Early-onset sensorineural hearing loss in Lassa fever.

Lassa fever (LF) is a viral hemorrhagic disease which affects one-fourth to two million people annually with the fatality rate of about 10,000. It is associated with sensorineural hearing loss (SNHL) usually at the convalescent stage. Recently, cases of SNHL at the acute phase have been reported. This study was done to further investigate the incidence and features of SNHL in acute phase of LF. It is a prospective case-control study of LF patients seen with acute SNHL conducted between July 2007 and April 2009 at Irrua Specialist Teaching Hospital Nigeria. The diagnosis of acute LF was based on the clinical features and detection of IgM antibodies and/or positive Lassa virus-specific reverse transcriptase-polymerase chain reaction using primers S36+ and LVS 339 while SNHL was diagnosed clinically and confirmed with PTA and speech discrimination tests. Patients with other acute febrile illnesses were used as control. Statistical analysis was done using SPSS version 11 and Fisher's exact test while level of significance was set at p < 0.05. Out of the 37 confirmed cases of LF, 5 (13.5%) and none (0%) of the control developed early-onset SNHL (p = 0.03). Forty percent of the cases studied had negative IgM. The audiograms showed involvement at all frequency groups with pure tone average 65-85 dB and the speech discrimination 20-40%. The overall case fatality rate was 27.0%, and for early SNHL cases 60.0% (p > 0.05). The incidence of SNHL in LF infection is about 13.5% and could be a reflection of a worse disease process. There is possibility of direct viral invasion aside immunological reaction as a causative mechanism.

Pattern and outcome of congenital malformations in newborn babies in a Nigerian teaching hospital.

BACKGROUND: Several types of congenital malformations have been seen in our settings, but the frequencies and pattern are not known. OBJECTIVES: To review the prevalence and pattern of congenital malformation in the Special Care Baby Unit (SCBU) of the University of Maiduguri Teaching Hospital, Maiduguri, over a 10-year period. METHODS: This was a retrospective study carried out in a semi-urban Nigerian Teaching Hospital. All admissions into SCBU from 1991 to 2000 were reviewed, using both the admission and discharge records. The information extracted from the case note of each patient included sex, age and weight on presentation, maternal age and parity, gestational age, presence of associated neonatal illnesses such as jaundice, sepsis and the type of malformation on physical examination only. RESULTS: Three hundred and ten (13.9%) of 2233 admissions had major congenital malformation. Thirty one (10%) gave a history of antenatal care while 279(90%) had no record of receiving antenatal care. Of the 310 babies, 140 (45.2%) abnormalities were of the gastro-intestinal system and 75 (24.2%) of central nervous system. Anterior abdominal wall defect 77(24.8%) was the commonest type of malformation seen followed by neural tube defect 63(20.3%) and imperforate anus 31(10.0%). Gastro-intestinal malformations were associated with a mortality rate of 60.9% as compared with 21.1% in those with central nervous system malformations. CONCLUSION: The high prevalence of malformation seen in this study could be associated with the fact that majority (75.4%) of the mothers delivered their babies outside the teaching hospital, whose antenatal care are unknown. The occurrence of congenital malformations is very high in North Eastern Nigeria, Environmental factors may have a role.

Prevalence and antimicrobial sensitivity pattern in urinary tract infection in febrile under-5s at a children's emergency unit in Nigeria.

The prevalence of urinary tract infection (UTI) in 300 consecutively admitted, febrile, preschool children with and without a focus of infection was evaluated to determine the contribution of UTI to febrile illnesses. Uncentrifuged urine was evaluated by culture and microscopy. The prevalence of UTI was 9% and was significantly higher in girls than in boys. It was also significantly higher when urine infection had been clinically suspected than in those with other diagnoses. Temperature >41 degrees C and abdominal pain were significantly associated with UTI. Other features significantly associated with UTI were fever of at least 7 days duration, a peak evaluation temperature >or=38.3 degrees C and a white blood cell count >10/mm(3). Escherichia coli, Klebsiella pneumonia and Staphylococcus aureus were the only organisms isolated and they all showed high in vitro sensitivity to clavulanic acid-potentiated amoxycillin, gentamicin and ceftriaxone but were poorly sensitive to co-trimoxazole.

Perception of voluntary screening for paediatric HIV and response to post-test counselling by Nigerian parents.

Nigeria may be taken to represent countries with an evolving HIV/AIDS epidemic. With particular reference to paediatric HIV, the voluntary testing of young children and their parents may provide an important entry point for the institution of control measures. However, there is a paucity of knowledge about how individuals perceive voluntary testing. This knowledge is important to the development of guidelines for counselling. To reduce this gap, 258 parents of hospitalized children (> 1 month to 15 years of age) were interviewed using a structured questionnaire. In addition, to complement the data, four examples of seropositive mother's responses during post-test counselling are presented and analyzed. In the survey, 223 (86%) parents were HIV/AIDS aware but only 88 (39%) of these parents could describe one or more route(s) of transmission and none described vertical transmission. Among the respondents, 153 (62%) of 248 would consent to the screening of self, and 195 (85%) of 230 to the screening of a hospitalized child if based on his/her clinical condition. Perceptions of good health and lack of exposure, and despair owing to lack of a specific treatment, were the common reasons for refusing consent. These represent some of the issues which would need to be addressed to increase the acceptance of voluntary testing. The fear of a break up of families with seropositive mothers but seronegative fathers was a major concern expressed during post-test counselling. HIV-discordance among couples may be frequent and should be considered in the formulation of policies on counselling and voluntary testing.

Perceptions of and management practices for Diarrhoeal Diseases by traditional healers in northeastern Nigeria.

In Nigeria, there is a paucity of data on the beliefs and practices of traditional healers concerning diarrhoeal diseases. This study was undertaken to provide baseline data for integrating activities of traditional healers into the national Control of Diarrhoeal Diseases (CDD) programme. Interviews of 14 traditional healers, drawn from two large ethnic groups in northeastern Nigeria, were conducted. All but one of them willingly discussed their beliefs and practices. Almost all traditional healers used herbs expecting that it would stop diarrhoea episode. Most traditional healers (n = 11) were, however, aware of the sugar-salt solution (SSS), and six of them had positive impression about it. Ten were willing to be further trained in the preparation/use of SSS, and five reported its past use. Some healers strongly believed that breast-feeding was an important cause of diarrhoea and that, in some cases, diarrhoea was only amenable to traditional treatment. The results of this study suggest that the traditional healers in the region may contribute to promoting the appropriate home management of diarrhoea. However, their perceptions and practices need to be upgraded to ensure success.

Management of children with prolonged fever of unknown origin and difficulties in the management of fever of unknown origin in children in developing countries.

This is Part II of a 2-part paper on fever of unknown origin (FUO) in children. It examines the aetiology and management of prolonged FUO in children and the difficulties in the management of FUO in children in developing countries. Part I of this paper discussed acute FUO in children and was published in the March 2001 issue of Paediatric Drugs. Prolonged FUO is documented fever of more than 7 to 10 days which has no apparent source and no apparent diagnosis after 1 week of clinical investigations. About 34% of cases of prolonged FUO are caused by infections, with bacterial meningitis and urinary tract infection accounting for about 6.5 and 11.4%, respectively, of cases attributable to infections. Chronic infections, particularly tuberculosis and 'old' disorders such as Kawasaki disease, cat-scratch disease and Epstein-Barr virus infection presenting with 'new' manifestations, collagen-vascular diseases and neoplastic disorders are the other issues of major concern in prolonged FUO. Overall, however, there is a trend towards an increased number of undiagnosed cases. This is due to advancements in diagnostic techniques, such that illnesses which were previously common among the causes of prolonged FUO are now diagnosed earlier, before the presentation becomes that of prolonged FUO. Clinical examination supplemented with laboratory tests to screen for serious bacterial infections should be the mainstay of initial evaluation of children with prolonged FUO. Use of scanning techniques (such as computerised tomography and ultrasound) as additional supplements to this clinical examination may allow for the earlier diagnosis of causes of prolonged FUO in children such as 'occult' abdominal tumours. A common error in management of children with prolonged FUO is the failure to perform a complete history and physical examination; repeated clinical examination and continued observation are of paramount importance in the diagnosis of difficult cases. Major difficulties in the management of FUO in children in developing countries include constraints in the availability and reliability of laboratory tests, cost, misuse of antibiotics and difficulties encountered in the diagnosis of malaria and typhoid fever. Malaria and typhoid fever are major aetiological considerations in both acute and prolonged FUO in children in developing countries. The newer quinolones may hold great promise for the treatment of serious bacterial infections, including meningitis, which are associated with prolonged FUO in developing countries.

Aetiology and management of children with acute fever of unknown origin.

This is part I of a 2-part paper on fever of unknown origin (FUO) in children. FUO is best defined as fever without obvious source on initial clinical examination and then classified into acute (illness of < or =1 week's duration) and prolonged (>7 to 10 days' duration). Aetiologically, there is a marked overlap between acute and prolonged FUO, and infections are major players in both. Age, climate, local epidemiology and host factors are the major aetiological factors that should be considered in the choice of definitive tests. Depending on age, serious bacterial infections (including bacteraemia, meningitis and urinary tract infection) occur in 3 to 20% of cases of acute FUO. Prevention of mortality and sequelae from these infections, particularly bacteraemia and meningitis, is of particular concern in acute FUO. An individualised approach, based on clinical evaluation supplemented with screening and definitive laboratory tests to determine the need for empiric antibiotic therapy and hospitalisation, seems to be the best approach to acute FUO (although this may be less applicable to neonates and infants younger than 90 days, particularly those aged 0 to 7 days). The place of laboratory tests, empiric antibiotic therapy and hospitalisation are important issues that are likely to remain so for some time.

Nutritional rickets in young Nigerian children in the Sahel savanna.

OBJECTIVES: To determine the prevalence of clinical and biochemical rickets in an under-five out-patient population, relate the prevalence of biochemical rickets (BR) to the sociocultural characteristics of families and determine the response of nutritional rickets to vitamin D therapy. DESIGN: Prospective cross-sectional and retrospective case-series surveys. SETTING: Paediatric general out-patient and consultant clinics. SUBJECTS: One hundred and ninety eight out-patients and twenty two patients aged >1 to 60 months treated for nutritional rickets. INTERVENTIONS: Clinical examination, interview with mothers and determination of biochemical abnormalities of under-fives and management of patients with rickets using stosstherapy. MAIN OUTCOME MEASURES: Prevalence of BR and response to stosstherapy. RESULTS: Eight (4%) patients in the survey had clinical and biochemical rickets while 33 (17%) had biochemical rickets only; 92 (47%) other patients had isolated hypocalcaemia and/or hypophosphataemia. The prevalence of BR was higher in males (p <0.05), and increased with age (p <0.001). The prevalence was lower in families who were indigenous to the area (p <0.05), children of Moslem families (p <0.05) and children whose mothers were full-time housewives, unskilled or traders (p <0.01), and who lacked any formal western education (p = 0.157). Three of the seven evaluable patients who received stosstherapy responded late. CONCLUSION: The results support the hypothesis that deficiency or reduced availability of dietary calcium may be of at least equal importance with vitamin D deficiency in the aetiology of nutritional rickets in the Sahel savanna.

Preliminary assessment of the efficacy of mefloquine/-sulphadoxine/ pyrimethamine combination in the treatment of uncomplicated malaria in children in North Eastern Nigeria.

Preliminary assessment of efficacy of mefloquine/-sulphadoxine/pyrimethamine (MSP) combination in the treatment of uncomplicated Plasmodium infections was conducted in-vivo in non-immune and semi-immune children in Damboa, in the North east of Nigeria using a 7-day protocol. Six hundred and forty-six (76.4%) subjects out of 846 screened had positive Plasmodium infections. Seventy-two patients aged 6 months to 11 years were enrolled, of whom 69 (95.8%) completed the study. MSP demonstrated high clinical efficacy, producing 100% cure rate against pure P. falciparum (77.8%), pure P. malariae (18.1%) and mixed P. falciparum and P. malariae (4.2%) infections. GMPDs for P. falciparum, P. malariae and mixed infections were 4,826, 3,680 and 12,573 a sexual stages per microl of whole blood. The mean parasite clearance time (MPCT) was 4.42 days for pure P. falciparum parasitaemia and 4.82 days for P. malariae alone. No parasitologic failure occurred in the patients. Clinical response occurred rapidly; all fever cases cleared within 24 hours. Moreover, significant (P<0.05) PCV improvement occurred in 7 days from an average of 33.8 +/- 4.5% on D0 to 35.5 +/- 3.5% on D7. Besides, this drug was well tolerated by majority of patients. Details of these findings are presented and discussed against the background of increased efforts towards effective malaria treatment and control in Nigeria.

Cerebral herniation in pyogenic meningitis: prevalence and related dilemmas in emergency room populations in developing countries.

This study aimed to determine the frequency and outcome of possible cerebral herniation in relation to lumbar puncture (LP) in postneonatal infants and children with pyogenic meningitis in the tropics. Children with meningitis aged between 6 weeks and 15 years (mean age 4.07 years; n=123) were recruited consecutively over 3 1/2 years at the University of Maiduguri Teaching Hospital, Nigeria. The frequency of possible herniation was determined by clinical evaluation in relation to the severity of illness (high versus low risk) on presentation and performance of LP. Previously described scoring schemes were used. Eighteen (15%) patients had evidence of herniation on presentation. The relative risk (RR) of herniation in high- versus low-risk patients was 66.6 (9.3 to 477.1, 95% CI),p<0.0001 while the RR of death or neurological sequelae in high- versus low-risk patients was 2.6 (1.8 to 3.7, 95% CI),p<0.0001. In 99 patients with known outcomes who had LP on presentation, 21 of 81 without herniation pre- or post-LP, four of four with herniation pre- and post-LP, seven of eight with herniation post-LP only, and five of six with herniation pre-LP only died or recovered with sequelae (chi2 = 25.24, df = 3, p<0.0001). It is concluded that outcome depends on the severity of illness and the presence and timing of herniation. A policy of selective rather routine LPs may improve the outcome in meningitis in developing countries.

Response to antimicrobial therapy in childhood bacterial meningitis in tropical Africa: report of a bi-centre experience in Nigeria, 1993-1998.

Recent reports of a high prevalence of in-vitro resistance to chloramphenicol (CHL) and penicillin (PEN)/ampicillin (AMP) cause concern because of cost implications in using the newer cephalosporins (CEPH) to treat meningitis in resource-poor countries. However, the clinical significance of many of the observations is uncertain because of limited back-up by clinical data. We analysed the response in an open study of 161 patients with bacterial meningitis treated with CHL (n = 31), CHL plus PEN or AMP (n = 101), PEN or AMP (n = 14) and CEPH (n = 15). No significant differences were observed in clinical course and outcome in the four treatment groups, other than a higher prevalence of seizures after 72 h of treatment and a higher prevalence of neurological sequelae in survivors in the CEPH and CHL groups. This may reflect the higher number of infants and greater frequencies of uncommon aetiological agents in the CHL and CEPH groups. It is concluded that response to initial chloramphenicol-based treatment regimens remains satisfactory and that there is as yet no compelling reason to switch to the cephalosporins as first-line therapy for bacterial meningitis in developing countries.

Rickets and deprivation: a Nigerian study.

Under-fives in 461 households were assessed clinically to determine the prevalence of rickets in sub-urban and rural communities in the Sahel savanna. Overt rickets was found in 11 (2.4%) of households and abnormalities suggestive of rickets in 69 (14.9%). There were significant variations (p < 0.05) in the prevalence of rickets in association with ethnic grouping (higher in southerners and non-Kanuri, non-Hausa-Fulani northerners), religion (more prevalent among Christians), and mother's occupation and educational status (higher with working class mothers and mothers with at least a primary education). A significantly higher prevalence was also associated with late introduction (at more than seven months of age) of cereals to the infant's diet, more than one under-five in a household and presence of under-fives aged 13-43 months. In contrast, no significant variations in prevalence were observed in association with duration of breast feeding, use of multivitamins or cod liver oil, history of convulsions in under-fives, sex, nutritional status, or history of diarrhoea within a recall period of six months. Thus, rickets is common in under-fives in rural and sub-urban communities in the Sahel savanna and may be related more to environmental and dietary factors than to culture and religion. Further studies are required to determine the relative roles of vitamin D or calcium deficiency to facilitate the planning and execution of a community-based intervention programme in the area.

Risk factors for an adverse outcome in bacterial meningitis in the tropics: a reappraisal with focus on the significance and risk of seizures.

The relationship of presentation to outcome in children with meningitis was analysed. The relative risk (95% confidence interval) of an adverse outcome (death or neurological sequelae) associated with presentation with at least three of ten features (age < or = 2 yrs, ill for > 7 days, antibiotic treatment, focal nerve deficits, abnormal posturing, abnormal muscle tone, lack of typical meningeal signs, shock, unrousable coma and seizures) was 4.9 (2.7, 8.8), p < 0.0001. The first six features were particularly associated with neurological sequelae, and shock and coma with death. Seizures were associated with either outcome. Two seizure types could be distinguished: seizures which occurred before or on diagnosis only (type I seizures) and seizures which occurred before and/or after diagnosis (type II seizures). Death occurred in 0/41 children without seizures and in 14/34 and 11/34 children with type I and type II seizures, respectively (p < 0.0001). Neurological sequelae occurred in 3/42 children without seizures and in 5/20 and 14/23 with type I and type II seizures, respectively (p < 0.0001).

Oral rehydration at home--with a little help from friends.

A training workshop was organized for selected members of two village populations in north-eastern Nigeria, whereby they acquired knowledge and skills enabling them to spread the word and practice of oral rehydration therapy for children suffering from diarrhoea in their communities. The difficulties encountered and the gains achieved in this empowerment programme are described below.

Presentation and outcome of HIV-1 infection in hospitalised infants and other children in north-eastern Nigeria.

There is limited information on HIV infection in children in West Africa. This prospective case series study was done to determine the size of the problem and the feasibility of selective screening for infection based on clinical presentation. It involved infants and other children admitted to the Children's Emergency Ward and Paediatric Medical Ward of the University of Maiduguri Teaching Hospital, Nigeria, from the beginning of September 1992 to the end of September 1994. Clinical evaluation followed by serologic tests (ELISA and Western blot techniques) was undertaken. Descriptive study; frequencies were compared using chi 2 test for Fisher's exact test as appropriate. One hundred and ninety nine (10.9%) of 1,822 admissions were screened. One hundred and fifty eight (79.4%) were ELISA negative and 17 (8.6%) ELISA and WB positive; a further 10 (5%) were ELISA positive but WB indeterminate and 14 (7%) were ELISA positive but WB negative in 12 or untested in two. All the infections were HIV-1. Sixteen (39%) patients (nine WB positive, three WB indeterminate and four ELISA positive only) are dead, 14 from HIV-related illnesses, two (4.9]) are alive and 23 (56.1%) lost to follow up; 11 of the HIV-related deaths involved infants. Presence of persistent diarrhoea, prolonged fever, oral thrush, hepatosplenomegaly, diagnosis of tuberculosis and severe malnutrition with gastroentereritis, and multiple (> 3) diagnosis on admission were significantly (p < 0.05) associated with WB confirmed HIV-1 seropositivity and could serve as indicators for selective screening. HIV-1 infection in hospitalised infants and children has become an important problem in Nigeria, presentation in infancy is associated with a high case fatality rate, and the practice of selective screening based on clinical presentation would appear to be feasible.

Caretakers' knowledge and preparation abilities of salt-sugar solution in north-eastern Nigeria.

Awareness and knowledge of oral rehydration therapy (ORT) and preparation abilities of salt-sugar solution (SSS) were investigated by means of focus group discussions and complemented by a structured questionnaire survey of mothers in rural and urban areas of north-eastern Nigeria. ORT awareness was high with some intra-regional variations. Perception of ORT function was, however, grossly unrealistic, with a third to four-fifth of mothers expecting ORT to stop diarrhoea. At least one quarter of mothers lacked adequate SSS preparation abilities and the materials and ingredients required for its preparation. Re-evaluation of the content and method of imparting health education messages in ORT promotion is recommended. Such messages should emphasise the function of ORT. It is also recommended that standardised cups for water, salt and sugar measurements be provided to households as a ready means of ensuring the correct preparation of SSS in the home-based management of diarrhoea.

PIP: Public education campaigns in northeastern Nigeria have since 1986 promoted the awareness, preparation, and use of oral rehydration therapy (ORT) against diarrhea and the prevention of dehydration and related deaths. The awareness and knowledge of ORT and preparation abilities of sugar-salt solution (SSS) were investigated between March 1993 and April 1994 through focus group discussions and surveys of mothers in rural and urban areas of northeastern Nigeria. The Kanuris and Buras comprised the body of study respondents sampled in Bama, Hawul, and Maiduguri. 260 respondents from each ethnic group were interviewed. In the survey, 77% of the Kanuri mothers and 84% of the Bura mothers were aware of ORT/SSS; some intraregional variations were observed. 64% of Kanuri mothers and 29% of Bura mothers expected ORT to stop diarrhea. At least 25% of mothers were unable to properly prepare SSS and the materials and ingredients required for its preparation. These results point to the need to re-consider the content and method of disseminating health education messages in ORT promotion. Messages should stress the function of ORT. In addition, standardized cups for water, salt, and sugar measurements should be provided to households to ensure the correct preparation of SSS in the home-based management of diarrhea.

Paediatric and teenage gynaecological disorders in northern Nigeria.

A retrospective analysis of 206 paediatric and teenage gynaecological disorders seen at the University of Maiduguri Teaching Hospital from January 1984 to December 1993 is presented. The age range was from birth to 19 years, with 94% aged between 12 and 19 years. Abortions constituted the most common gynaecological disorder seen (37.4%), followed by traumatic injury to the genitalia (30.6%). Other frequently seen disorders included ovarian cysts (4.9%), cryptomenorrhoea (4.4%), labial agglutination (3%), ruptured ectopic pregnancy (3%) and hydatidiform mole (1.4%). Management was based on usual, standard gynaecological practice.

Gram negative bacillary meningitis in infants and children in developing countries.

Gram negative bacillary meningitis (GNBM) in postneonatal infants and children is two to three times more common in developed compared to developing countries. Other major differences are in the pattern of pathogens (mainly Klebsiella spp and Salmonella spp in developing versus E. coli in developed countries) and associated conditions (diarrhoeal diseases and malnutrition in developing versus neurosurgical and urinary tract abnormalities in developed countries). 12 (11.5%) of 104 cases of bacterial meningitis were due to GNB, including Klebsiella spp seven, E. coli, two and untyped Coliform spp, three; the age range of patients with GNBM was 3-24 months. Among seven completely evaluable patients, six presented after seven days of illness, five convulsed on or before admission, and six had accompanying respiratory or gastro-enteritic illnesses but none was severely malnourished or had associated neurosurgical or urinary tract abnormalities. Three patients died, three were discharged with sequelae and one without sequelae. The only significant difference between patients with GNBM and those with meningitis due to "usual" pathogens was the greater tendency to delayed presentation among the former (6/7 patients with GNBM versus 11/36 "usual" pathogens; p = 0.011); this was also the only striking difference in presentation when compared with patients from developed countries. The need for further studies, preferably multicentred, and for a revision of the traditional combination of gentamicin and ampicillin or chloramphenicol and ampicillin for the treatment of GNBM in developing countries is discussed.

Awareness claims versus actual knowledge of oral rehydration therapy and the salt sugar solution in northeastern Nigeria.

Focus group discussions involving rural and urban residents drawn from Kanuri and Bura settlements, were conducted as part of an on-going survey of the perception and treatment of diarrhoea among major ethnic groups in northeastern Nigeria. Awareness of oral rehydration therapy (ORT) was universal among participants, but knowledge of its function and the preparation of the sugar salt solution (SSS) was markedly deficient among the Kanuris, especially in rural areas. Reported SSS use parallel the knowledge of ORT function/SSS preparation and seemed heightened by church-fellowship activities among the rural Buras. Surprisingly, tasting was apparently not realised by participants to be an important step in SSS preparation. These preliminary results suggest that knowledge of ORT function and SSS preparation need further emphasis in ORT awareness campaigns, and that religion-based activities could be a potent and actualizable method of ORT promotion.