Clinical and social determinants of diarrhoeal disease in a rural HIV/AIDS clinic, South Africa: a case-control study

Diarrhoeal diseases are a common cause of morbidity and are associated with mortality in HIV-infected populations. Little is known about the contribution of clinical and socio-environmental factors to the risk of diarrhoea in these populations in rural sub-Saharan Africa. We conducted a case-control study of people attending a rural HIV clinic with an episode of diarrhoea in Bushbuckridge, South Africa. Cases were defined as HIV-positive adults with symptoms of diarrhoea before or after initiation of antiretroviral therapy (ART). Controls without diarrhoea were randomly selected from clinic attendees. Structured questionnaires and case-file reviews were undertaken to describe clinical and socioenvironmental risk factors. We recruited 103 cases of diarrhoea from 121 patients meeting case definitions. Cases were more likely to be women (P = 0.013), aged over 45 years (P = 0.002), divorced or separated (P = 0.006), have limited formal education (P = 0.003), have inadequate access to sanitation facilities (P = 0.045), have water access limited to less than three days per week (P = 0.032) and not yet initiated on ART (P < 0.001). In multivariate analysis, diarrhoea remained associated with female gender (adjusted odds ratio [aOR]: 2.02, 95% CI 1.10-3.73), older age (aOR: 6.31, 95% CI 1.50-26.50), limited access to water (aOR: 2.66, 95% CI 1.32-5.35) and pre-ART status (aOR: 5.87, 95% CI 3.05-11.27). Clinical and socio-environmental factors are associated with occurrence of diarrhoeal disease among rural HIV patients in South Africa. Further intervention research is urgently needed, combining community- and clinic-based approaches, to improve access to water, sanitation and ART for rural areas with high HIV prevalence, along with structural interventions to address gender inequities.

Preliminary assessment of Treponema pallidum-specific IgM antibody detection and a new rapid point-of-care assay for the diagnosis of syphilis in human immunodeficiency virus-1-infected patients

The aims of the study were to assess whether Treponema pallidum-specific IgM may provide a useful marker of infectious syphilis in human immunodeficiency virus (HIV)-infected patients, and to compare the performance of a prototype IgM-rapid point-of-care test (PoCT) with a standard IgM-enzyme immunoassay (EIA). Twenty samples from HIV-infected patients with untreated syphilis (n = 4 primary syphilis, n = 11 secondary and n = 5 early latent) and 51 follow-up samples at three, six or 12 months after treatment were tested for the presence of IgM with the Mercia-EIA (Microgen Bioproducts Ltd, Camberley, UK) and a prototype PoCT (Select Vaccines Ltd, Melbourne, Australia). Although sample numbers were small, IgM detection by EIA appears to be a reliable marker for untreated syphilis in HIV-infected patients with primary (4/4 IgM-positive) or secondary syphilis (10/11 IgM-positive, 1/11 equivocal). After treatment, IgM was no longer detected after three months in the majority of patients (87%) and was either negative or equivocal in all patients after six and 12 months. The overall sensitivity of the IgM-PoCT was 82% and varied with clinical stage, being highest in secondary (10/10 EIA positives) but lower in primary (2/4 EIA positives) and early latent syphilis (2/3 EIA positives). Overall specificity was 95%. Rapid detection of IgM would enable clinicians to distinguish between past-treated and infectious syphilis and allow for diagnosis and treatment in a single visit.

A simple method for the fixation of armoured tubes for tracheostomy

A simple adaptation of currently available equipment is described which facilitates the secure fixation of armoured tracheostomy tubes.

Psittacosis. A flu like syndrome

BACKGROUND

Psittacosis is a relatively common cause of community acquired pneumonia in adults in Australia. Although the illness is usually mild to moderate in severity, it can, be life threatening. It should be considered as a possible cause of any flu like illness.

OBJECTIVE

This article aims to describe the clinical presentation, diagnostic investigation and outpatient management of psittacosis.

DISCUSSION

The key to the management of psittacosis is considering the diagnosis. If a history is obtained of contact with birds, a careful search for respiratory symptoms, signs or chest X-ray changes should take place. If the clinical likelihood is high, empirical therapy with doxycycline should be started. Acute and convalescent serology should then be taken to help establish the diagnosis.

Diffuse large cell, B-cell type lymphoma with a novel translocation (2;22)(p23;q11.2)

We observed a translocation (2;22)(p23;q11.2) in the bone marrow cells of a patient with multiple subcutaneous nodules. Tumor histology and immunohistochemical staining demonstrated a malignant lymphoma, diffuse large cell type, displaying a CD30 negative B cell immunophenotype. To our knowledge, this is the first report of this specific translocation in lymphoma, which may join the site of the anaplastic lymphoma kinase (ALK) gene at 2p23 to the region of the immunoglobulin lambda light chain gene at 22q11.2. The ALK gene was initially identified through its involvement in the t(2;5)(p23;q35) found most commonly in anaplastic large cell lymphoma. This observation in a CD30 negative large cell lymphoma of B cell lineage further extends the relationship of anaplastic large cell morphology, ALK activation, lymphoid lineage, and expression of the CD30 antigen.

Sterile corneal ulceration after cataract extraction in patients with collagen vascular disease

We report the occurrence of sterile corneal ulceration in 11 eyes of eight patients with collagen vascular diseases and dry eyes after cataract extraction with intraocular lens implantation. Keratolysis occurred after both extracapsular and intracapsular cataract extraction and appeared unrelated to the type of intraocular lens. Despite aggressive lubrication and other medical treatment, including systemic immunosuppressive agents, penetrating keratoplasty was often required. Although all eyes were saved, visual outcome was usually poor. The histopathologic finding of polymorphonuclear leukocytes localized near the areas of corneal dissolution provides evidence for the role of polymorphonuclear leukocyte-derived collagenase as a contributing factor in the pathogenesis of sterile corneal ulceration in these patients.

Traumatic wound dehiscence in pseudophakia

In a series of 11 pseudophakic patients (11 eyes) who sustained wound dehiscence as a result of blunt trauma, five intraocular lenses were dislocated, one was fractured, and two were expulsed. Wound rupture occurred from three days to one year after surgery; the most common cause of injury was a fall. Iris prolapse was observed in all patients, with hyphema observed in seven. Vitreous prolapse occurred in four patients, and three patients developed retinal detachment. Six of the 11 patients had a visual acuity of 20/40 or better after repair. The limbal wound of a pseudophakic eye can dehisce as a consequence of blunt trauma long after surgery, and the position of the intraocular lens can be disrupted. Patients undergoing cataract extraction with intraocular lens implantation should be advised about the importance of long-term protective eyewear.

Acanthamoeba keratitis in Tennessee: a growing problem in patients wearing contact lenses

All physicians evaluating a painful red eye in a contact lens wearer should consider the diagnosis of Acanthamoeba keratitis. Although it remains relatively rare, the incidence of this infection is on the rise. Clues to the correct diagnosis include a corneal abrasion that fails to heal appropriately, pain out of proportion to the clinical findings, and a history of poor contact lens hygiene. Prompt recognition and appropriate ophthalmologic intervention can improve the visual outcome for patients with this devastating corneal infection.

Herpes simplex masquerade syndrome: acanthamoeba keratitis

Acanthamoeba is a free-living, fresh-water protozoan that can cause severe corneal disease. Acanthamoeba keratitis can closely mimic epithelial and stromal Herpes simplex keratitis. Three cases of severe keratitis, were referred for treatment. One patient presented with a pseudodendritic epithelial lesion that gradually progressed to stromal involvement. A second patient presented with central stromal infiltrate and necrosis, while a third exhibited features of a disciform lesion with the later development of an immune ring. Acanthamoeba was recovered from the cornea in each case. The distinctive characteristics of the history and clinical findings in Acanthamoeba keratitis can aid the clinician in distinguishing between these two clinical entities. Cytopathology and special staining and culture techniques can confirm the diagnosis.

Orbital metastasis from cutaneous melanoma

Although orbital extension from ocular melanoma occurs frequently in advanced cases, orbital metastasis from cutaneous melanoma has been reported but eight times previously. We have reported two such cases. One of the patients had three previous primary melanomas; the other had metastasis to the cauda equina. Both patients died when orbital involvement developed years after the initial lesions. Ours are the first cases to include CT and MRI findings in metastatic orbital melanoma.

Visual impairment following radial keratotomy. A cluster of cases

Thirteen patients who underwent radial keratotomy developed complications leading to visual impairment. Three eyes were legally blind. Two groups of complications were seen: those common to surgical procedures involving the eye--optic atrophy, infections, cataract and retinal detachment, and those unique to radial keratotomy--complete failure of the procedure, marked undercorrection, marked overcorrection, and induced astigmatism. Symptoms due to anisometropia were prominent in the latter group who considered themselves visually disabled by the surgery. Radial keratotomy, like all surgical procedures, is liable to complications that may lead to visual impairment, blindness, or loss of an eye.

Hereditary sclerocornea

Sclerocornea is a primary anomaly in which scleralization of a peripheral part of the cornea, or the entire corneal tissue, occurs. In the peripheral type of sclerocornea, the affected area is vascularized with regular arcades of superficial scleral vessels. In total sclerocornea, the entire cornea is opaque and vascularized. To our knowledge, 97 cases of all types of sclerocornea have been reported in the world literature, either as a primary anomaly or in association with cornea plana. Peripheral sclerocornea in association with cornea plana was found in nine members of one family, in four of five generations studied. To our knowledge, this is the largest pedigree of hereditary peripheral sclerocornea identified. Our pedigree suggests the autosomal-dominant transmission of this entity but doesn't rule out phenocopies or other modes of inheritance in other cases of sclerocornea. Chromosomal analyses of representative family members revealed normal karyotypes.

Staphylococcus epidermidis endophthalmitis. Visual outcome following noninvasive therapy

Staphylococcus epidermidis has been reported with increasing frequency as a cause of bacterial endophthalmitis. Over the past eight years 18 consecutive postsurgical cases have been treated by combined antibiotic-corticosteroid therapy without intravitreal antibiotics or vitrectomy. Fourteen (78%) achieved a final visual acuity of 20/50 or better. When these cases were added to similarly reported cases in the literature, 72% achieved this level of vision. By contrast, 42% of adequately documented cases in the literature treated by intravitreal antibiotics, and 42% treated additionally by vitrectomy, achieved a vision of 20/50 or better. S. epidermidis is an organism with a low order of virulence. The use of intravitreal antibiotics and vitrectomy do not appear to be necessary for effective treatment.

Humoral and cell-mediated immune responses to epidermal growth factor in the rabbit

Epidermal growth factor (EGF), which has been shown to stimulate epidermal proliferation and keratinization and to induce regeneration of rabbit corneal epithelium, was studied for its immunogenic potential in rabbits. Mouse-derived EGF was administered topically, subconjunctivally, intrastromally, and systemically. Systemic immunization was done both with and without complete Freund's adjuvant (CFA). EGF-stimulated cultures of lymphocytes from peripheral blood, spleen, and lymph nodes of all immunized animals were tested for cell-mediated immunity (CMI) to EGF. All experimental animals demonstrated CMI as determined by either classic positive delayed skin tests or by in vitro production of migration inhibitory factors, regardless of the route of sensitization. Only animals immunized systemically with EGF and CFA produced high-titered specific anti-EGF antibody, and only this group showed ocular reactions after subsequent topical challenge of EGF. These results suggest that antibody to EGF is the major cause for ocular inflammatory reactions observed subsequent to topical EGF challenge of a sensitized animal.

HLA antigens in recurrent stromal herpes simplex virus keratitis

HLA-A, HLA-B, and HLA-C antigens were typed on 48 patients with recurrent herpes stromal keratitis. The HLA-Aw30 antigen occurred three times more frequently in patients with herpes stromal keratitis than in those who lack the Aw30 antigen. When the data for the probability of the HLA-Aw30 were corrected for the number of variables studied, the corrected P value was not significant. A previous report of an increased frequency of HLA-B5 with recurrent herpes keratitis was not confirmed by our study. No significant associations with the HLA-C antigens were noted. HLA-DR antigen typing of 25 herpes stromal keratitis patients indicated that the HLA-DRw3 antigen appeared to have an increased frequency in herpes stromal keratitis. However, the small sample size studied precluded interpretation of the increased phenotypic frequency and the possible association of HLA-DRw3 and herpes stromal keratitis needs further study.

Mycotic endophthalmitis in drug abusers

We diagnosed mycotic endophthalmitis by positive cultures in a 47-year-old man and a 42-year-old woman, both intravenous amphetamine users. Reinfection with a different fungal species was documented in one case. Rapid identification of the isolate, in vitro susceptibilities, selection of appropriate routes and dosages of antifungals, and the role of adjunctive corticosteroids are crucial factors in the management of these difficult cases. We prescribed antifungals and adjunctive corticosteroids, and our patients' vision improved.

PaO2 levels and retrolental fibroplasia: a report of the cooperative study

The relation between PaO2 and retrolental fibroplasia (RLF) was studied prospectively in 719 premature infants born in or treated in the intensive care units of a group of university hospitals. Blood gas studies were performed on 589 of these infants, 66 of whom had a diagnosis of RLF; in 27 of these 66, some grade of mostly nonblinding cicatricial disease developed. The frequency of RLF was highest among infants of lowest birth weight. A multivariate statistical method was used to analyze simultaneously the effect of possible etiologic factors associated with RLF. The occurrence of RLF was found to be unrelated to PaO2, as determined by the limited information available from intermittent sampling. RLF is associated with concentration of oxygen administered in the lightest birth weight group, but the strongest association, aside from birth weight, was with time in oxygen. None of the other variables involving blood chemical values appeared to be associated with RLF. The severity of cicatricial RLF is clearly greater in infants weighing less than 1,200 g at birth. Conservative administration of oxygen may have been responsible for failure to demonstrate quantitative association between PaO2 levels and disease. Agreement between the observed and predicted numbers of infants with RLF demonstrate the strength of the multivariate technique employed in making the statistical analyses.

Vidarabine therapy of complicated herpes simplex keratitis

Patients with active herpetic epithelial keratitis who had toxic reactions or were resistant to idoxuridine received vidarabine. Only one of 35 cases of herpetic epithelial keratitis without stromal disease failed to heal. Of 21 patients with active epithelial keratitis complicating stromal keratitis or uveitis. 11 had complete reepithelialization by day 14. Two patients were removed from the trial as treatment failures. The remaining cases healed in 21 to 48 days. In most instances the stromal keratitis was inactivated when the epithelial ulcer healed. In our patients treated with vidarabine, healing of herpes simplex epithelial ulcers was biphasic: Stage 1, progression from an active to an inactive viral ulcer, and Stage 2, complete reepithelialization.

Kinetics of corneal epithelial regeneration. II. Epidermal growth factor and topical corticosteroids

The kinetics of rabbit corneal epithelium regeneration were studied to determine if topical corticosteroid has an adverse effect on corneal epithelial wound healing, and if epidermal growth factor (EGF) can abrogate any adverse effect of topical corticosteroid. Healing of standardized 7 mm. central corneal epithelial wounds was determined by serial standardized color photography of the flourescein-stained defects and planimetry of the projected photographs. It has been found that topical application of 16 drops per day of vehicle or Decadron decreased the epithelial healing rate, as compared to saline drops four times daily. Decadron 0.1 per cent given hourly (16 drops daily) was no more detrimental to corneal epithelial healing rate than the vehicle similarly applied. EGF exhibited no capacity to alter the corneal epithelial healing rate when hourly drops of either the vehicle or Decadron 0.1 per cent were given. Under the conditions of these experiments, no adverse effect on corneal epithelial healing rate could be attributed to Decadron 0.1 per cent.

Presumed histoplasmic maculopathy: clinical course and prognosis in nonphotocoagulated eyes

In this chapter, we have tried to identify some of the variables related to the visual prognosis in eyes with presumed histoplasmic maculopathy. We are cognizant that a constellation of other as yet unidentifiable variables also may play a role in the visual prognosis. Also, we have reported our visual results in patients who were nt photocoagulated. Many of these patients received corticosteroid therapy in some form, but we found it impossible to compare treatment ot nontreatment groups. Our results for visual prognosis is all nonphotocoagulated eyes are in general agreement with those available in the literature. For instance, Gass et al. [1] report 20 of 38 eyes (52.6 percent) with visual acuity of 20/200 or less. Also, this same study documents retention of 20/30 or better central vision in 13 of 38 eyes (34 percent), and the visual results in our study for all 54 nonphotocoagulated eyes parallel the reported findings of Schlaegel et al. [3] where 59 percent of eyes ended with a visual acuity of 20/200 or worse, 30 percent with vision of 20/50 or better, and 18 percent with vision of 20/30 or better...

Presumed histoplasmic maculopathy: xenon photocoagulation

Every investigation into the efficacy and role of photocoagulation in the management of PHM has been handicapped by the lack of a valid control series. In all first eyes, the results of photocoagulation are better than in second eyes. The increased salvage rate of central visual acuityof 20/50 or better in first eyes without photocoagulation is on the order of 15.8 percent to 28.6 percent-versus 25 to 38 percent in first eyes with photocoagulation (an average of 54 percent salvage rate for all first eyes). However, in second eyes, even though the number of eyes is small, it appears that nonphotocoagulated eyes do better than those that have been photocoagulated: 46 percent of nonphotocoagulated second eyes versus 33 percent of second eyes with photocoagulation retain central vision of 20/50 or better. Comparison of our results with some of the other published studies indicates some disparity in results [1-5], arising, most plausibly, from variations in the severity of the maculopathy just prior to photocoagulation. It is our contention that carefully designed prospective studies are needed, in which cases would be randomized for treatment in groups classified according to severity of the process (for example, size of SNV, proximity of SNV to fovea, and amount and location of subretinal hemorrhage). In order to obtain sufficient cases for analysis, a collaborative study may be essential in which the results and analysis of the cases are compiled by an independent party not involved in the treatment of evaluation of the patients. Despite this lack of clinical corroboration, it is my firm belief based on clinical experience that photocoagulation does have a role in the management of this vision-threatning process.

Cholesterosis bulbi. Case report with modern chemical identification of the ubiquitous crystals

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