogens in community-acquired pneumonia in children: a hospital-based study

Agarwal, J., Awasthi, S., Rajput, A., Tiwari, M., Jain, A. — 2009-03-18

A total of 243 children aged one month to five years with World Health Organization defined severe community acquired pneumonia were studied for the presence of atypical bacterial pathogens: 24 were found positive for mycoplasma infection. There was no significant association with any of the clinical, laboratory and radiological variables in children with pneumonia by the atypical pathogen.

Tuberculous mycotic aneurysm of aortic root: an unusual cause of cardiac tamponade

2009-03-18

We describe a young male who presented to the emergency room with sudden onset dyspnea, and was found to have aortic root aneurysm with aortic regurgitation and cardiac tamponade. He underwent a Bentall procedure, and excised aortic root tissue showed epithelioid cell granulomas with panaortitis. He was started on anti-tubercular therapy, with which he improved. Although tubercular aortitis is fairly common, tuberculous mycotic aneurysm of the aorta is rare, with involvement of the aortic root being exceedingly uncommon. We report only the fifth case in English literature of tuberculous mycotic aneurysm of the aortic root.

Ascariasis-associated worm encephalopathy in a young child

Jat, K. R., Marwaha, R K, Panigrahi, I., Gupta, K. — 2009-03-18

Infestation with Ascaris lumbricoides in children has a varied manifestation, but encephalopathy is a very rare presentation. This report describes a case of ascariasis-associated encephalopathy in a child. An 18-month-old boy was admitted with altered sensorium. He had a history of vomiting and was passing Ascaris worms in the vomitus. The cerebrospinal fluid analysis did not reveal any abnormality. The patient was treated with an antihelminthic drug and he recovered completely. Worm encephalopathy should be considered as a differential diagnosis for unexplained encephalopathy in tropical areas.

Disseminated cryptococcosis in an HIV-negative patient

Rajpal, S, Dwivedi, S, Chaudhary, S. — 2009-03-18

A young, unmarried, immunocompetent female presented with complaints of fever and altered sensorium, along with lesions over the face and trunk. A provisional diagnosis of disseminated herpes simplex with giant molluscum contagiosum was made. However, cutaneous biopsy of the lesions showed numerous cryptococcal organisms which stained positive to periodic acid-Schiff. This case is reported to sensitise physicians to keep cryptococcosis as a differential diagnosis in such types of skin lesions, as the lesions resemble that of molluscum contagiosum very closely.

Dengue encephalitis: an entity now common in dengue-prone regions

Matlani, M., Chakravarti, A., Rawal, A., Kashyap, B., Gurtoo, A — 2009-03-18

As well as dengue fever (DF) and dengue haemorrhagic fever-dengue shock syndrome (DHF/DSS), other atypical manifestations of dengue virus infection have also been reported. The frequency of CNS involvement in dengue remains unknown, although isolated cases with neurological manifestations have been reported in Southeast Asia, Malaysia, Burma, Puerto Rico and India. We present two cases of encephalitis associated with DF and DHF from New Delhi, India.

Endomyocardial fibrosis: an enigmatic cause for a giant left atrium

Ker, J. — 2009-03-18

Endomyocardial fibrosis (EMF) was first described in 1948. It is an idiopathic disorder, characterized by the formation of fibrous tissue on the endocardial aspect of one or both ventricles, resulting in a restrictive cardiomyopathy with atrial enlargement. Originally described in Uganda, numerous cases have also been described in the Middle East.

Total knee replacement - the evolving sub-Saharan experience

George, A. O., Ofori-Atta, P. — 2009-03-18

Patients with moderate to severe osteoarthritis of the knee underwent primary elective knee arthroplasty in a well-equipped hospital in Accra, Ghana. Our main outcome measures was the new modified Oxford Knee scores (preoperative and postoperative scores). Median preoperative and postoperative knee scores were 10 and 42.5, respectively, at last follow-up with a P value <0.05 showing the reliability and significance of the scores. The average duration of inpatient hospital stay was 10 days. Of the seven patients who had surgery, one patient developed a chest infection postoperatively and another had failure of bone graft and required a revision. There was no postoperative wound infection or joint instability. The clinical outcome for this series of patients among other factors has been good within the prevailing circumstances and this shows that knee arthroplasty in developing Africa is a reality in the horizon.

Can brucella endocarditis be treated successfully with medical therapy alone?

Mohandas, N., Balasubramanian, R, Prasad, S. B. — 2009-03-18

Human brucellosis is caused by one of the three species of Brucella: Brucella mellitensis, B. abortus, and B. suis. Worldwide, the incidence of human brucellosis ranges from <0.01 to >200 per 100,000 population. Cardiovascular complications occur in <2%, but accounts for most of the mortality. Brucella endocarditis usually involves normal native aortic valves in 75% of cases. A combination of antibiotics and valve replacement is the most acceptable treatment. So far only 15 adult cases have been reported as having been cured with medical therapy alone. We report another case treated successfully with antibiotics alone.

Psoas abscess due to brucellosis

Kaya, S., Sayil, O. — 2009-03-18

Skeletal system involvement is a relatively common complication of human brucellosis. However, muscular involvement and psoas abscess are less frequently seen. Psoas abscess is usually secondary to spondylitis. We report on a 45-year-old man and a 51-year-old woman with brucellosis complicated with spondylitis and psoas abscess. The man was successfully treated with the triple antibiotic regimen with percutaneous drainage of abscess. The woman was treated using an antibiotic combination.

Plasmodium vivax malaria presenting as the nephrotic syndrome in an infant

David, J., Shanbag, P., More, V. — 2009-03-18

A randomised controlled trial comparing eusol and sugar as dressing agents in the treatment of traumatic wounds

Bajaj, G, Karn, N K, Shrestha, B P, Kumar, P, Singh, M. P. — 2009-02-10

We conducted a randomized controlled trial comparing EUSOL (Edinburgh University Solution of Lime) and sugar as dressing agents in the treatment of traumatic wounds. Patients in both groups were matched for age and gender. We found EUSOL did better than sugar in terms of contraction of size of wound, presence of discharge, floor area covered with slough, formation of healthy granulation and early possibility of wound coverage.

Improving glycaemic control in African diabetic patients on insulin: a resource-free approach

Gill, G. V, Gebrekidan, A., English, P. J, Tesfaye, S. — 2009-02-10

In the resource-poor areas of the tropics, diabetic patients requiring insulin are often treated with once-daily injections of intermediate-acting insulin. Glycaemic control on this regime is usually poor. We trialled a simple change to twice-daily insulin (same total daily dose, two-thirds given in morning, and one-third in evening) in a group of 20 Ethiopian diabetic patients treated in this way. Nurse support and contact, and self-glucose monitoring were not available. After three months, the haemoglobin Alc (HbAlc) had improved from 10.5 ± 1.8 to 8.0 ± 1.5% (P < 0.001). No improvement occurred in the 20 control patients who remained on once-daily insulin. Among the twice-daily insulin group there was a small increase in weight and mild hypoglycaemic episodes. However, all patients were very satisfied and wished to continue the new system. We conclude that a simple change from once- to twice-daily insulin, without monitoring or support, can lead to a significant improvement in the overall glycaemic control, and is suitable for resource-limited tropical countries.

A review of the epidemiology of cancers at the University Teaching Hospital, Lusaka, Zambia

Bowa, K, Wood, C, Chao, A, Chintu, C, Mudenda, V, Chikwenya, M — 2009-02-10

This is a retrospective study based on pathology reports of specimens reviewed at the University Teaching Hospital (UTH) pathology laboratory in Lusaka, Zambia, from January 1997 to December 2005. UTH is the main reference hospital in Zambia and has a catchment area covering 1.3 million people. The most common cancer among men was Kaposi's sarcoma followed by cancer of the eye, soft tissue sarcomas and cancer of the prostate. The most common cancer among women was cancer of the cervix, followed by cancer of the eye, cancer of the breast and Kaposi's sarcoma. Non-Hodgkin's lymphoma is the fifth most common cancer in both men and women. There has been a significant change in the pattern of malignancies at the UTH over the last 20 years, with an increase in Kaposi's sarcoma, cancer of the cervix and cancer of the eye.

Anal carcinoma in a tropical low socio-economic population in the new millennium: what has changed?

Irabor, D O, Dongo, A E — 2009-02-10

The paper is a retrospective look at the clinicopathological presentation of carcinoma of the anal canal in a tertiary health institution in Nigeria. Sixty-five patients were diagnosed with anal carcinoma over a five-year period (2002–2006) from a total of 394 patients who had malignancies of the colon, rectum and anus. The male: female ratio was 1.2: 1 showing a slight male predominance; the average age was 48 years; tenesmus, bleeding per rectum and anal pain were the most common presenting features. None of the patients tested positive to HIV during the duration of their stay in hospital. The most predominant histopathological subtype was adenocarcinoma – a departure from the hitherto squamous cell cancer dominance. Thus, only a few patients benefited from chemo-radiation; the majority had abdominoperineal resection while quite a significant proportion of patients (27.7%) declined any form of treatment for socio-cultural reasons.

Adolescent pregnancies and deliveries: problems encountered

Nkwabong, E, Fomulu, J N — 2009-02-10

Teenage pregnancies are increasing and need special attention. The aim of this retrospective study, conducted from 1 January 2004 to 31 December 2004 at the maternity department of the Yaoundé University Teaching Hospital, Cameroon, was to analyze the evolution of pregnancy and delivery in primiparous teenagers. The medical files of 190 teenagers and 403 patients aged between 20 and 25 years were analyzed and compared. Mean gestational age, the rate of pregnancy-induced hypertensive disease and the caesarean section rate were similar in both groups. However, there were a greater number of low Apgar scores, vaginal tears and instrumental deliveries in teenagers. Those aged 15 years or less had the additional risk of an increased rate of preterm labour, low birth weight and early neonatal death. Therefore, pregnancies and deliveries among teenagers, especially those aged 15 years or less, should be monitored regularly.

Is laparoscospic orchidectomy the treatment of choice in adults with impalpable testis in rural hospitals in the developing world?

Mir, I. S., Mohsin, M., Kirmani, O., Cheachek, B. A, Alam, I., Wani, M. — 2009-02-10

This study was undertaken in order to evaluate the feasibility and safety of performing laparoscopic orchidectomy (LO) in men for unilateral impalpable testis in non-teaching rural hospitals in a developing country. We also investigated the possibility of reducing the cost and length of stay in hospital for patients undergoing LO. This is a prospective analysis of patients with impalpable testis undergoing LO in three non-teaching rural hospitals in the Kashmir Valley from January 2001 to March 2007. The cohort represented men requiring LO aged 15 to 62 (mean 36.2) years. The main outcome parameters assessed included mortality, conversion to an open procedure, complications, reduction in the costs and the length of the hospital stay.

Forty-eight men with unilateral undescended testis on physical examination were studied. During laparoscopy the testis was identified near the deep ring in 30 patients, intra-abdominally in 16, and two had blind-ending vas and spermatic vessels near the deep ring. In 46 patients orchidectomy was performed. There were no deaths and none of the patients required conversion to an open procedure. Using reusable instruments, 00° polyglactin sutures and self-made extraction bags, about US$ 300/patient was saved. There was no case of malignancy of the testis on histopathology examination. LO is one of the most satisfactory methods for the management of men with impalpable testis, having both a diagnostic and a therapeutic role especially for patients in the underdeveloped countries. These simple methods can reduce the cost and the length of the hospital stay.

Barriers experienced by parents of children with clubfoot deformity attending specialised clinics in Uganda

Kazibwe, H., Struthers, P. — 2009-02-10

Clubfoot is a congenital structural impairment that, if untreated or inadequately treated, leads to deformity. Effective management is dependent on the compliance of parents to the treatment for clubfoot. A cross-sectional descriptive survey using a questionnaire identified the barriers parents encounter in bringing their children for treatment during the plaster-casting stage of managing clubfoot at the Talipes Clinics at Mbarara Regional Hospital and Mulago Hospital in Uganda. A total of 167 parents participated in the study. Ninety percent of the parents had attended weekly clinics with 67% indicating that they did not know about clubfoot and its treatment. The study found a significant association between compliance and transport costs (P = 0.014); distance travelled (P = 0.005); and family support (P = 0.028). Other barriers highlighted include the need to improve the communication skills between clinicians offering treatment to children with clubfoot and their parents. Informed parents could assist with compliance to treatment.

Newer methods over the conventional diagnostic tests for tuberculous meningitis: do they really help?

Baveja, C P, Gumma, V., Jain, M., Choudhary, M., Talukdar, B, Sharma, V K — 2009-02-10

Rapid diagnosis of tuberculous meningitis (TBM) is crucial as the disease outcome depends on the stage at which the treatment is initiated. The reliability of the available tests has not been established; thus, the present study was conducted to evaluate the conventional diagnostic tests as compared to the newer methods. Cerebrospinal fluid was collected from 100 children, and analyzed for various biochemical and cytological tests. The samples were subjected to Ziehl-Neelsen (Z-N) staining, Lowenstein-Jensen (L-J) culture, BACTEC culture and polymerase chain reaction (PCR). Twenty-two patients could be identified as definitive TBM based on the demonstration of Mycobacterium tuberculosis by BACTEC culture and PCR. Of these 22 cases, Z-N staining was positive in only two and L-J culture in six cases. Both the BACTEC culture and PCR had 100% agreement in the diagnosis of TBM. However, BACTEC culture could be a better diagnostic test as drug sensitivity can also be performed by this method.

Audit of the use of sugar dressings for the control of wound odour at Lilongwe Central Hospital, Malawi

Chiwenga, S, Dowlen, H., Mannion, S. — 2009-02-10

Seventy-one patients with malodorous, painful wounds were treated with sugar dressings in Lilongwe Hospital, Malawi, to assess the effects of such dressings on diminishing pain and odour. Pain and odour were assessed at the beginning of dressing application and then at frequent intervals. Mean patient odour scores reduced from 5.45 (out of 10) on application to 2.94 at 10 days, and mean patient discomfort scores reduced from 6.73 on application to 3.87 at 10 days. This very cheap treatment produced reproducible benefits as part of an appropriate protocol for use in developing world hospitals with limited resources and nursing care.

Improved assessment of child nutritional status using target weights and a novel, low-cost, weight-for-height slide chart

Kerac, M., Seal, A., Blencowe, H., Bunn, J. — 2009-02-10

Correctly identifying malnourished or at-risk children is the critical first step towards appropriate nutritional interventions. To improve weight-for-height assessment and classification of nutritional status, we present a novel, low-cost, weight-for-height slide chart. We also describe a target weight system for monitoring children's progress towards nutritional recovery.

Unusual presentations of Salmonella Typhi infections in children

Mittal, S., Saxena, A., Garg, P. — 2009-02-10

We report on three children with Salmonella typhi presenting with fever and urticaria, thrombocytopenic purpura and meningitis. We suggest that clinicians should consider S. typhi infection as a diagnosis even when the presenting features are more typical of other illnesses.

Re-emerging chloramphenicol sensitivity and emerging low level ciprofloxacin resistance among Salmonella enterica serotype typhi isolates in North India

Gupta, V., Kaur, J., Kaistha, N. — 2009-02-10

Ciprofloxacin has become the antibiotic of choice for the treatment of typhoid fever with the emergence and worldwide spread of Salmonella enterica typhi strains resistant to chloramphenicol. However, the rampant use of ciprofloxacin gradually led to an increase in its minimum inhibitory concentration against S. enterica typhi. This threatened its therapeutic efficacy and resulted in the re-emergence of chloramphenicol-sensitive S. enterica typhi strains.

Fine needle aspiration cytology in the diagnosis of abdominal TB: a review of 92 cases

Handa, U., Garg, S., Mohan, H. — 2009-02-10

During a period of eight years (1999–2006), 92 cases of abdominal TB were diagnosed by fine needle aspiration cytology (FNAC). Based on our findings, FNAC is a simple, fast, accurate and inexpensive diagnostic procedure for cases of suspected abdominal TB.

Burden of cryptococcal meningitis in Malawi

Makombe, S. D, Nkhata, A., Schouten, E. J, Kamoto, K., Harries, A. D — 2009-02-10

There is little information about the national burden of cryptococcal meningitis (CM) in African countries affected by the HIV/AIDS epidemic. From April 2005 onwards, we used national supervision visits of all health facilities that provided antiretroviral therapy to collect data on the number of new patients diagnosed and treated for CM in the previous quarters - using mainly fluconazole registers. For two 12-month reporting periods, there were 2125 and 2464 patients suffering from CM, giving an estimated annual incidence of 2.2% and 2.6%, respectively, of those infected with HIV in Malawi. Between 40–50% of all patients with CM were diagnosed and treated at central hospitals; no more than 1% were diagnosed and treated at smaller antiretroviral therapy sites. These data are useful for quantifying the need for better diagnostic reagents and antifungal drugs.

Louse-borne relapsing fever in Ethiopian children: experience of a rural hospital

Ramos, J. M., Malmierca, E., Reyes, F., Tesfamariam, A. — 2009-02-10

We describe the epidemiological and clinical aspects of louse-borne relapsing fever (LBRF) in a series of children attending in a rural hospital in Ethiopia during 1997–2007. From a total of 249 cases of LBRF, 154 (61.4%) were children (<15 years). The most frequent symptoms were: fever, headache, dizziness and musculoskeletal pains. The overall case fatality rate was 2.4 (10% for patients <1.1 years; 3.4% for 1.1 to 4.0 years; and 0% >4.0 years [P = 0.05]). The mortality in children was less than in adults (13.2%) (P = 0.003).

The Philippines 2004 measles campaign: a success story towards elimination

Sobel, H., Ducusin, J., De Quiroz, M., Cabotaje, M., Olive, J.-M. — 2009-02-10

Prior to the 2004 Philippines Measles Follow up Elimination Campaign, measles caused an estimated 6000 deaths among Filipino children. After the campaign, cases and deaths decreased by 96.4% and 99.2%, respectively. The Nationwide Rapid Coverage Assessments, with an extensive system of feedback, was the prime factor in reaching the under-immunized areas.

Survival from adult tetanus in Lagos, Nigeria

Ajose, F. O A, Odusanya, O. O — 2009-02-10

A longitudinal recruitment of adult tetanus patients to determine the survival rate of adult tetanus patients was conducted at the Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria. One hundred and sixty-four patients were admitted and forty-nine (30%) survived. The only significant determinant of survival was young age (P = 0.017).

Late-stage HIV/AIDS among children: the missing diagnosis of a preventable disease

Gouveia, J., Souza, E., Falbo, A. — 2009-02-10

We studied 126 malnourished children who had been admitted to the Instituto Materno Infantil Professor Fernando Figueira (IMIP) hospital. Nine (7.1%) had confirmation of HIV infection and all fulfilled the AIDS-defining criteria – all had been infected through mother-to-child transmission. Only one HIV-infected mother had been screened for HIV infection during prenatal care. There is, therefore, a need to increase HIV testing in all malnourished patients, especially when routine screening for HIV infection during prenatal care is not automatically undertaken.

Aetiology of paediatric portal hypertension - experience of a tertiary care centre in South India

2009-02-10

The aetiological profile of paediatric portal hypertension in our hospital, a tertiary care centre in South India, showed that the commonest causes were extrahepatic portal venous obstruction (EHPVO) and cirrhosis. Wilson's disease was the most common cause of cirrhosis.

The pattern of epilepsy in a rural African hospital - an approach adapted to local circumstances

Winkler, A. S., Schaffert, M., Schmutzhard, E. — 2009-02-10

The classification of epilepsy, which represents the commonest neurological disorder throughout the developing world, has been difficult due to lack of diagnostic tools. Adapted to the circumstances of an epilepsy clinic in northern Tanzania, we grouped people with epilepsy (PWE) according to an adjusted version of the International Classification of Epileptic Seizures with the main groups being: generalized types of seizures (206 PWE) divided into those starting within (147 PWE) and those starting outside (59 PWE) a specific age range (6–25 years); and partial types of seizures (102 PWE) with subgroups of generalized seizures with diffuse brain damage (41 PWE), those with predominantly focal signs (60 PWE) and complex partial seizures (1 PWE). Clinical implications are discussed.

Disseminated Cysticercosis

Basu, G., Surekha, V., Ganesh, A. — 2009-02-10

Cysticercosis is a common public health problem in the Tropics. However, disseminated cysticercosis is rare. We report a patient with chronic liver disease and seizures, in whom a simple plain radiographic examination helped in narrowing down the differential diagnosis to disseminated cysticercosis. The diagnosis was confirmed by serum cysticercal antibody enzyme-linked immunosorbent assay (ELISA) and computerized tomography of the brain.

Delusional parasitosis over dermatological morbidity: diagnostic and therapeutic challenges

Suganthan, J. S, Rajkumar, A. P, Jagannath, C, Pulimood, S. A, Jacob, K S — 2009-02-10

Delusional parasitosis is a rare psycho-dermatological disorder that lacks standard management guidelines. We report a case of an elderly woman with long standing multiple dermatological illnesses who later developed delusional parasitosis. We highlight the pertinent diagnostic and therapeutic challenges. We support multidisciplinary collaborative care combining effective pharmacotherapy with efficient non-pharmacological measures.

A bizarre appearance of a common disease, tuberculous dactylitis, involving multiple digits in an adult

Chrispal, A., Prabhakar, T, Booruga, H. K. — 2009-02-10

Tuberculosis is a common illness in developing nations. Tuberculous dactylitis is an unusual manifestation of tuberculous osteomyelitis seen predominantly in children. A woman presented with painless, fusiform swelling of multiple digits of the hand. Synovial biopsy revealed granulomatous inflammation and the pus smear was positive for acid-fast bacilli. She underwent debridement of the involved digits and was initiated on antituberculous therapy. This is an unusual presentation of tuberculous dactylitis in an immunocompetent host which involved multiple digits in a single hand.

The use of boluses of propofol for the management of severe tetanus in a child

Petitjeans, F., Turc, J., Coulet, O., Puidupin, M., Eve, O., Benois, A. — 2009-02-10

Tetanus is endemic in many developing countries. Although propofol has been proposed for sedation in tetanus, the routine use of this drug has not been clearly documented in published reports. A few studies have reported its beneficial effects but no randomized studies are available. We describe the case of a five-year-old boy who presented with severe tetanus in East Africa. The antispastic therapy consisted of benzodiazepine infusion with the addition of titrated boluses of propofol. Intubation and mechanical ventilation were avoided.

The efficacy of dexamethasone treatment in massive enteric bleeding in typhoid fever

Hosoglu, S., Ustun, C., Geyik, M. F. — 2009-02-10

Rectal bezoars due to pumpkin seeds

Mirza, M. S., Al-Wahibi, K., Baloch, S., Al-Qadhi, H. — 2009-02-10

Rectal bezoars commonly occur due to seeds, especially in children living in countries south of the Mediterranean and in the Middle-East. Dried seeds are considered a delicacy and consumed widely. Inadequate chewing or hastily eating without removing the hull may lead to their impaction as bezoars, which may require manual removal under general anaesthesia.

Retroperitoneal necrotizing fasciitis - when a simple procedure turns ugly

Alvi, A., Shamsi, G. — 2009-02-10

We present a case series of patients who underwent simple perianal procedures outside this hospital but developed postoperative and life-threatening retroperitoneal necrotizing fasciitis. With a high index of clinical suspicion and radiological imaging, we were able to establish earlier diagnosis. Resuscitation, the use of intravenous broad-spectrum antibiotics, aggressive surgical debridement and continuous organ support were essential in achieving a positive outcome in both of these patients.

Conservative management of subacute puerperal inversion of uterus

Chandra, J A, Zahra, F, Qureshi, S — 2009-02-10

Subacute puerperal inversion of the uterus is preferably managed by surgery. Conservative management by Aveling's repositor or vaginal packing was cumbersome and took long. However, a long surgery scar over the uterus carries a high risk of uterine rupture in the next pregnancy. A series of four village women with subacute puerperal inversion of the uterus were treated with vaginal packing. A twice-daily rigorous routine of dressing and packing of the uterus was followed, along with supportive treatment. The uterus was raised high in the pelvis so as to stretch the round ligaments, which then slowly pulled out the fundus in about a month. The vaginal packing method may be sincerely attempted in young women from remote areas, as this would reduce the risk of uterine rupture in the next pregnancy.

Chikungunya in West Bengal, India

2009-02-10

Fever of unknown origin broke out in several districts of West Bengal, from August 2007 to December 2007. The cases were suffering from high fever, severe joint pain lasting for several weeks after clinical cure and appearance of skin rashes. Patients' sera were collected at least five days after fever and were analyzed to detect specific IgM antibodies. A total of 800 patients were investigated and 321 (40.13%) were found to be reactive for Chikungunya antibodies. Of the patients, 66% were male. Predominant signs and symptoms observed in the sero-positive cases were fever (100%), arthralgia (96%) and diffuse erythematous skin rash (94%). Of the patients, 3% had haemorrhagic manifestations. Re-emerging Chikungunya virus spread in epidemic form in several districts of West Bengal after a gap of four decades.

Evidence-based medicine practice in Africa: is it feasible?

Chica, H. O., Okello, E. — 2009-02-10

Evidence-based medicine (EBM) is slowly transforming medical practice in the developed world by allowing physicians to use valid, systematically reviewed medical evidence in their daily routine. This letter explores the applicability of EBM and its potential to improve medical practice in developing countries.

Skilled attendance at delivery: who or where?

Ekele, B. — 2009-02-10

The third United Nations Process Indicator for emergency obstetric care is the proportion of all births that take place in maternity or obstetric facilities. This is in conflict with the concept of skilled attendance at delivery. Here, a case is made for emphasis to be on who conducts the delivery and not necessarily where.

What's it in this picture?

Kivukuto-Mutendela, J, Kuhigwa, T, Bulabula, A — 2009-02-10

The authors recall the chemoprophylaxis of helminthiasis from a case of intestinal obstruction due to roundworms. Unfortunately, in tropical countries, young patients continue to have heavy surgery related to this aetiology.

The eunuch patient

Mukhopadhyay, A., Chowdhury, R. — 2009-02-10

Eunuchs in India, commonly known as ‘Hirjas’, are under-represented and marginalized. They rarely access conventional health-provider systems due to mistrust and fear of censure. This is the story of Asha, who was brave enough to approach a community medicine resident in a municipal hospital for medical aid and counselling, and how she brought home the message that every patient deserves dignity and respect.