Assessing the risk of exposure to antimicrobial resistance at public beaches: Genome-based insights into the resistomes, mobilomes and virulomes of beta-lactams resistant Enterobacteriaceae from recreational beaches in Lagos, Nigeria

The role of recreational water use in the acquisition and transmission of antimicrobial resistance (AMR) is under-explored in low- and middle-income countries (LMICs). We used whole genome sequence analysis to provide insights into the resistomes, mobilomes and virulomes of 14 beta-lactams resistant Enterobacterales isolated from water and wet-sand at four recreational beaches in Lagos, Nigeria. Carriage of multiple beta-lactamase genes was detected in all isolates except two, including six isolates carrying blaNDM-1. Most detected antibiotic resistance genes (ARGs) were located within a diverse landscape of plasmids, insertion sequences and transposons including the presence of ISKpn14 upstream of blaNDM-1 in a first report in Africa. Virulence genes involved in adhesion and motility as well as secretion systems are particularly abundant in the genomes of the isolates. Our results confirmed the four beaches are contaminated with bacteria carrying clinically relevant ARGs associated with mobile genetic elements (MGE) which could promote the transmission of ARGs at the recreational water-human interface.

Frequency and Pattern of Shoulder Pain Syndrome in a Nigerian Tertiary Hospital

BACKGROUND

Shoulder pain syndrome (SPS) is a chronic condition affecting the shoulder joint, its periarticular structures, or less commonly, radicular pain typically from the neck.

OBJECTIVES

The objectives of this study were to assess the frequency and pattern of shoulder pain syndrome in OAUTHC, Ile-Ife.

METHODOLOGY

This was a descriptive study in which 50 patients with shoulder pain were recruited from the medical and general outpatient departments of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife over six months out of 350 patients with various musculoskeletal complaints. Detailed history, physical examinations and laboratory tests were done. Plain radiographs were taken for all the patients. Ethical approval was obtained and data analyzed using SPSS version 20.0.

RESULTS

The frequency of shoulder pain was 14.3%. Eighteen were males and 32 were females with a M: F ratio of 1:1.7. The mean age for all the patients was 59.74years (±10.64) with patients in the age range 50-59years accounting for the highest proportion (38%). The most common cause of shoulder pain syndrome was rotator cuff tendinopathy accounting for 72% of cases. Diabetes was the most frequent comorbidity and was found in 50% of patients.

CONCLUSION

Shoulder pain predominantly occurs in females with people in the fifth decade mostly affected. The most frequent cause of shoulder pain syndrome in this environment is rotator cuff disorder. Diabetes mellitus is an important comorbidity associated with shoulder pain. Therefore, management of shoulder pain should include assessment for risk factors.

Cellular stress affects the fate of microbial resistance to folate inhibitors in treatment wetlands

The environmental prevalence of antimicrobial resistance (AMR) has come into focus under the One Health concept. Wastewater treatment systems are among the significant sources of AMR in the environment. In such systems, it is uncertain to which extent antimicrobials present at sub-inhibitory concentrations constitute a selective pressure for bacterial maintenance and acquisition of antibiotic resistance (AR) genes. Here, we mapped AMR to inhibitors of folate biosynthesis in an aerated and a non-aerated horizontal subsurface flow treatment wetland receiving the same pre-treated municipal wastewater. General water characteristics and the concentrations of folate inhibitors were determined to define the ambient conditions over the longitudinal axis of the two treatment wetlands. Profiling of AMR as well as class 1 integrons, a carrier of AR genes against folate inhibitors and other antimicrobials, was conducted by cultivation-dependent and -independent methods. The wetlands achieved mean reductions of AR gene copy numbers in the effluents of at least 2 log, with the aerated system performing better. The folate inhibitors had no noticeable effect on the prevalence of respective AR genes. However, there was a transient increase of AR gene copy numbers and AR gene cassette composition in class 1 integrons in the aerated wetland. The comparison of all data from both wetlands suggests that higher levels of cellular stress in the aerated system promoted the mobility of AR genes via enhancing the activity of the DNA recombinase of the class 1 integron. The findings highlight that environmental conditions that modulate the activity of this genetic element can be more important for the fate of associated AR genes in treatment wetlands than the ambient concentration of the respective antimicrobial agents. By extrapolation, the results suggest that cellular stress also contributes to the mobility of AR gene in other wastewater treatment systems.

Occurrence of methicillin-resistant staphylococci in the pig-production chain in Ibadan, Nigeria

Staphylococcus species colonises humans and animals and is a major food contaminant with public health significance. Here, we assessed the occurrence of methicillin-resistant staphylococci (MRS) in the pig-production chain in Ibadan, Nigeria. Nares of 120 pigs and 10 farmers were sampled with sterile swabs whilst 54 pork samples were collected from a retail slaughterhouse. Staphylococcus species were isolated using enrichment, cefoxitin-aztreonam selective broth and Mannitol salt agar. Isolates were tested for susceptibility to cefoxitin (30 μg), oxacillin (1 μg) and vancomycin (30 μg). Methicillin-resistant staphylococci isolates were characterised using conventional biochemical tests. From 184 samples, 364 staphylococcal isolates were obtained. Amongst the 54 pork samples, 44.0% were contaminated with Staphylococcus species. Overall, 9 (2.5%) MRS were obtained and presumptively identified as Staphylococcus xylosus (n = 3), Staphylococcus sciuri (n = 3), Staphylococcus warneri (n = 2) and Staphylococcus cohnii (n = 1). There was no relationship between the prevalence of MRS between pigs and pig handlers in the farms, but Farm 2 had the highest frequency of 66.7% (p 0.05). Piglets had the highest prevalence of 66.7% (p 0.05) whilst MRS was absent in workers and pork samples. This study raises concerns about the cross-contamination of staphylococci in the food chain. Constant surveillance is imperative to ensure food safety.

P044 Have we been missing cases of Juvenile Systemic Lupus Erythematosus in Nigeria? The experience of a paediatric rheumatology trainee in Lagos

Background

Juvenile Systemic lupus erythematosus (JSLE) is a chronic multisystem autoimmune disease of childhood, which accounts for 10% to20% of systemic lupus erythematosus (SLE). It was initially thought that systemic lupus erythematosus (SLE), including JSLE, was rare in Blacks, this was eventually debunked with increasing reports from Africa. However, it is now known that SLE is more common among patients of African descent in western countries. While the estimated prevalence of JSLE in the developed countries is 0.36–2.5 per 100 000, data in Black Africans is scarce due to missed diagnosis, poor diagnostic capacity and under-reporting.

JSLE has protean manifestations similar to common paediatric conditions such as severe malaria, overwhelming septicaemia, hyper-haemolytic crisis in sickle cell anaemia etc., which often cause delayed or missed diagnosis. The objective is to describe the demographic and clinical characteristics, including outcome of children with JSLE, thus raising awareness on their occurrence and management in Nigerian children.

Methods

Retrospective review of records of children diagnosed with SLE at the Adult/paediatric Rheumatology Clinic and Paediatric Wards of Lagos State University Teaching Hospital (LASUTH) from May 2018 to May 2021.

Results

Twenty-two children, nineteen (n = 19) girls and three (n = 3) boys, aged 5–17 years, fulfilled the American College of Rheumatology (ACR)’s diagnostic criteria for JSLE out of 45 children newly diagnosed with paediatric rheumatic diseases during this period. The duration of symptoms before diagnosis ranged from two weeks to three years. The presentations included recurrent severe anaemia (n = 16), arthritis (n = 17), arthralgia (n = 17), malar rash (n = 17), neurologic symptoms (n = 5) oral ulcers (n = 17), cardiopulmonary symptoms (n = 5), photosensitivity (n = 10) and renal disease (n = 14). Laboratory findings included elevated ESR with a mean (±SD) of 99.68 ± 44.44, positive ANA (n = 22), positive anti-dsDNA (n = 12), low C3 & C4 (n = 2), positive anti-Smith antibody (n = 8) and massive proteinuria (n = 14). All patients were treated with steroids and disease modifying anti-rheumatic drugs (synthetics and biologics) based on disease severity and organ manifestations.

Sepsis (n = 4) was the most common preliminary diagnosis before a final diagnosis of JSLE was made, other preliminary diagnosis were pulmonary tuberculosis (n = 1), dermatitis (n = 1), acute glomerulonephritis (n = 1), Typhoid fever (n = 1), malaria (n = 1), deep vein thrombosis (n = 1), seizure disorder (n = 1), leukaemia (n = 1), meningitis (n = 1), meningoencephalitis (n = 1), hyper-haemolytic crisis in sickle cell anaemia (n = 1), Steven Johnson syndrome (n = 1), Juvenile Idiopathic Arthritis (n = 2), Eczema (n = 1), unexplained anaemia (n = 1) and acute rheumatic fever (n = 1).

One boy and three girls defaulted from clinic after commencement of treatment due to severe financial constraints of their parents and religious beliefs, however six girls died, four from an acute flare and two from end stage renal disease.

Conclusion

Our study has shown that JSLE has protean manifestations with a tendency to miss its diagnosis due to similarity of signs and symptoms with common childhood diseases in our environment. JSLE may not be as rare as commonly thought, thus its prompt diagnosis and treatment require a high index of clinical suspicion.

Biotherapies in Medical Practice: A Review and the Nigerian Experience

Biologics or Biological agents are pharmaceuticals manufactured, extracted from or semi synthesized from biological sources and used in the diagnosis, treatment or prevention of diseases. When used for rheumatic diseases, they are monoclonal antibodies targeting wide range of peptide mediators (cytokines), receptors and cells. They have complex structures and are about 200 to 1000 times larger than chemical molecule drugs. Biologics are being increasingly used in auto immune rheumatic and non-rheumatic diseases, especially when synthetic immunosuppressive have failed. They are also useful in various other auto immune diseases in other systems. There are a lot of these agents available depending on the targeted cytokine. Biologics use in rheumatic disease, rheumatoid arthritis was first documented in Nigeria in 2007. Ever since then, the two available biologics in Nigeria, Etanercept( Enbrel) and Rituximab( Mabthera) have been used in the management of diverse conditions. Many of the indications have been off label. While their efficacies are not in doubt, however their cost is prohibitive, and adverse effects are sometimes seen. This review describes the evolution of biotherapy, mode of action of biologics, indications for their use and challenges. It also gives our experience in the use of these agents among Nigerian patients seen in a private practice rheumatology clinic between 2007-2019.

Frequency of Osteoporosis in Black Nigerian Women Aged 50 and above with Degenerative Musculoskeletal Diseases and Fractures

BACKGROUND AND OBJECTIVES

Osteoporosis is a bone disease characterized by reduced bone density (and microarchitecture damage) prevalent in post-menopausal women, who are prone to fragility fractures. There is paucity of data regarding the prevalence of osteoporosis in Nigerian women. This study was carried out to evaluate the frequency of osteoporosis among Nigerian women with degenerative skeletal diseases and fractures who visited our hospital so as to suggest prevention and early treatment in order to reduce the occurrence of fragility fractures.

METHODS

Women aged 50 years and older, who visited the hospital with degenerative skeletal diseases and fractures during the study period were recruited. Their ages, diagnosis, Bone Mineral Density (BMD), T-score and interpretation were recorded in an anonymous database.

RESULTS

The ages of the 173 patients evaluated ranged between 51 and 89 years, of which 111 (64.1%) were aged between 61 and 80 years. The most common diagnosis was degenerative lumbar spine disease in 37.0% of patients, but only 13.9% had fractures. Knee and hip osteoarthritis (OA) accounted for fewer cases (22.5% and 3.5% respectively). Using WHO criteria for diagnosing osteoporosis, 35 (20.2%) of the patients had osteoporosis, while 82 (47.4%) had low BMD, 52 (30.1%) were normal and 4 (2.3%) had high BMD.

CONCLUSIONS

In this study, the frequency of osteoporosis increased with age and was higher among patients with a combination of cervical and lumbar degenerative disease, followed by fractures. We, therefore, recommend routine screening of women aged 50 and above with degenerative spine disease and fractures.

Visible-Light-Mediated Photodynamic Water Disinfection @ Bimetallic-Doped Hybrid Clay Nanocomposites

This study reports a new class of photocatalytic hybrid clay nanocomposites prepared from low-cost sources (kaolinite clay and Carica papaya seeds) doped with Zn and Cu salts via a solvothermal process. X-ray diffraction analysis suggests that Cu-doping and Cu/Zn-doping introduce new phases into the crystalline structure of Kaolinite clay, which is linked to the reduced band gap of kaolinite from typically between 4.9 and 8.2 eV to 2.69 eV for Cu-doped and 1.5 eV for Cu/Zn hybrid clay nanocomposites (Nisar, J.; Århammar, C.; Jämstorp, E.; Ahuja, R. Phys. Rev. B 2011, 84, 075120). In the presence of solar light irradiation, Cu- and Cu/Zn-doped nanocomposites facilitate the electron-hole pair separation. This promotes the generation of singlet oxygen which in turn improves the water disinfection efficiencies of these novel nanocomposite materials. The nanocomposite materials were further characterized using high-resolution scanning electron microscopy, fluorimetry, thermogravimetric analysis, and Raman spectroscopy. The breakthrough times of the nanocomposites for a fixed bed mode of disinfection of water contaminated with 2.32 × 10⁷ cfu/mL E. coli ATCC 25922 under solar light irradiation are 25 h for Zn-doped, 30 h for Cu-doped, and 35 h for Cu/Zn-doped nanocomposites. In the presence of multidrug and multimetal resistant strains of E. coli, the breakthrough time decreases significantly. Zn-only doped nanocomposites are not photocatalytically active. In the absence of light, the nanocomposites are still effective in decontaminating water, although less efficient than under solar light irradiation. Electrostatic interaction, metal toxicity, and release of singlet oxygen (only in the Cu-doped and Cu/Zn-doped nanocomposites) are the three disinfection mechanisms by which these nanocomposites disinfect water. A regrowth study indicates the absence of any living E. coli cells in treated water even after 4 days. These data and the long hydraulic times (under gravity) exhibited by these nanocomposites during photodisinfection of water indicate an unusually high potential of these nanocomposites as efficient, affordable, and sustainable point-of-use systems for the disinfection of water in developing countries.

Detection of the carbapenemase gene blaVIM-5 in members of the Pseudomonas putida group isolated from polluted Nigerian wetlands

There are increasing concerns about possible dissemination of clinically relevant antibiotic resistance genes, including genes encoding for carbapenemases in the environment. However, little is known about environmental distribution of antibiotic resistance in Africa. In this study, four polluted urban wetlands in Nigeria were investigated as potential reservoirs of carbapenem-resistant bacteria (CRB). CRB were isolated from the wetlands, characterized by Blue-Carba test, MIC determinations and whole genome sequencing (WGS). Nine of 65 bacterial isolates identified as members of the Pseudomonas putida group (P. plecoglossicida and P. guariconensis, respectively) harboured the metallo-beta-lactamase gene bla_VIM-5. WGS revealed the bla_VIM-5 in three novel Tn402-like class 1 integron structures containing the cassette arrays aadB|bla_VIM-5|bla_PSE-1, aadB|bla_VIM-5|aadB|bla_PSE-1, and bla_VIM-5|aadB|tnpA|bla_PSE-1|smr2|tnpA, respectively. Strains carrying the aadB|bla_VIM-5|bla_PSE-1 cassette also carried an identical integron without bla_VIM-5. In addition_, the strains harboured another Tn402-like class 1 integron carrying bcr2, several multidrug resistance efflux pumps, and at least one of ampC, aph(3”)-lb, aph(6)-ld, tetB, tetC, tetG, floR, and macAB. This is the first report of a carbapenemase gene in bacteria from environmental sources in Nigeria and the first report of bla_VIM-5 in environmental bacteria isolates. This result underscores the role of the Nigerian environment as reservoir of bacteria carrying clinically relevant antibiotic resistance genes.

Juvenile systemic lupus erythematosus in Nigeria

Juvenile systemic lupus erythematosus (JSLE) is a complex multisystemic autoimmune disorder of unknown cause. It accounts for about one in five cases of SLE. The tendency for SLE to run a fulminant course when it starts in childhood has made JSLE a potentially more severe disease than adult SLE. Reports of JSLE from sub-Saharan Africa are scanty in spite of the increasing reports of adult SLE. We conducted a 4-year retrospective study of JSLE cases seen at the Lagos State University Teaching Hospital between January 2010 and December 2014. Out of the 12 patients studied, eight were girls and four were boys. All patients had positive antinuclear antibody and extractable nuclear antibody tests. Anti-dsDNA antibody was positive in 10 patients. Eight patients had renal disease while four patients had neuropsychiatric manifestations. Haematological abnormalities and constitutional symptoms were present in all patients. Patients were treated with pulse methylprednisolone, oral prednisolone, hydroxychloroquine and azathioprine. Three patients also received rituximab. In conclusion, JSLE exists in Nigeria and exhibits clinical and immunological characteristics similar to its pattern in other parts of the world. It is, however, diagnosed late and is possibly being underdiagnosed as there is no paediatric rheumatologist in the country.

The incidence and distribution of Listeria monocytogenes in ready-to-eat vegetables in South-Western Nigeria

The study investigated the incidence of Listeria monocytogenes in ready‐to‐eat (RTE) vegetables: (Cucumber, Cucumis sativas; Cabbage, Brassica olerecea; Carrot, Daucus carota; Tomato, Solanum lycopersicum; Lettuce, Lactuca sativa) in six states in South‐Western Nigeria. A total of 555 composite samples were collected from 30 traditional markets within the states and only 244 L. monocytogenes species were isolated by standard methods. The incidence of L. monocytogenes was low and not statistically significant per vegetable type. The percentage distribution of the L. monocytogenes isolates in the RTE vegetables was 28.28, 9.02, 23.36, 19.67, and 19.67 for Cabbage, Carrot, Cucumber, Lettuce, and Tomatoes, respectively. Lagos state had the highest incidence of L. monocytogenes contamination (55%) followed by Ondo (48.89%), Oyo (48.75%), Ogun (44.09%), Osun (34.38%), and Ekiti (33.33%) states, respectively. Although the incidence of L. monocytogenes in the RTE vegetables in South‐Western Nigeria is low, its presence should be a source of concern as it could constitute a public health threat for its consumers.

Antibiotic resistance and resistance genes in Escherichia coli from poultry farms, southwest Nigeria

Introduction: This study investigated the mechanisms of resistance in 36 E. coli isolated from waste, litter, soil and water samples collected from poultry farms in Southwestern Nigeria. Methodology: Minimum inhibitory concentration (MIC) distributions of the isolates were determined using the methods of the Clinical and Laboratory Standard Institute and resistance genes detected by PCR. Results: A total of 30 isolates (94%) showed resistance to more than one antimicrobial. Percentage resistance was: tetracycline 81%, sulphamethoxazole 67%, streptomycin 56%, trimethoprim 47 %, ciprofloxacin 42%, ampicillin 36%, spectinomycin 28%, nalidixic acid 25%, chloramphenicol 22%, neomycin 14%, gentamicin 8%, amoxicillin-clavulanate, ceftiofur, cefotaxime, colistin, florfenicol and apramycin 0%. Resistance genes found among the isolates include bla-TEM (85%), sul2 (67%), sul3 (17%), aadA (65%), strA (70%), strB (61%), catA1 (25%), cmlA1 (13%), tetA (21%) and tetB (17%). Class 1 and 2 integrons were found in five (14%) and six (17%) isolates, respectively, while one isolate was positive for both classes of integrons. Seven out of eight isolates with resistance to ciprofloxacin and MIC ≤ 32 mg/L to nalidixic acid contained qnrS genes. Conclusions: Our findings provided additional evidence that the poultry production environment in Nigeria represents an important reservoir of antibiotic resistance genes such as qnrS that may spread from livestock production farms to human populations via manure and water.

RHEUMATOID ARTHRITIS ASSOCIATED WITH PULMONARY FIBROSIS IN NIGERIANS: TWO CASE REPORTS

Rheumatoid arthritis may sometimes present with extra-articular involvement, pulmonary involvement is not common. Rheumatoid arthritis has been reported among Nigerians and extra-articular manifestations are rarely seen. One of the patients was misdiagnosed and mismanaged as a patient with pulmonary tuberculosis. The study is to demonstrate that rheumatoid arthritis is not as rare as previously reported in Nigeria and its pulmonary involvement can mimic tuberculosis or other granulomatous lung disorder. Clinical and serological acumen are necessary to distinguish between the two. Two diagnosed patients with rheumatoid arthritis and pulmonary involvement seen at Olabisi Onabanjo University Teaching Hospital (OOUTH), are hereby presented.

Nephritis as an initial diagnosis of lupus in Nigerian patients

BACKGROUND

Systemic Lupus Erythematosus (SLE) is a multi-systemic autoimmune disease. Renal involvement is a common complication, causing considerable mortality and morbidity. SLE is rarely reported among black Africans, though recent reports from Nigeria indicate otherwise. Nephritis, though a common complication of SLE has rarely been reported as the initial diagnosis of lupus among black Africans.

AIMS

The aim of our study is to highlight the clinical, laboratory and histological features in Nigerian patients presenting with features of nephritis and subsequent diagnosis of SLE.

METHODS

This is a three year prospective study of patients with renal diseases, who were admitted to the rheumatology and nephrology units of the Lagos State University Teaching Hospital (LASUTH) Ikeja. Serology, biochemical, haematologic tests, kidney biopsy were done.

RESULTS

Twelve patients were studied (F11; M1); mean age 30.4 years (SD ± 9.8); mean illness 8 weeks (SD ± 6.6). Six patients had a nephritic condition. Nine of the patients had baseline hypertension while 3 had a rapidly progressive nephritis. Two patients had baseline End Stage Renal Disease (ESRD). All had dipstick proteinuria 2+/3+, mean protein creatinine ratio 2.2 (SD ± 0.6), mean 24hr protein 2.8 gm (SD ± 2.7); more than 10 red blood cells/hpf haematuria (n-6), hyaline casts (n-5), granular casts (n-2), mean GFR 31.4 ml/ min (SD ± 21.3.), mean serum creatinine 6.9 mg/dl (SD ± 5.3); mean urea 138.8 mg/dl (SD ± 56.2). For the serology, Anti Nuclear Antibody (ANA) was positive in all the 12 subjects; positive anti dsDNA -10 patients; ENA - 10. Renal biopsy showed mostly WHO/ISSN classes III, IV and V. Treatment was with Euro Lupus regimen and rituximab/ cyclophosphamide. Four patients had dialysis. In terms of the outcome, there were 3 deaths while 9 patients were discharged.

CONCLUSION

A high index of suspicion is needed to diagnose Lupus Nephritis in black Africans especially when their presentations do not fulfil the America College of Rheumatology (ACR) diagnostic criteria for SLE.

Inflammatory myopathies in Nigerians: case series and literature review

BACKGROUND

Idiopathic Inflammatory myopathies (IIM) are rare connective tissue diseases and have been rarely reported among Nigerians:

OBJECTIVE

To study the clinical, laboratory and electromyographic characteristics of Nigerian patients with polymyositis and dermatomyositis.

METHOD

In a retrospective study, patients attending a private practice rheumatology clinic in Lagos and fulfilling the Bohan and Peter's criteria for polymyositis and dermatomyositis were examined and common causes of proximal muscle weakness were excluded. Haematological, biochemical, serological and electromyographic studies were carried out. Patients were treated with standard drugs.

RESULTS

Fourteen patients (F-13, M-1) were diagnosed with Polymyositis (PM) and Dermatomyositis (DM). Seven had probable PM, 4 with possible PM and 3 with probable DM. Mean age was 35 years (range 22-54) ESR was markedly raised mean 105/min (26-150). Muscle and liver enzymes were raised in all patients. Creatinine kinase median 1134 (29-10,166); lactic dehydrogenase median 477 (209-787); ALT 43 (19-233); AST 136 (25-725). Serology for ANF was positive in eight patients; Anti Jo1 in 1 out of 9 while Anti Mi2 was negative in all tested. EMG in 6 tested showed myopathic pattern.

CONCLUSION

Inflammatory myopathies are rare among Nigerians but a heightened awareness is needed for diagnosis and management.

Anti-phospholipid syndrome in Nigeria: report of five cases

Five cases of secondary anti-phospholipid syndrome (APS) are presented and literature reviewed. Pregnancy loss was the most common presentation but neurologic manifestations are also seen. IgG ACA was more commonly seen than IgM ACA. Although APS has been infrequently reported in black Africans, an awareness of this condition is needed especially among females with previous recurrent pregnancy losses.

Recurrent pregnancy loss and antiphospholipid syndrome: an overlooked association

Antiphospholipid Syndrome (APS), a thrombophilic condition, is being increasingly recognised as an important cause of recurrent pregnancy loss, preeclampsia and possible infertility. It could occur as a primary condition or it may be secondary to connective tissue diseases, infections or malignancies. Though recurrent pregnancy loss is a common feature ofAPS, there are other presentations attributable to thrombosis. The mechanism of thrombosis is still not completely understood but there are various suggested mechanisms. Presence of anti-cardiolipin antibodies (aCL) and lupus anticoagulant (LAC) are diagnostic. Management is variously with heparin, aspirin and warfarin, although other treatment modalities are being deployed. A high index of suspicion is needed for this otherwise treatable condition. Management is ideally best done by an obstetrician and a rheumatologist.

Shoulder pain syndrome among Nigerians

OBJECTIVES

To identify aetiological causes of shoulder pain syndrome among patients attending a rheumatology clinic, and to highlight the therapeutic options.

DESIGN

Retrospective study.

SETTING

A private rheumatology clinic in Lagos, Nigeria fromJanuary 2002 to December 2006.

SUBJECTS

Forty female adult patients and 26 male adult patients aged 24-79 years.

MAIN OUTCOME MEASURES

Patient reported outcome in terms of pain relief and increased mobility.

RESULTS

Sixty six subjects were seen during the study period. Females were more commonly affected and were mostly middle aged. Adhesive capsulitis was the most common condition while septic arthritis and avascular necrosis were least diagnosed 22.7% of the subjects could not, however, be categorised.

CONCLUSION

Shoulder pain syndrome is common among Nigerians. Diagnosis and management are mostly based on the clinical presentations, especially considering the lack of sensitivity of plain radiographs and the high cost of more sensitive MRI. The treatment of these conditions are standard.

Avascular necrosis of femoral head associated with connective tissue disease in Nigerians: case series

BACKGROUND

Avascular Necrosis (AVN) or osteonecrosis has been frequently reported among Nigerians with sickle cell disease. Other known aetiologies include connective tissue diseases, alcohol, fat embolism, juvenile arthritis and pregnancy. Connective tissue disease (CTD) are uncommonly reported among Nigerians.

OBJECTIVE

To report the cases of three Nigerian female patients with radiological evidence of AVN associated with connective tissue diseases and inflammatory arthritis who presented to a rheumatology hospital in Lagos, Nigeria.

METHODS

The first patient was a 36-year-old woman who was initially diagnosed as systemic lupus erythematosus (SLE). After four years of treatment, she presented with intense pain in the left hip, which on radiograph showed AVN. She was initially treated with NSAIDS and narcotic analgesics. She eventually had a left hip replacement. The second patient was a 44-year-old female, who had presented seven years earlier with features of SLE. She had attended the clinic irregularly. She later developed pain in both hips and shortening of left lower limb over the preceding three years. Radiographs confirmed AVN. She was treated with analgesics. The third patient was an 18-year-old female undergraduate who had rheumatoid arthritis (RA) and later developed bilateral hip pain which on radiograph showed bilateral AVN. She was placed on analgesics and then referred for orthopaedic surgery.

CONCLUSION

Osteonecrosis may be associated with connective tissue diseases. A high index of suspicion is needed for the diagnosis, especially in SLE and RA patients with prolonged hip pain not responding to immunosuppressive.

Scleroderma (systemic sclerosis) among Nigerians

Scleroderma and other connective tissue diseases have rarely been reported among Africans. The objective of this paper is to have a retrospective study of the clinical and investigative characteristics of scleroderma patients seen in a rheumatology clinic. This was done in a private practice rheumatology clinic in Lagos, Nigeria. Patients were identified using the American College of Rheumatology criteria for diagnosis of scleroderma. A total of 14 cases of scleroderma are reported. Most of the patients were females and diffuse scleroderma was more frequently seen. Arthritis and reflux esophagitis were the most common nondermatological presentation while Raynaud's phenomenon and dysphagia were the least seen. Restrictive pattern of lung function tests were seen in most of those tested and pulmonary fibrosis was seen in some cases. Antinuclear antibodies were the commonest serological findings with the speckled staining pattern in most cases. Treatments were with standard medications. Scleroderma among Nigerians is rare as elsewhere and there are certain common characteristics as seen elsewhere as well as certain differences.

Neuropsychiatric systemic lupus erythematosus among Nigerians

Systemic Lupus Erythematosus (SLE) and concomitant complication of Neuropsychiatric lupus (NPSLE) are rarely reported among Africans. This retrospective study has the objectives of highlighting the clinical and laboratory characteristics of SLE subjects with neuropsychiatric manifestations seen in a private practice rheumatology clinic and comparing these with studies elsewhere. Such subjects were diagnosed using the American College of Rheumatology (ACR) criteria for SLE as well as the ACR Case definition for Neuropsychiatric SLE (NPSLE). A total of thirty three subjects (51.6%) out of the sixty four diagnosed SLE had features of NPSLE. Females were more commonly affected and the mean age was 32.8 years. Most of the subjects had either one or two concomitant syndromes. Headache was the commonest presentation (66.6%) while other common presentations were seizures (42.4), psychosis (30.3%) were also seen. Dementia was the least seen. The mean erythrocyte sedimentation rate was 95.5 mm/hr. Serology tests showed high frequencies of Anti Nuclear Antibody (ANA) and Anti ds DNA. Treatment was with standard immunosuppressives, and epileptics where indicated. The outcome was generally good with 54.5% better after six months while 7 subjects (21%) were lost to follow up and three were known to have died. NPSLE is a common presentation among Nigerian SLE patients and the pattern is as seen in other reports, though the frequencies of the syndromes vary widely. Early recognition and management with immunosuppressives are required.

Pattern of systemic lupus erythematosus among Nigerians

Systemic lupus erythematosus (SLE) has rarely being reported among African Blacks, in contrast with African-Americans. Such reports have been mostly case reports. Our encounter with new cases shows that this disease may not be rare after all. The objective of this study was to study the clinical presentations, laboratory and serological characteristics of Nigerians presenting with SLE. This is part of a retrospective study of patients presenting with rheumatic complaints to a private practice rheumatology clinic, Arthrimed Specialist Clinic located in Lagos, Nigeria. This is a retrospective study of consecutive SLE patients seen in a rheumatology clinic over a 6-year period and diagnosed using the ACR Criteria for SLE. Laboratory tests and serology were carried out when possible. Treatment was initiated with immunosuppressives, steroids, anti epileptics, aspirin and anti hypertensives as indicated. SLE accounted for 5.28% of all the 1,250 rheumatology cases seen over the study period of 6 years. Female constituted 95.5% of the 66 cases seen. The subjects were aged 17-55 with a mean of 33 years at presentation and had the symptoms for a mean of 2.6 years. Polyarthralgia, fever and hair loss were the most common presentation. Neuropsychiatric presentations were common. Erythrocyte sedimentation rate was markedly elevated in most cases. Anti-nuclear antibody titres were markedly high and were mostly speckled staining pattern. Treatment was with conventional immunosuppressives. SLE may not be uncommon among African blacks, contrary to previous reports. A high index of suspicion is needed for this otherwise severe disease in blacks. Early aggressive treatment with immunosuppressives is indicated.

The tetracycline resistance gene tet39 is present in both Gram-negative and Gram-positive bacteria from a polluted river, Southwestern Nigeria

AIM

Previous analysis of tet39 suggests it may be present in other bacterial species. Hence, we investigated the host range of tet39 among bacterial from a poultry waste polluted river in Southwestern Nigeria.

METHODS AND RESULTS

Thirteen resistant bacterial isolated from the water and sediment of the polluted river was investigated for the presence of tetracycline resistance genes tetA, tetB, tetC, tet39 and the transposon integrase gene of the Tn916/1545 family by PCR. While tetA, tetB, tetC and integrase genes cannot be detected in any of the organisms, tet39 was detected in eight of the tested organisms including three Gram-positive species. Sequence analysis showed the genes have high sequence identities (> or =99%) with tet39 of Acinetobacter sp. LUH5605, the first and only bacterial genus from which the gene has been reported to date. This is a novel observation.

CONCLUSIONS

This study shows that apart from Acinetobacter, tet39 is present in other bacterial species tested in this study.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study adds to available information on the occurrence and distribution of tet39 among environmental bacteria and suggests that the gene has a broader host range than previously reported.

Spectrum and outcome of clinical diseases in adults living with AIDS at the Ogun State University Teaching Hospital

OBJECTIVES

To evaluate the changing frequency of HIV/AIDS amongst medical admissions as well as the spectrum and outcome of clinical diseases among these patients.

DESIGN

Retrospective study.

SETTING

Tertiary hospital in Nigeria.

PARTICIPANTS

Two hundred and six People Living With AIDS (PLWA) admitted at the medical wards during the period 1992 to 2002.

INTERVENTION

Treatment was symptomatic in all patients and where appropriate, specific treatment was administered for indicator diseases. Highly Active Anti-retroviral Therapy (HAART) was not used.

MAIN OUTCOME MEASURES

Mortality within six months of diagnosis.

RESULTS

PLWA constituted 4.2% of all medical admissions. The frequency increased from 0% in 1992 to 7.6% in 2001, and dropped to 5% by the year 2002. Seventy patients (34%) died within six months of diagnosis.

RESULTS

This study has demonstrated an increasing frequency of HIV/AIDS amongst our medical in-patients from none in 1992 to 7.6% in 2001, and thereafter, a decline in 2002. We suspect that this decline could be a reflection of the health education on HIV, its increasing awareness and the widespread utilisation of effective control measures. Furthermore, the administration of highly active anti retroviral therapy (HAART) to a segment of PLWA in Sagamu by the community medicine department could be contributory.

CONCLUSION

A community based study would be needed to assess the efficacy or otherwise of these current control measures. The advent of saliva and urine tests for HIV detection would ease specimen collection and increase compliance and participation at the community level.

Pattern and outcome of medical admissions at the Ogun State University Teaching Hospital, Sagamu--a three year review

This is a three-year retrospective study of the pattern and outcome of acute medical admissions at the Ogun State University Teaching Hospital, Sagamu. Our findings showed that there were 1,938 admissions over the study period of which 1,044 (54%) were females and 894 (46%) were males. The ages of the patients ranged between 12 to 86 years with a mean of 49 +/- 1.7 years. The age range was 14 to 80 years for males with a mean of 47 +/- 6.1 years and 12 to 86 years for females with a mean of 49 +/- 4.5 years. The length of stay was between 5 to 25 days with a mean of 15 +/- 0.5 days. There were 16 patients per bed per year with a turn around of 8 days and bed occupancy of 65% 194 (10%) patients discharged themselves against medical advice and there were 488 (25%) deaths. The interval between admission and death ranged between 4 to 7 days with a mean of 5.5 +/- 0.07 days. Indications for admissions were infectious diseases (38%), neurological disorders (19.6%) gastro-intestinal disorders (11%), genito-urinary tract disorders (10.2%) endocrine disorder (10%), cardiovascular disorders (9.9%), respiratory disorders (6.4%) and haematological disorders (4.9%). Tuberculosis accounted for 10% of total medical admissions and was the commonest disease entity responsible for medical admissions. Acquired immuno deficiency syndrome (AIDS) constituted 1.8% of medical admissions. Mortality was highest for infections accounting for 32% of deaths while malaria accounted for the lowest. The reasons for the relative frequency and mortality are adduced. The study recommends improvement of preventive strategies towards communicable diseases in the community and encourages better admission policy, provision of appropriate facilities and manpower to improve the hospital services.

Auto--antibodies to DNA in the sera of Nigerians attending a rheumatic diseases clinic

The presence of auto-antibodies to DNA in the sera of 199 Nigerians: 46 with osteoarthritis, 16 with rheumatoid arthritis, 5 with SLE, 18 with chronic hepatitis, 24 peptic ulcer disease and 90 blood donors were assayed using a haemagglutination method. The positivity rates of auto-antibodies to DNA in these subjects were comparable [X2 = 1.56, P > 0.10]. The results of this study shows that the presence of auto-antibodies to DNA is not a reliable diagnostic index for auto-immune phenomena.

Comparative double blind study of the efficacy and safety of tenoxicam vs. piroxicam in osteoarthritis of knee and hip joints

The efficacy and safety of tenoxicam was compared to that of piroxicam in 48 Nigerian patients with Osteoarthritis of the knee or hips. Of these 31 females and 11 males, with a mean age of 52.5 +/- 11.0 years, were evaluated for comparable efficacy and tolerability. On fulfilling the selection criteria each patient was treated with either tenoxicam 20 mg or piroxicam 20 mg daily for six weeks. Efficacy was evaluated in terms of presence of pain (at rest, with mobility and after one day of normal activity), functional status and physicians global assessment of therapeutic efficacy. Tolerability was evaluated by incidence of adverse events whilst safety was evaluated by measurement of haematological and biochemical profile pre and post therapy. Thirty seven patients had been on previous medication before being switched over to trial drug. There was a dose change in three patients in the piroxicam group due to inefficacy. Also there was loss of efficacy during maintenance in one patient in the piroxicam group. Clinical efficacy was judged excellent or good in 82.3% of patients with tenoxicam and 76.0% with piroxicam. Tolerability was excellent or good in 88.2% of patients with tenoxicam and 60.0% with piroxicam. The incidence of adverse event was 15.8% with tenoxicam and 21.7% with piroxicam. Overall, when judged on various evaluation parameters, tenoxicam 20 mg/day appears to be more effective and better tolerated than piroxicam 20 mg/day, though these differences were not statistically significant.

Soft tissue rheumatism among Nigerians

Sixty-eight Nigerians were seen, investigated and treated for soft tissue rheumatism. Most of the subjects had capsulitis of the shoulder, commonly associated with Diabetes mellitus and Hypertension. Other diagnostic groups were however seen. The treatment modalities were basically intra articular steroids, analgesics and physiotherapy.

Diffuse idiopathic skeletal hyperostosis in a Nigerian (DISH Forestier's disease, ankylosing hyperostosis): a case report

A 61 year old diabetic patient with Diffuse Idiopathic Skeletal Hyperostosis is presented. There has been only one report of this rare disease in an African.

Peritoneal dialysis in a private hospital: a case for chronic peritoneal dialysis programme

Twenty patients presenting with renal failure were treated with peritoneal dialysis in a private hospital in Nigeria. Of the nine patients with acute renal failure, six survived. Four patients with chronic failure was maintained on Intermittent Peritoneal Dialysis and were sustained for variable periods. There were some complications, especially peritonitis and catheter obstruction. It is suggested that a chronic peritoneal dialysis programme should be encouraged in a developing country like Nigeria. This is an alternative to haemodialysis. Our suggestions are based on its proven efficacy, comparatively lower cost, easy maintenance and convenience to patients.

Levels of immunoglobulins (G, A and M) and circulatory immunocomplexes in Nigerians with joint pains

Serum immunoglobulin (G, A and M) and circulating immune complex concentrations were measured in eighty-three Nigerians having joint pains and forty apparently healthy Nigerians by the single radial immune-diffusion and polyethylene glycol precipitation methods respectively. The IgA level was significantly lower and IgM statistically higher in patients with joint pains than the controls. There was however no significant difference between the mean IgG concentrations in patients with joint pains and controls. The observed low circulating IgA levels could be as a result of depressed thymic activity, development of autoimmunity or utilization in immune complex formation. The mean concentration of soluble immune complexes was significantly higher in patients with joint pains than in the apparently healthy subjects. These immune complexes some of which may remain localized in the surface of cartilages, ligaments and menisci would cause activation of complement resulting in persistent inflammation and joint pains in these patients.

Tophaceous gout in a nigerian with rheumatoid arthritis

A male Nigerian patient, with co-existing gouty arthritis and rheumatoid arthritis, is presented. These two conditions rarely co-exist in the same patient. There has been no previous report in black Africans.