Disseminated Tuberculosis in a Nigerian Adolescent with Linear IgA Bullous Dermatosis: A Case Report and Review of Literature.

Linear IgA bullous dermatosis (LABD) is an auto-immune disease affecting young children and adults, characterized by the linear deposition of IgA at the basement membrane zone with resultant complement activation and a cascade of immune reactions. There is a loss of adhesion at the dermo-epidermal junction and subsequent blister formation. It is a rare disease that has a good prognosis with adequate therapy. However, the underlying depressed immunity associated with the disease may expose them to such infections as tuberculosis. We report the case of an 11-years-old Nigerian female adolescent with LABD, diagnosed at the age of four years but defaulted on follow-up, who developed disseminated tuberculosis (pulmonary, lymph nodes, abdominal and pericardial effusion) seven years after the appearance of the initial blistering skin lesions. She commenced anti-tuberculosis drugs, steroids, and a tube pericardiostomy for the pericardial effusion. Dapsone was initiated for the LABD during the continuation phase of anti-tuberculosis therapy, with subsequent disappearance of the skin rash within two weeks.

La dermatose bulleuse linéaire à IgA (DBL) est une maladie auto-immune affectant les jeunes enfants et les adultes, caractérisée par le dépôt linéaire d'IgA dans la zone de la membrane basale, avec l'activation du complément qui en résulte et une cascade de réactions immunitaires. Il y a une perte d'adhérence à la jonction dermo-épidermique et une formation ultérieure de vésicules. C'est une maladie rare qui a un bon pronostic avec un traitement adéquat. Cependant, l'immunité déprimée sous-jacente associée à la maladie peut les exposer à des infections telles que la tuberculose. Nous rapportons le cas d'une adolescente nigériane de 11 ans atteinte de la LABD, diagnostiquée à l'âge de quatre ans mais en défaut de suivi, qui a développé une tuberculose disséminée (pulmonaire, ganglions lymphatiques, épanchement abdominal et péricardique) sept ans après l'apparition des lésions cutanées vésiculeuses initiales. Elle a commencé à recevoir des médicaments antituberculeux, des stéroïdes et une péricardiostomie par sonde pour l'épanchement péricardique. La dapsone a été initiée pour la DLB pendant la phase de continuation du traitement antituberculeux, avec une disparition de l'éruption cutanée en deux semaines. Mots clés: IgA linéaire, dermatose bulleuse, tuberculose disséminée, adolescent.

Clinicopathological Pattern and Management of Primary Lung Cancer in Ilorin, Nigeria.

BACKGROUND: Lung cancer incidence and mortality rates have increased in some low and medium-resourced countries. OBJECTIVES: This study aimed to describe the clinicopathological pattern and management of lung cancer seen in our setting. METHODS: We reviewed cases of pulmonary neoplasm diagnosed and managed at the University of Ilorin teaching hospital over eight years. Cases with tissue diagnosis were enrolled in the study and relevant clinical data were collected from the medical record using a proforma. DESIGN: Hospital-based retrospective study. RESULTS: Out of the 71 cases of primary lung cancer reviewed, 44(62%) were males and the male to female ratio was 2:1. The mean age was 62±14 years and the occurrence was highest in aged 50-69 years. Thirty (42.3%) with histories of tobacco smoking were males. Adenocarcinoma accounted for 34(54.9%), 23(32.4%) were squamous cell carcinoma, 2(2.8%) were large cell carcinoma and 6(8.5%) were other histological variants. The majority (82.7%) presented at stage III-IV lung cancers, 56.3% had malignant pleural effusion and 74.6% received palliative care. Thirty-eight (53.3%) had chest tube drainage, 19(26.7%) underwent chemical pleurodesis and 22(31.0%) received Cisplatin-based systemic chemotherapy. One patient had curative surgery and none received radiotherapy. At 12 months, 4 (5.6%) were still alive, 14(19.7%) cases had medical records of their death and 53(74.7%) were lost to follow up. CONCLUSION: This study has highlighted the clinicopathological trend, high rate of mortality and late presentation of lung cancer in our setting. There is a need to increase the awareness of the warning signs and risk factors to ensure early detection and facilitate curative therapy.

CONTEXTE: L'incidence du cancer du poumon et les taux de mortalité ont augmenté dans certains pays à faibles et moyennes ressources. OBJECTIFS: Cette étude visait à décrire le modèle clinicopathologique et la prise en charge du cancer du poumon observé dans notre milieu. MÉTHODES: Nous avons passé en revue les cas de néoplasme pulmonaire diagnostiqués et pris en charge à l'hôpital universitaire de l'Université d'Ilorin pendant huit ans. Les cas avec diagnostic tissulaire ont été inclus dans l'étude et les données cliniques pertinentes ont été collectées à partir du dossier médical à l'aide d'un formulaire. CONCEPTION: étude rétrospective en milieu hospitalier. RÉSULTATS: Sur les 71 cas de cancer du poumon primitif examinés, 44 (62%) étaient des hommes et le ratio homme / femme était de 2:1. L'âge moyen était de 62 ± 14 ans et la fréquence était la plus élevée chez les 50 à 69 ans. Trente (42,3%) ayant des antécédents de tabagisme étaient des hommes. L'adénocarcinome représentait 34 (54,9%), 23 (32,4%) étaient des carcinomes épidermoïdes, 2 (2,8%) étaient des carcinomes à grandes cellules et 6 (8,5%) étaient d'autres variantes histologiques. La majorité (82,7%) des cancers du poumon de stade III-IV, 56,3% ont eu un épanchement pleural malin et 74,6% ont reçu des soins palliatifs. Trente-huit (53,3%) ont eu un drainage par sonde thoracique, 19 (26,7%) ont subi une pleurodèse chimique et 22 (31,0%) ont reçu une chimiothérapie systémique à base de cisplatine. Un patient a subi une chirurgie curative et aucun n'a reçu de radiothérapie. À 12 mois, 4 (5,6%) étaient encore en vie, 14 (19,7%) cas avaient un médical de leur décès et 53 (74,7%) étaient perdus de vue. CONCLUSION: Cette étude a mis en évidence la tendance clinicopathologique, le taux élevé de mortalité, et la présentation tardive du cancer du poumon dans notre milieu. Il est nécessaire d'accroître la sensibilisation aux signes avant-coureurs et aux facteurs de risque pour assurer une détection précoce et faciliter la thérapie curative. MOTS CLÉS: Clinico-pathologique, modèle, prise en charge, cancer du poumon, néoplasme, Nigéria.

Thoracic endometriosis syndrome at University of Ilorin Teaching Hospital.

BACKGROUND: Endometriosis is defined as the presence of endometrial tissue (stroma and functional glands) outside the uterine cavity in women of reproductive age. Ectopic sites are frequently located in the pelvis; extrapelvic sites have been reported in the gastrointestinal tract and thoracic cavity. Thoracic manifestation of endometriosis constitutes thoracic endometriosis syndrome (TES). OBJECTIVES: To examine the presentation pattern and outcome of in the management of TES. METHODS: This study is a retrospective review of medical records of patients diagnosed with endometriosis at the University of Ilorin Teaching Hospital over a 3.5-year period from January 2014 to June 2017. RESULTS: A total of 21 patients presented with endometriosis, of whom 8 (38.1%) presented with TES. The most common variety of TES was catamenial pleural effusion (CPE) accounting for 75%, followed by catamenial chest pain (37.5%). Two patients (25%) each presented with catamenial pneumothorax and catamenial haemoptysis, while 1 (12.5%) had catamenial surgical emphysema. Closed thoracostomy tube drainage plus chemical pleurodesis was the most frequent intervention technique, accounting for 62.5%. CONCLUSION: TES remains an uncommon entity, despite being the most common extrapelvic manifestation of endometriosis. CPE appeared to be the most common variant of TES in our environment. Currently available treatment options need to be improved, and more use made of video-assisted thoracoscopic surgery.

Relationship between Age; Radiographic Normal Heart Size and Cardio-Thoracic Ratio in a Nigerian Population

Background: Cardio-vascular disease (CVD) is now on the increase. The precise diagnosis of CVD is of immense clinical importance to the cardiac surgeons; pathologist and also for cardiologists. However; information on normal values for various cardio-vascular structures in Nigeria; a country with the highest population of blacks in the world is sparse. In this regard the age-related radiographic sizes of a Nigerian cohort of patients with non-cardiogenic complaints or consultations were therefore assessed.Objectives: To evaluate the limits of normal cardiac size in our environment ; determine if there was a relationship between the age and size of the heart and to evaluate the relationship between sex and cardiac size and cardio-thoracic ratio.Design: A cross-sectional study.Setting: The Radiology department of University of Ilorin Teaching Hospital; Ilorin; North Central Nigeria between January to June 2012.Subjects: One Hundred patients were consecutively recruited and their chest radiographs examined after fulfilling the inclusion criteria.Results: Males accounted for 55% of the study population. The age range was 1 month to 73 years; (Mean = 29.3; SD =2.41668). The mean cardiac size was 11.7cm. The average cardiac size for adult males and females; were 11.6cm and 11.5cm respectively while that of thoracic size was 29.0cm and 26.8cm respectively. Correlation between age and cardiac size was 0.66; age and thoracic size was 0.64 and between cardiac size and thoracic size was 0.89. The paired sample t-test for age and cardiac size was less than 0.05 (p value 0.05).Conclusion: knowing the average values of cardiac size for adult males and females (11.6cm and 11.5cm) and thoracic size (29.0cm and 26.8cm) respectively from this study presents a base line for early detection of variation from normal cardiac measurements in this environment

Neck trauma: a red-herring to diagnosis of chemodectoma.

Chemodectoma, a neuroendocrine tumour of the paraganglionic cells in the carotid body remains an uncommon tumour. We report the first case from University of Ilorin Teaching Hospital, Ilorin, Nigeria. Though with a red herring history of trauma induced swelling, clinical and radiologic features were characteristic of chemodectoma. Histologic features of the excised lesion are presented.

CT-guided percutaneous transthoracic lung biopsy: first experience in Ibadan, Nigeria.

Percutaneous lung biopsy had been described in the nineteenth century by Leyden, but image- guided needle chest biopsy only gained widespread acceptance in the 1970s. Currently, tissue sampling of a thoracic lesion is indicated when the diagnosis cannot be obtained by the non-invasive techniques and cytological diagnosis will modify the stage of the disease or influence the therapeutic strategy. Cytology obtained by small-gauge needle aspiration biopsy confirms the nature of the lesion in 80 - 95% of cases and carry a low incidence of major complications. The purpose of this report was to provide information on our first experience with CT-guided biopsy and show that with some innovativeness much can be achieve with limited resources and good team work. We performed a CT of the thorax using appropriately placed improvised metal markers, which determined the optimal cutaneous entry point. We then re-checked the location of the lesion scanning intermittently at 5mm slice thickness; we marked the entry point with a pen and cleaned the surface with methylated spirit. A local anaesthetic was subcutaneously injected around marked area. We used a 21G aspiration needle to obtain cytology sample then 18G Trucut biopsy needle to obtain histology specimen. The length of the needle was chosen based on predetermined distance of the target lesion from the skin estimated from the CT images. Our patient was a 51-year-old Nigerian female with a peripherally located nodule in the posterior aspect of the right lung. She had CT-guided biopsy of the nodule. The procedure was well tolerated with no complication of pneumothorax. The histology report provided the basis for treatment regimen. Our experience indicates that percutaneous transthoracic CT-guided needle biopsy is feasible and a safe procedure in our hospital for evaluation of undetermined lung lesions.

CIVILIAN VASCULAR INJURIES IN AN URBAN AFRICAN REFERRAL INSTITUTION.

OJECTIVE: To evaluate the pattern of civilian vascular injuries, demonstrate any change in pattern and document management challenges in a resource challenged environment. DESIGN: A retrospective study. SETTING: The division of Thoracic and Cardiovascular Surgery of University College Hospital a major referral centre, not only for south-west Nigeria but for the whole country. SUBJECTS: All patients presenting with vascular injury through the division during the study period were recruited. There were no exclusion criteria. RESULTS: Males accounted for 85% of the study group. Mean age was 31.98 years (± 14.94 S.D.) with peak in 20-29 years group (28.3%). Stab and gunshot injury were responsible in 36.7% and 30% respectively. Upper limb vessels were involved in 58.3%. Delayed presentation (> 4 hrs postinjury) occurred in 58.3% and presentation-operation interval was four to six hours in 55% of cases. Specific diagnostic investigation was required in only 20%. Morbidity, amputation and mortality rates were 10.1, 3 and 6.7% respectively. CONCLUSION: Penetrating vascular injuries are on the increase amongst civilian population. Poor transportation and lack of organised referral system contribute to delay in surgical intervention. Prompt evaluation for hard signs of vascular injury is of immense value in deciding for surgery in our environment where patients have financial challenges and resources are limited.

Presentation pattern and management of effusive-constrictive pericarditis in Ibadan.

BACKGROUND: Effusive-constrictive pericarditis is a syndrome in which constriction by the visceral pericardium occurs in the presence of a dense effusion in a free pericardial space. Treatment of this disease is problematic because pericardiocentesis does not relieve the impaired filling of the heart and surgical removal of the visceral pericardium is challenging. We sought to provide further information by addressing the evolution and clinico-pathological pattern, and optimal surgical management of this disease. METHODS: We conducted a prospective review of a consecutive series of five patients managed in the cardiothoracic surgery unit of University College Hospital, Ibadan, in the previous year, along with a general overview of other cases managed over a seven-year period. This was followed by an extensive literature review with a special focus on Africa. RESULTS: The diagnosis of effusive-constrictive pericarditis was established on the basis of clinical findings of features of pericardial disease with evidence of pericardial effusion, and echocardiographic finding of constrictive physiology with or without radiological evidence of pericardial calcification. A review of our surgical records over the previous seven years revealed a prevalence of 13% among patients with pericardial disease of any type (11/86), 22% of patients presenting with effusive pericardial disease (11/50) and 35% who had had pericardiectomy for constrictive pericarditis (11/31). All five cases in this series were confirmed by a clinical scenario of non-resolving cardiac impairment despite adequate open pericardial drainage. They all improved following pericardiectomy. CONCLUSION: Effusive-constrictive pericarditis as a subset of pericardial disease deserves closer study and individualisation of treatment. Evaluating patients suspected of having the disease affords clinicians the opportunity to integrate clinical features and non-invasive investigations with or without findings at pericardiostomy, to derive a management plan tailored to each patient. The limited number of patients in this series called for caution in generalisation. Hence our aim was to increase the sensitivity of others to issues raised and help spur on further collaborative studies to lay down guidelines with an African perspective.

Pattern of congenital heart disease in Ilorin, Nigeria.

AIMS AND OBJECTIVES: This study aimed at determining the frequencies and pattern of congenital heart lesions among patients who had echocardiographic scan for various cardiovascular-related complaints at the University of Ilorin Teaching Hospital, Nigeria. PATIENTS AND METHODS: All patients referred for echocardiography between May 2004 and April 2007 for various cardiovascular complaints were reviewed. Patients diagnosed with congenital heart disease were selected and analysed for frequencies of lesions, sex ratio and mean age. RESULTS: Seventy-six patients with a diagnosis of congenital heart disease were reviewed. Ventricular septal defect was the commonest lesion; seen in 27.6% of patients followed by atrial septal defect (21.1%), patent ductus arteriosus (13.1%) and tetralogy of Fallot (11.8%). Others were dextrocardia with situs inversus (6.6%) and bicuspid aortic valve (2.6%). CONCLUSION: The distribution of congenital heart lesions is similar to that reported from other parts of the world except for higher frequency of atrial septal defect and lower incidence of bicuspid aortic valve. There has been an improvement in diagnosis of CHD in the middle belt of Nigeria due to availability of echocardiographic imaging facility even though most patients have no access to surgical correction.

Peripheral vascular surgical procedures in Ilorin, Nigeria: indications and outcome.

BACKGROUND: Data on peripheral vascular surgical interventions from Nigeria is scanty. Reports form Western and Eastern Nigeria dates back about two decades. This study therefore analyses the various etiological conditions necessitating intervention, and their outcome. METHODS: A retrospective analysis of patients requiring surgical intervention on peripheral vessels from a prospectively collected single surgeon database over a two-year period was conducted. Data were analysed using SPSS version 15.0 windows statistical package. RESULTS: Fourteen peripheral vascular surgical procedures were performed. The age range was 2-70 years (24.4 ± 16.3) with five cases (35.7%) in 20-29 year group. Trauma accounted for 11 (73.3%) cases. Upper limb involvement occurred in 7 (63.6%) of the traumatic cases whereas all 2 true aneurysm occurred in the lower limb. Direct repair was possible in re-establishing anatomic continuity in about 64% of cases. Of the six morbidities, wound infection accounted for 50% followed by failure of re-vascularizaton (33.3%) and there was one mortality. CONCLUSION: Trauma is the leading cause of peripheral vascular condition necessitating surgery from our study. Young adults predominate. Though direct repair are often feasible, there is a need for the availability of graft options. Wound infection constitutes the highest post-operative morbidity.

Influence of performance status on the risk and outcome of nosocomial pneumonia in the elderly admitted to an open medical ward.

BACKGROUND: nosocomial pneumonia (NP) has been observed to complicate the course of management of some elderly patients in medical wards and this impacts negatively on the outcome of care of this group of patients. OBJECTIVE: to determine the relationship of pre-treatment performance status (PTPS) on the risk and outcome of NP in elderly patients admitted to an open medical ward. METHODS: a prospective clinical surveillance of all elderly patients admitted to the medical wards of a University Teaching Hospital was carried out over a period of nine years. RESULTS: in the nine-year period 531 patients; aged 65 to 107 years were seen, 184(34.7%) of whom developed NP. Eleven (21%) patients had PTPS of 75% or more (i.e. able to care for selves without assistance), one (0.2%) of whom developed NP. Seventy-eight (14.7%) patients had PTPS of 51-74% (i.e. required occasional assistance for routine care); 13(2.4%) of whom also developed NP. Of the 217 (40.9%) patients who had PTPS of 26-50% (i.e. requiring considerable assistance for self care), 73(13.7%) of them had NP while 97 (18.3%) out of 225 patients with PTPS below 25% (i.e. completely dependent on others for routine care) developed nosocomial pneumonia. CONCLUSION: a low performance status score increases the risk of development of NP in the elderly and this risk is influenced by type of treatment-related interventions a patient has on admission.

Genital self-mutilation.

We present a case report of a 22-year-old Nigerian student who presented to the accident and emergency unit of a Nigerian Teaching Hospital with a history of self-inflicted genital injury following a suicide attempt. He had background history of predisposition to depressive illness, a current diagnosis of a major depressive disorder, and had had two attempted suicidal episodes in the last 3 months prior to this event. The clinical finding shows a patient with sad affect, feeling of hopelessness, and worthlessness; however, the vital signs remained fairly stable. At examination under anesthesia, the testes were exposed and the right already self-castrated. The penis was degloved to the level of the Buck's fascia with intact corpora cavernosa and urethra. He had surgical excision of the hanging self-castrated right testis with debridement and primary closure of the genital laceration. He was promptly reviewed by the psychiatrists who co-managed appropriately.

Early experience with outpatient tube drainage for management of pleural collections

BACKGROUND: Increasing cases of pleural effusion leads to pressure on bed spaces and a stretch of the limited facilities available for intervention in our centre. This therefore prompted a search for acceptable alternative way of treatment. OBJECTIVE: To evaluate the use of ambulatory drainage system for chronic infectious and malignant pleural effusion on outpatient basis. METHODS: Eight of 113 routinely performed closed tube thoracostomies drainage were converted to ambulatory drainage system at the time of patients' discharge to follow-up clinic. This was after the catheter care had been thoroughly explained to the patients and their relatives. RESULTS: Eight patients (seven males and one female) had ambulatory outpatient tube management. Their mean age was 44.9 ± 18years with a range of 22­70 years. Histologically confirmed causes of the effusion were; metastatic adenocarcinoma in two(25%) of the cases; chronic non-specific inflammation in another two(25%) and tuberculous empyema thoracis in three(37.5%) one of whom had TB/HIV co-infection and one(12.5%) of chronic bacterial parapneumonic empyema. One case each of metastatic adenocarcinoma and chronic nonspecific suppuration had failed chemical pleurodesis before the outpatient drainage procedure. Half of the cases (including tuberculous and non-tuberculous) were successfully weaned off their catheters. Minor complications such as pain, discomfort, minimal stoma bleeding, and peri-catheter leak were recorded. Rapid fluid re-accumulation prevented weaning in two (25%) of the cases. CONCLUSION: Out-patient chest tube drainage is effective for the management of both malignant and suppurative pleural effusion. This approach would reduce the ever increasing cost of hospital care for this group of patients. WAJM 2009; 28(6): 364­367

Early experience with outpatient tube drainage for management of pleural collections.

BACKGROUND: Increasing cases of pleural effusion leads to pressure on bed spaces and a stretch of the limited facilities available for intervention in our centre. This therefore prompted a search for acceptable alternative way of treatment. OBJECTIVE: To evaluate the use of ambulatory drainage system for chronic infectious and malignant pleural effusion on outpatient basis. METHODS: Eight of 113 routinely performed closed tube thoracostomies drainage were converted to ambulatory drainage system at the time of patients discharge to follow-up clinic. This was after the catheter care had been thoroughly explained to the patients and their relatives. RESULTS: Eight patients (seven males and one female) had ambulatory outpatient tube management. Their mean age was 44.9 (18) years with a range of 22 to 70 years. Histologically confirmed causes of the effusion were; metastatic adenocarcinoma in two(25%) of the cases; chronic nonspecific inflammation in another two(25%) and tuberculous empyema thoracis in three(37.5%) one of whom had TB and HIV coinfection and one(12.5%) of chronic bacterial parapneumonic empyema. One case each of metastatic adenocarcinoma and chronic non-specific suppuration had failed chemical pleurodesis before the outpatient drainage procedure. Half of the cases (including tuberculous and non-tuberculous) were successfully weaned off their catheters. Minor complications such as pain, discomfort, minimal stoma bleeding, and peri-catheter leak were recorded. Rapid fluid re-accumulation prevented weaning in two (25%) of the cases. CONCLUSION: Out-patient chest tube drainage is effective for the management of both malignant and suppurative pleural effusion. This approach would reduce the ever increasing cost of hospital care for this group of patients.