Myeloma Presenting as Paraparesis: A Case Report.

Aim: To highlight the need to consider multiple myeloma as a probable diagnosis while evaluating a patient presenting with paraparesis and backache. Presentation of Case: A 55 year old woman presented to a hospital in Calabar, Nigeria with complaints of low back pain and progressive difficulty in walking for three months. There was associated constipation and weight loss. She had received two units of whole blood prior to presentation on account of severe anaemia. Physical examination revealed marked cachexia, pallor, dehydration and oral candidiasis. There was bilateral lower extremity weakness and exaggerated deep tendon reflexes. Investigation revealed anaemia, elevated erythrocyte sedimentation rate, hypoalbuminemia and increased serum globulin. Corrected serum calcium and uric acid were also elevated. Radiographic studies revealed generalized osteopenia and gross reduction in vertebral body height of T6, T9, T11 and L2 with lytic lesions on the ribs and skull. She was managed with blood transfusions and cycles of systemic chemotherapy comprising of vincristine, adriamycin and dexamethasone and referred for radiotherapy. Discussion: This case posed a diagnostic challenge. The presenting complaints suggested a compressive myelopathy which is more commonly caused by tuberculosis in our setting. Other considerations were benign or malignant tumours, HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) and neurolathyrism. Conclusion: In the evaluation of a patient with paraparesis and backache, multiple myeloma should be considered. Failure to investigate for multiple myeloma will lead to delays in diagnosis and treatment. Early diagnosis can be made by demonstrating M proteins in either serum or urine, and showing more than 10% of these malignant plasma cells in the bone marrow.

Predictors of Delayed Enrolment for Care among People Living with HIV in a Tertiary Hospital in South Eastern Nigeria.

Aim: This study aimed to identify predictors of delayed enrolment to HIV care in Calabar, Nigeria. Study Design: This was a cross sectional observational study. Place and Duration: This study was carried out in a tertiary level hospital in Calabar, Nigeria between February 1st, 2013 and June 30th, 2013. Methodology: We recruited 500 consecutive HIV-infected persons presenting to care for the first time following HIV diagnosis using a validated, semi-structured and pretested questionnaire. The outcome variable of interest was delayed enrolment for HIV care (>12 months after HIV diagnosis). The independent variables included age, sex, marital status, occupation, income, level of education and exposure to risky behaviour. Others were sexual orientation, duration between HIV testing and presentation for care, residential conditions, lack of spousal HIV status disclosure, distance of residence from nearest HIV care centre and being in a long-standing steady partnership. Results: A total of 45 (9.0%) of the participants enrolled for HIV care within twelve months of HIV diagnosis while 455 (91.0%) enrolled for care after 12 months of diagnosis. The average CD4+ count of those who enrolled early was 248cells/μl which was much lower than the average CD4+ count of those who delayed enrolment (310cells/μl). The average distance of participants who enrolled early for care was lower (296km) than those who delayed enrolment (346km). The covariates significantly associated with delayed enrolment on bivariate analysis were sex, occupation, alcohol use and CD4+ count. Three out of the four covariates retained their significance following multivariate logistic regression and they were CD4+ count, male sex and farming. Conclusion: A significant proportion of clients diagnosed with HIV infection delay in enrolling for care in Calabar. The predictors of delayed enrolment are CD4+ count, male sex and farming. A multifaceted approach of advocacy and social mobilization, poverty alleviation strategies and provision of effective health insurance for all is required.

Chronic foot ulcer complicating a traumatic arteriovenous fistula

Background: Chronic foot ulcers could be a complication of traumatic arteriovenous (A-V) fistulation. We report a rare case of chronic foot ulcer and deformity resulting from arteriovenous fistula of the anterior tibial artery. Method: The clinical presentation and the outcome of treatment in a patient treated at the University of Calabar Teaching Hospital (UCTH) Calabar are reported. The relevant literature on this subject matter is briefly reviewed. Result: A case of chronic foot ulcer and oedema secondary to traumatic arteriovenous fistula of the anterior tibial artery was managed by the authors at the University of Calabar Teaching Hospital. The diagnosis was mainly clinical as sophisticated equipment was not readily available and satisfactory healing was achieved by exploration; quadruple ligation; skin grafting and cast application. Conclusion: Prompt diagnosis and treatment of difficult cases should warrant sophisticated equipment to make diagnosis

Anaesthetic challenges in surgical excision of phaeochromocytoma

Background: Phaeochromocytoma is a rare tumour; which is benign but metabolically active; with a potential for malignancy. This tumour of adrenal or extra adrenal origin usually presents as hypertension; which can be sustained or paroxysmal and with lethal complications. Aim: To present an anaesthetic experience during the surgical resection of a phaeochromocytoma. Method: A 26-year old woman with phaeochromocytoma of the right adrenal gland is presented. The tumour was excised under general anaesthesia. The anaesthesia involved the use of continuous infusion of esmolol (an ultra short-acting intravenous cardioselective beta-antagonist) and propofol. The resected tumour was sent for histopathological examination. Results: The tumour was completely excised under general anaesthesia. The haemodynamic changes that occurred during tumour handling were controlled with fentany1;propofol/esmolol infusion. Histopathological findings confirmed phaeochromocytoma. Conclusion: Although; the anaesthetic and surgical management of a phaeochromocytoma could be an uphill task; it is possible in an environment with limit laboratory and intensive care facilities

Tropical Surgical abdominal emergencies blunt splenic rupture in Calabar

A detailed study of splenic rupture in 34 consecutive patients living in souttheastern equatorial rainforest Nigeria was conducted during a 5-years period. The results clearly show that blunt abdominal injury from road traffic accident (RTA) was the cause of rupture in the vast majority of cases. Road traffic accident was due in many cases to collision with a motor bike which is a popular means of transportation in this region. Although the external injury to the abdomen was slight; and in some cases nil; the ensuing trauma to the spleen was extensive. In contrast RTA due to the motor car; seen in 5 of the 34 patients studied; caused much associated injury to the patient. The pattern of splenic rupture seen in this tropical African community is out-standingly in contrast with that of the developed countries of the West where spontaneous rupture of diseased spleen seems to be common