Tuberculosis culture testing at a tertiary care hospital: options for improved management and use for treatment decisions.

SETTING: Chris Hani Baragwanath Hospital, a tertiary care hospital in Johannesburg, South Africa. OBJECTIVES: To determine the proportion of patients with positive Mycobacterium tuberculosis cultures and whether those who were positive were on treatment. DESIGN: Tuberculosis (TB) culture results were obtained from the laboratory for a 3-month period. Positive results were checked against registrations at the hospital TB Care Centre (TBCC). The treatment status of non-registered patients was obtained from various records at the hospital, district clinics and from home visits. RESULTS: Overall, 3909 patients had 5404 samples sent for culture. Of these, 708 patients (18%) had at least one positive culture. The positive yield from 2749 adult sputum samples was 33% and ranged from 6% to 40% for different extra-pulmonary specimens. Among 1160 children, the yield varied from 0% to 12%, with 12% in sputum and gastric washing specimens. Of the 708 culture-positive patients, 429 (61%) patients were registered at the TBCC and were known to have started TB treatment. Of the 279 subjects not registered (39% overall), 100 (36%) died. Only 67 of the 179 survivors were confirmed on treatment, 40 were not on treatment and 72 could not be traced. CONCLUSIONS: Large numbers of TB culture tests were performed, some inappropriately. Study findings highlight inadequacies in the management of culture-confirmed TB at this hospital.

Tuberculosis at Chris Hani Baragwanath Hospital: an intervention to improve patient referrals to district clinics.

SETTING: A study in 2001 described the process of managing tuberculosis (TB) at Chris Hani Baragwanath hospital, the numbers of patients diagnosed and poor outcomes of referring patients to clinics in the adjacent sub-districts. The present study describes and evaluates an intervention to address the problems. OBJECTIVES: To describe the intervention process (education and referral of TB patients) and the subsequent results over a 2-year period from 2003 to 2005. METHODS: The process of establishing the system and how it was evaluated at district clinics in Johannesburg are described. RESULTS: In the first 2 years of operation, August 2003 to July 2005, 13,138 patients were registered. Extra-pulmonary tuberculosis (EPTB) was diagnosed in 34%. Of the 46% tested for human immunodeficiency virus (HIV), 93% were positive. Successful referral to clinics was achieved for 94% of patients. CONCLUSIONS: Very large numbers of patients are diagnosed with TB at Chris Hani Baragwanath Hospital. A TB care centre has successfully addressed important referral, education and registration requirements for the comprehensive management of TB with links to clinics. It is suggested that this model be applied at other hospitals.

Membranous obstruction of the inferior vena cava and its causal relation to hepatocellular carcinoma.

Although rare in most countries, membranous obstruction of the inferior vena cava (MOIVC) occurs more frequently in Nepal, South Africa, Japan, India, China, and Korea. The occlusive lesion always occurs at approximately the level of the diaphragm. It commonly takes the form of a membrane, but may be a fibrotic occlusion of variable length. Controversy exists as to whether MOIVC is a developmental abnormality or a result of organization of a thrombus in the hepatic portion of the inferior vena cava. The outstanding physical sign associated with MOIVC are large truncal collateral vessels with a cephalad flow. A dilated vena azygous is seen on chest radiography. Definitive diagnosis is made by contrast inferior vena cavography. The long-standing obstruction to hepatic venous flow causes severe centrolobular fibrosis and predisposes to the development of hepatocellular carcinoma (HCC). Percutaneous balloon angioplasty, transatrial membranotomy, or more complex vena caval and portal decompression surgery should be performed to prevent these complications. HCC occurs in more than 40% of South African Black and Japanese patients with MOIVC, but less often in other populations. It is thought to result from the tumour-promoting effect of continuous hepatocyte necrosis, although the associated environmental risk factors have not been identified.

Tuberculosis at Chris Hani Baragwanath Hospital: numbers of patients diagnosed and outcomes of referrals to district clinics.

SETTING: Chris Hani Baragwanath Hospital, in Johannesburg. South Africa is experiencing a serious epidemic of tuberculosis (TB), with a measured rate of 500 cases per 100,000 population. Patients in public hospitals are referred for treatment to district clinics or to specific TB hospitals. OBJECTIVES: To measure numbers of patients diagnosed with TB, and to describe the type of disease and referral outcomes. METHODS: A descriptive study of patients diagnosed with TB in a tertiary hospital. Data in patient files were collected for medical and paediatric patients, and patients were interviewed by researchers who visited clinics to check if referred patients had attended. RESULTS: In the 8-week study period, 1291 patients were diagnosed with TB: 74% had pulmonary disease and 80% of those tested for HIV were positive; 19% died in hospital, and 21% required transfer to a TB hospital. Only half of the patients referred to clinics attended within 2 weeks. CONCLUSIONS: Patients with advanced TB are commonly seen at this hospital. Notifications were an inadequate record and an unacceptable proportion of patients were lost between hospital and clinics. This study has recommended that opportunities for education and discussion must be provided if patients are to reach clinics successfully.

Sister Joseph's nodule in hepatocellular carcinoma.

We describe three black South African patients in whom hepatocellular carcinoma metastasized to the umbilicus. Sister Joseph's nodule has previously been reported in only two patients with this tumour. A number of routes for this spread are possible: malignant hepatocytes in the portal venous system may reach the umbilicus via a patent umbilical vein; the tumour may propagate directly along the ligamentum teres hepatis to the umbilicus; contiguous spread of the tumour to the umbilicus from anterior peritoneal tissue, either directly infiltrated by hepatocellular carcinoma or the site of metastatic nodules, may occur; embolization of malignant hepatocytes to the umbilicus might take place by way of its arterial blood supply; or hepatocellular carcinoma might reach the umbilicus as a result of retrograde lymphatic spread from para-aortic lymph nodes or from the anterior abdominal wall, to which the tumour has metastasized.

Gastric mucormycosis.

A case of gastric mucormycosis proven on culture and histologic examination and successfully treated with resectional surgery and Amphotericin B is described.

Pityriasis rotunda as a cutaneous marker of hepatocellular carcinoma: a comparison with its prevalence in other diseases.

In an attempt to substantiate the claim that pityriasis rotunda may be a useful cutaneous marker of hepatocellular carcinoma in South African Blacks, the prevalence of the rash in 63 unselected South African Blacks with this tumour was compared to that in 63 matched patients with active tuberculosis, 63 with other malignant tumours, and 63 with various forms of chronic benign hepatic disease. The prevalence of pityriasis rotunda in hepatocellular carcinoma was 15.9%, which was appreciably greater (P = 0.0005) than the overall prevalence of the rash (2.6%) in the controls. The prevalence was 4.8% for tuberculosis (P = 0.038), 0% for other malignant diseases (P = 0.0007), and 3.2% for chronic benign hepatic disease (P = 0.015). We conclude that the presence of pityriasis rotunda is a useful pointer to the diagnosis of hepatocellular carcinoma in South African Blacks.

Horner's syndrome and tuberculosis. A case report.

Horner's syndrome and recurrent laryngeal palsy are rare complications of cervical tuberculous lymphadenopathy. A case, which mimicked malignant disease, is reported.

Multiple liver abscesses caused by Yersinia enterocolitica. A case report.

Yersinia enterocolitica is an important cause of multiple liver abscesses in iron-overloaded or debilitated patients. The condition has a high mortality rate and causes diagnostic and therapeutic problems. The successful management of an iron-overloaded patient presenting with jaundice and chronic renal failure is described.

Obstructive jaundice in the South African black population.

We report the causes of obstructive jaundice in 56 black South African patients. Chronic pancreatitis and malignant biliary obstruction occurred with equal frequency. These two conditions may be difficult to differentiate clinically and radiologically, and only operative pancreatic biopsy may be diagnostic. Choledocholithiasis caused jaundice in only 7.1% of the patients, reflecting the relatively low prevalence of gallstones in this population.

Pityriasis rotunda. A cutaneous marker of hepatocellular carcinoma in South African blacks.

Although paraneoplastic phenomena occur frequently in patients with hepatocellular carcinoma, cutaneous changes have rarely been reported. During the past two years, ten South African blacks with hepatocellular carcinoma and pityriasis rotunda have been seen in a single hospital. The rash affected the trunk, especially the lower back and buttocks. The lesions ranged in size from 1.5 to 25 cm and were always multiple. They had a characteristic circular or arcuate configuration with scaling and varying degrees of hyperpigmentation. Pityriasis rotunda may prove to be a useful cutaneous marker of hepatocellular carcinoma in South African blacks.

Prevalence of hepatitis B virus infection among black children in Soweto.

Roughly 15% of black children in rural areas of southern Africa are carriers of the hepatitis B virus. The purpose of the present study was to determine the prevalence of chronic hepatitis B virus infection among urban black children born and growing up in Soweto. A total of 2364 children were studied, ranging in age from 3 to 19 years, and of these, 1319 (56%) were girls. The children were drawn from the highest and the lowest socioeconomic classes. Serum samples were tested for all hepatitis B virus markers as well as IgG antibody against hepatitis A virus. HBsAg was detected in 23 (0.97%) of the children, anti-HBc and anti-HBs together in 155 (6.6%), anti-HBc alone in 17 (0.7%), and anti-HBs alone in 72 (3%). Of the 2364 children, 2097 (88.5%) were negative for all hepatitis B virus markers. IgG antibody to hepatitis A virus was present in 175 (97%) of a sample of 179 children. There was no difference in prevalence of hepatitis B virus markers between children from the upper and lower socioeconomic classes. HBsAg was more common in boys (16 out of 1043 (1.5%) than girls (seven out of 1321 (0.57%), and the prevalence of all hepatitis B virus markers increased with age. The youngest carrier of hepatitis B virus was 7 years old. The remarkable difference in the hepatitis B virus carrier rate between urban and rural black children offers a unique opportunity to investigate the favourable influences operating in an urban environment to limit the prevalence of hepatitis B virus infection.

Paraplegia in Paget's disease of the vertebral column. A case report.

A case of Paget's disease of the lumbar and thoracic vertebrae together with gradual-onset paraplegia is reported. The need for early recognition of the disease and early institution of medical treatment is highlighted.

Factitious hypoglycaemia in a rural black man. A case report.

An unusual case of factitious hypoglycaemia is described. The distinction between exogenous and endogenous hyperinsulinism is illustrated.

Chronic active hepatitis at Baragwanath Hospital.

In a retrospective analysis of 35 Black patients with chronic active hepatitis (CAH) admitted to Baragwanath Hospital, Johannesburg, during the period 1972--1980, four major aetiological categories were found: auto-immune (lupoid, immunological (57%)), drug induced (isoniazid and alpha-methyldopa (17%)), hepatitis B virus-related (14%), and alcohol-related (11%) CAH. Alcohol-related CAH was found in males only. Upper abdominal pain was a presenting feature of alcohol-induced CAH, while jaundice was a common, presenting feature of the other types. Systemic features such as skin rashes (acne, urticaria), bacterial infections and congestive cardiac failure were prominent in the auto-immune type of CAH. The liver was enlarged in the majority of cases. Hepatitis B virus-related CAH showed an absence of tissue nonspecific auto-antibodies. Cirrhosis was present in approximately 50% of patients at the time of diagnosis. Despite the facts that isoniazid and alpha-methyldopa are commonly used and hepatitis B infections and alcohol abuse are frequent in this population, CAH remains an uncommon condition in South African Blacks.

Cirrhosis of the liver associated with inferior vena-caval obstruction.

Seven patients with inferior vena-caval obstruction associated with cirrhosis of the liver are described. Inferior vena-caval obstruction is suggested when an enlarged azygous vein is seen on chest radiography, or when superficial collateral veins draining upwards are visible on the abdomen and chest. When a short obstruction or 'web' is present, this should be treated surgically. Venous thrombosis below the obstruction may result in occlusion of a long segment of the vena cava. Chronic suprahepatic venous obstruction may cause macronodular cirrhosis and predispose to the development of hepatocellular carcinoma.