Selenium Deficiency as a Risk Factor for Peripartum Cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a multifactorial disease. Although the specific aetiology and pathogenesis of PPCM are unknown, several hypotheses have been proposed, including selenium deficiency. However, the risk of PPCM from selenium deficiency was not previously quantified. This posthoc analysis of peripartum cardiomyopathy in Nigeria (PEACE) registry data aimed to determine if selenium deficiency is an independent risk factor for PPCM.

METHODS

Apparently healthy women who delivered within the previous 8 weeks and PPCM patients in Kano, Nigeria, were compared for selenium deficiency (<70µg/L) and other relevant socio-demographic and clinical characteristics. Selenium level was measured at recruitment for each subject. Independent predictors of PPCM were determined using logistic regression models.

RESULTS

159 PPCM patients and 90 age-matched controls were consecutively recruited. 84.9% of the patients and 3.3% of controls had selenium deficiency. Selenium deficiency independently increased the odds for PPCM by 167-fold while both unemployment and lack of formal education independently increased the odds by 3.4-fold.

CONCLUSION

Selenium deficiency was highly prevalent among PPCM patients in Kano, Nigeria, and significantly increased the odds for PPCM. These results could justify screening of women in their reproductive years for selenium deficiency, particularly those living in regions with high incidence of PPCM. The results also call for the setting up of a definitive clinical trial of selenium supplementation in PPCM patients with selenium deficiency, to further define its benefits in the treatment of PPCM.

Phenotypic Characterisation of Staphylococcus aureus Isolated from Patients in Healthcare Institutions in Zaria Metropolis, Kaduna State, Nigeria

BACKGROUND

Staphylococcus aureus is a cosmopolitan and pathogenic microorganism associated with various diseases spectra and antimicrobial resistance of public health importance.

AIM

This study determined the phenotypic characteristics of S. aureus isolated from patients in healthcare institutions in Zaria metropolis.

STUDY DESIGN

A cross-sectional hospital-based study was carried out in 5 healthcare institutions. Four hundred and twenty clinical samples were collected and analyzed.

RESULTS

Majority of the patients (54.3%) were within the age range 21-40 years and mean age of 26.04 ± 12 years. Approximately, 70% of the respondents had history of antibiotic use prior to consultation in the hospitals and were self-prescribed, and 91.2% were outpatients. The most commonly abused antibiotics were ampicillin-cloxacillin (19.5%) and cotrimoxazole (10.0%), and the mean duration of their use was 3.5 ± 1.3 days. The detection rate for S. aureus was 10% and 5.2% for MRSA. The S. aureus isolates showed the highest frequency of resistance against ampicillin 42 (100%), followed by penicillin G 39 (92.9%) and least was to gentamicin 5 (11.9%). The frequency of resistance for the MRSA were ampicillin 22 (100%), penicillin G 21(95.5%) and least was to gentamicin 2 (9.1%). The minimum inhibitory concentrations of oxacillin were greater than 128 μg /ml.

CONCLUSION

The detection rate of S. aureus and MRSA strains are of great public health concern which requires continuous health education on rational use of antibiotics among others.

A cross-sectional study of cytomegalovirus retinitis in HIV-1 infected adults in Nigeria

Background

Cytomegalovirus (CMV) retinitis is one of the most important opportunistic infections in HIV-infected patients in developing countries before the introduction of highly active antiretroviral therapy. In Nigerian and African HIV populations, CMV retinitis is under-reported.

Patients and Methods

In a cross-sectional study, 250 HIV-infected adults ≥18 years were recruited by systematic random sampling from March to August 2013. Using a structured questionnaire, information was obtained on socio-demographic characteristics and symptoms of visual impairment. HIV disease was staged according to the WHO clinical staging, and CD4+ T-lymphocyte count was measured. Participants with symptoms of impaired vision and/or CD4+ T-lymphocyte count <50 cells/μL had indirect ophthalmoscopic examination of the retina to detect CMV related eye lesions.

Results

Two hundred and fifty adults were HIV-infected, out of which 114 (46%) were males and 136 (54%) were females. The mean age of study participants was 35 years. History of impaired vision was reported by 21 (8.4%) of participants. The right eye was involved in 7 (33%), the left eye in 4 (19%), and both eyes in 10 (48%) of participants. The predominant symptoms were blurred vision 9 (43%), floaters 9 (43%), and blindness 3 (14%). Among participants who had indirect ophthalmoscopy, 3 (1.2%) had characteristic retinal changes suggestive of CMV retinitis. Two (67%) of patients with CMV retinitis were females and 1 (33%) was male. Mean CD4+ count was 25.33 ± 14.19 and all were WHO HIV clinical stage 4 with death occurring within 6 months of diagnosis.

Conclusion

CMV retinitis though rare is associated with advanced HIV disease and attendant morbidity and mortality. We recommend integration of CMV diagnostic services and ophthalmological services as routine in HIV care and treatment programs in Nigeria targeted toward high-risk patients.

Factors affecting snakebite mortality in north-eastern Nigeria

Snakebite is an important cause of mortality among rural dwellers in the savannah region of West Africa. We conducted a retrospective review of snakebite patients managed by experienced medical staff at Kaltungo in north-eastern Nigeria to determine the cause of death. During a 36 month period there were 94 deaths among 6687 victims (1.41%). Relative risk (RR) of mortality increased to 2.29 (95% CI 1.35-3.89) during a period when source of antivenom became unreliable. The increase was not due to seasonal variation. In a logistic regression model predictors of mortality were new central nervous system (CNS) features (Odds ratio (OR) = 24.61; 95% CI 6.93-87.41) and delay from bite to hospitalization (OR for every 1 h delay = 1.01; 95% CI 1.00-1.02). Treatment with antivenom was protective (OR = 0.17; 95% CI 0.03-0.96). Relationship of anaemia and shock to mortality were not maintained following adjustment. Effort should be made to provide regionally appropriate, affordable and effective antivenoms in addition to enforcement of continuous regulatory control measures. Antivenoms should be distributed to affected areas and treatment access points of care expanded to communities to diminish travel time. The populations at risk should be educated on avoiding unnecessary delays and on prevention of bites.

Pilot study on multidrug resistant tuberculosis in Nigeria

BACKGROUND

Drug resistant tuberculosis (TB) has lately emerged and it represents a serious public health problem. We set out to determine drug resistance among TB patients.

METHODS

Using automated BACTEC cultures, multidrug resistant-tuberculosis (MDR-TB) was investigated in 117 diagnosed cases in Abuja, Nigeria.

RESULTS

Ten (31%) of 32 culture-positive patients were resistant to at least one and four (13%) to all of the four drugs tested. No association between drug resistance and human immunodeficiency virus (HIV) infection was found.

CONCLUSIONS

MDR-TB is present in Nigeria and larger studies are urgently required. TB clinical management and control efforts should be improved.

Assessment of right ventricular systolic function using tricuspid annular-plane systolic excursion in Nigerians with systemic hypertension

AIM

Right ventricular (RV) systolic function in patients with hypertensive heart disease (HHD) is not well characterised. The primary aim of this study was to assess the systolic function of the right ventricle in patients with HHD using tricuspid annular-plane systolic excursion (TAPSE).

METHODS

The study was cross-sectional in design and carried out in Kano, Nigeria. Patients were recruited if they had HHD on echocardiography and were at least 15 years of age. Patients with other cardiac pathologies such as ischaemic and valvular heart diseases were excluded. Patients were considered to have abnormal RV systolic function if they had reduced values of TAPSE ( < 15 mm). A p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 186 patients were serially recruited over seven months. Of these, 131 (70.4%) had normal RV systolic function (group 1) and 55 patients (29.6%) had abnormal function (group 2). Group 2 patients were older (p = 0.002) and had a higher prevalence of peripheral oedema (p = 0.002), moderate to severe dyspnoea, higher heart rate and lower left ventricular ejection fraction (p < 0.001). Atrial arrhythmias were also more prevalent among group 2 patients (p < 0.05). The best correlate to TAPSE was the septal mitral annularplane systolic excursion (r = +0.541, p < 0.001). Several variables such as age predicted the presence of reduced TAPSE.

CONCLUSION

The study found that almost one-third of patients with HHD in Kano had RV systolic dysfunction as defined by reduced TAPSE, and these patients had a greater prevalence of factors associated with morbidity and mortality.

Amputation and disability following snakebite in Nigeria

Snakebite is an important cause of amputation and disability in rural communities throughout the tropics. However, the details of the causes, types and estimates of disability are lacking. This report describes 16 snakebite victims who had amputations, including two who had above-knee amputations. The patients presented with limb swelling (16), gangrene (15), ischaemia (4) and three had possible compartment syndrome. All the patients used ineffective time wasting remedies that were potentially harmful as first-aid. The median delay to hospital following bite was 2.5 days. In order to prevent disability, efforts should be made to: reduce delay before hospital presentation; improve the knowledge of first-aid; provide effective antivenoms; improve wound and clinical care in communities; and improve facilities.

Response to the meningococcal meningitis epidemic (MME) at Aminu Kano Teaching Hospital, Kano (2008-2009)

In December 2008 an outbreak of Meningococcal Meningitis swept across sub Saharan Africa with Nigeria, especially its northern states worst affected. The management of Aminu Kano Teaching Hospital constituted an Emergency Preparedness & Response (EPR) committee. Over the course of 18 weeks from 5 January 2009 to 15 May 2009, AKTH managed 222 cases of suspected meningitis with 14 deaths (case fatality rate [CFR] of 6.3%). Twenty three per cent (23%) were microbiologically proven as meningococcal meningitis while 9% were confirmed to be pneumococcal meningitis. Male to female ratio was 1:1 with most patients (81%) aged below 14 years. The epidemic peaked in weeks 10 and 13 with 38 admissions in the respective weeks. Meningococcemia with purpura fulminans, post meningitic immune complex cutaneous vasculitis and polyarthritis were observed. Control measures instituted included provision of free ceftriaxone, chemoprophylaxis to contacts, vaccines to staff/families, and creation of dedicated isolation wards. Clinical management guidelines were developed and hospital staffs were also enlightened. Lessons learnt included the difficulty of discriminating between nosocomial transmission and community clusters; relative increase in pneumococcal meningitis during the epidemic; unreliability of penicillin/chloramphenicol; the utility of internet for communication; and the inadequacy of vaccines to meet staff & public demand.

Adherence to anti retroviral therapy (ART) during Muslim Ramadan fasting

Annual fasting during the month of Ramadan is observed in Muslim countries, some of which have widespread HIV infection. We studied treatment adherence and customary practices among 142 fasting 'FT' and 101 non-fasting 'NFT' patients on anti-retroviral therapy (ART) in Nigeria. Adherence on ART among FT and NFT patients was similar during Ramadan, 96% and 98%, and ever since commencement of ART, 80% and 88%, respectively. FT patients altered their typical daily behaviors by advancing morning and delaying evening doses thereby prolonging dosing intervals, eating heavier meals pre-dawn and on breakfast at sunset (78%), and changing or reducing their sleeping and waking times (40%). This preliminary study suggests that adherence and drug taking frequency appear uncompromised in FT HIV infected patients on ARVs.

Envenoming after carpet viper (Echis ocellatus) bite during pregnancy: timely use of effective antivenom improves maternal and foetal outcomes

The report describes successful management of 10 women in 2nd and 3rd pregnancy trimesters with EchiTab IgG antivenom after carpet viper (Echis ocellatus) envenoming. All women survived but foetal loss in a victim with delayed presentation and a case of mild hypersensitivity reaction were recorded. Excellent outcomes can be achieved in rural and semi-nomadic populations without specialized care and immediate access and provision of effective antivenoms is paramount in curtailing snakebite maternal morbidity, mortality and foetal loss.

Respiratory distress in nonimmune adults with imported malaria

Acute respiratory distress (ARD) in two nonimmune adults with imported mixed and vivax malarial infections with low and resolving parasite load is described. Malarial pulmonary edema exacerbated by hypoalbuminemia and fluid redistribution without overload occurred in the latter patient. ARD led to mortality in one of the two. ARD should be promptly recognized and managed.

A clinical audit of presentation and outcome of Salmonella septicaemia

INTRODUCTION

Enteric fever is imported to developed countries while non-typhoidal salmonella infections occur globally. Clinicians and trainees need to recognise the varied presentations of serious salmonella infections.

MATERIALS AND METHODS

We reviewed the clinical presentations, hospital course, complications and outcomes of 50 patients who were blood culture positive for Salmonella spp seen in 2 years.

RESULTS

Nineteen of 24 patients with enteric fever had recently travelled to Asian countries. All the enteric fever patients recovered fully. Out of 26 patients with non-typhoidal salmonellosis, 10 had malignancies, 7 had immune dysfunction states and 3 had aortic aneurysms. Five patients had recurrent episodes of salmonellosis. Eight of these patients who had cancer (4), diabetes mellitus with renal failure (2) and gastric diseases (2) died. Fatal cases were older with multiple admissions and co-morbidities (median, 3) and presentation followed immunosuppressive interventions, often with no fever (4). Onset was sudden with a short and fatally unresponsive course despite effective antimicrobial agents with microbiologic diagnosis made posthumously (4). Death resulted rapidly from overwhelming sepsis and aneurysmal complications. Antibiotic resistance to ampicillin, cotrimoxazole and chloramphenicol was noted.

CONCLUSION

Enteric fever should be considered in travellers returning from Asian countries with fever, and third-generation cephalosporins or quinolones should be used for empiric treatment. Given the presentation of non-typhoidal salmonella septicaemias, clinicians need to have a high index of suspicion and to consider preemptive therapy in patients with prior infection who are likely to develop severe immunosuppression following interventions.

Widespread antibiotic resistance in savannah Nigeria

There is minimal data on antibiotic resistance from savannah northern Nigeria. A retrospective study of 438 patients seen in 12 months (2000) with microbial pathogens from urinary and respiratory tracts was undertaken. Antibiotic susceptibilities were determined using stokes disc diffusion technique. Resistance in Escherichia coli (E. coli) reached 91-96% to cotrimoxazole, tetracycline and ampicillin but was 11%, 17% and 28% to colistin, nitrofurantoin and nalidixic acid. Resistance of other uropathogens (Klebsiella and Proteus spp) reached 83-99% to cotrimoxazole, tetracycline and ampicillin but was 14-40% to colistin, nitrofurantoin and nalidixic acid. Pneumococci were non-susceptible to penicillin (93%), cotrimoxazole (92%), tetracycline (84%), ampicillin (53%), chloramphenicol (21%) and cefazolin (8%). Antibiotic resistance is widespread in savannah northern Nigeria. Resistance is less to chloramphenicol, colistin, nalidixic acid, nitrofurantoin and the latter generation cephalosporins and quinolones than to penicillin, ampicillin, cotrimoxazole and tetracycline.

Community-acquired Klebsiella pneumoniae central nervous system infections in adults in Singapore

A series of successfully managed community-acquired Klebsiella pneumoniae infections of the central nervous system (CNS) that occurred in six non-neurosurgical adult patients in Singapore over a 2-year period is reported. Three patients had abscesses that were drained, and three had meningitis; all were treated with third-generation cephalosporins. All six patients were middle-aged adults, three of whom were food handlers. Clinicians should be aware of Klebsiella pneumoniae as an important CNS pathogen, particularly in East Asia. Although third-generation cephalosporins have had a major impact on the outcome of Klebsiella pneumoniae CNS infections, the emergence of extended-spectrum beta-lactamase-producing strains may lead to their reduced efficacy in this clinical setting.

Tetanus complicating snakebite in northern Nigeria: clinical presentation and public health implications

BACKGROUND

There is inequality in vaccination coverage, and adult farmers in tropical rural communities could have missed tetanus toxoid as campaigns target children. Snakebite is not uncommon and partly because of lack of effective antivenom, management in inaccessible areas could be complicated with tetanus in unimmunized victims.

PATIENTS AND RESULTS

Four snakebite victims who developed tetanus were seen in northern Nigeria. Three were bitten while farming and patients took 10-25 days before presenting to hospital. All patients had incised bite sites and applied local medicinal herbs and in one case, a black 'snake' stone. Bites were by the cobra (Naja nigricollis) and carpet viper (Echis ocellatus) in the extremities and victims had swollen limbs and bleeding with incoagulable blood. Three of the patients were given anti-tetanus serum (ATS) after development of tetanus symptoms in a primary facility and only one recalled receipt of one dose of tetanus toxoid prior to bite. Patients had trismus, rigidity, backache, spasms and one had autonomic dysfunction and was managed with antispasmodics, ATS, wound care, antibiotics and supportive measures. Two patients with envenoming and severe tetanus received antivenom, but died. One of the two surviving patients developed osteomyelitis with prolonged hospital stay, while the other recovered with residual disability.

CONCLUSION

Tetanus could follow snakebite in inaccessible rural agricultural communities with inadequate health care provision. Clinical presentation is typical but late and is confounded by snakebite complications leading to considerable morbidity and mortality. The cases highlight the triple problems of inadequacy, inaccessibility and inequality in health care and calls for measures aimed at improvement.

Snake bite in Nigeria

Four families of venomous snakes are found in Nigeria--Viperidae, Elapidae, Colubridae and Actraspididae but three species carpet viper (Echis ocellatus), black-necked spitting cobra (Naja nigricollis) and puff adder (Bitis arietans), belonging to the first two families, are the most important snakes associated with envenoming in Nigeria. The incidence of bites has been reported as 497 per 100,000 population per year with a 12 percent natural mortality, with Echis ocellatus accounting for at least 66 percent in certain foci. Bites occur more often while victims were farming, herding or walking although the spitting cobra may bite victims who roll upon it in their sleep. Carpet viper venom contains a prothrombin activating procoagulant, haemorrhagin and cytolytic fractions which cause haemorrhage, incoagulable blood, shock and local reactions/ necrosis. The spitting cobra bite manifests with local tissue reaction and occassionally with bleeding from the site of bite, but no classic neurotoxic feature has been observed except following Egyptian cobra (N. haje) bites. Cardiotoxicity and renal failure may occassionally occur following bites by the carpet viper and the puff adder. In the laboratory, haematological and other features are noted and immunodiagnosis has a role in species identification. Immobilisation of the bitten limb is probably the single most important first aid measure. Antivenom should be used cautiously when indicated. As only 8.5 percent of snake bite victims attend hospitals in Nigeria, health education should be the main preventive measure, mean-while, the study of immunisation of occupationally predisposed individuals in endemic areas should be intensified. A new Fab fragment antivenom specific to Nigerian Echis ocellatus was investigated clinically, just as the local herbs-Aristolochia spp, Guiera spp and Schummaniophyton spp are investigated experimentally.

First clinical experiences with a new ovine Fab Echis ocellatus snake bite antivenom in Nigeria: randomized comparative trial with Institute Pasteur Serum (Ipser) Africa antivenom

During the past decade, effective snake antivenoms have become scarce in northern Nigeria. As a result, many patients severely envenomed by the saw-scaled or carpet viper (Echis ocellatus), which is responsible for more than 95% of the snake bites in the region, did not receive effective treatment and mortality and morbidity increased. To combat this crisis, a new monospecific ovine Fab antivenom (EchiTab) is being developed. Its theoretical advantages over conventional equine F(ab')2 antivenom are a more rapid tissue penetration and larger apparent volume of distribution (the volume of [tissue] fluid in which the the antivenom would be uniformly distributed to achieve the observed plasma concentration). In a preliminary study, two vials (20 ml; 1.0 g of protein) of EchiTab rapidly and permanently restored blood coagulability and cleared venom antigenemia in seven envenomed patients. Four experienced early reactions that responded to epinephrine. In a randomized comparative trial of one vial (10 ml; 0.5 g protein) of EchiTab or four ampules (40 ml; 2.12 g of protein) of Institute Pasteur Serum (Ipser) Africa polyspecific F(ab')2 antivenom, there were fewer reactions, but only 36% and 35% of patients, respectively, showed permanent restoration of coagulability, with the remainder requiring further doses. This suggests that 0.5 g (one vial) of EchiTab is approximately equivalent to 2.12 g (four ampules) of Ipser Africa antivenom, and that a higher initial dose will be required for most patients. Measurements of circulating venom and antivenom levels reflected the clinical events.