Reduced thyrotropin in euthyroid goitrous patients suggesting subclinical hyperthyroidism.

BACKGROUND: Subclinical hyperthyroidism, a biochemical finding of low serum thyrotropin (TSH) with the serum levels of thyroxine (T4) and triiodothyronine (T3) within the reference range, could easily be ignored by clinicians, as it, usually, does not manifest with any thyroid specific symptoms. It is of two types: endogenous and exogenous. However, patients with the findings of low TSH, normal T4 and T3 develop some abnormalities in the cardiovascular system, such as atrial fibrillation, increase in left ventricular mass and diastolic dysfunction. It is believed that treatment intervention may reduce or halt the progression of the cardiac abnormalities. The main objective of the study was to determine how frequent subclinical hyperthyroidism was occurs and to serve as a reminder to the existence of the disorder. METHODS: It was a hospital-based study carried out at the Jos University Teaching Hospital (JUTH). Consecutive clinically euthyroid goitre patients attending the outpatient department of JUTH, were studied for various parameters including TSH, T4 and T3 The serum concentrations of T4 and T3 were determined by enzyme-linked immunosorbent assay (ELISA) technique. The serum TSH concentration was estimated using a 2nd generation ELISA technique. RESULTS: 98 patients participated in the study. Nine patients had non-specific symptoms not referable to the thyroid and found to have high levels of thyroid hormone concentration with depressed TSH and were excluded from further analysis, while 7 had subclinical hyperthyroidism giving a prevalence rate of 7.9% among these clinical euthyroid goitre patients. The subjects with this condition were mainly above 60 years of age and mainly had long-standing goitre. CONCLUSION: Endogenous subclinical hyperthyroidism was present in 7.9% of these clinically euthyroid goitre patients mainly 60 years and above, with long-standing goitre. This high prevalence rate calls for high index of suspicion as this condition is associated with morbidities that can raise mortality.

Reduced Thyrotropin in Euthyroid Goitrous Patients Suggesting Subclinical Hyperthyroidism

B a c k g r o u n d : Subclinical hypertyhroidism; a biochemical finding of low serum thyrotropin (TSH) with the serum levels of thyroxine (T4 ) and triiodothyronine (T3) within the reference range; could easily be ignored by clinicians; as it; usually; does not manifest with any thyroid specific symptoms. It is of two types : endogenous and exogenous. However; patients with the findings of low TSH; normal T4 and T3 develop some abnormalities in the cardiovascular system; such as atrial fibrillation; increasein left ventricular mass and diastolic dysfunction. It is believed that treatment intervention may reduce or halt the progression of the cardiac abnormalities. The main objective of the study was to determine how frequent subclinical hyperthyroidism was occurs and to serve as a reminder to the existence of the disorder. Methods : It was a hospital-based study carried out at the Jos University Teaching Hospital (JUTH). Consecutive clinically euthyroid goitre patients attending the outpatient department of JUTH; were studied for various parameters including TSH; T4 and T3. The serum concentrations of T4 and T3 were determined by enzyme-linked immunosorbent assay (ELISA) technique. The serum TSH concentration was estimated using a 2nd generation ELISA technique. Results : 98 patients participated in the study. Nine patients had non-specific symptoms not referable to the thyroid and found to have high levels of thyroid hormone concentration with depressed TSH and were excluded from further analysis; while 7 had subclinical hyperthyroidism giving a prevalence rate of 7.9among these clinical euthyroid goitre patients. The subjects with this condition were mainly above 60 years of age and mainly had long-standing goitre. Conclusion: Endogenous subclinical hyperthyroidism was present in 7.9of these clinically euthyroid goitre patients mainly 60 years and above; with long - standing goitre. This high prevalence rate calls for high index of suspicion as this condition is associated with morbidities that can raise mortality

Lacidipine in the treatment of hypertension in black African people: antihypertensive, biochemical and haematological effects.

This is an open trial investigating the efficacy and metabolic effects of 3 months' treatment with lacidipine in 25 Nigerian Africans with mild to moderate hypertension. There was a significant fall in sitting diastolic blood pressure, with treatment (p = 0.01). There were no significant weight changes. The heart rate initially rose significantly with the drug but this normalised with time. All biochemical and haematological indices remained essentially unchanged during therapy. Lacidipine therefore proved an efficacious and metabolically neutral antihypertensive in mild to moderate hypertension in Africa.

Non-dilated cardiomyopathy in Nigerians evaluated by echocardiography.

Non-dilated cardiomyopathy (NDCM), a condition said to be uncommon, has been found to occur in 4.6% of cases undergoing echocardiography in our centre. Its echocardiographic features have been given (normal cavity dimensions, reduced contractility, thick walls) and clinical implications highlighted. Since it is not an entirely innocuous state, patients should, when discovered, be followed up closely. This would afford clinicians the opportunity to determine factors that lead to stability or deterioration of DCM.

The effect of lacidipine on patients with mild to moderate hypertension and the effect of a combination of lacidipine and hydrochlorothiazide in the treatment of hypertension uncontrolled after four weeks of lacidipine treatment: an open study.

In the treatment of hypertension, some patients may go off control while still on the drugs. This occurs especially with sympathetic inhibitors and vasodilators. Lacidipine, a new calcium antagonist acts principally by vasodilatation. After a wash out period, patients with mild to moderate hypertension received 4 mg of Lacidipine for two weeks. After evaluation at two weeks, those uncontrolled received 6 mg of Lacidipine, while those controlled continued with 4 mg of Lacidipine for another two weeks. By the next evaluation, while patients continued whatever doses they were on, any one who had gone off control had 25 mg of Hydrochlorothiazide added. They were evaluated finally after another two weeks. It was found in this study that 91.3% (21/23) were controlled by the end with only Lacidipine either in 4 mg or 6 mg doses. Another 8.7% (2/23) initially controlled on Lacidipine went off control while still on the drug, and were eventually controlled by adding Hydrochlorothiazide. Some transient side effects not warranting discontinuation were encountered. It is concluded that Lacidipine is effective as monotherapy in mildly to moderately hypertensive Nigerian Africans; with good tolerance and safety profile. Where transient control is encountered, addition of a diuretic could be beneficial.

Lysis of left ventricular thrombus with urokinase in a patient with alcohol heart disease.

A dilated cardiomyopathy patient whose congestive cardiac failure was made refractory to treatment by a left ventricular thrombus is reported. Thrombolectomy is usually the preferred therapeutic approach over anticoagulation and thrombolysis, as the latter approaches are said to carry the risk of stroke and haermorrhage. Facilities for thrombolectomy may not be available or affordable in our setting, and in some patients not practicable. Where 2-D echo facilities are available to indicate complete lysis, thrombolysis may be a way out.

The outcome of peripartum cardiac failure in Zaria, Nigeria.

We have studied 227 women who had peripartum cardiac failure (PPCF) in Zaria, Nigeria, since 1969-72. This follow-up and review of survivors in 1993-95 depended chiefly on a Zaria woman (A. Abdullahi) and on her careful reporting. Overall, 31 (13.7%) were completely lost to follow-up, 17 (7.5%) were thought to be alive, and there were data on 179 others (78.8%). Of the 75 known deaths, 55 were cardiovascular--20 due to PPCF, 31 due to cardiac failure unrelated to pregnancy (CF), and four were due to a cerebrovascular accident. PPCF recurred in 13% of 551 subsequent pregnancies. Thirty-two women had a recurrence of PPCF only, and 27 an episode of CF only. Blood pressures rose steadily over the years. An enlarged left ventricle on discharge after the index admission predicted a poor prognosis. In 1993-5, we compared 100 survivors with 100 non-PPCF controls: 96 PPCF women but only 50 control women took extra salt (p = 0.0001). Significantly more PPCF women than controls had a diastolic pressure of 110 mm Hg (p = 0.011). The syndrome is probably provoked in potentially hypertensive women by the traditional practices of eating kanwa, which is rich in Na+, taking additional excess salt and heating the body after delivery. Evidence is presented that PPCF women are potentially hypertensive, and cannot handle the excess ingested sodium which therefore leads to hypervolaemia and thus PPCF.

Hypertension and primary myocardial disease in congestive cardiac failure.

This study has tried to use end diastolic diameter the index of chamber dilatation to discriminate between hypertensive heart failure and diluted cardiomyopathy as both conditions are known to overlap in cases of congestive cardiac failure. The sensitivity, specificity and positive predictive value was 66.7%, 68% and 66.7% respectively. This means that alone, end diastolic diameter is not a very acute discriminator in cases where an overlap as shown in the figure occurs. It is therefore necessary to use all discriminatory indices in combination to get better accuracy.

Changes in urinary enzyme levels following the use of antihypertensive agents in patients with essential hypertension.

When choosing antihypertensive agents for the treatment of hypertension, it is necessary to consider the predisposition of individuals to renal damage, which may be associated with the long-term effect of such agents. In this respect, this study examined the effect of two commonly used antihypertensive drugs (Brinerdin and Minizide) on renal function over 24 months in patients diagnosed as having essential hypertension. We utilized urinary enzyme studies, which are indicators of subtle renal dysfunction. Other parameters of glomerular and tubular function were also determined in the pretreatment period, as well as during and at the end of treatment of 28 patients (16 males and 12 females) with therapeutic doses of Brinerdin and 22 patients (12 males and 10 females) with conventional doses of Minizide. During the follow-up period, blood pressure (BP) fell from a mean of 160/108 +/- 9/4 (SD) mmHg to 130/90 +/- 7/4 on Brinerdin and from a mean of 160/106 +/- 5/2 (SD) mmHg to 130/90 +/- 8/5 on Minizide. There was no significant difference in the levels of BP between the patients taking Minizide and those taking Brinerdin before, during, and at the end of treatment. Significant elevation (p < 0.05) of the levels of urinary protein, lactate dehydrogenase (LDH), and N-acetyl-B-D-glycosaminidase (NAG) was observed in patients on Minizide during treatment, and these levels remained elevated during the latter part of the study. Normotensive, untreated, age- and sex-matched control subjects showed no such urinary parameter changes.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of hypertension in dilated cardiomyopathy: an echocardiographic assessment

Follow-up and radiological studies have been carried out in the past speculating on the interlationship between hypertension and dilated cardiomyopathy; and what proportion of the later would be predominantly blamed on the former. Follow-up studies have the problem of time and drop-out rate to contend with; while radiological features pathognomonic of hypertension. A 2-D echocardiographic study of cases of biventricular failure due to hypertension and dilated cardiomyopathy (because at point of admission; no cause was evident) was undertaken to see what if any relationship exists. Certain echo indices were found to be indicative of significant hypertension in patients diagnosed as having biventricular failure due to dilated cardiomyopathy. Using this method it would be possible to tell the dilated cardiomyopathy patient who will benefit at onset from some form of antihypertensive therapy

Atrial natriuretic peptide, aldosterone, and plasma renin activity in peripartum heart failure.

Plasma concentrations of atrial natriuretic peptide and aldosterone and plasma renin activity were measured in patients with peripartum heart failure and in age matched healthy women post partum. Both groups had carried out traditional postpartum practices of salt consumption and body heating. Plasma concentrations (mean (SEM)) of atrial natriuretic peptide were significantly higher in the seven patients with peripartum heart failure (146.9 (24.3) pg/ml) than in the seven controls (4.4 (0.8) pg/ml). Both plasma aldosterone and plasma renin activity were suppressed in the patients with peripartum heart failure. After treatment for the heart failure plasma atrial natriuretic peptide fell considerably and there were associated increases in plasma aldosterone and plasma renin activity. The high plasma concentrations of atrial natriuretic peptide may have been a compensatory response to salt and water retention as well as to the heart failure. These high concentrations could also, in part, have suppressed the release of aldosterone and renin in an attempt to correct for volume overload.

Cerebrospinal fluid changes in tetanus: raised proteins and immunoglobulins in patients with severe disease.

34 patients with tetanus were studied; all had normal serum proteins and albumin. Only 3 samples of cerebrospinal fluid (CSF) contained cells (a few polymorphonuclear leucocytes). Protein levels in the CSF were elevated in 26 patients (76.5%); 11 cases with clinically mild tetanus had a mean CSF protein of 400 +/- 250 mg/litre (normal 100-400 mg/litre), while the CSF protein levels of 10 patients who died (mean 1596 +/- 985 mg/litre; P less than 0.005) and those of 4 others with severe disease who absconded were much higher (mean 1220 +/- 562 mg/litre; P less than 0.005). As a group, 19 patients with severe disease including the 10 fatal cases also had significantly higher mean CSF protein values (1582 +/- 938 mg/litre; P less than 0.005) than did the mild cases. Immunochemical analysis of the proteins using a radial immunodiffusion assay showed that these proteins were immunoglobulin G (IgG). Polyacrylamide gel electrophoresis demonstrated an oligoclonal gammaglobulin pattern, suggesting intrathecal IgG synthesis in these patients. These studies suggest that measurement of CSF proteins may supplement clinical evaluation in tetanus and that there may be a local immune stimulus (perhaps a tetanus antigen or to some other mitogen) in the central nervous system.

Peripartum cardiac failure. A ten year follow-up study.

A cohort of patients with peripartum cardiac failure (PPCF) was followed for 10 years after the initial illness. The follow up rate was 78%. Fifty two per cent of patients improved without further episodes of heart failure. PPCF recurred in 26 per cent. Heart failure unrelated to pregnancy was seen in 13%, and 9% of the patients progressed to dilated cardiomyopathy. Transient hypertension was seen in 87% of patients on admission, and later hypertension was found in 45%. Late hypertension influenced heart size more when recurrent PPCF or progressive heart failure was present. Anaemia on admission had no effect on subsequent heart size. The electrocardiogram may continue to be abnormal for up to 10 years in normotensive patients who had no heart failure. The abnormal electrocardiogram in patients with persistent cardiomegaly may represent progressive myocardial damage. Mortality rate was highest (11%) in the first year and declined thereafter. Cardiac deaths were common in patients with recurrent PPCF or progressive heart failure.

A clinical and electrocardiographic method of assessing the severity of aortic stenosis.

A formula was devised by Wagner et al. (1977) for calculating gradients across stenotic aortic valves by using clinical and electrocardiographic criteria for patients aged two to 21 years. A modification of this formula was used in a preliminary survey to assess gradients across stenotic aortic values in eight older patients; the findings were similar to those obtained from cardiac catheterization. This formula was subsequently used for assessing the gradient across stenotic aortic valves in a further 14 patients; a high positive correlation coefficient (r = 0.75; p less than 0.01) with findings at cardiac catheterization was obtained in 13 patients in whom both sets of figures were available. This formula should be useful in conjunction with other clinical and laboratory findings, in the non-invasive evaluation of the severity of aortic stenosis.

A case of blastomycosis from Zaria, Nigeria.

A case of blastomycosis from Zaria, Nigeria is reported. The clinical features were indistinguishable from those of tuberculosis which is very common in this environment. Lack of response to anti-tuberculosis therapy within eight weeks prompted the search for other organisms which resulted in the isolation of Blastomyces dermatitidis. Compatible histological evidence was obtained. Subsequent favourable response to amphotericin B was evident. Infection with this organism should be included in the differential diagnosis of pulmonary and pleural lesions simulating tuberculosis in West Africa.

Postpartum cardiac failure--heart failure due to volume overload?

Ventricular function has been studied in 43 patients with the peripartum cardiac failure (PPCF) syndrome which occurs around Zaria. All patients had an echocardiogram on admission and 10 patients had right heart catheterization. Despite the gross edema, left ventricular function assessed by echocardiography and systolic time intervals was relatively good and the estimated cardiac output were high. At catheterization, although the pressures were high, the cardiac outputs were greater than normal in four out of six patients. No patient had a low cardiac output. These findings are not compatible with a severe heart muscle disorder, or cardiomyopathy. We suggest that the primary event in PPCF of Zaria is fluid retention which leads to a form of high output cardiac failure. The postpartum practices in this area (taking high sodium diets and lying on heated beds) almost certainly cause the fluid to accumulate initially, but the heart may be unable to meet the demands either because of preexisting heart muscle disease or, more likely, because of a rise of the peripheral resistance due to the volume expansion, overburdens such dilated hearts and leads to myocardial damage. Since there are similarities between this condition and PPCF in temperate climates, it is possible that there is a common mechanism which the traditional practices of this area have unveiled.

Yersinia enterocolitica infection from West Africa--a case report.

A case of Yersina enterocolitica infection is described from West Africa. Intestinal function studies demonstrated an associated protein-losing enteropathy whilst the histo-pathological appearance of the rectum suggested an ischaemic colitis. Y. enterocolitica infection has been infrequently reported from the African continent and may be manifested in a variety of clinical presentations leading to difficulty in diagnosis.

Single injection treatment of meningococcal meningitis. 1. Long-acting penicillin.

A single injection of a long-acting preparation of penicillin (Triplopen) was compared with a five-day course of crystalline and procaine penicillin in the treatment of meningococcal meningitis. The clinical response of patients treated with Triplopen was very similar to that of patients treated with crystalline penicillin and much more convenient to administer. However, four patients treated with Triplopen had a positive CSF culture 48 or 72 hours after their injection. One injection of Triplopen cannot, therefore, be recommended as an entirely safe form of treatment for meningococcal meningitis unless patients can be carefully followed.