Mortality from HIV-associated meningitis in sub-Saharan Africa: a systematic review and meta-analysis.

INTRODUCTION: HIV-associated cryptococcal, TB and pneumococcal meningitis are the leading causes of adult meningitis in sub-Saharan Africa (SSA). We performed a systematic review and meta-analysis with the primary aim of estimating mortality from major causes of adult meningitis in routine care settings, and to contrast this with outcomes from clinical trial settings. METHODS: We searched PubMed, EMBASE and the Cochrane Library for published clinical trials (defined as randomized-controlled trials (RCTs) or investigator-managed prospective cohorts) and observational studies that evaluated outcomes of adult meningitis in SSA from 1 January 1990 through 15 September 2019. We performed random effects modelling to estimate pooled mortality, both in clinical trial and routine care settings. Outcomes were stratified as short-term (in-hospital or two weeks), medium-term (up to 10 weeks) and long-term (up to six months). RESULTS AND DISCUSSION: Seventy-nine studies met inclusion criteria. In routine care settings, pooled short-term mortality from cryptococcal meningitis was 44% (95% confidence interval (95% CI):39% to 49%, 40 studies), which did not differ between amphotericin (either alone or with fluconazole) and fluconazole-based induction regimens, and was twofold higher than pooled mortality in clinical trials using amphotericin based treatment (21% (95% CI:17% to 25%), 17 studies). Pooled short-term mortality of TB meningitis was 46% (95% CI: 33% to 59%, 11 studies, all routine care). For pneumococcal meningitis, pooled short-term mortality was 54% in routine care settings (95% CI:44% to 64%, nine studies), with similar mortality reported in two included randomized-controlled trials. Few studies evaluated long-term outcomes. CONCLUSIONS: Mortality rates from HIV-associated meningitis in SSA are very high under routine care conditions. Better strategies are needed to reduce mortality from HIV-associated meningitis in the region

Reliability and Diagnostic Performance of CT Imaging Criteria in the Diagnosis of Tuberculous Meningitis

The original publication is available at http:// www.plosone.orgPublication of this article was funded by the Stellenbosch University Open Access Fund.Introduction: Abnormalities on CT imaging may contribute to the diagnosis of tuberculous meningitis (TBM). Recently, an expert consensus case definition (CCD) and set of imaging criteria for diagnosing basal meningeal enhancement (BME) have been proposed. This study aimed to evaluate the sensitivity, specificity and reliability of these in a prospective cohort of adult meningitis patients. Methods: Initial diagnoses were based on the CCD, classifying patients into: ‘Definite TBM’ (microbiological confirmation), ‘Probable TBM’ (diagnostic score $10), ‘Possible TBM’ (diagnostic score 6–9), ‘Not TBM’ (confirmation of an alternative diagnosis) or ‘Uncertain’ (diagnostic score of ,6). CT images were evaluated independently on two occasions by four experienced reviewers. Intra-rater and inter-rater agreement were calculated using the kappa statistic. Sensitivities and specificities were calculated using both ‘Definite TBM’ and either ‘Definite TBM’ or ‘Probable TBM’ as gold standards. Results: CT scan criteria for BME had good intra-rater agreement (k range 0.35–0.78) and fair to moderate inter-rater agreement (k range 0.20–0.52). Intra- and inter-rater agreement on the CCD components were good to fair (k = ranges 0.47–0.81 and 0.21–0.63). Using ‘Definite TBM’ as a gold standard, the criteria for BME were very specific (61.5%–100%), but insensitive (5.9%–29.4%). Similarly, the imaging components of the CCD were highly specific (69.2–100%) but lacked sensitivity (0–56.7%). Similar values were found when using ‘Definite TBM’ or ‘Probable TBM’ as a gold standard. Discussion: The fair to moderate inter-rater agreement and poor sensitivities of the criteria for BME suggest that little reliance should be placed in these features in isolation. While the presence of the CCD criteria of acute infarction or tuberculoma(s) appears useful as rule-in criteria, their absence is of little help in excluding TBM. The CCD and criteria for BME, as well as any new criteria, need to be standardized and validated in prospective cohort studies.Funding: KB received funding from the Discovery Foundation (Academic Fellowship Award; http://www.discovery.co.za/portal/loggedout-individual/discoverycommunity- about), College of Neurology of South Africa (K.M. Browse Award; http://www.collegemedsa.ac.za/Default.aspx ) and the University of Stellenbosch. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Publisher's versio

Phaeochromocytoma and reversible myocardial ischaemia in a 23-year old female

Background: Phaeochromocytoma is a rare neuroendocrine tumour with highly variable clinical presentation including serious and potentially lethal cardiovascular complications. Aim: To present a case of myocardial ischaemia in Phaeochromocytoma which was reversed after surgery. Setting: University of Port Harcourt Teaching Hospital (UPTH). Case report: A young female undergraduate aged 23 years presented with recurrent blackouts, paroxysmal hypertension which was resistant to several anti- hypertensive drugs and marked postural drop was referred from a private clinic to UPTH. Rest electrocardiogram (ECG) showed ischaemic changes and right axis deviation. Ultrasound scan and computerised tomographic (CT) scan showed a mass on the anteromedial portion of the left kidney with centrally located cystic areas. The 24-hour urine level of vanillyl mandelic acid (VMA) was normal. The tumour was excised by open surgery and histopathological findings confirmed Phaeochromocytoma. The ECG changes reversed after surgical excision. There was no recurrence or metastasis postoperatively after a long term follow up of 5 years. Her blood pressure remained normal postoperatively without taking antihypertensive medication. Conclusion: Phaeochromocytoma is a catecholamine secreting neuroendocrine tumour with a high cardiovascular morbidity and mortality. ECG features of myocardial ischaemia can be reversed by surgical intervention. Keywords: Phaeochromocytoma, Reversible myocardial ischaemia, Surgical interventionPort Harcourt Medical Journal Vol. 2 (3) 2008: pp. 263-26

Clinical pattern of stroke in the University of Port Harcourt Teaching Hospital - a prospective study

Background: Stroke has been identified as a major cause of morbidity and mortality in the African. Aim: To determine the hospital frequency of stroke, identify associated risk factors, find out the  diurnal variation (if any), and access the morbidity and mortality pattern of stroke at the University of Port Harcourt Teaching Hospital (UPTH). Methods: A prospective study of patients admitted with stroke in the medical wards of the University of Port Harcourt Teaching Hospital (UPTH) from 1st  January 1996 to 30th  June 1997 within 14 days of onset was done. Data extracted via an interviewer structured questionnaire included age, sex, occupation, time and day of presentation, risk factors, stroke subtypes and outcome. Results: There were 100 cases of stroke admitted over the period. This gave a stroke frequency of 0.95% of hospital admissions, 8.40% of medical admissions and 41.00% of neurological   admissions.   The   mean   age  of patients was 58.0 ± 14.6 years. There were 46(46.0%) males and 54(54.0%) females. Stroke was found to have morning peaks and tended to occur more during the midweek and weekends. Clinically, cerebral infarction accounted for 52.0% of cases, followed by intracerebral haemorrhage 27.0%, and subarachnoid haemorrhage 8.0%. Unclassified subtype was 13.0%. Hypertension remained a predominant risk factor affecting 73.0% of all cases.  Of the total number of patients with stroke, 34 (34.0%) recovered with minimal disability, 27 (27.0%) recovered with moderate disability while 15(15.0%) were severely disabled. Twenty four (24.0%) of the stroke patients died. Conclusion: Stroke is a major cause of morbidity and mortality at UPTH. Detection of risk factors through health education and population screening should be encouraged.   Key words: Stroke, Adults, Clinical pattern, Prospective study, Port Harcour

A 14-year-old Nigerian female with idiopathic intracranial hypertension (Pseudotumor cerebri or benign intracranial hypertension)

A 14-year-old secondary school girl presented with acute onset severe generalized headache associated with vomiting and diplopia. These followed an initial fever, which responded to chloroquine. She had been on perflacine for a left knee septic arthritis until onset of her symptoms. The main findings on physical examination were mild obesity, left abducent nerve palsy, bilateral papilledema and evidence of resolving arthritis of her left knee. The results of her investigations, including a brain CT scan were within normal limits. A diagnosis of IIH was made. She responded satisfactorily to oral acetazolamide with complete resolution of her symptoms and signs within 12 days of hospitalization and 2 weeks of follow-up

The Nigeria Parkinson Disease Registry: Process, Profile, and Prospects of a Collaborative Project

BACKGROUND: Clinical disease registries are useful for quality improvement in care, benchmarking standards, and facilitating research. Collaborative networks established thence can enhance national and international studies by generating more robust samples and credible data and promote knowledge sharing and capacity building. This report describes the methodology, baseline data, and prospects of the Nigeria Parkinson Disease Registry. METHODS: This national registry was established in November 2016. Ethics approval was obtained for all sites. Basic anonymized data for consecutive cases fulfilling the United Kingdom Parkinson's Disease Brain Bank criteria (except the exclusion criterion of affected family members) are registered by participating neurologists via a secure registry website (www.parkinsonnigeria.com) using a minimal common data capture format. RESULTS: The registry had captured 578 participants from 5 of 6 geopolitical zones in Nigeria by July 2019 (72.5% men). Mean age at onset was 60.3 ± 10.7 years; median disease duration (interquartile range) was 36 months (18–60.5 months). Young‐onset disease (<50 years) represented 15.2%. A family history was documented in 4.5% and 7.8% with age at onset <50 and ≥ 50, respectively. The most frequent initial symptom was tremor (45.3%). At inclusion, 93.4% were on treatment (54.5% on levodopa monotherapy). Per‐capita direct cost for the registry was $3.37. CONCLUSIONS: This is the first published national Parkinson's disease registry in sub‐Saharan Africa. The registry will serve as a platform for development of multipronged evidence‐based policies and initiatives to improve quality of care of Parkinson's disease and research engagement in Nigeria