Primary cerebral angitis of the central nervous system: case report.

We report a case of a 28 year old female who presented with variedly progressive stroke like illness and raised intracranial pressure. Brain MRI scans revealed pericallosal and periventricular hyperintensities with oedema. Various medications like intravenous immunoglobulin, antibiotics, acyclovir, methyl prednisolone and management for raised intracranial pressure were instituted. She rapidly deteroriated and died on tenth hospital day. Only at autopsy was the diagnosis of primary angitis of central nervous system established.

A review of electroencephalograms done at the Kenyatta National Hospital, Nairobi.

BACKGROUND: Electroencephalogram based studies done elsewhere suggest that epileptiform activity originates predominantly from the left cortical hemisphere. There is evidence that partial epilepsies (focal spike and wave epileptiform discharges on tracings) connotes focal; secondary structural cortical dysfunction. Studies seeking similar findings have not been done locally. OBJECTIVE: To review electroencephalograms (EEGs) done at Kenyatta National Hospital (KNH); looking for various types of epileptiform discharges and their cerebral cortex of origin. DESIGN: Retrospective observational study. SETTING: Kenyatta National Hospital, Nairobi, Kenya--from January 1986 to June 2004. RESULTS: A total 10431 EEG records were reviewed. Ninety Eight percent of referrals for EEG evaluation was for clinical differential diagnosis of epilepsy. Abnormal EEGs comprised 32.2% of the study population. Epileptiform abnormalities (i.e. focal spike and wave, generalized spike and wave and 3Hz spike and wave) discharges accounted for 75.2% of all abnormal EEG waveform discharges. Of the epileptiform abnormalities, focal spike and wave discharges comprised 71%. Focal spike and wave discharge implies a possible secondary aetiology of epilepsy. The left cerebral hemisphere was the origin of 49.8% of focal spike and wave epileptiform EEG discharges. Multifocal loci in cerebral cortices (i.e. frontal, temporal and parietal) were the foci of origin of abnormal EEG waveforms in 69.9% of recordings. CONCLUSION: Focal spike and wave epileptiform discharges, with attendant likely secondary aetiology of epilepsy is predominantly evident in this study. It contrasts findings from western literature. The left cerebral hemisphere is more epileptogenic as is noted in other studies.

Pathological sub-types, risk factors and outcome of stroke at the Nairobi Hospital, Kenya.

BACKGROUND: Stroke is one of the most common causes of morbidity and mortality the world over. Established risk factors such as arterial hypertension, diabetes mellitus, cigarette smoking, hyper-lipidaemia, micro-vascular rupture, male gender, age and observed co-morbities such as sickle cell disease, HIV/AIDS infection and cerebral malaria are increasingly being encountered in the tropics. OBJECTIVES: To determine pathological sub-types, risk factors, in-hospital period prevalence and in-hospital outcome of stroke. DESIGN: Hospital-based retrospective study. SETTING: The Nairobi Hospital, Nairobi, Kenya. SUBJECTS: Patients with recorded diagnosis of stroke/cerebral vascular accident; as per WHO criteria for diagnosis of stroke, all gender and age > or = 18 years were studied. RESULTS: A total of 2629 patients were admitted to the division of medicine at the hospital during study period. Eighty patients had diagnosis of stroke; giving an in-hospital period prevalence of 3042/100,000. Mean age was 61.3 years, mode; 63 years, range 34-95 years. Males were 43 (53.8%), M to F ratio 1.2:1 stroke sub-types: Ischaemic stroke 68 (85%), haemorrhagic stroke seven (8.8%). In five patients (6.3%) no evidence of stroke sub-type was on-record. Established risk factors for stroke included hypertension and diabetes mellitus. Hypertension was found in 64 patients (80%) and diabetes-mellitus in 27 (33.7%). Twenty three patients (28.8%) had both hypertension and diabetes-mellitus. Co-morbidities were observed and included mitral-stenosis, cardiac-arrhythmias cardio-myopathy, HIV/AIDS, Left Ventricular Hypertrophy (LVH), infective endocarditis, atrial septal aneurysm, carotid plaques with or without stenosis and hyper-homocystenemia. Mean hospital stay was 12.5 days; range 22-70 days. Seventy five patients (93.8%) were discharged and four (5%) died in hospital. All patients who died had anterior circulation ischaemic stroke as per Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. CONCLUSION: Ischaemic stroke is the most common pathological sub-type observed in this study. Hypertension is the leading observed risk factor for stroke. Hospital period prevalence for stroke of 3042/100,000 was found. Seventy five patients (93.8%) were discharged and four (5%) died in hospital.

Clinical and laboratory characteristics of hospitalised patients with neurological manifestations of HIV/AIDS at the Nairobi hospital.

OBJECTIVE: To determine the profile of clinical and laboratory characteristics of hospitalised HIV positive patients with neurological complications at a private hospital in Nairobi, Kenya from January 2000 to June 2005. DESIGN: Retrospective observational study. SETTING: The Nairobi Hospital, Nairobi, Kenya. SUBJECTS: One hundred and fifty hospitalised patients. RESULTS: Records of 708 HIV positive hospitalised patients were reviewed, 150 patients had neurological complications; giving a six-year point prevalence of 21.2%. Males were 86 (57.3%) and females 64 (42.7%) M:F ratio = 1.3:1. Mean age was 38.84 years. The five commonest neurological complications were; cryptococcal meningitis 33 (22%), encephalitis 28 (18.7%), cerebral toxoplasmosis 19 (12.7%), stroke 19 (12.7%) and tuberculous meningitis 16 (10.7%). Overall, 72 patients (63%) had CD4+ counts done. Cryptococcal meningitis patients' CD4+ count, (mean 60, median 17, range 1-273/cmm). Encephalitis patients' CD4+count, (mean 82, median 54, range 3-495/cmm). Cerebral toxoplasmosis patients' CD4+count, (mean 59, median 58, range 11-120/cmm). Stroke patients' CD4+ count, (mean 120, median 30, range 15-394/cmm) and Tuberculous meningitis patients' CD4+ count, (mean 67, median 62 and range 12-154/cmm). The other rare neurological manifestations included peripheral neuropathy, HIV associated dementia (HAD), myelopathy and myopathy amongst others. One hundred and eight (72%) patients were on anti-retroviral therapy. The commonest drugs used in various regimen combinations included efavirenz and combivir. Fourteen (9.3%) patients died while in hospital; eight of them were among those with the top five neurological complications. CONCLUSION: The findings show that patients come to hospital when severely immune compromised and hence have overwhelming opportunistic infections. The profile of opportunistic infection is comparable to that observed in studies elsewhere. Some of the facts observed here may not reflect the situation in public health institutions where resources are scarce. RECOMMENDATION: To do a multi-centre prospective study of neurological manifestations of HIV/AIDS.

Osmotic demyelination syndrome: case report.

We present a 40 year old man who was admitted to the hospital with convulsions. His final diagnosis was osmotic demyelination syndrome (ODS). We discuss the diagnostic and management challenges and the possible complications of this rare diagnosis.

Hemifacial spasm: case report.

A 53 year old lady with diabetes mellitus presented with right hemi-facial spasm (HFS). Brain MRI Scan revealed extensive pan-sinusitis and mild bilateral mastoiditis. She responded well to intravenous ceftriaxone therapy and the hemifacial spasm resolved. The symptoms of hemifacial spasm and pain over the right cheek and peri-orbital area recurred after three weeks. She was admitted to hospital for Functional Endoscopic Sinus Surgery (FESS); following findings on repeat para-nasal sinus CT-Scan. Several reviews over six month's period revealed complete resolution of hemi facial spasm symptoms save for mild intermittent right blepharospasm; particularly on exposure to wind. This is a very rare cause of hemifacial spasm and clinicians should be on the look out for infective/inflammatory aetiology of hemifacial spasm; particularly in patients who present with recent onset HFS and have features of infection and or inflammation in the cranium.

Lyme disease: report of two cases.

Lyme disease is a tick-borne multisystem disease. It was first described in Lyme, Connecticut, USA in 1975. Cases have been reported in Canada, Switzerland, Austria, Australia and Great Britain. It is an inflammatory disease that has varied clinical manifestations ranging from skin rash (erythema migrans), arthritis, fibromyalgia, and regional lymphadenopathy, cardiac conduction defects to neurological manifestations of meningoencephalitis, Bell's palsy, peripheral neuropathy, and painful radiculoneuropathy. There has been no case record of Lyme disease in Kenya and indeed literature on Lyme disease in Africa is very scanty. We present two cases of Lyme disease with predominant neurological manifestations; outline their clinical presentation and management.

Dystonia: case series of twenty two patients.

OBJECTIVE: Dystonia is a rare neurological disorder characterised by sustained muscle contraction with resultant bizarre muscle movements and hence bizarre posturing. The pathophysiology is not well understood but it is believed there is dysfunction of the cortico-striatal-thalamo-cortical circuitry and projections. There is very scanty literature in sub-Saharan Africa. DESIGN: Retrospective descriptive case series. SETTING: Outpatient clinics of the authors, the Nairobi Hospital and the Mater Hospital, Nairobi, Kenya. SUBJECTS: A cohort of twenty two consecutive patients of indigenous Kenyan origin, seen by the authors between 1996 and January 2005 were described. This study was carried out to describe characteristics of 22 patients. RESULTS: Males comprised of 15 (68.2%) of the cases. Late onset dystonia was found in 12 (54.5%) cases. Over half of the patients had focal dystonia and only 13.6% had generalized dystonia, all of whom were of early onset variety. There was significant delay in diagnosis of dystonia with 68.2% of patients being diagnosed after 12 months of onset of symptoms. CONCLUSION: Dystonia is rare; however, multi-centre studies are required to map out prevalence rates of the disease in the country. There is need to highlight the presentation of the disease amongst clinicians and patients as this would improve diagnosis rate, early intervention and appropriate management. Genetic studies need to be done.

Headache associated disability in medical students at the Kenyatta National Hospital, Nairobi.

OBJECTIVE: To study headache associated disability in a group of medical students at the Kenyatta National Hospital. STUDY DESIGN: Cross sectional survey. RESULTS: Between October 1994 and January 1995 we conducted a survey on headache characteristics on medical students at both the Kenya Medical Training Centre and the Medical School of the University of Nairobi. Six hundred and twenty-five (87%) of the 711 students surveyed admitted having had at least one episode of headache in the last six months. Using the International headache society (IHS) case criteria 314 students (50%) had tension type headache, 240 (38%) migraine headache and 71(12%) unclassified headache. Eighty-six percent of the students with headache had their working ability disturbed to various degrees. Eighty-five percent of the students reported that their social activities were interfered with by headache. Migraine headaches had the greatest impact on both the working and social activities at a p-value of 0.0005 and 0.0004 respectively. One hundred and forty-one students (23.6%) had missed at least one day of work or school in the last one-year as a direct result of the headache. There was an association between headache severity with working ability and social effect. There was no association between the days students missed work or classes with the severity of the headache. No gender difference was found in the headache associated disability. CONCLUSION: Headache is a prevalent condition with disability both in working and social activities.

Migraine headaches in a group of medical students at the Kenyatta National Hospital, Nairobi.

A survey was carried out on 711 medical students from both the medical school and the Kenya Medical Training Centre on headaches using a closed ended questionnaire. Six hundred and twenty five (88%) of the students reported to have at least one episode of headache in the last six months. Two hundred and forty (33.8%) of these were classified as migraine using the International Headache Society case definition. Seventy (29%) had migraine with aura, the rest being migraine without aura. The mean age was 22.7 +/- 5 years with a male to female ratio of 1:1.3. The majority of the respondents (43%) had an average of two to three headache episodes per month. The major triggering factors for the headache were physical activities, emotional disturbance and studying, each occurring in 21% of the student respondents. It was reported by 43.6% of the respondents that there was a member of their nucleus family with a similar headache. Only 40% of the respondents had sought medical attention for their headache in the last one year. The main reason for not seeking medical services was self medication in 56% of those who did not attend medical services. Only 27 (11%) of the respondents were currently on medication which consisted of simple analgesics and antimalarials. There were only two students who were on specific drugs for migraine. The majority of the respondents continued to be inadequately treated despite the development of wide range of effective treatment.

Efficacy and tolerability of oral sumatriptan in the treatment of acute migraine.

An open prospective study of the efficacy and tolerability of oral sumatriptan in the treatment of acute migraine attacks at the Kenyatta National Hospital, Nairobi, Kenya, is presented. Thirty two patients were initially recruited and 24 completed the trial giving a drop-out rate of 25%. The age range was 17 to 55 years with a mean of 35 years. Sumatriptan was found to be effective in 22 (92%) out of 24 patients. Side effects occurred in 38% (9/24) patients. These were mild and transient and included nausea, vomiting, numbness of limbs, fever and a feeling of heat in the head. It is concluded that oral sumatriptan is an effective drug in the treatment of acute migraine headaches. It has few side effects and is well tolerated by majority of patients.