Ballah Akawu Denue

Prevalence of Anemia and Immunological Markers in HIV-Infected Patients on Highly Active Antiretroviral Therapy in Northeastern Nigeria

Background There are conflicting reports on the impact of highly active antiretroviral therapy (HAART) in resolving hematological complications. Whereas some studies have reported improvements in hemoglobin and other hematological parameters resulting in reduction in morbidity and mortality of HIV patients, others have reported no improvement in hematocrit values of HAART-treated HIV patients compared with HAART-naïve patients. Objective This current study was designed to assess the impact of HAART in resolving immunological and hematological complications in HIV patients by comparatively analyzing the results (immunological and hematological) of HAART-naive patients and those on HAART in our environment. Methods A total of 500 patients participated, consisting of 315 HAART-naive (119 males and 196 females) patients and 185 HAART-experienced (67 males and 118 females) patients. Hemoglobin (Hb), CD4+ T-cell count, total white blood count (WBC), lymphocyte percentage, plateletes, and plasma HIV RNA were determined. Results HAART-experienced patients were older than their HAART-naive counterparts. In HAART-naive patients, the incidence of anemia (packed cell volume [PCV] <30%) was 57.5%, leukopenia (WBC < 2.5), 6.1%, and thrombocytopenia < 150, 9.6%; it was, significantly higher compared with their counterparts on HAART (24.3%, 1.7%, and 1.2%, respectively). The use of HAART was not associated with severe anemia. Of HAART-naive patients, 57.5% had a CD4 count < 200 cells/μL in comparison with 20.4% of HAART-experienced patients (P < 0.001). The mean viral load log10 was significantly higher in HAART-naive than in HAART-experienced patients (P < 0.001). Total lymphocyte count < 1.0 was a significant predictor of <CD4 counts < 200 cells/μL in HAART-naïve patients, but this relationship was not observed in HAART-experienced patients. Conclusion HAART has the capability of reducing the incidence of anemia, other deranged hematological and immunological parameters associated with disease progression, and death in HIV-infected patients. Total lymphocyte count fails to predict CD4 count < 200 cells/μL in our cohort; thus, its use in the management and monitoring of HIV-infected patients in our settings is not reliable.

A survey of hepatitis B and C virus prevalence in human immunodeficiency virus positive patients in a tertiary health institution in North Eastern Nigeria

Co-infection of hepatotropic virus(es), with HIV has been associated with a reduced survival rate, an increased risk of progression to severe liver disease, and an increased risk of hepatotoxicity associated with active antiretroviral therapy. Information regarding prevalence of HBV and HCV co-infection with HIV in Nigeria is limited. This study was designed to determine the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV), and the impact of co-infection on baseline serum alanine transaminase (ALT), CD4+ T lymphocyte (CD4) count, and plasma HIV-RNA (viral load) in a cohort of HIV-infected Nigerians. Patients confirmed to be positive for HIV infection by Western blot analysis were consecutively recruited into the study from Infectious Disease Clinic, General Out-patient Department and Medical Wards of University of Maiduguri Teaching Hospital, Nigeria. Demographic data and pre-treatment laboratory results (hepatitis B surface antigen (HBsAg), and HCV antibodies (anti-HCV), ALT, CD4 count and viral load) were analysed. A total of 569 HIV-infected patients (male: female ratio, 1:1.4) were consecutively recruited. HBsAg was present in 12.3%; anti- HCV in 0.5% and both markers was not present in any patients. HBsAg prevalence was 12.3% in both male and females, while anti-HCV was detected in 0.8% in males and 0.3% females. HIV-infected patients alone had a higher mean baseline CD4 count compared to those without anti- HCV or HBsAg (181 vs. 117 cells/mm 3 , respectively; p = 0.01). Serum ALT was higher among patients co-infected with HBsAg or anti-HCV than only HIV infected (37 vs. 34 International Units (IU), respectively p = 0.1). The high frequency of HBsAg confirms the need for routine screening for these markers in HIV-infected patients in our setting. CD4 count was significantly lower, in patients with prior exposure to hepatitis B or C, while ALT was slightly higher among those positive for HBV or C infection. These findings are pointer to the importance of testing for HBV and HCV in all HIV-infected persons in our setting.

Risk factors for hepatitis C virus sero-positivity among haemodialysis patients receiving care at kidney centre in a tertiary health facility in Maiduguri, Nigeria.

Hepatitis C virus (HCV) is an important health care problem in haemodialysis. Hepatitis C virus is both a cause and complication of kidney diseases. Yet there are limited information on antibody against HCV in patients on haemodialysis. The purpose of this study was to determine the prevalence of anti-HCV and the risk factors associated with HCV infection in a cohort of 100 participants on haemodialysis. They were consecutively recruited into the study, anti-HCV testing was made by the 3rd-generation ELISA System (C-100, C-33c, C-22). The prevalence of HCV antibody was 15%, risk factors associated with HCV antibody were history of blood transfusion and duration of session of haemodialysis; the risk increased with increased with the number of blood transfusion and seasons of haemodialysis. The observed high prevalence of HCV antibody among patients on haemodialysis reflect the quality of healthcare services and the standards of infection control practices in our haemodialysis units. Routine screening for HCV should be done before blood transfusion using third generation ELISA assays with high sensitivity and specificity. Safety measures should be taken in our haemodialysis units to prevent cross infection among patients and staffs. These safety measures include; discarding syringes, needles, gloves, bloodlines and dialysers after single use, and the use of sterile dressings on each patient visit.

Changes in Lipid Profiles and Other Biochemical Parameters in HIV-1 Infected Patients Newly Commenced on HAART Regimen.

Abnormalities of lipid metabolism are common in human immunodeficiency virus (HIV)-infected patients and tend to be accentuated in those receiving antiretroviral therapy, particularly with protease inhibitors (PIs). However, there is a dearth of information on serum lipid profiles and biochemical parameters among treatment-naive HIV-positive patients in our environment. We found that after 24 months of highly active antiretroviral therapy (HAART), there was a significant increase in serum lipids. After 24 months of HAART, renal impairment was associated with a low increase in mean HDL and a high increase in triglycerides (TG). In conclusion, abnormality of serum lipid is common and showed female preponderance among treatment-naive HIV patients in our environment. Patients with HIV infection on HAART should be screened for lipid disorders given their high prevalence as observed in this study, because of its potential for morbidity and mortality in patients on HAART.

Evaluating Total Lymphocyte Counts and Other Hematological Parameters as a Substitute for CD4 Counts in the Management of HIV Patients in Northeastern Nigeria

This study was designed to validate or refute the reliability of total lymphocyte count (TLC) and other hematological parameters as a substitute for CD4 cell counts. Participants consisted of two groups, including 416 antiretroviral naive (G1) and 328 antiretroviral experienced (G2) patients. CD4+ T cell counts were performed using a Cyflow machine. Hematological parameters were analyzed using a hematology analyzer. The median ± SEM CD4 count (range) of participants in G1 was 199 ± 10.9 (5–1840 cells/µL) and the median ± SEM TLC (range) was 1. 61 ± 0.05 (0.07–6.63 × 103/µL). The corresponding values among G2 were 421 ± 15.8 (13–1801) and 2.13 ± 0.04 (0.06–5.58), respectively. Using a threshold value of 1.2 × 103/µL for TLC alone, the sensitivity of G1 was 88.4% (specificity (SP) 67.4%, the positive predictive value (PPV) 53.5% and negative predictive value (NPV) of 93.2% for CD4 < 200 cells/µL, the sensitivity for G2 was 83.3%, SP 85.3%, PPV 23.8%, and NPV of 93.2%. Using multiple parameters, including TLC < 1.2 × 103/µL, hemoglobin < 10 g/dL, and platelets < 150 × 103/L, the sensitivity increased to 96.0% (SP, 82.7%; PPV, 80%; NPV, 96.7%) among G1, while no change was observed in the G2 cohort. TLC < 1.2 × 103/µL alone is an insensitive predictor of CD4 count of , 200 cells/µL. Incorporating hemoglobin < 10 g/dL, and platelets < 150 × 103/L enhances the ability of TLC < 1.2 × 103/µL to predict CD4 count < 200 cells/µL among the antiretroviral-naive cohort. We recommend the use of multiple, inexpensively measured hematological parameters in the form of an algorithm for predicting CD4 count level.

Evaluation of a rapid dipstick test (Crystal Vc®) for the diagnosis of cholera in Maiduguri, Northeastern Nigeria

Background: Cholera is a preventable diarrheal disease associated with rapidly progressing dehydration. Early detection of the causative agent, Vibrio cholerae (VC) among symptomatic patients is a key step in cholera outbreak management to minimize disease spread and mortality. Materials and Methods: We prospectively evaluated the performance of Crystal VC®, a commercially available test kit for rapid detection of VC serotypes 01 and 0139 directly from stool samples. Patients included in this study were those admitted to the cholera treatment unit from August 14, 2017, to September 20, 2017, during the cholera outbreak in Maiduguri, northeastern Nigeria. Conventional bacterial stool culture is considered the gold standard and was used as the comparator. Results: A total of 156 stool specimens were collected and tested. Compared with stool culture results, the Crystal VC® test had sensitivity (SE) of 95.1% and specificity (SP) of 59.3%. The positive and negative likelihood ratios were 2.33 and 0.08, respectively. The positive predictive value (PPV) was 81.5% while the negative predictive value (NPV) was 86.5%. There was no gender variation with respect to SE, SP, PPV, and NPV. Conclusion: The cholera rapid dispstick test (RDT), Crystal VC®, is a useful tool for diagnosis of diarrheal disease due to VC serotypes 01 and 0139 and may provide an initial alert in an outbreak situation. It may also be used for case surveillance in cholera epidemic prone situations resulting from displacement to camps or overcrowded shelters due to human conflict or natural disasters. Although it is less sensitive than conventional stool culture, it is a convenient and simple test to perform with faster turnaround time.

Cryptococcal neorformans Antigenemiaamong HIV-Infected Patients in NorthEastern Nigeria

Background: Cryptococcus neoformans infection is a common fungal infection that is cosmopolitan in distribution and causes a life-threatening disease among HIV-infected patients especially in advanced disease. Screening for cryptococcal antigen (CrAg) in patients enrolling in ART programs may identify those at risk of cryptococcal meningitis and permit targeted use of pre-emptive therapy. Methods: This was a cross survey study of 215 consecutive HIV-infected patients at an ART treatment centre were screened for cryptococcal antigenaemia using the cryptococcalantigen lateral flow assay (CrAg LFA). Study subjects were assessed for clinical features of Cryptococcus neoformans infection. CD4+ cell count, haemoglobin concentration as well as HIV-1 RNA viral load was also compared between cryptococcalantigen positive and negatives. Results: 37 (16.7%) patients were positive for cryptococcal antigenaemia. Cryptococcal antigen positive subjects had a lower median CD4+ cell count (58 cells/uL vs. 273 cells/uL, p<0.001) and higher median viral load (log 3.6 copies/mL vs. log2.3 copies/mL, p=0.05) compared to cryptococcal antigen negative subjects. The commonest predictors of positive CrAg status in the study were; low BMI, low Hb, fever and cough. Conclusion: The study has shown the prevalence of cryptococcal antigenaemia to be high among the study subjects attending this service. Therefore, screening of patients receiving care at this centre may help in identifying individuals who are at risk of cryptococcalmeningitis for prophylactic treatment.

Isolated tuberculous splenic abscess in a HIV-positive patient

Tuberculous splenic abscess is a rare cause of pyogenic splenic abscess and occurs most often in the setting of an immunosuppressive state. It is a life-threatening condition associated with high mortality without prompt management. The diagnosis can be challenging as it has no characteristic clinical and radiological findings. Hence high index of suspicion, imaging studies including ultrasound-guided aspiration of the abscess under aseptic technique is helpful in its diagnosis. We report a 32-year-old patient with HIV infection who presented with 5 weeks history of abdominal pain, fever, anorexia, and significant weight loss. Abdominal ultrasound scan showed splenomegaly with multiple areas of mixed echogenicity. About 30 ml of foul smelling, creamy dark brown diagnostic, and therapeutic aspirate drained under trans-abdominal ultrasound scan guidance yielded positive for Mycobacterium tuberculosis (TB) under culture. Our patient died on the 12 th day of admission before bacteriology result. Tuberculous Splenic abscess could be fatal it not promptly managed; it should be considered in patients presenting with fever and abdominal pain especially in the setting of HIV infection. Due to lack of characteristic clinical and imaging findings, it poses a serious diagnostic dilemma with attendant consequences as occurred in our case. Ultrasound-guided aspiration of the abscess under aseptic technique is helpful in its diagnosis. Empiric anti-TB therapy should be considered in patients that failed to respond to broad-spectrum antibiotics in highly endemic areas.

Extrapulmonary TB in North Eastern Nigeria: A 10-Year Retrospective Review

Background: Information on extrapulmonary TB is scarce in Nigeria despite being one of the 22 countries with highest burden of tuberculosis in the world and the most populous country in sub-Saharan Africa where the dual epidemics of TB and HIV/AIDS mutually co-exist. Objective: The purpose of this study was to document the burden of extrapulmonary TB in North-eastern Nigeria. Methodology: A retrospective cross-sectional study was conducted at a DOTS treatment centre in a tertiary hospital in North-eastern Nigeria. TB treatment registers and case records of 1240 patients were reviewed over a 10-year period. Results: Out of the 1240 TB cases who received treatment at the facility; 179 (14.4%) had extra-pulmonary TB. Skeletal TB and TB lymphadenitis were the predominant forms of extra-pulmonary TB in the study i.e. 51 (28.5%) and 50 (28.0%), respectively. This was closely followed by abdominal TB (38 (21.2%), tuberculous pleural effusion (23 (12.8%), miliary TB (9 (5.0%), TB meningitis (3 (1.7%) and others (5 (2.8%): viz; 1 (0.6%) each of- TB of the breast, TB of the skin, adrenal TB, genitourinary TB and TB pericarditis respectively. Only 101 (56.4%) of the study subjects had information on their HIV status; of whom 52 (51.5%) were HIV positive and 49 (48.5%) HIV negative. Conclusion: The study has shown that extrapulmonary TB was relatively common among TB patients receiving care at the facility despite its diagnostic challenges particularly in a resource poor setting like ours.

A rare image of spontaneous enterocutaneous fistula in morbidly obese patient with metabolic syndrome

32 year old lady, a morbidly obese grand multipara developed spontaneous enterocutaneous fistula. Wound around right para-umblical region started as boil, it ruptured and started discharging purulent pus associated fever, colicky central abdominal pain, nausea and non projectile vomiting of recently ingested fluid. One week to presentation she started discharging feacal material from the wound site, she had intravenous ceftriazone 1gram twice daily and intravenous metronidazole 500 mg eight hourly for 5 days at referring hospital. On examination, she was morbidly obese (BMI = 45kg/m2), febrile, pale (Haematocrit = 9g/dl), anicteric, no pedal edema. She had elevated BP= 110/80mmHg, E/U/Cr was normal, elevated uric acid was 9.0 mg (4.0 - 6.5)mg, Fasting lipid profile (Total Cholesterol 206 mmol/l, Triglyceride 157 mmol/l, HDL 39 mmol/l, LDL 172 mmol/l), Fasting blood glucose of [6.9mg/dl(2.5 - 6). Patient is a known dyspeptic and Diabetes mellitus. Spontaneous fistula is rare in clinical practice and often complicated by malnutrition, fluid and electrolyte imbalance, anemia and sepsis. The Triad of sepsis, malnutrition, and fluid/electrolytes disturbance is associated with high mortality. The index case presented with anemia and sepsis with no significant weight loss. In view of rarity of this presentation, an image of spontaneous enterocutaneous fistula with peri umblical sepsis in a young lady with metabolic syndrome is hereby presented.