Enrico Rino Bregani

Outcome of severely malnourished children treated according to UNICEF 2004 guidelines: a one-year experience in a zone hospital in rural Ethiopia

Malnutrition still has a dramatic impact on childhood mortality in sub-Saharan African countries. Very few studies have tried to evaluate the outcome of severely malnourished children treated according to the UNICEF 2004 guidelines and reported fatality rates are still very high. During 2006, 1635 children were admitted to the paediatric ward of St. Luke Catholic Hospital in Wolisso, South West Shewa, Ethiopia. Four hundred and ninety-three (30.15%) were severely malnourished and were enrolled in the study. We reviewed the registration books and inpatient charts to analyze their outcome. A mortality rate of 7.1% was found, which is significantly lower than reported in the literature. 28.6% of deaths occurred within 48 h of admission; the recovery rate was 88.4%; the drop-out rate was 4.5%. Early deaths were due to the poor condition of the children on admission, leading to failure of treatment. Late mortality was considered to be related to electrolyte imbalances, which we were unable to measure. The clinical skills of nursing and medical staff were considered an important factor in improving the outcome of malnourished patients. We found that proper implementation of WHO guidelines for the hospital treatment of severely malnourished children can lead to a relatively low mortality rate, especially when good clinical monitoring is assured.

Case report: intraocular localization of Mansonella perstans in a patient from south Chad

A case of Mansonella perstans infection with visual impairment and a retinal lesion is described. After a course of diethylcarbamazine and a further course of mebendazole the symptoms improved and the microfilariae blood concentration decreased. The symptoms and response to antifilarial treatment strongly suggested the intraocular localization of an M. perstans worm.

Snake bites in Moyen Chari district, Chad: a five-year experience

Snake bites are of major public health importance in Africa as a cause of morbidity and mortality. Echis ocellatus is responsible for the majority of envenomation cases in West Africa. Antivenom immunotherapy is the only specific treatment available for envenomed patients. From January 1997 to December 2001, 325 patients suffering from snake bites were enrolled in a survey undertaken at Goundi Hospital, Chad. We analysed the percentage of envenomed patients, sex distribution, distribution along the year, lethality, hospital stay and recovery clotting time. Two hundred and ninety-eight patients showed signs of envenomation and were treated with antivenom immunotherapy with three different sera in consecutive periods. Young males were more frequently involved. The overall lethality was 8%. Lethality and hospital stay were significantly different in the differently treated patients. Most of the data in our series were similar to those from other sub-Saharan countries but, overall, the percentage of snake bite victims who were admitted to hospital was higher.

Prevalence of filariasis in symptomatic patients in Moyen Chari district, south of Chad.

Filarial parasites infect an estimated 140 million people worldwide. Wuchereria bancrofti, Onchocerca volvulus, Loa loa and Mansonella perstans are responsible for most filarial infections in sub-Saharan Africa. We describe the prevalence and the clinical characteristics of filariasis in symptomatic patients in Goundi Sanitary district:167 patients were enrolled (99 men, 68 women). M. perstans microfilariae were isolated in peripheral blood in 164 cases, while Loa loa and Wuchereria bancrofti filariasis were diagnosed in only six and three cases, respectively. The most frequent filariasis observed in our study were due to M. perstans and L. loa, while the few cases of W. bancrofti filariasis seem to have been acquired abroad. No cases of O. volvulus were observed. Microfilarial burden was not related to symptoms, but a correlation between eosinophilia and pruritus was evident. No relationship was observed between eosinophils and symptoms. The prevalence observed in symptomatic patients could reflect the real prevalence of filariasis.

Filariasis due to blood transfusion.

Dear Sir, In his letter to Blood Transfusion, Viroj Wiwanitkit emphasises the screening of donated blood to look for microfilariae in order to prevent a possible risk of transmitting a communicable disease1. Cases of tourism-acquired microfilariosis by Mansonella ozzardi and M. perstans were cited. The case of M. perstans microfilariasis2 described, actually occurred in an endemic zone in south Chad, and was not a case imported into a non-endemic area. An infant with malaria-related severe anaemia received blood from a parent carrying M. perstans microfilariae. The patient’s follow-up showed a progressive clearance of microfilariae from the blood without any occurrence of symptoms or eosinophilia for 4 months. Our conclusion was that, at least in endemic zones, M. perstans microfilariae transfusion could be safe, the disease probably being due to the action of or immunological reaction against the adult worm. It is likely that only adult worms are responsible for symptoms and eosinophilia, while microfilariae in the blood are unable to give clinical manifestations. The eosinophilia that can be observed in some but not all patients with M. perstans infection is probably due to the body’s reaction against the adult worm rather than against microfilariae and the absence of eosinophilia in the case described could indicate that M. perstans microfilariaemia is quite well tolerated and can be considered a possible confirmation of the absence of pathogenicity due to the presence of microfilariae alone. M. perstans microfilariae can persist in the host for up to 3 years after transfusion3, but from our observation we suggest that transfused M. perstans microfilariae may be eliminated from the blood quite quickly in endemic areas. In the case of real need of blood, the presence of M. perstans microfilariae in donated blood is probably not an absolute contra-indication to perform a transfusion, at least in endemic areas in which chronic immunological stimulation against filarial infection is possible.

Holter monitoring in children with severe plasmodium falciparum malaria during i.v. quinine treatment

Standard treatment in severe Plasmodium falciparum malaria is with parenteral quinine in most rural hospitals of developing countries where expensive artemisinine compounds are seldom available but little is known about the toxicity of quinine in children. Quinine has potential heart toxicity due to prolongation of the treatment that could lead to the onset of ventricular arrythmias but African children under quinine treatment have not been extensively studied. Quinine pharmacokinetics have been studied in children showing a significant lengthening of the QRS interval in children up to 24 months of age suggesting the possibility that young children are more susceptible to quinine toxicity than older children. (excerpt)

Diagnostica elettrocardiografica: quando il QRS è largo

Differential diagnosis of one or more wide QRS complexes on an electrocardiogram under emergency conditions takes into account three main sets of clinical conditions: ventricular pre-excitation, aberrant conduction and ventricular beats and it is based on the morphological analysis of the ECG and patients anamnestic data. Several criteria can facilitate the differential diagnosis and if properly used and integrated with clinic data they can achieve good diagnostic accuracy in most cases. In this review several criteria based on evidence and literature are presented, paying attention in recognizing some morphologic pathways that can be used in emergency room and allow a correct ECG assessment.Differential diagnosis of one or more wide QRS complexes on an electrocardiogram under emergency conditions takes into account three main sets of clinical conditions: ventricular pre-excitation, aberrant conduction and ventricular beats and it is based on the morphological analysis of the ECG and patients anamnestic data. Several criteria can facilitate the differential diagnosis and if properly used and integrated with clinic data they can achieve good diagnostic accuracy in most cases. In this review several criteria based on evidence and literature are presented, paying attention in recognizing some morphologic pathways that can be used in emergency room and allow a correct ECG assessment.

Pre-hospital oily chloramphenicol treatment in meningitis outbreaks in low resources environments

Bacterial meningitis is an important cause of death and disability in sub-Saharan Africa and, with pre-treatment in peripheral health centres, the poorest populations could avoid early death, especially if they live far from hospital. During the 2001 meningitis epidemic in south Chad, Moyen Chari sanitary district peripheral health centres were equipped with oily chloramphenicol (CAP) to administer before hospital referral in suspected cases of meningitis. Eighty-six patients treated with CAP in whom the diagnosis was definitively confirmed subsequently in hospital were compared with patients receiving CAP at hospital admission during the same period. A statistically significant reduction in lethality rate, need of second line treatment or adjunctive antibiotics, and mean hospital stay were confirmed in pre-treated patients.

Echocardiography in low-resource rural tropical hospitals

Cardiopathies are common in tropical regions and echocardiography could be of substantial value. However, it is difficult to practice. We suggest simple techniques with conventional instruments that are available in many rural hospitals, and describe the most common echocardiographic procedures and findings that can be undertaken with short training by non-cardiologist physicians.