Clinical neglect of aspergillosis in pulmonary tuberculosis co-infection: a case report of avoidable mortality in a resource-constrained setting

Background: Pulmonary aspergillosis (PA) is common among patients with tuberculosis (TB). With both infections presenting with similar clinical and radiologic features, diagnosis of PA is often made too late or missed completely due to lack of clinical suspicion and poor diagnostic laboratory capacity for mycotic infections prevalent in our settings. We present a case of preventable mortality caused by delayed diagnosis and treatment of PA in a patient with pulmonary TB (PTB). Case presentation: A 13-year-old female was diagnosed and treated for PTB, having received anti-TB regimen for 8 months in a mission hospital from where she was referred due to worsening cough, chest pain and progressive breathlessness. The patient was re-assessed and investigated, with GeneXpert detecting Mycobacterium tuberculosis, susceptible to rifampicin. Diagnosis of pulmonary tuberculosis complicated by right pneumothorax was made indicating an emergency thoracotomy and chest tube insertion and continuation of the first line anti-TB regimen. At about 2 weeks into admission, patients had features of superimposed acute bacterial sepsis with fever becoming high grade, marked neutrophilia with toxic granulation and elevated sepsis biomarker, and this necessitated empiric antibiotic treatment with parenteral meropenem and vancomycin. However, the patient only had mild clinical improvement following which there was progressively worsening respiratory symptoms and massive haemoptysis. Result of sputum fungal study was available on admission day 20 and revealed a growth of Aspergillus flavus. Treatment with intravenous voriconazole was however commenced rather late when the fungal respiratory disease could no longer be remedied. The patient died on admission day 23. Conclusion: Diagnosis of PA in patients with background TB is often made too late to guarantee timely and effective antifungal treatment with negative consequences on patients' outcomes. Improving clinical and laboratory capacities is essential to reducing mortality from PA in healthcare facilities.

An evaluation of open tracheostomy in oral and maxillofacial surgery

This study was carried out to evaluate the indications; utilisation and the overall impact of tracheostomy on the practice of Oral and Maxillofacial Surgery at the University College Hospital; Ibadan; Nigeria. In a retrospective study of a total of 381 patients operated under general anaesthesia by the Department of Oral and Maxillofacial Surgery within the study period; 41 patients (10.8) were tracheostomised. There were 26 males and 15 females with a ratio of 1.7:1 and the mean age was 28.9 years (SD = 12.25; range of 5 - 65 years). Indications for tracheostomy were orofacial tumours 70.7 (n=29); trauma 19.5 (n=8); temporomandibular joint (TMJ) ankylosis 7.3 (n=3) and post operative airway obstruction 2.4 (n=1). Orofacial tumours account for a major part of the indication for tracheostomy as a surgical airway intervention which is safe and with low morbidity