Background. George Regional Hospital (GRH) is a 272-bed regional referral hospital for the Eden and Central Karoo districts, Western Cape Province, South Africa. The perception among emergency centre (EC) staff is that a high burden of tuberculosis (TB) is being diagnosed and that infection control procedures are currently lacking, leading to a high risk of nosocomial transmission.
Objectives. To establish the burden of pulmonary TB (PTB) presenting to GRH via the EC and audit current infection prevention and control practices, to quantify the risk of transmission of PTB in the EC and to establish whether infection control measures are inadequate.
Methods. An audit of infection control based on the Centers for Disease Control audit tool for TB, analysis of results, and implementation of new infection control measures including a new standard operating procedure based on a set of triage criteria.
Results. Implementation of new triage criteria and a standard operating procedure led to the longest length of stay of a patient with suspected TB in the EC being reduced by 40% (from 142 hours to 84 hours). The average time between seeing a doctor and leaving the EC for patients with suspected TB was reduced by 20% (from 20 hours 40 minutes to 16 hours 45 minutes).
Conclusion. Simple measures implemented in the EC led to a significant reduction in the time patients with suspected or confirmed TB spent in the EC. This should lead to a reduced risk of nosocomial transmission of TB to both staff and patients.
Background. Fifty percent of spontaneous miscarriages (SMs) are attributed to chromosomal abnormalities. Cytogenetic analysis is an important tool for patient counselling and assessment of the risk of recurrence in future pregnancies. Conventional karyotyping has been the gold standard for chromosomal investigation of products of conception (POC), but it has limitations due to sample maceration, culture failure and maternal cell contamination. molecular cytogenetic approaches have therefore been developed and found valuable in the cytogenetic investigation of these samples. The Prenatal BoBs and KaryoLite BoBs, based on the newly developed BACs-on-Beads technology, have been described as reliable tests for rapid detection of aneuploidies in prenatal and POC samples, respectively.
Objective. To describe our clinical experience of routine screening of POC samples with Prenatal BoBs, the test used by our laboratory in France.
Methods. Seventeen samples collected at the University Hospital of Sidi Bel Abbès (Western Algeria) and a further 60 from the University Hospital of Clermont-Ferrand (France) were analysed (19 chorionic villi from products of curettage, 12 placentas, 9 amniotic cells and 37biopsy specimens). All were screened for the frequent aneuploidies (chromosomes 13, 18, 21, X and Y) in addition to nine microdeletion/ microduplication syndrome regions by Prenatal BoBs. Standard karyotyping was performed on 51 samples, but failed in 38 cases.
Results. Prenatal BoBs identified one trisomy 21 and one deletion of 17p13.3. Furthermore, it provided a conclusive result in cases of culture failure (n=38) and in samples with macerated tissue (n=19). The overall failure rate was 11.4%.
Conclusions. Prenatal BoBs is a promising technology that represents a fast, sensitive and robust alternative to routine screening for chromosomal abnormality in products of SM. Furthermore, it overcomes the limitations of conventional karyotyping and current molecular cytogenetic techniques.
An HIV-positive 39-year-old man presented with generalised nodular lesions. He was apyrexial and normotensive, with a normal respiratory rate. The rest of the examination was normal. He had been on antiretroviral therapy for >4 years; most importantly, he was on a second line regimen (lopinavir/ritonavir (Aluvia) based). The appearance of the lesions, together with the history, led to the following possible diagnoses: bacillary angiomatosis, cutaneous cryptococcosis, nodular Kaposi sarcoma or cutaneous histoplasmosis.
Cryptococcus neoformans is a ubiquitous encapsulated yeast found worldwide, especially in areas with pigeons. The fungus thrives in pigeon droppings and is responsible for primary pulmonary infection, but may disseminate and cause infection of the central nervous system, skin and bone. Most cases are reported in immunocompromised hosts, most commonly those infected with HIV. However, infection has been reported in immunocompetent hosts. Primary infection of the larynx is uncommon, and to date only 12 cases have been reported. We present the first South African report of a young woman with HIV who presented with hoarseness of uncertain aetiology, which was later confirmed to be cryptococcal laryngitis.
Thyrotoxic myopathy frequently occurs in clinical practice; however, the association of hyperthyroidism with a flaccid, areflexic paraplegia, so-called Basedow paraplegia, appears to represent a controversial and doubtful entity. An 18-year-old female with undiagnosed and untreated Graves' disease presented with acute onset of global weakness predominantly in the lower limbs, but also affecting the upper limbs. The weakness was accompanied by hypotonia and areflexia. Clinically, the patient had a goitre and signs of thyroid ocular disease. Laboratory testing confirmed the presence of hyperthyroidism, and thyroid-stimulating hormone receptor antibodies were positive. The cerebrospinal fluid protein level was raised. The electroneuronographic and needle examinations were compatible with a clear denervation process, such as acute motor axonal neuropathy, a variant of Guillain-Barrésyndrome. Intravenous immunoglobulin therapy, carbimazole and propranolol were administered.The occurrence of hyperthyroidism with a flaccid, areflexic paraplegia appears to represent more of a fortuitous than a causative association. It is important to consider and treat other causes, such as acute idiopathic polyneuritis.
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a standard procedure worldwide, used in conjunction with bronchoscopy to obtain biopsies for mediastinal disorders.
A 67-year-old man with a 40 pack-year smoking history presented with a 2-year history of hoarseness and weight loss. He also had a history of asbestos exposure. On examination under anaesthesia a lesion of the right false vocal fold was found and histology showed a moderately differentiated infiltrating keratinising squamous carcinoma. The question posed was whether this mass could be ascribed to metastatic supraglottic carcinoma or if it was indeed a metachronous primary bronchus carcinoma, as the treatment of these two malignancies differs significantly. Traditional bronchoscopy with TBNA is the least invasive procedure to obtain a cytological diagnosis,but the proximity of the aorta and pulmonary arteries and the mass being 14 mm from the bronchus would have made sampling by means of this procedure near impossible. We used EBUS to localise the mass and noted the position of the major vessels on Doppler ultrasound. Real-time ultrasound guidance allowed us to bridge the tissue plane between the mass and bronchial lumen using the longer EBUS needle and to obtain a fine-needle aspirate of the mass, which proved to be a keratinising squamous carcinoma. We describe this case in which EBUS-TBNA was pivotal in reducing the number of invasive procedures in a patient with metastatic supraglottic carcinoma.
Acute ataxia in childhood is often caused by toxin ingestion. With the increasing number of paediatric patients on antiretroviral medication, we observe more side-effects of these drugs. Acute ataxia is defined as unsteadiness of walking or fine motor movement of < 72 hours. The most common causes are post infectious acute cerebellar ataxia, toxin ingestion and Guillain-Barré syndrome. However, the possibility of a mass lesion must always be excluded.
Reported neurological abnormalities in HIV-positive children range from 10% to 68%. A South African study found the prevalence of neurological complications to be 59%, the most common of which were HIV encephalopathy and long-tract motor signs; however, no cases of cerebellar dysfunction were documented. Ataxia rarely occurs in an HIV-positive person, the chronic sequelae being neurocognitive impairment and polyneuropathy.
Ataxia in the setting of HIV is generally secondary to an infectious, vascular or neoplastic cerebellar lesion. However, most infections are opportunistic and unlikely to occur when CD4 levels are adequate. The vascular or mass lesions are readily excluded with neuro-imaging. We report two cases of efavirenz toxicity that caused ataxia. We treated two children who presented in a 1-month period, which highlighted an important differential to consider in HIV-positive paediatric patients presenting with ataxia.
Hepatocellular carcinoma (HCC) is rare in women of reproductive age. If diagnosed, the underlying cirrhosis is associated with infertility in the majority of cases. There is limited literature on HCC in pregnancy, even more so for cases of metastatic disease. We present a case of delayed presentation and diagnosis of metastatic HCC in pregnancy.
A 30-year-old pregnant woman presented at 23 weeks' gestation and was diagnosed as HIV-infected, with anaemia. She was initiated on an efavirenz-based fixed-dose combination and oral haematinics. She subsequently presented at 32 weeks' gestation with dyspnoea, and was diagnosed with pre-eclampsia. She was also found to have hepatosplenomegaly and ascites. She went into spontaneous preterm labour at 32weeks and 4 days. A diagnosis of metastatic HCC was made postpartum, based on the radiological findings and biochemistry. We discuss the challenges of diagnosing metastatic HCC in pregnancy.
Polymerase chain reaction (PCR) testing is the gold standard for determining the HIV status in children < 18 months of age. However, when clinical manifestations are not consistent with laboratory results, additional investigation is required. We report a 15-month-old HIV-exposed boy referred to our hospital after he had been admitted several times for infectious diseases. A rapid antibody test on the child was positive, while routine diagnostic HIV PCRs using the Roche COBAS Ampliprep/COBAS TaqMan HIV Qual Test were negative at 6 weeks, 6 months, 7 months and 15 months. In addition, the same PCR test performed on the HIV-infected mother was also negative. Alternative PCR and viral load assays using different primer sets detected HIV RNA or proviral DNA in both child and mother. Gag sequences from the child and his mother classified both infections as HIV-1 subtype C, with very rare mutations that may have resulted in PCR assay primer/probe mismatch. Consequently, the child was commenced on antiretroviral therapy and made a remarkable recovery. These findings indicate that more reliable PCR assays capable of detecting a wide range of HIV subtypes are desirable to circumvent the clinical problems created by false-negative PCR results.
Kounis syndrome is characterised by a group of symptoms that manifest as unstable vasospastic or non-vasospastic angina secondary to a hypersensitivity reaction. It was first described by Kounis and Zavras in 1991 as the concurrence of an allergic response with ananaphylactoid or anaphylactic reaction and coronary artery spasm or even myocardial infarction. Since then, this condition has evolved to include a number of mast cell activation disorders associated with acute coronary syndrome. There are many triggering factors, including reactions to multiple medications, exposure to radiological contrast media, poison ivy, bee stings, shellfish and coronary stents. In addition to coronary arterial involvement, Kounis syndrome comprises other arterial systems with similar physiologies, such as mesenteric and cerebral circulation resulting in ischaemia/infarction of the vital organs. The incidence of this condition is difficult to establish owing to thenumber of potential instigating factors and its relatively infrequent documentation in the literature.
We report the case of an HIV-negative 39-year-old man with no coronary risk factors or family history of premature coronary artery disease, who developed Kounis syndrome after the administration of fluoroquinolone for dysuria. However, to the best of our knowledge, no data on the incidence and prevalence of Kounis syndrome in South Africa have ever been reported in the literature. The recent understanding of Kounis syndrome has led to the condition being classified into three syndrome variants.