HBV, HIV co-infection at Kisumu District Hospital, Kenya

Background: Patients with dual infection of HBV and HIV are increasingly being recognised. The two viruses, HBV and HIV share the same route of transmission and HBV is more efficiently transmitted than HIV. There is evidence that HBV will contribute significantly to continuing morbidity and mortality within the HIV infected population over the coming years. This is due to the widespread use/accessibility of the highly active anti-retroviral (HAART) drugs hence patients live longer. There are few published data in the tropical region on these patients especially in regions where HBV and HIV are endemic. Objectives: To determine the prevalence of HBV, HIV co-infection in patients who presented with jaundice and the pattern of CD4 cell counts in these patients. Design: A prospective, cross-sectional, descriptive study of all consecutive patients included in the study. Setting: Medical wards, medical outpatient clinic and liver clinic, Kisumu District Hospital, Western Kenya. Subjects: Five hundred and nineteen (261 females and 258 males) patients who had jaundice were screened for the study. One hundred and eighty five (110 males and 75 females) patients were excluded. Three hundred and thirty four patients 151 (45.2%) males and 183 (54.8%) females were included and completed the study between August 2002 and October 2003. Main outcome measures: Socio-demographic data, HBsAg positive, HlV serology (positive or negative), CD4 cell counts, ALT and AST, IgG anti-HBc and IgM anti-HBc. Results: The age range was 7-76 years with a mean of 36 (±13) years. The mean age for males and females was 37 (± 13) years and 35 (±12) years respectively. One hundred and seventy seven (53%) had co-infection and 157(47%) had HBV mono-infection. IgG anti-HBc and IgM anti-HBc were detected in 17 (5%) and 317(95%) patients respectively. Of the 317 patients with IgM anti-HBc, 177 (55.8%) had co-infection while 140 (44.2%) had HBV mono-infection (p= 0.05). The overall mean CD4 cell count for the whole population was 391 (±314) cells /mm3. The mean CD4 cell count for patients with co-infection was lower, (120 (±112) cells/mm3) than for patients with HBV monoinfection, 694 (±140) cells/mm3. The transaminases were uniformly elevated in both groups with mean AST of 207 (±147) U/L and ALT of 356 (±177) U/L. In the co-infection and mono-infection groups, AST was 286 (± 117) U/L and 306(± 175) U/L (p=0.23) and is not statistically significant, and the ALT was 338(± 135) U/L and 375(± 213) U/L respectively p=0.05 and the difference is statistically significant. Conclusion: HBV and HIV co-infection is recognised in this region, which is endemic for both viral infections. The patients with dual infection had very low CD4 cell counts. This will influence the choice of highly active anti-retroviral therapy (HAART) in favour of Lamivudine containing combinations to cover the HBV infection. East African Medical Journal Vol.81(12) 2004: 626-63

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

CD4 + Cell Response to Anti-Retroviral Therapy (ARTS) In Routine Clinical Care Over One Year Period in a Cohort of HAART Naive, HIV Positive Kenyan Patients

Background: Untreated HIV/AIDS leads to severe immune depletion with opportunistic                                                                    infections and other co-morbidities. Highly active anti-retroviral therapy (HAART) enhances immunity by sustained HIV- viral suppression, increase in CD4+ cell count and immune restoration. HAART reduces risk of neutropaenia, anaemia and accompanied decrease in incidence of opportunistic infections.Objectives: To study the CD4+ cell response in patients with severe HIV/AIDS disease over one year period while on HAART.Design: Observational, descriptive, longitudinal study.Setting: Kisumu District Hospital (Medical outpatient clinic, medical and surgical wards), Nairobi Rhematology clinic and The Mater Hospital between July 2001 and March 2007.Subjects: Four hundred and sixty three consenting patients were screened for the study.Intervention: The 103 patients included received HAART within one to four weeks and appropriate treatment for the opportunistic infections and other co-morbidities. Various HAART combinations including combivir/efavirenz, stavudine/lamivudine/nevirapine and triomune 30/40 (fixed dose combination of stavudine, nevirapine and lamivudine) were used. Some delayed HAART because of the co- morbidities which had to be managed first (severe anaemia, hepatitis and meningitis).Main outcome measures: CD4+ cell increase, new clinical events.Results: Four hundred and sixty three patients (256 males and 207 females) were screened. One hundred and three patients (55 males and 48 females) were included and 360 (201 males and 159 females) patients were excluded. Mean age was 37.9 ± 9.0 years range of (15-70). The mean CD4+ cell counts over the study period were 141.7 ± 176.5 (1-1022), 192.4 ± 198.5 (3-1275), 221.2 ± 178.0 (3-1300), 247.2 ± 197.7 (1-1401) and 268.6 ± 189.9 (1-1390) cells/µl at 0,3,6,9 and 12 months respectively. Nine patients had higher CD4+ cell counts > 350 cells/µl (433-1022) at baseline and higher HIV-viral RNA range between  51,830-1million copies/µl. The patients had multiple co-morbidities,namely, had tuberculosis, sepsis, cryptococcus meningitis, herpes zoster virus, four had non- Hodgkinfs lymphoma, oral candidiasis, hepatitis B virus, pneumocytis jiroveci pneumonia and HIV with renal dysfunction. Seventy (68%) patients had . 2 opportunistic infections. Mean AST, ALT and haemoglobin levels were 127.8 ± 79.8 IU/L, 157.2 ± 50.1 IU/L and 9.1 ± 4.3 g/dl respectively. No patient tested positive foranti-HCV antibodies.Conclusion: The majority of patients had advanced HIV infection at baseline. There was a slow but steady increase in CD4+ cell count over one year. However only 30(29.1%) of patients achieved immune restoration. Seventy three (70.9%) of patients still had immune depletion with low CD4+ cell counts at one year of receiving HAART. Patients with low CD4 + cell counts at baseline had a steady increase of CD4+ cells over the first six months and this emphasises the need to initiate HAART early in public health policy strategy. Expedited HAART initiation should be done in  patients with CD4+ cell counts < 350 cells/µl. Delayed HAART, at low CD4+ cell counts, is associated with poor immune recovery/restoration

Halothane induced hepatitis: Case report

Halothane as a cause of hepatitis is rare and may be overlooked when evaluating a patient with sudden onset jaundice. A 34-year-old lady, a nurse, presented to the liver clinic with sudden onset non - pruritic jaundice. Viral and collagen serological tests were all normal, malaria and sickling tests were negative, but transaminases were elevated. She reported inadvertent exposure to halothane in surgical theatre where she works. She improved on conservative management, then had a re-exposure to halothane after three weeks and developed a similar clinical picture, which improved on conservative management. In an area endemic of malaria, hepatitis and haemolysing conditions like sickle cell anaemia, the diagnosis of halothane hepatitis requires high index of suspicion. The mechanism of halothane-induced hepatic damage in this patient is very likely idiosyncratic. This is because of the modest dose at first exposure and more severe clinical picture at re-exposure. East African Medical Journal Vol.81(10) 2004: 538-53

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

Osteopaenia and Osteonecrosis in HIV Infection: Report of Two Cases

The introduction in the mid 1990’s of highly active anti-retroviral drugs therapy (HAART) in the treatment of human immunodeficiency virus (HIV) infection has significantly changed the course, manifestation of HIV disease and improved the life expectancy of HIV infected patients.The consequence of longer survival has manifested increasing rates of co-morbid diseases and aroused interest in the interaction of HIV and aging The pathogenesis of the resultant conditions though not fully understood is likely multifactorial and may be related to direct effect of the HIV virus and associated immunodeficiency, underlying opportunistic events, immunoactivation ,related vasculopathies and inflammatory processes and toxic effects of anti-retroviral agents Bone disorders as such osteopaenia, osteoporosis and bone fractures, osteonecrosis and accompanying metabolic changes, has been reported with increasing frequency. We report two cases of patients known to be HIV positive and on HAART who presented with hip pain. The first patient had radiological evidence of osteonecrosis (avascular necrosis) of the head of femur, and second patient who presented with acute sudden onset pain had fracture of the neck of femur. Literature is reviewed to elucidate possible mechanism of disease and a brief consideration of possible therapy is discussed

Vasculitis in HIV: report of eight cases

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