Hereditary spherocytosis with successful splenectomy in a pregnant black South African lady: a case report.

Hereditary spherocytosis is a rare cause of chronic haemolytic anaemia. It is rarer in the black population with extremely few cases reported. Initial assessment of a patient with suspected disease should include documenting clinical features of chronic haemolysis and a family history. Its management in pregnancy is challenging and needs a multidisciplinary team. We report on a black South African woman with hereditary spherocytosis and massive splenomegaly presenting with severe haemolytic anaemia at 23rd week of pregnancy. She had a successful splenectomy.

Graves' disease following hypothyroidism due to Hashimoto's thyroiditis in a black South African lady: a case report.

Graves' disease and Hashimoto's thyroiditis are autoimmune thyroid disorders with distinct pathological and histopathological features. The conversion from Hashimoto's thyroiditis to Graves' disease has been rarely reported throughout the world with no reports in the African race to our knowledge. We here report an African lady who was initially diagnosed with primary hypothyroidism following Hashimoto's disease but later became thyrotoxic due to Graves' disease.

Metformin-associated lactic acidosis treated successfully by peritoneal dialysis in a resource limited setting: case report.

Metformin is a commonly used treatment modality in type 2 diabetes mellitus with lactic acidosis as a rare but life-threatening side effect. In this case report we highlight the importance of recognizing this uncommon side effect and the treatment options in a resource limited situation. We present a 14-year-old African girl who ingested an unknown amount of metformin intentionally after an argument with her mother. She was referred late to our institution in severe lactic acidosis. Lactic acidosis resolved with appropriate treatment including peritoneal dialysis. We conclude that in resource constrained settings, peritoneal dialysis may be used for metformin associated lactic acidosis with favourable outcome.

Diabetes mellitus in Nigeria: The past, present and future.

Diabetes mellitus (DM) is a diverse group of metabolic disorders that is often associated with a high disease burden in developing countries such as Nigeria. In the early nineties, not much was known about DM in Nigeria and traditionally, people related DM to "curses" or "hexes" and diagnosis was made based on blood or urinary tests for glucose. Currently, oral hypoglycaemic agents but not insulin are readily accessible and acceptable to persons with DM. The cost of diabetes care is borne in most instances by individuals and often payment is "out of pocket"-this being a sequel of a poorly functional national health insurance scheme. An insulin requiring individual on a minimum wage would spend 29% of his monthly income on insulin. Complementary and alternative medicines are widely used by persons with DM and form an integral component of DM care. Towards reducing the burden of DM in Nigeria, we suggest that there be concerted efforts by healthcare professionals and stakeholders in the health industry to put in place preventative measures, a better functioning health insurance scheme and a structured DM program.

Glucose and lipid assessment in patients with acute stroke.

BACKGROUND: Stroke is a major health issue in Nigeria and it is also a common cause of emergency admissions. Stroke often results in increased morbidity, mortality and reduced quality of life in people thus affected. The risk factors for stroke include metabolic abnormalities such as dyslipidaemia and diabetes mellitus (DM). The stress of an acute stroke may present with hyperglycaemia and in persons without a prior history of DM, may be a pointer to stress hyperglycaemia or undiagnosed DM. METHODOLOGY: This was a cross sectional study carried out over a period of one year in a teaching hospital in Lagos, Nigeria. Patients with acute stroke admitted to the hospital within three days of the episode of stroke and who met other inclusion criteria for the Study were consecutively recruited. Clinically relevant data was documented and biochemical assessments were carried out within three days of hospitalization. Tests for lipid profile, glycosylated haemoglobin(HbA1c), and blood glucose at presentation were carried out. The presence of past history of DM, undiagnosed DM, stress hyperglycaemia and abnormal lipid profile were noted. Students t test and Chi square were the statistical tests employed. RESULTS: A total of 137 persons with stroke were recruited of which 107 (76%) met the defining criteria for ischaemic stroke. The mean age and age range of the Study subjects were 62.2 (11.7) and 26-89 years respectively. The Study subjects were classified according to their glycaemic status into the following categories viz; stress hyperglycaemia, euglycaemia, DM and previously undiagnosed DM. Stress hyperglycaemia occurred commonly in the fifth decade of life and its incidence was comparable between those with cerebral and haemorrhagic stroke. The commonly occurring lipid abnormalities were elevated LDL-C and low HDL. CONCLUSIONS: The detection of abnormal metabolic milieu is a window of opportunity for aggressive management in persons with stroke as this will improve outcome. Routine screening for hyperglycaemia in persons with stroke using glycosylated haemoglobin tests and blood glucose may uncover previously undiagnosed DM.

Glycosylated haemoglobin is markedly elevated in new and known diabetes patients with hyperglycaemic ketoacidosis.

BACKGROUND: Glycosylated haemoglobin (HbA1c) and random blood glucose are markers of chronic and acute hyperglycaemia respectively. OBJECTIVE: We compared HbA1c levels in ketoacidosis (DKA) occurring in known and newly diagnosed diabetes. METHODS: Retrospective review of medical records for 83 DKA admissions in 2008 and 2009 with results for HbA1c at presentation. RESULTS: There were 52 and 31 DKA admissions in known and newly diagnosed diabetes patients respectively. Fifty of the 83 DKA admissions were in females. The mean age (per admissions) and HbA1c of all admissions are 43.4 ± 20.3 years (n=83) and 12.7 ± 3.4 % (n=83) respectively. Mean HbA1c in known Type 1, known Type 2 and newly diagnosed diabetes patients were similarly very high: 12.4 ± 3.3 %, 12.5 ± 3.3 %, 13.1 ± 3.7 %; P = 0.6828. The HbA1c levels in newly diagnosed diabetes patients less than 30 years (likely Type 1 diabetes) and ≥ 30 years (likely Type 2 diabetes) were similar. There was a tendency to significantly positive correlation between blood glucose and HbA1c in new diabetes patients. CONCLUSIONS: In our setting, DKA is associated with markedly elevated HbA1c levels in known type 1, known type 2 and new onset diabetes.

Islet immunity and beta cell reserve of indigenous Black South Africans with ketoacidosis at initial diagnosis of diabetes.

OBJECTIVE: Islet immunity and beta cell reserve status were utilized to classify persons with ketoacidosis as the initial manifestation of diabetes. The clinical features of the various diabetes classes were also characterized. DESIGN: Prospective cross sectional study. SETTING: Nelson Mandela Academic Hospital, Mthatha, Eastern Cape Province, South Africa. PATIENTS: Indigenous Black South Africans with ketoacidosis as the initial manifestation of diabetes. INTERVENTIONS: Islet immunity and beta cell reserve were respectively assessed using serum anti-glutamic acid decarboxylase 65 (GAD) antibody and serum C-peptide after 1 mg of intravenous glucagon. OUTCOME MEASURES: Serum anti-GAD 65 antibody > or = 5 units/L and < 5 units/L, respectively defined anti-GAD 65 positive (A+) and negative (A-). Replete (beta+) and deplete (beta-) beta cell reserve were serum C-peptide after glucagon injection of > or = 0.5 ng/mL and < 0.5 ng/mL, respectively. The proportions of patients with A+beta-, A+beta+, A-beta- and A-beta+ and their clinical characteristics were determined. RESULTS: Of the 38 males and 33 females who participated in the study, patients were categorized in various classes: A-beta+, 46.5% (n=33/ 71); A-beta-, 26.8% (n=19/71); A+beta-, 22.5% (n=16/71); and A+beta+, 4.2% (n=3/71). The ages of the various classes were: 41.8 +/- 13.8 years for A-beta+ (n=33); 36.5 +/- 14.6 years for A-beta- (n=19); and 20.6 +/- 7.1 years for the combination of A+beta- with A+beta+ (n=19) (P<.0001, P<.0001 for the combination of A+beta- and A+beta+ vs A-beta+, P=.001 for the combination of A+beta- and A+beta+ vs A-beta-and P=.2 for A-beta- vs A-beta+. The clinical features of type 2 diabetes were most prevalent in A-beta+ class while the A+beta- and A+beta+ groups had the clinical profile of type 1A diabetes. CONCLUSIONS: Most of the indigenous Black South African patients with ketoacidosis as the initial manifestation of diabetes had islet immunity, beta cell reserve status and clinical profiles of type 2 diabetes.

Basal cortisol levels and correlates of hypoadrenalism in patients with human immunodeficiency virus infection.

OBJECTIVE: To determine the frequency of occurrence of hypoadrenalism in patients with human immunodeficiency virus (HIV) infection and document the clinical correlates of hypoadrenalism for this group of patients. SUBJECTS AND METHODS: A descriptive study was carried out on 66 hospitalized HIV patients in a semi-urban setting of South Africa. Hypoadrenalism was diagnosed based on a basal cortisol level of less than 400 nmol/l with or without overt signs and symptoms. Clinical and biochemical parameters of hypoadrenalism were compared between subjects with suboptimal and normal cortisol levels. Statistical analysis included Student's t test, χ(2) and Pearson's correlation coefficient tests. RESULTS: The prevalence of hypoadrenalism was 27% with a high occurrence of contributory factors (cytomegalovirus infection in 100% and tuberculosis in 68.2% of the study subjects). Typical features of hypoadrenalism included: hyponatremia, 19.6%; hyperkalemia, 6.1%; mucosal hyperpigmentation, 12%, and loss of axillary hair, 15%. Comparison of clinical and biochemical parameters of hypoadrenalism did not show a correlation between CD4 count and cortisol levels (r = 0.1 and p = 0.3). CONCLUSION: The prevalence of hypoadrenalism in our patients with HIV infection was high and the clinical features were comparable in subjects with normal and subnormal cortisol levels.

Advanced age, altered level of consciousness and a new diagnosis of diabetes are independently associated with hypernatreamia in hyperglycaemic crisis.

BACKGROUND: There is limited literature on hypernatreamia in the setting of hyperglycaemic crisis. This is despite the fact that the presence of hypernatreamia may impact on the classification of hyperglycaemic crisis and its management particularly with regards to the nature of fluid therapy. We determined the prevalence of hypernatreamia and its associated factors at presentation for hyperglycaemic crisis. METHODS: This was a retrospective review of data for hyperglycaemic crisis admissions in Nelson Mandela Academic Hospital, Mthatha, South Africa. The prevalence of hypernatreamia (uncorrected Serum Sodium at presentation >145 mmol/L) was determined. Hyperosmolality was defined by calculated effective osmolality >320 mosmols/Kg. Multivariate logistic regression was undertaken using variables that were statistically significant in univariate analysis to ascertain those that were independently associated (Odds Ratio (OR) with 95% Confidence Interval (CI)) with hypernatreamia. RESULTS: The prevalence of hypernatreamia in our admissions for hyperglycaemic crisis was 11.7% (n = 32/273 including 171 females and 102 males). All admissions with hypernatreamia met the criteria for hyperosmolality. Age ≥ 60 years (OR = 3.9 95% CI 1.3-12.3; P = 0.018), Altered level of consciousness (OR = 8.8 95% CI 2.3-32.8; P < 0.001) and a new diagnosis of diabetes (OR = 3.7 95%CI 1.2-11.5; P = 0.025) were independently associated with hypernatreamia. CONCLUSION: The prevalence rate of hypernatreamia in hyperglycaemic admissions was high with all hypernatreamic admissions meeting the criteria for hyperosmolality. Advanced age, altered conscious level and a new diagnosis of diabetes were independently associated with hypernatreamia.

Diabetes foot ulceration in a Nigerian hospital: in-hospital mortality in relation to the presenting demographic, clinical and laboratory features.

This prospective study assessed in-hospital mortality from diabetic foot ulcer in relation to the demographic, clinical and laboratory features at presentation. Forty-two patients admitted with diabetic foot ulcer were followed up from admission till discharge from hospital. Those who survived or died were compared for any differences in demographic, clinical and laboratory parameters at presentation. The mean age and duration of diabetes for the 42 patients were 56.1 +/- 1.9 years and 8.3 +/- 1.1 years, respectively. The in-hospital mortality rate amongst the 42 subjects was 40.5%. Ulcer grade > or =4, leucocytosis and anaemia were more prevalent in those who demised in comparison with survivors.