Socio-demographic and clinical aspects of rheumatoid arthritis

Objective: To determine the socio-demographic profiles and some clinical aspects of patients with rheumatoid arthritis (RA).Design: Prospective, cross-sectional study.Setting: Ambulatory out- patient clinics of Kenyatta National Hospital (KNH), a public national and referral hospital.Subjects: Out of 180 patients interviewed and examined, 60 met American College of Rheumatology (ACR) diagnostic criteria of RA.Results: Of the 60 patients recruited 52 (87%) were females with male: female ratio of 1: 6.5. The mean age of patients was 41.38(± 16.8) years. There were two peaks of age of occurrence, 20-29 and 40-49 years. In 75% of the study patients, one or more of metacarpophalangeal joints of the hand were involved in the disease. Other frequently involved sites were - wrists, elbows, knees, ankles and glenohumeral joints of shoulders in a symmetrical manner. Serum rheumatoid factor was positive in 78.9% while rheumatoid nodules were present in 13.3% of the study patients. A large majority of patients (88%) had active disease with 18% having mild disease, 38% moderate activity and 32% having severe disease. Only 12% of patients had disease in remission. Forty six point seven per cent (46.7%) of the study patients were on at least one Disease Modifying anti Rheumatic Drugs (DMARD) from a selection of methotrexate, sulphasalazine, hydroxychloroquine and leflunamide. The most frequent drug combination was methotrexate plus prednisolone at 30% of the study population; while 66.7% were on oral prednisolone with 25% of the study patients taking only Non-Steroidal anti Inflammatory Drugs (NSAIDS).Conclusion: A large majority of ambulatory patients with RA had active disease. Most of’ them were sub-optimally treated, especially the use of DMARDS. About two thirds were on oral steroids. Sub-optimal therapy in relatively young patients, peak 20-29 and 40-49 years is likely to impact negatively on their disease control and quality of life

Clinical and socio-demographic profile of patients on treatment for osteoporosis in Nairobi, Kenya

Background: Osteoporosis is a chronic, progressive disease of multifactorial aetiology and one of the most common metabolic bone diseases worldwide. There is a paucity of data on osteoporosis in Africa as it’s generally thought not to affect the non-Caucasian population. We sought to describe the population with osteoporosis in a Nairobi rheumatology clinic.Objective: To evaluate the clinical characteristics of patients with osteoporosis seen at a rheumatology clinic in Nairobi.Methods: Clinical, with emphasis on musculoskeletal manifestations, treatment and selected comorbidities in 56 patients diagnosed with osteoporosis were followed up and evaluated in the Nairobi Arthritis Clinic.Results: The age distribution was 31- 95 years with majority being above the age of 60 years at 71.5%. Majority were female (89.3%). The main musculoskeletal manifestations were polyarthralgia (30.4%) followed by lower back pain (19.6%) and pathological fractures (12.5%). The types of osteoporosis were grouped as primary (9%), secondary (44.6%) and post-menopausal (46.4%). The most common clinical association being rheumatoid arthritis (39.3%) followed by steroids therapy (25%). Other comorbidities included osteoarthritis, fibromyalgia, systemic lupus erythromatosus and diabetes. Seven study participants had history of fracture with lumbar spine fractures leading at 42.8%. None of the study participants were smokers. The number of patients on calcium supplements was at 71.4% and bisphosphonates was low at 32%.Conclusion: The findings of this study from age to comorbidities on osteoporosis are in keeping with literature. The number of patients on bisphosphonates was low which differed from Western literature. Persons at increased risk for osteoporosis in this set-up include post-menopausal women with debilitating chronic illness causing reduced mobilization over time and presenting with bone pains.These patients should be investigated for osteoporosis and effective treatment administered early.Keywords: Osteoporosis, Clinical profile, Nairobi, Keny

Stratification of persons with diabetes into risk categories for foot ulceration

Background: Patients with diabetes mellitus are at a higher risk of lower extremity complications as compared to their non-diabetic counterparts.Objective: To study risk factors for diabetic foot ulcer disease and stratify patients with diabetes into risk categories for foot ulceration.Design: Cross-sectional descriptive study over five months period.Setting: Diabetic outpatient clinic, at the Kenyatta National Hospital.Subjects: Two hundred and eighteen ambulatory subjects with diabetes mellitus without active foot lesions.Results: The prevalence of previous foot ulceration was 16% while that of previous amputation was 8%. Neuropathy was present in 42% of the study subjects and was significantly associated with age, male gender, duration of diabetes, random blood sugar, systolic blood pressure and the presence of foot deformity. Peripheral arterial disease was present in 12% and showed significant association with male gender. Foot deformities were observed in 46% of study subjects and were significantly associated with age, male gender, and presence of neuropathy. Subsequently 57% were categorised into IWGDF group 0 - no neuropathy, 10% were placed in group 1- neuropathy alone, 16% were put in group 2 - neuropathy plus either peripheral arterial disease or foot deformity and 17% were placed in risk group 3 - previous foot ulceration/amputation.Conclusion: More than one third (33%) of diabetic patients were found to be at high risk for future foot ulceration (lWGDF groups 2 and 3). Published evidence exists that shows improved outcomes with interventions targeting individual patients with diabetes at high-risk of foot ulceration. Long term prospective studies to determine outcomes for the different risk categories should be carried out locally

Morbidity and CD4+ Cell Counts at Initial Presentation of a Cohort of HAART-Naive, HIV Positive Kenyan Patients: Implications to Initiating HAART

Background: Sub-Saharan Africa with under 10% of the worldfs total population accounts for 60-70% of all HIV/AIDS cases. While these patients require HAART to manage the disease, HAART is not universally available. Majority of the patients are in resource-constrained settings, have multiple co- morbidities/infections, opportunistic infections, present late for treatment and are in the advanced stages of the HIV/A}IDSinfection.Objective: To describe the CD4+ cell counts, opportunistic infections and laboratory parameters of a cohort of HIV positive, HAART-naive patients at first presentation.Design: Cross sectional, prospective, descriptive, consecutive entry study.Setting: Kisumu District Hospital wards (medical, surgical) and medical outpatient clinic, Nairobi Rheumatology Clinic, Nairobi West Hospital and the Mater Hospital between January 2001 and December 2008.Main outcome measures: Socio-demographic parameters, opportunistic infections, CD4+ cell counts and complete blood count, biochemistry, HBsAg markers and anti- HCV serostatus.Results: Eight hundred and thirty four (350 males and 484 females) patients were screened. Three hundred and seventy (94 males and 276 females) patients were excluded. Four hundred and sixty four (256 males and 208 females) patients were finally included in the study. The mean age was 37.2 }10.6 years, range (12-78). The M: F ratio was 1.2:1. The mean CD4+ cell count was 106.5 } 125.2 cells/µl manifesting severe immnosuppression. Fifteen (3.2%), 19(4.1%), 43(9.3%) and 387(83.5%) had CD4+ cell counts of > 500, 350-499, 200-349 and < 200 cells/ƒÊl respectively. The mean white blood cell count was 8.63 } 8.8 ~ 103/ml (4.8-10.8 ~ 103/µl). Over half (51.3%) patients had leucopaenia, white cell count < 4.8 ~ 103/µl, 35 (7.5%) had leucocytosis and the rest 191 (41.2%) patients had normal white blood cell counts. The mean haemoglobin level was 7.16 } 5.01 g/dl (12-18 g/dl) and 154 (33.2%) had haemoglobin level < 5g/dl manifesting severe anaemia. The patients had multiple co-morbidities and 248 (53.4%) had . 2 co-morbidities.Conclusion: The patients presented with severe immunosuppression evidenced by low CD4+ cell counts, anaemia and multiple co-morbidities. Majority presented late at which point the cost of management is high and outcomes are likely to be poor. They required HAART and prompt  management of the co-morbidities to mitigate morbidity and reduce mortality. It would be prudent to study treatment outcomes and their determinants overtime in patients with severe HIV disease. Also, requiring study is how long such patients with severe HIV disease who commence HAART would last on first line treatment before requirement of alternative treatment

Severe malaria in children leads to a significant impairment of transitory otoacoustic emissions--a prospective multicenter cohort study.

BACKGROUND: Severe malaria may influence inner ear function, although this possibility has not been examined prospectively. In a retrospective analysis, hearing impairment was found in 9 of 23 patients with cerebral malaria. An objective method to quickly evaluate the function of the inner ear are the otoacoustic emissions. Negative transient otoacoustic emissions are associated with a threshold shift of 20 dB and above. METHODS: This prospective multicenter study analyses otoacoustic emissions in patients with severe malaria up to the age of 10 years. In three study sites (Ghana, Gabon, Kenya) 144 patients with severe malaria and 108 control children were included. All malaria patients were treated with parental artesunate. RESULTS: In the control group, 92.6 % (n = 108, 95 % confidence interval 86.19-6.2 %) passed otoacoustic emission screening. In malaria patients, 58.5 % (n = 94, malaria vs controls p < 0.001, 95 % confidence interval 48.4-67.9 %) passed otoacoustic emission screening at the baseline measurement. The value increased to 65.2 % (n = 66, p < 0.001, 95 % confidence interval 53.1-75.5 %) at follow up 14-28 days after diagnosis of malaria. The study population was divided into severe non-cerebral malaria and severe malaria with neurological symptoms (cerebral malaria). Whereas otoacoustic emissions in severe malaria improved to a passing percentage of 72.9 % (n = 48, 95 % confidence interval 59-83.4 %) at follow-up, the patients with cerebral malaria showed a drop in the passing percentage to 33 % (n = 18) 3-7 days after diagnosis. This shows a significant impairment in the cerebral malaria group (p = 0.012 at days 3-7, 95 % confidence interval 16.3-56.3 %; p = 0.031 at day 14-28, 95 % confidence interval 24.5-66.3 %). CONCLUSION: The presented data show that 40 % of children have involvement of the inner ear early in severe malaria. In children, audiological screening after severe malaria infection is not currently recommended, but is worth investigating in larger studies

Pyomyositis in HIV: A Series of 12 Cases

Background: Pyomyositis is a bacterial infection of the large skeletal muscles presenting with muscle pain and swelling. It is commonly seen in the tropics but is being recognised more in end-stage HIV/AIDS. In HIV-associated pyomyositis, leukocytosis and bacteraemia is rare due to deranged immune response. Surgical drainage, antibiotic treatment and HAART are the mainstay of treatment.Objective: To describe pyomyositis in HIV positive patients, their CD4+ cell counts, clinical stages of pyomyositis and anatomical sites affected.Design: Cross sectional, prospective, descriptive, consecutive entry study.Setting: Kisumu District Hospital and Nairobi Rheumatology Clinic between January 2002 to December 2007.Subjects: Twelve patients with HIV infection and pyomyositis.Main Outcome Measures: CD4+ cell counts, clinical stage and site of pyomyositis.Results: Twelve patients (six males and six females) were enrolled with mean age of 39.3 years (24-52). Pyomyositis was localised in the following regions:two each in gluteal and calf, six in the thigh and one each in the right arm and abdominal wall. CD4+ cell counts were low with a mean of 166.8 cells/µl (1.0-433) (normal range is 355-1600 cells/µl), indicating severe immunosuppression. They also had leucocytopaenia with a mean white blood cell count of 3.67 ~ 103/µl (1.5-7.1 ~ 103/µl) with a mean neutrophil count of 62.7% (43-78). Random blood sugar and creatine kinase levels were all normal. The co-morbidities comprised one case of deep venous thrombosis (DVT) and five of oral candidiasis. Pus swab grew Staphylococcous aureus in eight instances and Streptococcous pyogenes in four.Conclusion: Pyomyositis in HIV positive patients tends to occur at low CD4+ cell counts. Staphylococcus aureus was the most common causative organism

An evaluation of health related quality of life in patients with rheumatoid arthritis

Objective: To determine Health Related Quality Of Life (HRQOL) profiles of patients with Rheumatoid Arthritis (RA). Design: Prospective, cross-sectional study. Setting: Ambulatory out-patient clinics of Kenyatta National Hospital (KNH), a public national referral hospital. Subjects: Of the 180 patients interviewed and examined, 60 met the American College of Rheumatology (ACR) diagnostic criteria for RA. Results: Of the 60 patients recruited, 58% of study patients had physical component HRQOL scores ranging from poor to fair, compared to 65% who had mental component HRQOL scores ranging from good to very good. Both physical and mental health HRQOL summary scores showed significant negative correlations with disease activity (DAS-28) scores (p&lt; 0.001 for both) among the study patients. The HRQOL physical health summary scores were significantly better in the 28 study patients who were on treatment with at least one DMARD (mean score 67.25 &plusmn; 18.17) than in the other 28 study patients who had not been on DMARD therapy (mean score 53.93 &plusmn; 18.55), p = 0.008. The trend was similar but less prominent with mental health QOL summary scores, with means of 75.11 &plusmn; 19.19 with DMARDs, and 62.29 &plusmn; 21.85 without DMARDs (p = 0.034). There was a significant association between consistency of treatment with any drug and QOL physical health summary scores, with mean score for patients consistently on treatment (65.16 &plusmn; 19.26) being much better than for those on intermittent drug treatment (50.94 &plusmn; 16.27), p = 0.009. These associations were similar for QOL mental health summary scores but did not reach significance. Conclusions: In this population of ambulatory patients with RA, physical component HRQOL ranged from poor to fair, while mental component HRQOL ranged from good to very good in the majority of patients. Severity of disease showed a strong negative association with HRQOL among the study patients, while DMARD therapy and adherence to drug treatment showed a positive association with HRQOL. Improved and better adherence to DMARD therapy with resultant decrease in disease activity is likely to result in improved HRQOL in this population of patients with RA

Vasculitis in HIV: report of eight cases

No Abstract. East African Medical Journal Vol 82(12) 2005: 656-65