Ulrich Laaser

Tuberculous meningitis: a disease of fatal outcome in children.

In Pakistan, untreated paediatric cases of tuberculosis may rapidly progress to tuberculous meningitis. Early BCG prophylaxis and parental awareness are vital in combatting the disease [1, 2, 3, 4, 5, 6]. According to the WHO, globally more than 1.3 million new paediatric tuberculosis (TB) cases are notified each year [7]. Mortality due to tuberculous meningitis (TBM) has amounted to 170,000 children (aged <1–5 years) annually. Pakistan ranks eighth among the list of 22 high -burden countries (incidence 177 per 100,000) from tuberculosis where death toll due to TB mounts to 50,000 annually [7]. A rapidly increasing number of children contract tuberculosis (TB) every year and face fatal outcomes like TBM [1, 2, 3, 4, 5, 6, 7]. Prompt detection and treatment of TBM is a major challenge in poor resource settings as its manifestations are vague, and diagnosis requires skills and advanced diagnostic procedures [3]. In 2000 (JanuarySeptember, 2000), 34 children (age 0–13 years) with TBM were admitted to a tertiary hospital in Northern Pakistan. Retrospective review of medical records envisaged unique interpretations. Of26/ 34 cases, 26 were confirmed TBM (smear positive) with pulmonary involvement (20 female, 14 male) and eight cases were extra-pulmonary. Eighteen of the18/ 34 cases had an adult TB case in the family. Twenty children had no BCG scar. Of the 16/ 34 TBM cases, 16 were undernourished, had prior pulmonary involvement and later developed complications like, hydrocephalus (n=5), encephalitis (n=6), miliary TB (n=2), complete brain death (n=2), and cirrhosis (n=1). In the extra-pulmonary TB cases, abdominal TB (n=3), cirrhosis with ascities (n=2), tuberculous dactylitis (n=1), tuberculous lymphadinitis (n=1), and one TBM with acute hepatitis (n=1). A total of 15 TBM cases were admitted in stage 3, two in stage 2 (with moderate to severe disabilities) and the rest were in stage 1 (see glossary). Onset and manifestations of severe neurological sequelae e.g., movement and behavioural disorders, and altered mental state were noticed upon admission. Delay in the diagnosis occurred in ca. 33%two third of cases. Treatment was frequently interrupted ( £ 1 month) and therapies other than medical, were given. Therapy given was mostly unsupervised and sub-standardizsed (n=15). Eleven of 34 cases were resistant to multiple drugs e.g., isoniazid, rifampicine, and ethambutol. Superimposed infections and debilitating physical state allegedly complicated the clinical outcome. Two case fatalities were reported. The average admission stay was ‡10 days. Chemotherapy was tailored and supervised for the initial two months depending upon the results of drug susceptibility testing. A total of nine TBM cases received adjuvant chemotherapy with second -line drugs. Chemotherapy was supplemented by multivitamins and nutritional support for the underweight children. These data emphasizse the shortcomings in management and cause fatal consequences. A meta-analysis has shown that the protective effect of BCG against these life-threatening forms of TB is close to 90% [5, 6, 7]. Research further claims that the risk of progression of primary TB to an advanced state like TBM is higher among children and complicates 0.3% of untreated or maltreated primary infections [3, 4, 6]. There is a firm belief that 40% to 50% of untreated TB infection develops disease within a 1 to 2 years period and progresses more rapidly towards complications [4]. Judicious efforts are required to enhance case detection, improve case management, and contact tracing. Early prophylaxis by BCG vaccination and awareness among parents are vital issues to be addressed. Eur J Pediatr (2003) 162: 281–282 DOI 10.1007/s00431-003-1172-4

A zero prevalence of anti-HIV in blood donors in Gaza : how can it be sustained?

Concerns about the quality of Palestine’s HIV/AIDS reporting system were raised in 1998 when three cases of AIDS were notified to the Ministry of Public Health but paradoxically no cases of HIV were reported that same year. Hence a study was conducted to investigate the prevalence of anti- HIV in blood donors in Gaza. In a study population of 16493 blood donors the overall prevalence of HIV-1 was 0.18%; of which 4.8% were blood and factor VIII recipients 0.15% were drug addicts and 0.23% were sexually transmitted disease patients. To sustain the low level of HIV infections in Gaza a national effort should be done to educate the public about HIV transmission and prevention to maintain meticulous blood screening and control high-risk groups of HIV infection.