Thrombocytopenia in Haart naive HIV infected patients attending the comprehensive care clinic at Kenyatta national hospital

Background: Haematological abnormalities are common in HIV infected patients. Thrombocytopenia has been associated with progression of disease. The presence of thrombocytopenia is significantly associated with decreased survival and is a predictor of mortality.Objective: To determine the prevalence of thrombocytopenia and clinical characteristics of HIV infected patients who are HAART naive attending the Kenyatta National Hospital Comprehensive Care Clinic..Design: Cross-sectional descriptive Study.Setting: Kenyatta National Hospital Comprehensive Care Clinic.Subjects: HIV positive HAART naive patients.Results: Three hundred and forty HIV infected HAART naive patients with a mean age of 37.3years and range of 18years to 72years were recruited. The male to female ratio was 1:1.6.The study population comprised mostly of; young patients (39.9% between 30-40yrs), females (61.6%) in WHO clinical stage I (57.6%) and with CD4 count between 200-500 cell/mm3. The mean platelet count was 230,000 cells/ul. The prevalence of thrombocytopenia in this population was 3.8%. Most of the patients (66.7%) with thrombocytopenia had a bicytopenia with the rest having isolated thrombocytopenia or pancytopenia. Bleeding tendencies were observed more in the thrombocytopenia group (p= 0.011). Patients with CD4 count < 200cells/mm3 were more likely to have thrombocytopenia (p <0.050).Conclusion: The prevalence of thrombocytopenia is low among ambulant HIV infected HAART naive patients attending the Kenyatta National Hospital Comprehensive Care Clinic. This could be attributed to young age, predominant female gender and early disease WHO Stage 1 in the study population. Other studies found older age, male gender and advanced HIV infection population to be determinants where higher prevalence of thrombocytopenia have been reported

Congenital afibrogenaemia in a Kenyan child: Case report

CCongenital afibrinogenaemia (CA), is a rare inherited bleeding disorder characterised by complete deficiency of fibrinogen in the plasma. Blood clotting tests are indefinitely prolonged in patients. The mode of inheritance is autosomal recessive. Typically patients present with excessive cord bleeding after birth with intracerebral haemorrhages reported in childhood. Other manifestations include musculoskeletal haemorrhages, mucocutaneous bleeds with poor wound healing reported occasionally. In females, menorrhagia, repeated early pregnancy loss and post-partum haemorrhages are common. We present a four year old female who initially presented with severe cord bleeding after birth, warranting a blood transfusion. Currently she experiences recurrent epistaxis, easy bruising and excessive post -traumatic haemorrhages. All her clotting times are markedly prolonged. Her plasma fibrinogen and fibrinogen antigen are undetectable. An older sibling died from excessive cord haemorrhage after birth. Bleeds in CA respond very favourably to fibrinogen concentrates, cryoprecipitate and fresh plasma. To date, 242 cases of CA have been reported worldwide, none of them in Kenya. Our aim in reporting this case is to document the disorder, and also to raise the index of suspicion of the condition

ANALYSIS OF COST AND EFFECTIVENESS OF PRE-TRANSFUSION SCREENING OF DONOR BLOOD AND ANTI-MALARIAL PROPHYLAXIS FOR RECIPIENTS

Objectives: To determine the prevalence of malaria in donor units in a low and a high endemic region in Kenya and evaluate the cost effectiveness of recipient anti-malarial prophylaxis and pre-transfusion screening (using an automated method) as options to prevent post transfusion malaria.Design: A descriptive cross-sectional study.Setting: Two regional blood banks, Nairobi and its environs (National Blood Transfusion Services, Nairobi) a low malaria endemic region and western region (National Blood Transfusion Services, Kisumu) high malaria endemic region.Subjects: All the donated units were included in the study for analysis, during the duration of study, from the two study sites.Main outcome measures: Prevalence of malaria in donor units in low endemic area (Nairobi) and high endemic area (Kisumu). Cost per case prevented for the two options, Option I Prophylactic administration of anti-malarial (sulfadoxine pyrimethamine SP) drugs to recipients, and Option II pre-transfusion screening using an automated technique.Results: A malaria prevalence of 0.67% was found in Nairobi and its environments (low endemic) and 8.63% for Kisumu and its environments (high endemic area). The cost analysis showed a cost per case prevented of Ksh.105 (US$1.4) adult, Ksh.52.5 (US$0. 69) and paediatric for the option of recipient prophylaxis using an SP based drug. The cost escalated to Ksh.592 (US$7.79) adult Ksh.444 (US$5.84) paediatric if the prophylaxiswas upgraded to the recommended artemisinin derivative (ACT-artemisinin based combination) and for the option of pre-transfusion screening using an automated technique the cost was Ksh.2.08 (US$0.03).Conclusion: The prevalence of malaria in donors showed the expected regional variation in the low and high endemic areas and was comparable to data obtained elsewhere. If malaria positive donor units were to be excluded from the national blood supply, an estimated 5% (compared to 1.3% for human Immunodeficiency virus, 3.6% for hepatitis B virus and 1.3% for hepatitis C virus) would be wasted. The cost per case prevented of transfusion-associated malaria is considerably higher for recipient antimalarial prophylaxis than pre-transfusion screening using an automated technique. The cost escalates by five to seven times if the newer  artemesinin based combination antimalarial drugs are adopted

DISSEMINATED HISTOPLASMOSIS DIAGNOSED ON BONE MARROW ASPIRATE CYTOLOGY: REPORT Of fOuR CASES

Histoplasmosis, caused by two varieties of dimorphic fungi, Histoplasma capsulatumvariant capsulatum and Histoplasma capsulatum variant duboisii is a systemic fungalinfection. It has a worldwide distribution and is shown to be more prevalent in NorthAmerica and Central America. Both variants occur in Africa. Disease spectrum rangesfrom asymptomatic primary infection to disseminated disease in immunocompromisedpatients. Since the upsurge of Acquired Immune Deficiency Syndrome (AIDS) anddespite the availability of High Active Anti-Retroviral Therapy (HAART) many patientsstill present with opportunistic infections of which histoplasmosis is one.four cases are presented; two infants and two adults. All had disseminated disease withmultiple organ involvement and the disease was not suspected clinically. Diagnosiswas made incidentally on bone marrow aspirate cytology. The two adult cases wereHIV positive, one with CD4 counts of 132 cells/microlitre and was not on HAART.The other was on HAART but the CD4 had not been determined. One of the infantstested HIV negative and the others status was unknown. A high index of suspicionis required for diagnosis as the disease may mimic tuberculosis(TB) and other causesof hepatosplenomegaly such as visceral leishmaniasis.Laboratory diagnosis includes culture, direct staining, antigen and antibody detection.Antibody detection may give false negative in the immunocompromised patient. Theinfection responds well to antifungal agents (amphotericin B is the drug of choice)and life long maintenance therapy may be required in AIDS especially if CD4 countsremain less than 150 cells/microlitre.Histoplasmosis should be a differential diagnosis in immunosuppressed patients withunexplained fever, weight loss, hepatosplenomegaly and chest findings especially ifnot responding to anti-TB treatment

CONGENITAL AFIBROGENAEMIA IN A KENYAN CHILD: CASE REPORT

Congenital afibrinogenaemia (CA), is a rare inherited bleeding disorder characterised by complete deficiency of fibrinogen in the plasma. Blood clotting tests are indefinitely prolonged in patients. The mode of inheritance is autosomal recessive. Typically patients present with excessive cord bleeding after birth with intracerebral haemorrhagesreported in childhood. Other manifestations include musculoskeletal haemorrhages, mucocutaneous bleeds with poor wound healing reported occasionally. In females, menorrhagia, repeated early pregnancy loss and post-partum haemorrhages are common. We present a four year old female who initially presented with severe cord bleeding after birth, warranting a blood transfusion. Currently she experiencesrecurrent epistaxis, easy bruising and excessive post -traumatic haemorrhages. All her clotting times are markedly prolonged. Her plasma fibrinogen and fibrinogen antigen are undetectable. An older sibling died from excessive cord haemorrhage after birth.Bleeds in CA respond very favourably to fibrinogen concentrates, cryoprecipitate and fresh plasma. To date, 242 cases of CA have been reported worldwide, none of them in Kenya. Our aim in reporting this case is to document the disorder, and also to raise the index of suspicion of the condition

Health Economic Value of Blood in Kenya, Ghana and Ivory Coast: The Case of Maternal Bleeding

Background: In sub-Saharan Africa, severe bleeding accounts for up to 44% of maternal deaths, and the need for blood products far outstrips supply.Aims and objectives: We aimed to map the causes and consequences of blood shortage in Kenya, Ghana and Ivory Coast and estimate the health economic impact of overcoming blood shortages resulting in maternal bleeding.Methods: We conducted a targeted literature review to evaluate the impact of blood shortage on maternal mortality rates due to post-partum haemorrhage (PPH). Clinical experts from the selected countries were included as an additional source of information. Using a de novo budget impact model, costs associated with severe maternal bleeding were compared with investment costs to adequately manage maternal bleeding.Results: Of the estimated 4 000 941 births/year, 118 428 will be confronted with severe PPH requiring blood transfusion. The estimated total yearly value of life years lost for the three countries combined would be 57 104 042 USD. The total cost to provide adequate blood supply (13 units/patient) was 33 781 945 USD, meaning that blood transfusion in PPH results in 23 322 097 USD saved with savings starting from the first year onwards in Kenya and Ghana, and from the second year onwards in Ivory Coast.Conclusion: In Kenya, Ghana and Ivory Coast, an increased investment in blood supply would likely provide large cost savings in less than two years. French title: Valeur économique du sang pour la santé au Kenya, au Ghana et en Côte d'Ivoire : le cas de l'hémorragie maternelle Contexte : En Afrique subsaharienne, les hémorragies sévères représentent jusqu'à 44 % des décès maternels, et le besoin en produits sanguins dépasse de loin l'offre.Buts et objectifs : Nous avons cherché à cartographier les causes et les conséquences des pénuries de sang au Kenya, au Ghana et en Côte d'Ivoire et à estimer l'impact économique sur la santé de la résolution des pénuries de sang entraînant des saignements maternels.Méthodes : Nous avons effectué une revue ciblée de la littérature pour évaluer l'impact de la pénurie de sang sur les taux de mortalité maternelle due à l'hémorragie du post-partum (HPP). Des experts cliniques des pays sélectionnés ont été inclus comme source d'information supplémentaire. À l'aide d'un modèle d'impact budgétaire de novo, les coûts associés aux saignements maternels graves ont été comparés aux coûts d'investissement pour gérer correctement les saignements maternels.Résultats : Sur les 4 000 941 naissances/an estimées, 118 428 seront confrontées à une HPP sévère nécessitant une transfusion sanguine. La valeur annuelle totale estimée des années de vie perdues pour les trois pays combinés serait de 57 104 042 USD. Le coût total pour fournir un approvisionnement en sang adéquat (13 unités/patient) était de 33 781 945 USD, ce qui signifie que la transfusion sanguine dans l'HPP permet d'économiser 23 322 097 USD avec des économies à partir de la première année au Kenya et au Ghana, et à partir de la seconde à partir d'un an en Côte d'Ivoire.Conclusion : Au Kenya, au Ghana et en Côte d'Ivoire, un investissement accru dans l'approvisionnement en sang permettrait  probablement de réaliser d'importantes économies en moins de deux ans. &nbsp