Hypertension and Its Associated Mental Health Challenges Among Female African Refugees in Durban, South Africa

ABSTRACT

Hypertension is a serious medical condition that leads to various adverse health complications when left untreated. In addition to psychological challenge that female migrant refugees are exposed to premigration, they encounter barriers to care postmigration from xenophobia that affects their hypertension. We investigated the extent and mental health drivers of hypertension in refugees in Durban, South Africa. We interviewed 178 adult female African help-seeking refugees/migrants for hypertension (blood pressure ≥130/90 mm Hg) and mental health challenges (e.g., adverse childhood experience [ACE] and depression using the Center for Epidemiologic Studies-Depression scale). Eighty-six percent (n = 153) of participants were hypertensive, and based on the adjusted regression models, exposure to at least one ACE (adjusted odds ratio [aOR], 2.83; 95% confidence interval [CI], 1.11-7.26) and depression (aOR, 3.54; 95% CI, 1.10-11.37) were associated with hypertension, independent of smoking, alcohol, obesity, and physical exercise status. Hypertension and its associated mental health challenges are overlooked conditions in this population, with further efforts for screening being needed.

Clinical Sequelae Associated with Unresolved Tropical Splenomegaly in a Cohort of Recently Resettled Congolese Refugees in the United States-Multiple States, 2015-2018

Tropical splenomegaly is often associated with malaria and schistosomiasis. In 2014 and 2015, 145 Congolese refugees in western Uganda diagnosed with splenomegaly during predeparture medical examinations underwent enhanced screening for various etiologies. After anecdotal reports of unresolved splenomegaly and complications after U.S. arrival, patients were reassessed to describe long-term clinical progression after arrival in the United States. Post-arrival medical information was obtained through medical chart abstraction in collaboration with state health partners in nine participating states. We evaluated observed splenomegaly duration and associated clinical sequelae between 130 case patients from eastern Congo and 102 controls through adjusted hierarchical Poisson models, accounting for familial clustering. Of the 130 case patients, 95 (73.1%) had detectable splenomegaly after arrival. Of the 85 patients with records beyond 6 months, 45 (52.9%) had persistent splenomegaly, with a median persistence of 14.7 months (range 6.0-27.9 months). Of the 112 patients with available results, 65 (58.0%) patients had evidence of malaria infection, and the mean splenomegaly duration did not differ by Plasmodium species. Refugees with splenomegaly on arrival were 43% more likely to have anemia (adjusted relative risk [aRR]: 1.43, 95% CI: 1.04-1.97). Those with persistent splenomegaly were 60% more likely (adjusted relative risk [aRR]: 1.60, 95% CI: 1.15-2.23) to have a hematologic abnormality, particularly thrombocytopenia (aRR: 5.53, 95% CI: 1.73-17.62), and elevated alkaline phosphatase (aRR: 1.57, 95% CI: 1.03-2.40). Many patients experienced persistent splenomegaly, contradicting literature describing resolution after treatment and removal from an endemic setting. Other possible etiologies should be investigated and effective treatment, beyond treatment for malaria and schistosomiasis, explored.

"It isn't that we're prostitutes": Child protection and sexual exploitation of adolescent girls within and beyond refugee camps in Rwanda

BACKGROUND

While refugee camps can protect children from harm, they can also introduce new risks and vulnerabilities. Research suggests that adolescent girls are at particular risk for gender-based violence and sexual exploitation.

OBJECTIVE

This study aimed to identify existing social and economic vulnerabilities of female adolescents in refugee camps in Rwanda.

PARTICIPANTS AND SETTING

Research was carried out in two Congolese refugee camps in Rwanda.

METHODS

Ten focus group discussions (FGDs) were held with 87 boys and 79 girls aged 12-17 years Six FGDs were held with a total of 36 parents and caregivers in the two camps. Key informant interviews were held with nine local and national level stakeholders.

RESULTS

Study findings centered upon intersectionality. Camps designed for security and containment introduced new forms of vulnerability and threats. Economic stressors threatened the viability of families. Girls had material needs but few options to meet those needs within the camps. Their families expected them to do domestic work at home. Participants reported that the convergence of material deprivation, lack of economic opportunity, and vulnerability led to transactional sex and exploitation within and around the camps. The study concludes that vulnerabilities and threats associated with gender and generation must be examined concurrently with the conditions associated with being a refugee in a setting of protracted displacement.

Perceptions of Dietary Habits and Risk for Type 2 Diabetes among Congolese Immigrants

OBJECTIVE

To explore the perceptions of dietary habits and type 2 diabetes risk among Congolese immigrants living in the US.

METHODS

Data were collected from 20 in-depth interviews and photo-elicitation techniques conducted with Congolese immigrants. The PEN-3 cultural model was used as a guide to analyze the data collected.

RESULTS

Participants identified positive, existential, and negative perceptions, enablers, and nurturers associated with dietary habits and type 2 diabetes risk. Participants also acknowledged intrinsic cultural ways of understanding and interpreting the interaction between dietary habits and type 2 diabetes risk among the Congolese people which may influence their health-seeking practices.

CONCLUSIONS

The findings underscore the importance of culture and how sociocultural factors may play a role with designing culturally appropriate interventions aimed at addressing the risk for type 2 diabetes among Congolese immigrants in the US.

Pathological spirit possession as a cultural interpretation of trauma-related symptoms

OBJECTIVE

Spirit possession is a phenomenon frequently occurring in war-torn countries. It has been shown to be an idiom of distress entailing dissociative symptoms. However, its association with trauma exposure and trauma-related disorders remains unclear. This study aimed to explore subjective disease models and the relationship between pathological spirit possession and trauma-related disorders in the Eastern Democratic Republic of the Congo.

METHOD

Seventy-three (formerly) possessed persons (74% female, mean age = 34 years), referred by traditional and spiritual healers, were interviewed about their experiences of pathological spirit possession, trauma exposure, posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, shame and guilt, psychotic symptoms, somatic complaints, and the impairment of psychosocial functioning.

RESULTS

The most common disease model for pathological spirit possession was another person having sent the spirit, mostly a family member or a neighbor, out of jealousy or conflict over resources. Significant correlations were found between spirit possession over lifetime and PTSD symptom severity, feelings of shame and guilt, depressive symptoms, somatic complaints, and psychotic symptoms. Spirit possession during the preceding 4 weeks was associated with PTSD symptom severity, impairment of psychosocial functioning, and psychotic symptom severity.

CONCLUSIONS

The results of this study indicate that pathological spirit possession is a broad explanatory framework for various subjectively unexplainable mental and physical health problems, including but not limited to trauma-related disorders. Understanding pathological spirit possession as a subjective disease model for various mental and physical health problems may help researchers and clinicians to develop culturally sensitive treatment approaches for affected individuals. (PsycINFO Database Record

The Cycle of Violence: Associations Between Exposure to Violence, Trauma-Related Symptoms and Aggression--Findings from Congolese Refugees in Uganda

War-related trauma exposure has been linked to aggression and enhanced levels of community and family violence, suggesting a cycle of violence. Reactive aggression--an aggressive reaction to a perceived threat--has been associated with posttraumatic stress disorder (PTSD). In contrast, appetitive aggression--a hedonic, intrinsically motivated form of aggression--seems to be negatively related to PTSD in offender and military populations. This study examined the associations between exposure to violence, trauma-related symptoms and aggression in a civilian population. In semistructured interviews, 290 Congolese refugees were questioned about trauma exposure, PTSD symptoms, and aggression. War-related trauma exposure correlated positively with exposure to family and community violence in the past month (r = .31, p < .001), and appetitive (r = .18, p = .002) and reactive aggression (r = .29, p < .001). The relationship between war-related trauma exposure and reactive aggressive behavior was mediated by PTSD symptoms and appetitive aggression. In a multiple sequential regression analysis, trauma exposure (β = .43, p < .001) and reactive aggression (β = .36, p < .001) were positively associated with PTSD symptoms, whereas appetitive aggression was negatively associated (β = -.13, p = .007) with PTSD symptoms. Our findings were congruent with the cycle of violence hypothesis and indicate a differential relation between distinct subtypes of aggression and PTSD.

Antimalarial activity of medicinal plants from the Democratic Republic of Congo: A review

ETHNOPHARMACOLOGICAL RELEVANCE

Malaria is the most prevalent parasitic disease and the foremost cause of morbidity and mortality in the Democratic Republic of Congo. For the management of this disease, a large Congolese population recourses to traditional medicinal plants. To date the efficacy and safety of many of these plants have been validated scientifically in rodent malaria models. In order to generate scientific evidence of traditional remedies used in the Democratic Republic of Congo for the management of malaria, and show the potential of Congolese plants as a major source of antimalarial drugs, this review highlights the antiplasmodial and toxicological properties of the Congolese antimalarial plants investigated during the period of 1999-2014. In doing so, a useful resource for further complementary investigations is presented. Furthermore, this review may pave the way for the research and development of several available and affordable antimalarial phytomedicines.

MATERIALS AND METHODS

In order to get information on the different studies, a Google Scholar and PubMed literature search was performed using keywords (malaria, Congolese, medicinal plants, antiplasmodial/antimalarial activity, and toxicity). Data from non-indexed journals, Master and Doctoral dissertations were also collected.

RESULTS

Approximately 120 extracts and fractions obtained from Congolese medicinal plants showed pronounced or good antiplasmodial activity. A number of compounds with interesting antiplasmodial properties were also isolated and identified. Some of these compounds constituted new scaffolds for the synthesis of promising antimalarial drugs. Interestingly, most of these extracts and compounds possessed high selective activity against Plasmodium parasites compared to mammalian cells. The efficacy and safety of several plant-derived products was confirmed in mice, and a good correlation was observed between in vitro and in vivo antimalarial activity. The formulation of several plant-derived products also led to some clinical trials and license of three plant-derived drugs (Manalaria(®), Nsansiphos(®), and Quinine Pharmakina(®)).

CONCLUSION

The obtained results partly justify and support the use of various medicinal plants to treat malaria in folk medicine in the Democratic Republic of Congo. Antimalarial plants used in Congolese traditional medicine represent an important source for the discovery and development of new antimalarial agents. However, in order to ensure the integration of a larger number of plant-derived products in the Congolese healthcare system, some parameters and trends should be considered in further researches, in agreement with the objectives of the "Traditional Medicine Strategy" proposed by the World Health Organization in 2013. These include evaluation of geographical and seasonal variation, investigation of reproductive biology, assessment of prophylactic antimalarial activity, evaluation of natural products as adjuvant antioxidant therapy for malaria, development of plant-based combination therapies and monitoring of herbal medicines in pharmacovigilance systems.

One size fits all? Standardised provision of care for survivors of sexual violence in conflict and post-conflict areas in the Democratic Republic of Congo

Background

Outcomes of sexual violence care programmes may vary according to the profile of survivors, type of violence suffered, and local context. Analysis of existing sexual violence care services could lead to their better adaptation to the local contexts. We therefore set out to compare the Médecins Sans Frontières sexual violence programmes in the Democratic Republic of Congo (DRC) in a zone of conflict (Masisi, North Kivu) and post-conflict (Niangara, Haut-Uélé).

Methods

A retrospective descriptive cohort study, using routine programmatic data from the MSF sexual violence programmes in Masisi and Niangara, DRC, for 2012.

Results

In Masisi, 491 survivors of sexual violence presented for care, compared to 180 in Niangara. Niangara saw predominantly sexual violence perpetrated by civilians who were known to the victim (48%) and directed against children and adolescents (median age 15 (IQR 13–17)), while sexual violence in Masisi was more directed towards adults (median age 26 (IQR 20–35)), and was characterised by marked brutality, with higher levels of gang rape, weapon use, and associated violence; perpetrated by the military (51%). Only 60% of the patients in Masisi and 32% of those in Niangara arrived for a consultation within the critical timeframe of 72 hours, when prophylaxis for HIV and sexually transmitted infections is most effective. Survivors were predominantly referred through community programmes. Treatment at first contact was typically efficient, with high (>95%) coverage rates of prophylaxes. However, follow-up was poor, with only 49% of all patients in Masisi and 61% in Niangara returning for follow-up, and consequently low rates of treatment and/or vaccination completion.

Conclusion

This study has identified a number of weak and strong points in the sexual violence programmes of differing contexts, indicating gaps which need to be addressed, and strengths of both programmes that may contribute to future models of context-specific sexual violence programmes.

Mai-Mai militia and sexual violence in Democratic Republic of the Congo

This article sets the reasons for the brutal violence against women. It focuses on three field sites providing insight into Mai-Mai motivations and their attitudes toward sexual violence. According to most sources, 5.5 million people have died since the beginning of the war in the Democratic Republic of the Congo (DRC) in 1994, and rape is used as a weapon of destruction. More than 15,000 rapes were reported in the DRC in the last year--accounts of these rapes include descriptions of horrific acts, such as mutilation and the killing of unborn children. The sexual violence is so severe in the DRC that some have described rape in the country as the worst in the world. Sexual violence has long lasting consequences and far-reaching impacts on individual survivors, their families, and their communities in the Democratic Republic of the Congo.

Ferroportin Q248H mutation, hyperferritinemia and atypical type 2 diabetes mellitus in South Kivu

BACKGROUND

The ferroportin Q248H mutation is relatively common in sub-Saharan Africa. No previous study examined its relationship with atypical diabetes mellitus (DM) in this area.

OBJECTIVE

To determine the potential interactions between ferroportin Q248H mutation, hyperferritinemia and DM in South Kivu (RDC).

METHODOLOGY

Presence of ferroportin Q248H mutation and iron status were investigated in diabetic patients (n=179, age (mean) 57.7 years, CRP (median) 0.16 mg/L) and non-diabetic subjects (n=86, age 44.5 years, CRP 0.07 mg/L) living in the city of Bukavu. Hyperferritinemia was considered for values greater than 200 and 300 μg/L in women and in men, respectively.

RESULTS

The prevalence of ferroportin Q248H mutation [12.1%] was non-significantly higher in diabetics than non-diabetics [14.0% vs. 8.1%, p=0.17]. Similarly, hyperferritinemia frequency was higher in diabetic patients with Q248H mutation [44.0% vs. 14.3%, p=0.16] and in mutation carriers [37.0% vs 16.5%, p=0.001] than in the control groups, respectively. The association between Q248H mutation and DM was nevertheless not significant [adjusted OR 1.70 (95% CI: 0.52-5.58), p=0.37], whereas hyperferritinemia [OR 2.72 (1.24-5.98), p=0.01] showed an independent effect after adjustment for age and metabolic syndrome.

CONCLUSIONS

The present work suggests a potential association between abnormal iron metabolism, ferroportin Q248H mutation and atypical DM in Africans, which may be modulated by environmental factors.

Farming the battlefield: the meanings of war, cattle and soil in South Kivu, Democratic Republic of the Congo

Prior to 1996 and the Congolese wars, exploitative land policies pushed farmers in the eastern highlands of the Democratic Republic of the Congo (DRC) into a vulnerable position, with cattle manure sustaining intensive cultivation. This exposed households to a complete breakdown in mixed farming as cattle became targets of war. This study of villages in South Kivu offers an inside understanding of continuity and change in farming practices in a region where there are no easy solutions, and it assesses how the province lost its present and where farmers look when they glance to the future. For farmers, who hold a broad view of soil fertility, the casualties of war were not only people and cattle but also the land itself, which has enduring scars. Perceiving a rupture in tradition, South Kivu farmers are searching desperately for new livelihoods that are built on education instead of livestock, setting aside old ethnic signifiers to seek a future beyond protracted conflict.

Persistence of high fertility in tropical Africa: the case of the Democratic Republic of the Congo

The article explores how geography, history, and society have shaped childbearing behaviors over the last half-century, and how they are now being reshaped by modernity and the exigencies of urban life, in the democratic Republic of the Congo. The decline of prolonged postpartum abstinence and involuntary childlessness initially raised fertility to high levels (6–7 children per woman). More recently, socioeconomic differentials in fertility have emerged, suggesting that the country may be entering a phase of fertility decline. A full-blown transition, however, seems still a remote prospect. Supported both by cultural traditions and by economic rationality, Congo's people remain largely convinced of the benefits of many children for their own and their kin's security. While an eventual fertility transition may be taken for granted, the article examines the many hurdles, contradictions, and tensions that will have to be overcome to achieve that outcome.

The metabolic syndrome in a Congolese population and its implications for metabolic syndrome definitions

AIM

Metabolic syndrome defined by International cut-off values are limited to detect people at high cardiometabolic risk in Central Africans in comparison with metabolic syndrome defined by ethnic-specific definition. We examined the relationship between metabolic syndromes, diabetes control, abdominal obesity, HDL-cholesterol groups and atherosclerotic complications.

MATERIALS AND METHODS

A representative sample of type-2 diabetic central Africans from Kinshasa were studied. Outcome measures included control of diabetes, atherosclerosis, abdominal obesity, insulin resistance, total cholesterol, triglycerides, HDL-cholesterol, metabolic syndromes and atherosclerosis.

RESULTS

Of 1266 type-2 diabetic patients (48.8%), (61.8%), (27.1%) and (81%) had uncontrolled diabetes, atherosclerotics, metabolic syndrome (IDF/Europe), and metabolic syndrome (IDF/local) respectively. There was a significant U-shaped relationship between atherosclerotics complications, insulin resistance, delta postprandial glycaemia and HDL-cholesterol stratification. There was also a significant U-shaped relationship between cardiometabolic risk (P<0.01) and atherosclerotic complications.

CONCLUSION

Type-2 diabetic Central Africans exhibit very high rates of uncontrolled diabetes, atherosclerotic complications and metabolic syndrome. Both, abdominal obesity, insulin resistance, low and very high HDL-cholesterol levels are cardiometabolic risk factors.

The land of milk and honey: a picture of refugee torture survivors presenting for treatment in a South African trauma centre

Intake data obtained from 55 refugee torture survivors accessing trauma treatment services at a centre in Johannesburg, South Africa, paints a picture of suffering beyond the torture experience. The intake forms part of a more comprehensive monitoring and evaluation system developed for the work done with torture survivors accessing psychosocial services. The diverse sample with different nationalities highlights that torture occurs in many countries on the African continent. It also highlights South Africa's role as a major destination for refugee and asylum seekers. However, "the land of milk and honey" and the process of arriving here, often poses additional challenges for survivors of torture. This is reflected in the high levels of Post Traumatic Stress Disorder (69%), anxiety (91%), and depression (74%) for our sample, all of which were significantly correlated. The loss of employment status from before the torture experience until the time of intake was great for this sample, impacting on their recovery. In addition the presence of medical conditions (44%), disabilities (19%), and pain (74%) raise serious questions regarding interventions that focus mainly on psychosocial needs. No significant gender differences were found. The paper begins to paint a clearer picture of the bio-psycho-social state of torture survivors accessing services in South Africa, as well as highlighting many of the contextual challenges which impact on recovery.

HIV-positive man from DRC deemed a "person in need of protection"

In an in camera hearing on 9 July 2008, the Refugee Protection Division of the Immigration and Refugee Board of Canada, accepted that the manner in which the government of the Democratic Republic of the Congo (DRC) dealt with the HIV epidemic in its country posed a "risk to life" to an HIV-positive man from that country who was applying for asylum in Canada.

Clinical correlates of left ventricular hypertrophy in black patients with arterial hypertension

OBJECTIVE

To assess the relationship between the lipid profile, other cardiovascular risk factors and left ventricular hypertrophy (LVH) in black hypertensive patients.

MATERIALS AND METHODS

We undertook a cross-sectional study of a case series at the hypertension clinic, University of Kinshasa Hospital. Lipids, lipoproteins and other cardiovascular risk factors were analysed in 100 consecutive hypertensive patients. Left ventricular hypertrophy was assessed by 12-lead electrocardiography (ECG) using Cornell voltage index.

RESULTS

Forty-eight hypertensive patients, 26 men and 22 women, had LVH. With univariate analysis, the patients with LVH were older (age 52 +/- 9 vs 45 +/- 9 years; p </= 0.001), had higher pulse pressure levels (57 +/- 11 vs 50 +/- 15 mm Hg; p </= 0,01), and more were receiving antihypertensive treatment (68 vs 28%; </= 0.001) compared to those without LVH. With multiple logistic regression analysis, the duration of hypertension, high high-density lipoprotein cholesterol (HDL-C) and plasma glucose levels, and being on antihypertensive treatment have emerged as the main predictors of the presence of LVH. The patients with duration of hypertension two years or more (adjusted OR 7.23; 95% CI: 1.576-42.884) had a higher risk for LVH; however, those with HDL-C >/= 1.03 mmol/l (adjusted OR 0.19; 95% CI: 0.057-0.651), plasma glucose >/= 6.11 mmol/l (adjusted OR 0.19; 95% CI: 0.046- 0.828), or on treatment for hypertension (adjusted OR 0.23; 95% CI: 0.082-0.645) had a lower risk for cardiac damage compared to their respective control groups.

CONCLUSION

LVH is a common complication in Congolese hypertensives. Dyslipidaemia, high plasma glucose levels, the duration of hypertension and being on antihypertensive therapy appear to be the main predictors of hypertensive cardiac damage.

Refugee Women's Health: Collaborative Inquiry with Refugee Women in Rwanda

A collaborative capacity building experience in a Rwandan refugee camp with refugee women from the Democratic Republic of Congo (DRC) is described in this article. In service to the American Refugee Committee, I taught 13 refugee women how to plan and facilitate focus group sessions with the larger community of refugee women. The facilitators then conducted 18 focus group sessions gathering data from 100 refugee women. Thematic results included the health implications of poverty, the struggle to survive, the overburden of daily work, ambivalence about family planning, and the lack of freedom to express themselves.

Action responses of Congolese refugee women

PURPOSE

To describe Congolese refugee women's action responses to difficult living situations.

DESIGN

Interpretive qualitative.

METHODS

Narrative data were collected from 14 Congolese refugee women using minimally structured interviews and were analyzed for patterns in their responses to their difficult situations.

FINDINGS

The narratives about participants' difficult circumstances indicated six action responses: refiguration, advocacy, resistance, resignation, sorrow, and faith.

CONCLUSIONS

When encountering difficult life circumstances, refugee participants demonstrated actions with varying influence on their agency.

Maternal Depression and Anxiety and Infant Development: A Comparison of Foreign-Born and Native-Born Mothers

Studies that investigate infant and/or child development in families of depressed or anxious mothers do not include samples of foreign-born non-English-speaking mothers. This article describes a pilot study investigating infant development, maternal depression, and anxiety in comparison samples of native-born and foreign-born mothers and children from Vietnam, Laos (Hmong), and the Democratic Republic of Congo. Maternal depression and anxiety were measured with the Hopkins Symptom Checklist-25, and the developmental status of children 0-25 months of age was measured with the Denver II. Foreign-born mothers were more anxious than native-born mothers. Non-English-speaking foreign-born mothers were clinically depressed (1.83) and moderately anxious (1.62). Infants of native-born mothers and English-speaking foreign-born mothers performed better on the Denver II than children of foreign-born non-English-speaking mothers. Infants and toddlers of non-English-speaking mothers appear to be at high risk for delays during their first 25 months of life. Public health nurses need to advocate for appropriate interpreter services and mental health resources for non-English-speaking mothers of young children. Developmental screening should reflect cultural variations in parental expectations of how and when children meet developmental milestones. Replication studies and investigation about the long-term development of this high-risk group of children are needed.

[Diagnostic image (105). A woman with painful nodules. Infection with O. volvulus]

A 17-year-old woman from the Democratic Republic of Congo presented with painful nodules on the legs and malaise. An infection with Onchocerca volvulus was diagnosed.

HLA class II polymorphism in Aka Pygmies and Bantu Congolese and a reassessment of HLA-DRB1 African diversity

HLA-DRB1, -DQB1 and -DPB1 polymorphisms were investigated in two African populations, the Basse Lobaye Aka Pygmies of the Central African Republic, and a Bantu-speaking group from the Democratic Republic of Congo Kinshasa. Allelic and haplotypic frequency distributions reveal marked differences between the two populations in spite of their geographical proximity: the Aka exhibit high frequencies for several alleles, especially at the DPB1 locus (0.695 for DPB1*0402), probably due to rapid genetic drift, while the Bantu distributions are more even. Genetic distances computed from DRB1 allelic frequencies among 21 populations from North and sub-Saharan Africa were applied to a multidimensional scaling analysis. African populations genetic structure is significantly shaped by linguistic differentiation, as confirmed by an analysis of molecular variance. However, selective neutrality tests indicate that many African populations exhibit an excess of heterozygotes for DRB1, which is likely to explain the genetic similarity observed between some North African and Bantu populations. Overall, this study shows that natural selection must be taken into account when interpreting the patterns of HLA diversity, but that this effect is probably minor in relation to the stochastic events of human population differentiations.

[Disseminated infection by Histoplasma capsulatum with AIDS]

Histoplasmosis is an illness which occurs very rarely in Europe and it is especially rare in Germany. A generalised infection with Histoplasma capulatum, a systemic mycosis of the mononuclear phagocyte system (MPS), occurs only in individuals with weakened immune systems. Within the framework of diagnostics, a pathologist can be confronted with histoplasmosis since there has been an increase in travel to and from endemic regions, as well as an increase in the number of diseases of the immune system. The presented case reports the histological intravital and post-mortem diagnostics of disseminated histoplasmosis in existing HIV-infection in the stage of manifest AIDS.

[Glucose-6-phosphate dehydrogenase deficiency in 2 girls]

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common erythrocyte enzymopathy, affecting over 400 million people worldwide. Portugal is a low prevalence country, but immigrants from endemic regions are common, particularly in the south of the country. In the present study, we report the laboratory findings observed in two black proband children with low G6PD enzyme activity (23 and 18%). The study also included their first-degree relatives. Both biochemical parameters (enzyme activity, electrophoretic mobility and cytochemical test) and genetic determinations (mutation and haplotype characterisation) were performed.

[Acute pulmonary syndrome and cavernous pulmonary tuberculosis in a patient with sickle cell disease]

HISTORY AND CLINICAL FINDINGS

A 17-year-old girl from Zaire was admitted to hospital with fever, cough, dyspnoea and severe chest pain. In addition to marked anaemia (haemoglobin 6.6 g/dl) she was known to have cavitary/exudative pulmonary tuberculosis (PTb) with bilateral basal infiltrations.

INVESTIGATIONS

Blood gas analysis indicated partial respiratory failure (pO2 55 mm Hg, pCO2 36 mm Hg). Blood smear under air exclusion showed erythrocyte sickling. Haemoglobin electrophoresis demonstrated 92.7% HbS and thus confirmed sickle cell anaemia. A small spleen on sonography and the presence of Howell-Jolly bodies were interpreted as signs of functional asplenia. Microbiological and radiological tests confirmed exudative-cavitary PTb.

TREATMENT AND COURSE

The findings were interpreted as due to an acute chest syndrome, caused by sickle cell thrombi in the pulmonary blood vessels, precipitated by the PTb. Transfusion of two units of erythrocyte concentrates led to improvement of the chest pain and the respiratory failure within a few hours. The PTb was successfully treated without any complications.

CONCLUSION

Acute chest syndrome is a vascular occlusive complication of sickle cell disease, pulmonary tuberculosis precipitating the development of this acute condition. Administration of erythrocyte concentrate rapidly improves the signs and symptoms.

IGF-I resistance in virus-transformed B-lymphocytes from African Efe Pygmies

To investigate IGF-I resistance in African Efe Pygmies, we examined clonal responsiveness to IGF-I in Epstein-Barr virus-transformed B-lymphocytes from three Efe Pygmies and three American control subjects. The Efe B-lymphoblasts did not increase clonal responsiveness when incubated with IGF-I (as high as 250 micrograms/liter) in contrast to the control B-lymphoblasts which showed a bimodal dose-response with a maximal stimulation of 50% above baseline. The proliferative response of Efe B-lymphoblasts was similar to that of control B-lymphoblasts when incubated with another growth factor, phorbol 12-myristate 13-acetate, which does not activate the IGF-I receptor. These findings indicate that Efe Pygmy B-lymphoblasts are resistant to IGF-I as measured by in vitro clonal proliferation assays. Coupled with our previous report of IGF-I unresponsiveness in Efe Pygmy HTLV-II-transformed T-lymphocytes, these data suggest that IGF-I resistance is generalized and may play a central role in the etiology of short stature in this population.

Relationship between mephenytoin, phenytoin and tolbutamide hydroxylations in healthy African subjects

Mephenytoin, phenytoin and tolbutamide are metabolised by the cytochrome P-450 (CYP) 2C family. Recently, it has been shown that phenytoin and tolbutamide are metabolised by CYP2C9/10 whereas mephenytoin is metabolised by CYP2C19. Until now, in vivo studies were only undertaken in Caucasian subjects and showed a strong relationship between phenytoin and tolbutamide metabolism but no significant relationship between the two drug metabolisms and that of mephenytoin. The metabolism of the three drugs was investigated in eight black Africans by urinary analysis. In this ethnic group, a strong relationship was found between phenytoin and tolbutamide oxidations (rs = -0.83, P = 0.01). On the other hand, no significant relationship was found between mephentoin oxidation and phenytoin or tolbutamide oxidations (rs = 0.31 and rs = -0.33, respectively). This study suggests that, in black Africans, phenytoin and tolbutamide but not mephenytoin are also hydroxylated by similar CYP enzyme(s).

Insulin-like growth factor I resistance in immortalized T cell lines from African Efe Pygmies

Previous investigations suggested that resistance to GH was the cause of short stature of African Pygmies. Because many of the actions of GH are mediated by insulin-like growth factor I (IGF-I), we sought to determine whether Pygmy tissue was responsive to IGF-I. An initial effort to obtain HTLV-II-transformed T lymphoblast cell lines resulted in a single cell line that showed complete resistance to both IGF-I and GH in a clonal proliferation assay as well as decreased IGF-I binding. In the current study, we examined T cell lines from seven Efe Pygmy subjects, three neighboring Lese farmers, and six American controls and quantified clonal responses to IGF-I, GH, and insulin. The T cell lines from the Efe Pygmies were all completely resistant to the growth-promoting actions of IGF-I concentrations less than 250 micrograms/L and GH concentrations less than 500 micrograms/L. The Lese population, with whom there is admixture with the Efe population, showed heights and clonal responses to IGF-I and GH intermediate between those of Pygmies and American controls. The Pygmy T cell lines showed reduced clonal proliferation in response to high insulin concentrations known to act through the IGF-I receptor. These findings indicate that genetic IGF-I resistance is present in the T cell lines of Efe Pygmies and suggest that unresponsiveness to IGF-I may be responsible for their short stature.

[Trichophyton soudanense as the pathogen of tinea corporis et capitis]

Tinea capitis and corporis caused by Trichophyton soudanense were identified in a 6-year-old coloured boy who was born in Zaire and had been living for 3 years in Germany. This dermatophyte is very rarely seen outside the region in Africa where it is endemic. The disease is frequently overlooked at diagnosis because of the pathogen's capacity for causing chronic and oligosymptomatic infections. In our case the tinea did not a become apparent until the patient had been in Germany for 3 years. No-one else in his family had any comparable scalp or skin lesions. Consistent therapy with itraconazole (Sempera) dosed at 3 mg/kg body weight per day over a period of 4 weeks led to a permanent cure.

Examining ethnomedical diagnoses and treatment choices for diarrheal disorders in Lubumbashi Swahili

This article examines the basis of ethnomedical classification of diarrheal disease among the Swahili speaking population of Lubumbashi, Zaire and the association of specific diagnoses with treatments given. Results from two research methods are reported: group interviews and large sample surveys. A series of group interviews with mothers of small children provided information about how they commonly diagnose illnesses related to childhood diarrheal disease as well as which symptoms, causes, and treatments they associate with those illnesses. Data from the interviews were used to formulate questions about the diagnosis of illness and treatments given for recent cases of diarrhea. A baseline and a follow-up survey provided information about the symptoms associated with reported episodes of illness and about the treatments given at home. The results provide evidence that ethnomedical diagnoses are based on observed symptoms, that they affect how and why oral rehydration therapy (ORT) is used or not used for diarrhea, and that the terms chosen by survey researchers to ask about diarrhea and ORT may affect survey results in predictable and systematic ways.

Distribution of HLA and haplotypes of Colombian and Jamaican black populations

To investigate the genetic background of the black populations of Colombia and Jamaica, we determined HLA types of 78 Colombian and 98 Jamaican blacks from 2 different socioeconomic groups (Jamaican #1 and Jamaican #2) and estimated the frequencies of HLA genes and haplotypes. A phylogenetic tree based on the HLA gene frequencies revealed that Jamaican #1 and Jamaican #2 were distinct from each other, Jamaican #1 being closely related to the Colombian blacks and the Jamaican #2 being closely related to Senegalese and Zairean populations. Three-locus HLA haplotypes of Colombian and Jamaican #1 blacks were an admixture between Africans and Caucasians or South American Indians, while Jamaican #2 blacks were relatively homogeneous and appeared to conserve African lineages. The major five-locus HLA haplotypes were not shared among Colombian, Jamaican #1 and Jamaican #2 blacks. These results indicated that the black populations of Colombia and Jamaican were originated from African blacks and admixed variably with Caucasians and South American Indians to make genetic subpopulations in Colombia and Jamaica.

Ischaemic heart disease risk factors in young black Africans from urban Zaire

Blood pressure, pulse and body mass index were measured in 64 healthy black men, aged 20-44 years, from an urban region in Zaire. A required blood test for AIDS was extended to include plasma renin activity (PRA), total cholesterol (TC), triglycerides (TG) and high density lipoprotein cholesterol (HDL-C). Mean BMI was 21.99. Mean BP was 132.2/85.3 mmHg and hypertension (> 160/95 mmHg) was found in 17.2% of subjects. Very low PRA was found in 28 subjects and high PRA in one normotensive man. Mean PRA was 1.3 +/- 1.2. Mean plasma TC, TG and HDL-C were 136, 84, and 46 mg/dl, respectively, and mean TC/HDL-C ratio was 3:1. The frequency of hypertension in this study population is higher than that previously described for a different segment of the same population. It is, however, offset by a more favourable lipid profile that determines a more favourable overall cardiovascular risk profile.

[Molecular analysis of an African family with sickle cell disease and alpha-thalassemia-2]

An etiological examination was performed on the DNA of a 13-year-old Zairean girl, who had some abnormalities in hematological and red cell morphological examinations and was homozygote for an abnormal Hb like HbS. DNA was amplified by the PCR method to obtain 1.7 kb size DNA containing the 5' region of the beta globin gene. The amplified DNA was digested with Eco 81 I and electrophoresis of the digest revealed the absence of its active site, which is on codons beta 5-7 (CCTGAGGAG) of the normal DNA. Sequencing of the cloned DNA by the dideoxy method confirmed that the codon beta 6 (GAG, Glu) mutated to a new codon GTG (Val) which is the beta S globin gene producing abnormal HbS. The haplotype of the chromosome having beta S gene was --+---++, which is the most common type in Zaire area. On the other hand, when the genomic DNA was digested with Bgl II or Bam HI and hybridized to an alpha probe, a fragment (16 kb/Bgl II or 10.5 kb/Bam HI) in addition to the normal ones (12.5 and 7.5 kb/Bgl II or 14 kb/Bam HI) was observed. This resulted from the deletion of 3.7 kb from the alpha gene arrangement, which led to alpha-thalassemia-2 (genotype: alpha 3.7-/alpha alpha). A family study demonstrated that her parents were heterozygote for HbS and her father had alpha-thalassemia-2.

[Transmission of the human immunodeficiency virus during breast feeding and heterosexual contacts]

Two cases of the transfer of HIV infection are described: a child got HIV infection through breast feeding from the mother infected with HIV as the result of blood transfusion made 2 weeks after the birth of the child and 2 men were infected with HIV as the result of sexual relations with a woman found to be a HIV carrier.

Hysterical manifestations in Africa and Europe. A comparative study

A group of 30 black African patients and a group of 30 occidental patients, all presenting a hysterical structure, were compared with regard to clinical manifestations, provoking psychosocial stressors and histrionic personality traits. Cultural characteristics in several areas are discussed as possible explanations of the differences found.

AIDS in two African infants born in Belgium

Two African infants born in Belgium, dying from the acquired immune deficiency syndrome are reported. The first patient was a premature baby girl born to healthy parents. However, her asymptomatic mother was found to have polyclonal hypergammaglobulinaemia, a reversed T-helper/T-suppressor ratio and a decreased lymphocyte response to mitogens. The second patient's mother was treated for pneumocystis carinii pneumonia during the fourth month of gestation and was subsequently diagnosed with AIDS. The rapid clinical evolution of the acquired immunodeficiency syndrome in infancy suggests that the incubation period is shorter than in adults.

[Results of abdominal x-ray computed tomography in 25 patients with the acquired immunodeficiency syndrome or the lymphadenopathy syndrome]

An abdominal computed tomographic examination was performed to 20 patients with Acquired Immunodeficiency Syndrome (AIDS) and to 5 patients with Lymphadenopathy Syndrome (LAS). Intraabdominal lymph nodes were seen in 18 out of 20 cases of AIDS and in 5 cases of LAS. Lymph nodes have a normal size or are slightly enlarged but they are too numerous. Splenomegaly was found in 17 patients. Rectal modifications secondary to a proctitis were seen in the homosexual patients.

Lymph node modification in patients with the acquired immunodeficiency syndrome (AIDS) or with AIDS related complex (ARC). A histological, immuno-histopathological and ultrastructural study of 45 cases

The authors present the results of a histopathological study on the lymph-nodes taken from 45 subjects suffering from either an AIDS or from a chronic adenopathy corresponding to the definition of AIDS related complex (ARC). The various aspects observed were classed as type I to type IV. The lymph-node modifications observed in the 29 patients with an ARC could be divided into three principle groups: an extensive follicular hyperplasia associated with other elementary lesions or type IA (25 lymph-nodes from 23 patients); changes resembling a multicentric Castleman syndrome or type IB (1 case); angioimmunoblastic-like (AIL) lesions or type II (2 cases) and an association of lesions of type II (7 lymph-nodes from 6 patients). During AIDS, the adenopathy usually disappears, and the small lymph-nodes removed, especially on autopsy, show an extensive lymphoid depletion (type III) with systematic sclerosis (15 lymph-nodes from 14 patients). When adenopathy persists, it is due to infections complications (tuberculosis, cryptococcosis, avian mycobacteriosis and Whipple's disease like lesions). Of the 10 patients in whom a Kaposi's sarcoma was observed, only 6 showed lymph-node involvement, or type IV. The different histopathological lesions seem to appear according to an evolving succession, proven by certain association of lesions and by successive biopsies. In our series, 17% of subjects with an ARC evolved to AIDS. Lymph-node biopsy allows a possible ARC to be implicated on the association of the following simple lesions: follicular hyperplasia with partial or total destruction of the perifollicular lymphocytic cisterna, infiltration of the germinative centres by streams of small lymphocytes, evolving to an aspect of a "burst" germinative centre and various sinusal reactions with, in particular, the presence of neutrophilic polynuclear cells. The biopsy also allows the forms with bad prognosis to be recognized: those with AIL-like aspect or multicentric Castleman-like syndrome, which seems to represent a particular evolutive form. Finally, it also detects, in certain cases, the localization of a Kaposi syndrome, signalling the passage to AIDS. The immunopathological studies present a double interest. Firstly, they offer arguments in favour of the diagnosis: increase in the number of T8 lymphocytes in the germinative centres with the formation of small clusters and disruption of the network of dendritic reticular cells, and the inversion of the T4/T8 ratio in the extra-follicular cortical regions, by either a decrease in T4 lymphocytes or by an increase in T8 lymphocytes.(ABSTRACT TRUNCATED AT 400 WORDS)

Congenital trypanosomiasis in a child born in London

A female infant of 22 months was referred to the Hospital for Sick Children, London, because of delayed psychomotor development. Extensive investigations revealed no cause, but eventually trypanosomiasis was diagnosed. The infant had not been outside the UK, but her mother came from Zaire, where the disease is endemic, but had lived in Kinshasa, where there is no sleeping sickness. It is thought, that the mother may have been asymptomatically infected by a fresh-blood transfusion four years earlier, since no other source of infection was apparent.