Correlation of the ultrasound thyroid imaging reporting and data system with cytology findings among patients in Uganda

BACKGROUND

Ultrasonography is a noninvasive modality for the initial assessment of thyroid nodules. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) has demonstrated good performance in differentiating malignant thyroid nodules. However, the combination of ACR TI-RADS categories and cytology has not been studied extensively, in Uganda. The study aims to correlate ACR TI-RADS with cytology among patients referred for US-guided fine-needle aspiration at Mulago National Referral Hospital.

METHODS

This was a hospital-based cross-sectional study that recruited 132 patients with thyroid nodules. Spearman's correlation was used to establish a relationship between TI-RADS and cytology findings. The diagnostic accuracy of TI-RADS was assessed using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios.

RESULTS

Of 132 study participants, 90% (n = 117) were females, and the mean age was 41 ± 13 years. One hundred sixty-one thyroid nodules were analyzed. More than half of the thyroid nodules (54.7%, n = 87) were solid or almost solid, 96.9% (n = 154) were shaped wider than tall, 57.2% (n = 91) had smooth margins, 83.7% (n = 133) were hyperechoic or isoechoic, and 88.7% (n = 141) had no echogenic foci. TI-RADS 3 was the most common at 42.9% (n = 69). The proportions of malignancy for TI-RADS 4 and TI-RADS 5 were 73.3% and 85.7%, respectively. The correlation between ACR TI-RADS and the Bethesda system of thyroid classification scores was r = 0.577. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of ACR TI-RADS were 90.9%, 98.5%, 90%, 99.3%, 62.3, and 0.1, respectively.

CONCLUSION

We found that ACR TI-RADS classification is an appropriate and noninvasive method for assessing thyroid nodules in routine practice. It can safely reduce the number of unnecessary fine-needle aspiration in a significant proportion of benign thyroid lesions. Thyroid nodules classified as TI-RADS 3 should be followed routinely. ACR TI-RADS should be standardized as the screening tool in resource-limited areas.

Iatrogenic giant subclavian artery pseudoaneurysm following clavicle fracture repair: A case report

Subclavian artery aneurysms are infrequently observed in clinical settings, and are divided into intrathoracic and extra-thoracic segments. Atherosclerosis, cystic necrosis of the tunica media, trauma, or infections are more common. Blunt trauma or piercing is more frequently the cause of pseudoaneurysms, and broken bones following surgery should be evaluated. A 78-year-old woman attended the vascular clinic with a closed mid-clavicular fracture due to plant trauma before 2 months. Physical examination revealed a well-healed wound and no palpable pain, but a massive pulsating mass with normal overlying skin in the superior side of the clavicle. Thoracic CT angiography and a neck ultrasound revealed a distal right subclavian artery pseudoaneurysm of 50 × 49 mm. Arterial injuries were repaired by a ligature and bypass. The recovery from surgery was successful, and a 6-month follow-up examination revealed a right upper limb that was symptom-free and well-perfused.

Correlation between clinical and brain computed tomography findings of stroke patients: A cross-sectional study

Background and Aims

In developing countries, the burden of stroke is growing and causing significant morbidity and disability with high mortality rates. Neuroimaging plays a crucial role in differentiating ischemic stroke from an intracerebral hemorrhage, as well as entities other than stroke. This study sought to determine the correlation between the clinical and brain CT scan findings of stroke patients attending three hospitals in Kampala, Uganda.

Methods

This was a cross-sectional study of clinically suspected stroke patients who were sent for brain CT scan at three selected hospitals in Kampala, Uganda. All brain CT scans of patients with suspected stroke were evaluated and the Alberta stroke program early CT score (ASPECTS) was used for middle cerebral artery (MCA) strokes. Univariate analysis was used to describe the clinico-demographic and brain CT features of stroke and summarized them as percentages. Bivariate and multivariate analysis were used to determine the adjusted odds ratios as a measure of association with a 95% confidence interval (CI).

Results

Of the 270 study participants, 141 (52.2%) were male. 162 (60%) had CT findings of stroke, and 90 (33.3%) had normal brain CT findings. Eighteen (6.7%) had other CT findings like tumor, dural hemorrhage, epidermoid cyst, and others. Ischemic stroke, hemorrhagic stroke, and subarachnoid hemorrhage accounted for 124 (45.9%), 34 (12.6%), and 4 (1.5%) respectively. Limb weakness (55.2%), headache (41.1%), and loss of consciousness (39.3%) were associated with stroke findings on CT. Among the acute ischemic strokes, 30 (73.2%) had a worse (0-7) ASPECT score. Those aged ≥65 years were associated with a worse ASPECTS [AOR: 22.01, (95% CI: 1.58-306.09) p = 0.021].

Conclusion

More than a third of patients with a clinical diagnosis of stroke had either no CT features of stroke or had other findings. The most commonly affected vascular territory was left MCA. Old age was strongly associated with having the worst ASPECTS score.

Generalisability of fetal ultrasound deep learning models to low-resource imaging settings in five African countries

Most artificial intelligence (AI) research and innovations have concentrated in high-income countries, where imaging data, IT infrastructures and clinical expertise are plentiful. However, slower progress has been made in limited-resource environments where medical imaging is needed. For example, in Sub-Saharan Africa, the rate of perinatal mortality is very high due to limited access to antenatal screening. In these countries, AI models could be implemented to help clinicians acquire fetal ultrasound planes for the diagnosis of fetal abnormalities. So far, deep learning models have been proposed to identify standard fetal planes, but there is no evidence of their ability to generalise in centres with low resources, i.e. with limited access to high-end ultrasound equipment and ultrasound data. This work investigates for the first time different strategies to reduce the domain-shift effect arising from a fetal plane classification model trained on one clinical centre with high-resource settings and transferred to a new centre with low-resource settings. To that end, a classifier trained with 1792 patients from Spain is first evaluated on a new centre in Denmark in optimal conditions with 1008 patients and is later optimised to reach the same performance in five African centres (Egypt, Algeria, Uganda, Ghana and Malawi) with 25 patients each. The results show that a transfer learning approach for domain adaptation can be a solution to integrate small-size African samples with existing large-scale databases in developed countries. In particular, the model can be re-aligned and optimised to boost the performance on African populations by increasing the recall to [Formula: see text] and at the same time maintaining a high precision across centres. This framework shows promise for building new AI models generalisable across clinical centres with limited data acquired in challenging and heterogeneous conditions and calls for further research to develop new solutions for the usability of AI in countries with fewer resources and, consequently, in higher need of clinical support.

Aspergillus-specific IgM/IgG antibody serostatus of patients hospitalized with moderate-critical COVID-19 in Uganda

Invasive pulmonary aspergillosis is known to complicate the coronavirus diseases-2019 (COVID-19), especially those with critical illness. We investigated the baseline anti-Aspergillus antibody serostatus of patients with moderate-critical COVID-19 hospitalized at 3 COVID-19 Treatment Units in Uganda. All 46 tested patients, mean age 30, and 11% with underlying respiratory disease had a negative serum anti-Aspergillus IgM/IgG antibody immunochromatographic test on day 3 (mean) of symptom onset (range 1-26), but follow up specimens to assess seroconversion were not available.

Myxoid Dermatofibrosarcoma Protuberans of the Scrotum: Rare Tumor in an Uncommon Location

Background

Case Presentation

Conclusion

Non‐traumatic myositis ossificans circumscripta in the anterior abdominal wall of a seven‐year‐old Ugandan child: A case report

Myositis ossificans circumscripta (MOC) is a benign and self‐limiting heterotopic ossification in the subcutaneous fat, tendons, muscles, and nerves. It is commonly due to trauma and is frequently encountered in the arm, shoulder, thigh, and hand which are prone to trauma. Non‐traumatic MOC arising from the abdominal muscles is extremely rare. We report a case of 7‐year‐old male child with a three‐year history of progressive painless abdominal swelling in the left hypochondria region with no history of associated trauma. CT scan of the abdomen showed a well‐defined hyperdense mass in the left external oblique muscle. Histological diagnosis confirmed myositis ossificans of the external oblique muscle. The mass was removed surgically with no immediate or late complications.

Non‐traumatic MOC of the abdominal muscles is very rare. Radiological investigations are crucial in the diagnosis and for differentiating a MO lesion from other malignant soft‐tissue tumors as we demonstrated in this case report.

Chest X-ray findings in drug-sensitive and drug-resistant pulmonary tuberculosis patients in Uganda

Background

Methods

Results

Conclusions

Cardiovascular risk factors and clinical outcomes of patients hospitalized with COVID-19 pneumonia in Somalia

Background:

Coronavirus disease-2019 (COVID-19) is a potentially life-threatening illness with no established treatment. Cardiovascular risk factors (CRFs) exacerbate COVID-19 morbidity and mortality.

Objective:

To determine the prevalence of CRF and clinical outcomes of patients hospitalized with COVID-19 in a tertiary hospital in Somalia.

Methods:

We reviewed the medical records of patients aged 18 years or older with a real-time polymerase chain reaction (RT-PCR)–confirmed COVID-19 hospitalized at the De Martino Hospital in Mogadishu, Somalia, between March and July 2020.

Results:

We enrolled 230 participants; 159 (69.1%) males, median age was 56 (41–66) years. In-hospital mortality was 19.6% ( n = 45); 77.8% in the intensive care unit (ICU) compared with 22.2%, in the general wards ( p < 0.001). Age ⩾ 40 years [odds ratio (OR): 3.6, 95% confidence interval (CI): 1.2–10.6, p = 0.020], chronic heart disease (OR: 9.3, 95% CI: 2.2–38.9, p = 0.002), and diabetes mellitus (OR: 3.2, 95% CI: 1.6–6.2, p < 0.001) were associated with increased odds of mortality. Forty-three (18.7%) participants required ICU admission. Age ⩾ 40 years (OR: 7.5, 95% CI: 1.7–32.1, p = 0.007), diabetes mellitus (OR: 3.2, 95% CI: 1.6–6.3, p < 0.001), and hypertension (OR: 2.5, 95% CI: 1.2–5.2, p = 0.014) were associated with ICU admission. For every additional CRF, the odds of admission into the ICU increased threefold (OR: 2.7, 95% CI: 1.2–5.2, p < 0.001), while the odds of dying increased twofold (OR: 2.1, 95% CI: 1.3–3.2, p < 0.001).

Conclusions:

We report a very high prevalence of CRF among patients hospitalized with COVID-19 in Somalia. Mortality rates were unacceptably high, particularly among those with advanced age, underlying chronic heart disease, and diabetes.

COVID-19, HIV-Associated Cryptococcal Meningitis, Disseminated Tuberculosis and Acute Ischaemic Stroke: A Fatal Foursome

Background

Several viral, bacterial and fungal co-infections have been associated with increased morbidity and mortality among patients with COVID-19. We report a fatal case of severe COVID-19 pneumonia in a patient with a recent diagnosis of advanced HIV disease complicated by cryptococcal meningitis, disseminated tuberculosis and acute ischemic stroke.

Case Presentation

A 37-year-old Ugandan woman was diagnosed with HIV infection 8 days prior to her referral to our center. She was antiretroviral naïve. Her chief complaints were worsening cough, difficulty in breathing, fever and altered mental status for 3 days with a background of a 1-month history of coughing with associated drenching night sweats and weight loss. The reverse transcriptase-polymerase chain reaction for SARS-CoV-2 of her nasopharyngeal swab sample was positive. Chest radiograph demonstrated military pattern involvement of both lungs. The serum and cerebrospinal fluid cryptococcal antigen tests were positive. Urine lipoarabinomannan and sputum GeneXpert were positive for Mycobacterium tuberculosis. Computed tomography of the brain showed a large acute ischemic infarct in the territory of the right middle cerebral artery. Regardless of the initiation of treatment, that is, fluconazole 1200 mg once daily, enoxaparin 60 mg, intravenous (IV) dexamethasone 6 mg once daily, oral fluconazole 1200 mg once daily, IV piperacillin/tazobactam 4.5 g three times daily and oxygen therapy, the patient passed on within 36 hours of admission.

Conclusion

Co-infections worsen COVID-19 outcomes.

Oral health seeking behaviors of adults in Nebbi District, Uganda: a community-based survey

Background

Dental health is often neglected by the majority of the population and has contributed to the global burden of oral diseases. We assessed awareness, utilization and barriers to seeking oral health care among adults in Nebbi District, Uganda.

Methods

A community-based, cross sectional study was conducted in the central division, Nebbi District in Uganda among adults between the age of 18 years or older. An interviewer-administered, semi-structured questionnaire was used for data collection on socio-demographic characteristics, oral health awareness, oral health utilization, associated factors and barriers.

Results

A total of 400 adults with a median age of 32 years (interquartile range 24–43) years were enrolled. More than half (57.5%, n = 230) of the participants were female. Participants identified smoking (42.8%, n = 171) and consumption of sugary foodstuffs (29.0%, n = 116) as risk factors for oral disease. Not brushing was also identified by 260 participants (65.0%) as the cause of tooth decay and 95.8% (n = 383) believed brushing one’s teeth could prevent tooth decay. Of the 51.5% (n = 206) who had experienced a toothache or discomfort 12 months prior to the study but only about half (52%, n = 106) had sought healthcare from a dental clinic or facility. About 89.5% (n = 94) of the participants were able to see a dentist during their last visits. Dental carries (76.6%, n = 70) and gum bleeding (14.9%, n = 14) were the most frequent reasons for visiting a dental clinic, and 73.7% (n = 70) had their tooth extracted. Barriers to seeking oral healthcare were cost of treatment (47.5%, n = 190), and long waiting time (18.5%, n = 74). The odds of seeking oral healthcare was 2.8-fold higher in participants who were being married (Odds ratio (OR): 2.8, 95% CI 1.3–6.3, p = 0.011) and 3.5-fold higher among housewives (COR: 3.5, 95% CI 1.1–11.4, p = 0.040).

Conclusion

About half of the participants had sought healthcare following a dental condition. Cost of treatment seems to be an important factor affecting utilization of oral health services. Optimization of costs, and creating awareness regarding benefits of utilizing preventive dental services are recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01824-5.

Zenker's diverticulum in an 85-year-old Ugandan man

Background

Zenker’s diverticulum (ZD) is an uncommon disorder due to an outpouching of tissue through the Killian triangle that is thought to be caused by dysfunction of the cricopharyngeal muscle.

Case presentation

An 85-year-old male patient presented with odynophagia and dysphagia of initially solid food followed by fluids that was associated with a significant weight loss over a one-year period. Barium swallow videofluoroscopy demonstrated a posterior outpouching of proximal esophagus that was 2 cm from the epiglottis. With the diagnosis of medium sized ZD, the patient underwent endoscopy guided diverticulotomy. Six months after the procedure, he was asymptomatic and had gained weight.

Conclusions

Dysphagia and weight loss raises a clinical suspicion for a malignancy. Barium swallow examination is an inexpensive method for the diagnosis of ZD.

Harlequin fetus: A mayhem in a consanguineous marriage?

Ichthyosis fetalis is a very rare and life-threatening dermatological disorder that is very difficult to treat, especially in low-resource settings.

Synchronous bilateral Wilms' tumor with liver metastasis

Background

Wilms’ tumor (nephroblastoma) is mostly unilateral; however, bilateral Wilms’ tumors are seen in about 5–8% of patients. This can be synchronous or metachronous. It is uncommon to get liver metastasis from bilateral Wilms’ tumor.

Case presentation

An 8-year-old male Ugandan presented with a history of abdominal swelling and flank pains for 1 year. There was no history of hematuria. Both ultrasound and computed tomography of the abdomen demonstrated multiple solid lesions in both kidneys and a huge solid mass in segments V, VI, VII and VIII of the liver. Histological examination of renal biopsy specimen was favorable for chemotherapeutic regimens. However, following a multidisciplinary tumor board consensus, a nephron-sparing surgery was deemed unsuitable, and he was managed conservatively with chemotherapy (adriamycin and vincristine) with a palliative intent.

Conclusions

Metastatic bilateral Wilms’ tumor has a particularly poor prognosis. There are no clear evidence-based guidelines for the management of this rare presentation. This patient benefited from early palliative care and symptom management.

Thyroid hemiagenesis with a TI-RADS 2 nodule in the contralateral lobe

Background

Thyroid hemiagenesis is a rare congenital anomaly in which one lobe of the thyroid gland fails to develop. There is an increased incidence of associated thyroid disorders in patients with thyroid hemiagenesis.

Case presentation

A 32-year-old Ugandan woman presented with a complaint of painless neck swelling of 3-months duration. The swelling was associated with a globus sensation. There was no history of thyroid – related problems or treatment prior to this presentation. Physical examination demonstrated a mobile right thyroid swelling without an obvious nodular contour. Neck ultrasound showed an absent left lobe of thyroid gland, a right lobe with a solitary nodule scoring two points on the Thyroid Imaging, Reporting and Data System (TI-RADS) and an isthmus in situ. Extensive search for possible ectopic thyroid tissue was negative. She was biochemically euthyroid. The patient was counseled about thyroid hemiagenesis and was put on a regular follow up in the clinic for the TI-RADS 2 nodule.

Conclusion

Thyroid hemiagenesis is often associated with other thyroid disorders. Its diagnosis should prompt an active search for other associated morphological or functional thyroid abnormalities.

T-cell non-Hodgkin's lymphoma of both breasts: An uncommon presentation of a common disease

Secondary T-cell non-Hodgkin's lymphoma of the breasts is a very rare disease and can be easily missed as inflammatory carcinoma at initial presentation. High index of suspicion and radiological investigations has a big role in identifying the primary lymphoma.

Prospective verification of sonographic fetal weight estimators among term parturients in Uganda

BACKGROUND

Accuracy of fetal weight estimation by ultrasound is essential in making decisions on the time and mode of delivery. There are many proposed formulas for fetal weight estimation such as Hadlock 1, Hadlock 2, Hadlock 3, Hadlock 4 and Shepard. What best applies to the Ugandan population is not known since no verification of any of the formulas has been done before. The primary aim of this study was to determine the accuracy of sonographic estimation of fetal weight using five most commonly used formulas, and analyze formula variations for different weight ranges.

METHODS

This was a hospital based prospective cohort study at Mulago National Referral Hospital, Kampala, Uganda. A total of 356 pregnant women who consented and were within 3 days of birth were enrolled. Prenatal ultrasound fetal weight determined by measuring the biparietal diameter, head circumference, abdominal circumference, femoral length, and then was compared with actual birth weight.

RESULTS

The overall accuracy of Hadlock 1, Hadlock 2, Hadlock 3, Hadlock 4 and Shepard formula were 66.9, 73.3, 77.3, 78.4 and 69.7% respectively. All Hadlocks showed significant mean difference between weight estimates and actual birth weight (p < 0.01) whereas Shepard formula did not [p - 0.2], when no stratification of fetal weights was done. However, all Hadlocks showed a none significant (p-values > 0.05) mean difference between weight estimates and actual birth weight when the actual birth weight was ≥4000.0 g. Shepard weight estimates showed a none significant mean difference when actual birth weight was < 4000 g. Bland-Altman graphs also showed a better agreement of weight estimated by Shepard formula and actual birth weights.

CONCLUSION

All the five formulas were accurate at estimating actual birth weights within 10% accuracy. However, this accuracy varied with the fetal birth weight. Shepard was more accurate in estimating actual birth weights < 4000 g whereas all Hadlocks were more accurate when the actual birthweight was ≥4000 g.

Overlapping holoprosencephaly-polydactyl syndrome and asphyxiating thoracic dystrophy, an incidental finding in late prenatal ultrasound: A rare case report

Holoprosencephaly-polydactyly syndrome and asphyxiating thoracic dystrophy rarely overlap but if they do, they have poorer prognosis. Early prenatal detection of multiple congenital anomalies plays a crucial role in the management of pregnancy.

Dumbbell-Shaped Extramedullary Hemangioblastoma of the Thoracic Spine as a Diagnostic Dilemma of Solitary Fibrous Tumor

Introduction

Extramedullary hemangioblastoma is a very rare entity that has been rarely reported in the literature.

Case Presentation

A 17-year-old female presented with limping that rapidly progressed to paraparesis and urine incontinence over a one-month duration. Clinically, she had a small swelling on her spine. There was a diagnostic challenge when an enhanced magnetic resonance imaging (MRI) suggested dumbbell – shaped intradural extramedullary mass in the lower thoracic spine, hypointense on T1 and hyperintense on T2 sequences and heterointense on post contrast sequence. The radiologic differentials were pictures of nerve sheath tumors. However, histopathological examination of en bloc excisional biopsy showed hemangioblastoma with a differential of solitary fibrous tumor. Complete excision of the mass was done intraoperatively and the patient improved clinically.

Conclusion

Contrast-enhanced MRI and histopathologic correlation are important for evaluating these rare tumors.

Mature cystic teratoma of anterior mediastinum in a 4-month-old infant: a rare case report

Teratomas of anterior mediastinum are rare tumors and are often slow growing, asymptomatic and detected incidentally on chest imaging. We report, a rare case of an anterior mediastinal teratoma occurring in early childhood. A 4-month-old male infant presented to the pediatric unit of our hospital with a 2-week history of a progressive difficulty in breathing and stridor. He had received several courses of oral and intravenous antibiotics for a clinical diagnosis of pneumonia. The baby started to show social smile and hold his head fairly steady. Chest radiography and chest ultrasound revealed a cystic anterior mediastinal mass which was confirmed by a contrasted chest CT. An ultrasound-guided trucut biopsy of the mass was performed and histopathology showed mature cystic teratoma. Surgical removal of the mass was done with excellent post-operative outcome. Occurrence of a mature cystic anterior mediastinal teratoma is uncommon in early infancy. Early and complete surgical resection offers the best possible prognosis.

Primary Intradural Extramedullary Spinal Burkitt's Lymphoma: A Case Report

Background

Non-Hodgkin's lymphoma (NHL) rarely involves the spine primarily, and if it does, is almost always associated with advanced disease.

Case Presentation

An 8-year-old male presented with a one month history of nuchal pain followed by stiffness and rapidly progressive upper and lower limb weakness. He was seronegative for HIV and EBV. Computed tomography myelogram and magnetic resonance imaging of the cervical and thoracic spine showed a long segment (C2 to T1) complete absence of cerebrospinal fluid signal and mildly enhancing intradural extramedullary lesion with an extradural and right paravertebral muscle extension, respectively. Post-excision biopsy histopathology and immunohistochemistry confirmed the diagnosis of a CD 10+, CD20+, CD45+, Bcl-2+, Ki67+, and EBER in situ hybridization for EBV negative, Burkitt's lymphoma (BL). Cytogenetic analysis showed chromosomal translocations of 8q24. CHOP plus intrathecal cytarabine, methotrexate was given as chemotherapy regimen. 1.8 grays (Gy) per fraction to the local area for an average total dose of 36 Gy was given with a resultant significant clinical improvement.

Conclusion

Though considered uncommon spinal canal tumors, BL should be in the differential diagnosis, if multilevel involvement is demonstrated on imaging.