Oesophageal ulceration in HIV-infected patients

Objective. To determine the aetiology of oesophageal ulceration in HIV-infected patients. Design. A retrospective clinical, endoscopic and histopathological analysis of patients with confirmed HIV infection and an oesophageal ulcer diagnosed on endoscopy. Setting. A tertiary referral, gastrointestinal clinic in Cape Town. Results. Fifty-one patients with HIV infection and oesophageal ulceration were seen from January 2001 to December 2007. Median CD4 count was 26 cells/µl. Mean age was 35.5 years. Sixty per cent of patients were female. Forty-nine per cent of oesophageal ulcers were idiopathic while 23% were caused by cytomegalovirus infection. The remainder were due to miscellaneous causes. Conclusion. A surprisingly small number of patients with HIV associated oesophageal ulceration were seen during the study period. This may reflect local referral practices or the fact that patients with severe immunosuppression succumb before developing oesophageal ulcers. As in other series, idiopathic oesophageal ulcers and cytomegalovirus ulcers made up the majority of cases. Correct biopsy technique and appropriate histological and microbiological investigations are associated with improved diagnostic yield in these patients

A natural history of efavirenz drug-induced liver injury

Background. Efavirenz (EFV), a non-nucleoside reverse transcriptase inhibitor, has been a component of first-line antiretroviral therapy (ART) in the South African HIV/AIDS programme since 2004. It is extensively used in ART programmes in other low- and middle-income countries. The natural history of the previously recognised EFV drug-induced liver injury (DILI) is not known.Objectives. To define and establish a causality assessment for EFV DILI and document its natural history by detailing a patient cohort. All relevant features characterising the patterns of clinical and histological injury, the duration of clinical and biochemical recovery and the associated mortality rate were documented. Factors associated with specific histological patterns of liver injury were analysed.Methods. Patients were prospectively included after meeting causality and inclusion criteria for EFV DILI. Clinical, demographic and liver histological features (where possible) were documented from the time of presentation and throughout follow-up. Prednisone at 0.25 - 0.5 mg/kg was initiated at the discretion of the treating hepatologist.Results. Fifty patients were prospectively included in the analysis. The median age was 34 (interquartile range (IQR) 29 - 39) years, males being older than females (p=0.014). Most (92%) were female, and 86% were of black African ethnicity. The median duration of ART at presentation was 6 months, with half of the women having initiated ART during pregnancy, at a median gestation of 24 (IQR 11 - 36) weeks. The median CD4 nadir at ART treatment initiation was 517 cells/µL, with no significant difference in CD4 nadir between those who were pregnant and those who were not (p=0.6). The median RUCAM (Roussel Uclaf Causality Assessment Method) score was 7, and among the 75% of patients who had liver biopsies, three histological patterns were identified: submassive necrosis (60%), nonspecific hepatitis (35%), and mixed cholestatic hepatitis (5%). On multivariate analysis, predictors for the development of submassive necrosis included younger age (<30 years; p=0.045), ART initiation in pregnancy (p=0.02), and a baseline CD4 count >350 cells/µL (p=0.018). For the nonspecific hepatitis group, pregnancy was also an associated factor (p=0.04). The mortality rate was 14%, with a median time from admission to death of 15 days. The median (IQR) time to initial hospital discharge was a lengthy 33 (24 - 52) days. Biochemical recovery was prolonged, necessitating a follow-up period of more than a year at an outpatient specialist clinic, with 86% of patients initiating a protease inhibitor-based ART regimen successfully.Conclusions. EFV DILI is a severe drug complication of ART with appreciable mortality and significant inpatient morbidity, requiring prolonged hospitalisation and follow-up

Contemporary management of primary parapharyngeal space tumors

The parapharyngeal space is a complex anatomical area. Primary parapharyngeal tumors are rare tumors and 80% of them are benign. A variety of tumor types can develop in this location; most common are salivary gland neoplasm and neurogenic tumors. The management of these tumors has improved greatly owing to the developments in imaging techniques, surgery, and radiotherapy. Most tumors can be removed with a low rate of complications and recurrence. The transcervical approach is the most frequently used. In some cases, minimally invasive approaches may be used alone or in combination with a limited transcervical route, allowing large tumors to be removed by reducing morbidity of expanded approaches. An adequate knowledge of the anatomy and a careful surgical plan is essential to tailor management according to the patient and the tumor. The purpose of the present review was to update current aspects of knowledge related to this more challenging area of tumor occurrence.Peer reviewe

Oesophageal Ulceration in Human Immunodeficiency Virus Infected Patients

Objective. To determine the aetiology of oesophageal ulceration in HIV-infected patients. Design. A retrospective clinical, endoscopic and histopathological analysis of patients with confirmed HIV infection and an oesophageal ulcer diagnosed on endoscopy. Setting. A tertiary referral, gastrointestinal clinic in Cape Town. Results. Fifty-one patients with HIV infection and oesophageal ulceration were seen from January 2001 to December 2007. Median CD4 count was 26 cells/μl. Mean age was 35.5 years. Sixty per cent of patients were female. Forty-nine per cent of oesophageal ulcers were idiopathic while 23% were caused by cytomegalovirus infection. The remainder were due to miscellaneous causes. Conclusion. A surprisingly small number of patients with HIVassociated oesophageal ulceration were seen during the study period. This may reflect local referral practices or the fact that patients with severe immunosuppression succumb before developing oesophageal ulcers. As in other series, idiopathic oesophageal ulcers and cytomegalovirus ulcers made up the majority of cases. Correct biopsy technique and appropriate histological and microbiological investigations are associated with improved diagnostic yield in these patients. South African Medical Journal Vol. 99 (2) 2009: pp. 107-10

Achalasia complicated by squamous cell carcinoma of the oesophagus

Case reportA 63 year old male presented with a 4 year history ofprogressive dysphagia to solids. He had no backgroundmedical or surgical history. He did not smoke or consumeany alcohol. On examination, he was markedly wasted

An atypical cause of retroperitoneal fibrosis: Case report and literature review

Introduction: Retroperitoneal fibrosis (RPF) is a rare inflammatory disease resulting in the development of a retroperitoneal mass, which may encase the aorta and its branches, as well as the ureters. Observation: The systemic inflammatory response causes constitutional symptoms. The mass itself leads to symptoms of non-specific back pain and abdominal pain, as well as ureteric obstruction and subsequent renal insufficiency. Immunoglobulin 4 (IgG4) has recently been found to be involved in the pathogenesis of multiple autoimmune and inflammatory disorders, including RPF. Blood work-up, imaging and biopsy of the mass remain the mainstay of diagnosis. Conclusion: RPF remains a diagnosis of exclusion. Treatment hinges on corticosteroids, but other immunosuppressants and disease-modifying agents are also being used more commonly. Surgical intervention is only carried out when conservative measures have failed or are contraindicated, and in order to preserve renal function

Giant angiomyolipoma in a tuberous sclerosis patient and review of the literature

textabstractIntroduction: About 20% of renal angiomyolipomas (RAML) are associated with tuberous sclerosis complex (TS). About 34–80% of patients with TS present with RAML. RAMLs associated with TS are at higher risk of potentially life-threatening hemorrhage and hypovolemic shock. Only a few case reports of giant RAML, defined as larger than 10 cm in diameter, and its management, have been reported. Observation: We present a 21 year old woman with abdominal distension over the last 2 years. A contrast-enhanced CT scan revealed a giant RAML on the left side. Based on the presence of at least 3 major features of the clinical diagnostic criteria of tuberous sclerosis complex, the diagnosis was made. An open nephrectomy was performed. Therapeutic options described in literature are conservative management, medical treatment with mTOR inhibitors, arterial embolization, radioablation and partial or total nephrectomy. Conclusion: In giant TS-associated RAML total nephrectomy, rather than conservative treatment, is the treatment of choice in order to reduce the risk of potentially life-threatening bleeding

Castleman’s disease in the HIV-endemic setting

Esam-Rajab Mahroug,1 Candice Sher-Locketz,1 Minodora-Silvia Desmirean,2,3 Emmanuel-Akinola Abayomi,1,4 Ciprian Tomuleasa,3,5,6 Ravnit Grewal1,7 1Division of Haematology, Department of Pathology, University of Stellenbosch, Tygerberg Academic Hospital, Cape Town, South Africa; 2Department of Pathology, Military Hospital of Cluj Napoca, Cluj Napoca, Romania; 3Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania; 4Department of Hematology, Nigeria Institute for Medical Research, Lagos, Nigeria; 5Research Center for Functional Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania; 6Department of Hematology, Ion Chiricuta Clinical Research Center, Cluj Napoca, Romania; 7Department of Pathology, South African Bioinformatics Institute, University of The Western Cape, Bellville, South Africa Introduction: Castleman’s disease (CD), first described by Benjamin Castleman in 1954, is a giant or angiofollicular lymph node hyperplasia, described as a rare monotypic polyclonal B-cell lymphoproliferative disorder with an incompletely understood pathogenesis and variable clinical behavior. This study aimed to determine the incidence of CD diagnosis over an 11-year period. Additionally, the study aimed to describe the demographic, laboratory, and pathological features of CD. Methods: This is a retrospective study where the demographic and laboratory data were retrieved from the Tygerberg Academic Hospital (TAH) patient electronic records and Tygerberg Lymphoma Study Group (TLSG) and statistical analysis performed on the patients diagnosed with CD. Results: Fifty-four patients were diagnosed with CD during this period. The median age at presentation was 39 years (range: 9–58). HIV serology was available in 53 patients, of which 51 were HIV-positive and two were HIV-negative. The history of initiation of antiretroviral therapy at diagnosis was available in 43 patients (38 on treatment, four were not on treatment, and one defaulted treatment). The median CD4 count was 232.50 cells/μL (range: 2–883). The HIV viral load was performed in 43 patients at diagnosis, which was <49 HIV-1 RNA copies/μL in more than half of the patients (58%). Diagnosis was made on lymph node biopsies in 53 patients, with one case diagnosed on a spleen biopsy. Kaposi sarcoma was found on the same tissue biopsy in 13 cases. A bone marrow biopsy was performed in 31 patients. The predominant features noted were a disorganized hypercellular marrow with plasmocytosis. Conclusion: CD is a rare polyclonal B-cell lymphoproliferative disorder. However, we demonstrated a significant increase in the incidence of HIV-associated multicentric CD over the last decade in our area in South Africa. Keywords: Castleman’s disease, HIV-endemic setting, HHV-8 status, CD4 count, clinicopathological correlatio

A dimorphic fungus causing disseminated infection in South Africa

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