Clinical aspects and outcomes of patients with malaria at Chris Hani Baragwanath Academic Hospital,Johannesburg, South Africa

BACKGROUND

South Africa (SA) is currently experiencing a significant increase in malaria cases despite having shifted focus from malaria control towards malaria elimination. The clinical features of malaria are nonspecific, but their relative frequency on presentation are not well described. HIV and malaria are both independently associated with high mortality in sub-Saharan Africa. There are important interactions between HIV and malaria.

OBJECTIVES

To describe the population characteristics of patients with malaria at Chris Hani Baragwanath Academic Hospital, Johannesburg, SA, clinical and biochemical features of severity, the proportion of patients with HIV infection, management and outcomes.

METHODS

A prospective observational study was conducted whereby patients with a confirmed laboratory diagnosis of malaria were identified, approached and consented for study inclusion over the time period January 2017 - January 2018. Clinical and biochemical data were collected at the time of consent and later analysed.

RESULTS

The mean (standard deviation) age was 35.7 (12.98) years, and 72 (70.6%) of the 102 patients were male. Peak admissions for malaria were in January, with 58 patients (56.9%) admitted during January 2017 and 2018. All malaria cases were imported, with 74.5% associated with travel to Mozambique. The majority of the patients (61.8%) were expatriates living in SA. The most common presenting symptoms were chills (95.1%), weakness (94.1%), fever (91.2%), headache (90.2%) and lethargy (88.2%). The most common clinical signs were dehydration (31.4%), prostration (19.6%) and jaundice (13.7%). Among the 40 patients (39.2%) who had severe malaria, prostration was the most common feature of severity (19.6%), 8 (7.8%) were admitted to an intensive care unit, and 6 (5.9%) required haemodialysis. The median (interquartile range) duration of hospital stay was 5 (3 -6) (range 2 - 35) days. HIV status was known in 83 patients (81.4%), of whom 32 (38.6%) were HIV-positive. Malaria prophylaxis had been taken by only 8 patients. The all-cause mortality rate was 4.9%, and mortality attributable to malaria 3.9%.

CONCLUSIONS

There was a high proportion of complicated malaria cases, particularly in January. The majority of patients were young expatriate males with a history of travel to southern Mozambique or Limpopo Province, with very few taking malaria prophylaxis. Most clinical signs and symptoms were constitutional and nonspecific. A large number of patients were found to be HIV-positive, and most were newly diagnosed. Mortality was high, at around five times the national average, and may have been an underestimate.

What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations?

OBJECTIVE:

To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa.

METHODS:

A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation.

RESULTS:

Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm³. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each).

CONCLUSION:

PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.

Use of a rapid test of pneumococcal colonization density to diagnose pneumococcal pneumonia

BACKGROUND

There is major need for a more sensitive assay for the diagnosis of pneumococcal community-acquired pneumonia (CAP). We hypothesized that pneumococcal nasopharyngeal (NP) proliferation may lead to microaspiration followed by pneumonia. We therefore tested a quantitative lytA real-time polymerase chain reaction (rtPCR) on NP swab samples from patients with pneumonia and controls.

METHODS

In the absence of a sensitive reference standard, a composite diagnostic standard for pneumococcal pneumonia was considered positive in South African human immunodeficiency virus (HIV)-infected adults hospitalized with radiographically confirmed CAP, if blood culture, induced good-quality sputum culture, Gram stain, or urinary Binax demonstrated pneumococci. Results of quantitative lytA rtPCR in NP swab samples were compared with quantitative colony counts in patients with CAP and 300 HIV-infected asymptomatic controls.

RESULTS

Pneumococci were the leading pathogen identified in 76 of 280 patients with CAP (27.1%) using the composite diagnostic standard. NP colonization density measured by lytA rtPCR correlated with quantitative cultures (r = 0.67; P < .001). The mean lytA rtPCR copy number in patients with pneumococcal pneumonia was 6.0 log(10) copies/mL, compared with patients with CAP outside the composite standard (2.7 log(10) copies/mL; P < .001) and asymptomatic controls (0.8 log(10) copies/mL; P < .001). A lytA rtPCR density ≥8000 copies/mL had a sensitivity of 82.2% and a specificity of 92.0% for distinguishing pneumococcal CAP from asymptomatic colonization. The proportion of CAP cases attributable to pneumococcus increased from 27.1% to 52.5% using that cutoff.

CONCLUSIONS

A rapid molecular assay of NP pneumococcal density performed on an easily available specimen may significantly increase pneumococcal pneumonia diagnoses in adults.

Nocardial infection as a complication of HIV in South Africa

OBJECTIVES

To assess the occurrence, clinical and microbiological features of nocardial infections complicating HIV in Soweto, South Africa.

METHODS

A prospective study was carried out over a 2-year period. Patients were identified after isolation of Nocardia spp. from a clinical specimen. Clinical details were recorded. The nocardial isolates were identified to species level and susceptibility tests performed.

RESULTS

Ten patients were identified as having nocardial disease complicating HIV. Clinical presentations were pulmonary (five patients), pulmonary and cerebral (one patient), cerebral (one patient) and skin and soft tissue infection of the lower limb (three patients). Three infections were fatal. The isolates were Nocardia asteroides (seven patients), N. farcinica (two patients) and Nocardia spp. (one). Isolates of N. farcinica demonstrated opacification of Middlebrook agar. All isolates were sensitive to amikacin and minocycline. Most nocardial isolates were susceptible to cefotaxime, imipenem and coamoxiclav. In vitro resistance to cotrimoxazole was present in five.

CONCLUSIONS

Nocardial infection occurs as a complication of HIV infection in the Republic of South Africa. Pulmonary cases may be difficult to distinguish from tuberculosis. Nocardia asteroides is the most common species isolated. Nocardia farcinica has resistance to multiple antibacterial agents and demonstrates opacification of Middlebrook agar, a useful screening test for this species. Agents with good in vitro antinocardial activity were amikacin, minocycline, cefotaxime, imipenem and coamoxiclav. There was a high level of resistance in vitro to cotrimoxazole.

Sisters of women with premature ovarian failure may not be ideal ovum donors

OBJECTIVES

To determine whether the sisters of women with premature ovarian failure (POF) showed a response to gonadotropin stimulation comparable to that of anonymous ovum donors.

DESIGN

Historical cohort study.

SETTING

Records of 228 consecutive ovum recipients in an academic assisted reproductive technology program.

PATIENT(S)

Criteria for inclusion were oocyte recipients age < or = 40 years, FSH > 18 mIU/mL (conversion factor to SI unit, 1.00), and/or failure to respond appropriately to controlled ovarian hyperstimulation (COH). Seventy-nine recipients were classified on the basis of whether they received oocytes from anonymous donors (group I, n = 66) or sister donors (group II, n = 13).

MAIN OUTCOME MEASURE(S)

Controlled ovarian hyperstimulation response, pregnancy rates (PRs), and implantation rates.

RESULT(S)

The ages of the donors to groups I and II were comparable (31.1 +/- 16.7 versus 29.8 +/- 7.2 years), but those in group II exhibited a higher baseline FSH level (12.8 +/- 2.1 versus 8.6 +/- 5.8 mIU/mL). Group II versus I had a relative risk of 5.1 for cancellation (4 of 13 [30.8%] versus 4 of 66 [6.1%], respectively). In completed cycles of groups I and II, respectively, there was no difference in serum E2 on the day of hCG administration (2,356 +/- 826 versus 1,847 +/- 843 pg/mL; conversion factor to SI unit, 3,671), number of oocytes retrieved (25 +/- 14 versus 22 +/- 13), number of embryos transferred (4.4 +/- 2.1 versus 4.0 +/- 1.0), spontaneous abortion rate (22.7% versus 25.0%), PR (35.5% versus 36.4%), and implantation rate (16.2% versus 16.4%).

CONCLUSION(S)

There is an increased cancellation rate and, consequently, an overall trend toward decreased ovarian response to gonadotropin stimulation in the sisters of patients with POF. Despite these factors, the implantation rates and PRs of embryos derived from patients reaching retrieval were similar to those from anonymous donors. We recommend counseling women with POF that their sisters may not be ideal ovum donors.

Age-related decline in female fertility is not due to diminished capacity of the uterus to sustain embryo implantation

OBJECTIVE

To evaluate the contribution of the uterus to age-related reproductive failure in women.

PATIENTS

Thirty-eight ovum donors (30.2 +/- 4.9 years [mean +/- SD]) donating oocytes throughout 102 ovum donations. Fifty-one cycles were documented in "younger" recipients (35.8 +/- 3.1 years) and 51 in "older" recipients (44.0 +/- 3.1 years). The study was prospectively designed; same-cohort oocytes obtained from one young donor during a specific cycle were evenly distributed between "young" and "old" ovum recipients. Use of oocytes from a single source and a unique ovulatory cohort provides strict control over oocyte quality. Uterine age is varied by design, according to the age of the recipient at the time of ET. The role of the aging uterus in the decline of female fertility can be thus isolated and scrutinized.

RESULTS

No significant (NS) difference in the number of ova received (7.9 +/- 3.4 versus 7.0 +/- 3.5), ova fertilized (4.4 +/- 1.5 versus 4.5 +/- 2.3), or embryos transferred (4.1 +/- 1.5 versus 4.1 +/- 1.6) was observed between the < 40 and > or = 40 recipient age groups. A total of 23 pregnancies occurred among the 102 ETs (22.6%). Eleven clinical pregnancies (21.6%) resulting in 10 deliveries were observed in the < 40 recipient age group, and 12 clinical pregnancies (23.5%) leading to 10 deliveries occurred in the > or = 40 recipient age group (NS). The pregnancy loss rates were 9.1% (1 of 11) and 16.7% (2 of 12) for the two recipient age groups, respectively, (NS).

CONCLUSION

The capacity to conceive and to gestate a conception to term when oocyte quality is controlled appears to be independent of uterine aging through the fifth decade of life.

Is there (sex) life after coronary bypass?

The heart has been regarded throughout history as the central core of life and emotions, of kindness and generosity, courage and grief. Cardiac disease can be overwhelming for both the patient and for the partner, and fear of death is a common and quite normal response. Sexual activity after convalescence is a valuable incentive for patients to undergo rehabilitation. Self-confidence and satisfaction can be greatly enhanced by affectionate closeness, and prolonged foreplay can be savored at any age. Sex play is relaxing and healthful whereas anxious sexual preoccupation, frustration, and avoidance may actually be greater risk factors than the mild physical effort involved for coitus or coital alternatives. Male and female patients with cardiac disease expressed regret that their primary physician, cardiologist, or surgeon had not broached the subject of sexual function before or after the acute illness. They were interested, but both patients and physicians were probably uncomfortable with explicit sexual dialogue. Some common sense reminders to post-MI and post-CABS patients about sexual function may be given verbally or in written form, together with diet and exercise instructions. These should include: a heavy meal or heavy alcohol intake before coitus should be avoided; early morning can be an ideal time for coitus or sex play; moderate room temperature is best; a comfortable sexual position can be found with experimentation; chest pain or palpitations are signals to use appropriate medications; and coital death is rare in a stable, long-standing sexual relationship.(ABSTRACT TRUNCATED AT 250 WORDS)