Bone metabolism in healthy ambulatory control premenopausal women and in epileptics on anti-convulsant drugs.

BACKGROUND: Long term anti-epileptic drug use causes multiple abnormalities in calcium and bone metabolism that have been documented in both institutionalised and ambulatory patients. OBJECTIVE: To assess bone metabolism in ambulatory females of reproductive age, on antiepileptic drugs. DESIGN: Cross sectional comparative study. SUBJECTS: Ambulatory females in reproductive age group with epilepsy and on regular follow up were compared to healthy females of similar ages not on any treatment. RESULTS: The mean duration of treatment for epilepsy was eight years (+/- 6.3). Majority of the patients were on enzyme inducing drugs like phenobarbital, phenytoin, carbamazepine and valproate, either alone or in combination with non-enzyme inducers like lamotrigine (98.2%). There was a significantly lower mean serum calcium and a higher alkaline phosphatase level among the patients (P = 0.002 and 0.0001 respectively) than among the comparators. The urinary marker of bone loss (mean urine calcium excretion) was also significantly raised among the patients (P=0.003). The mean lumbar BMDT-score results were not significantly different in the two groups. CONCLUSIONS: Long-term anti-epileptic drug use significantly affects biochemical parameters of bone metabolism. These effects on bone biochemistry markers were not reflected in lumbar spine BMD in this study.

Stratification of persons with diabetes into risk categories for foot ulceration.

BACKGROUND: Patients with diabetes mellitus are at a higher risk of lower extremity complications as compared to their non-diabetic counterparts. OBJECTIVE: To study risk factors for diabetic foot ulcer disease and stratify patients with diabetes into risk categories for foot ulceration. DESIGN: Cross-sectional descriptive study over five months period. SETTING: Diabetic outpatient clinic, at the Kenyatta National Hospital. SUBJECTS: Two hundred and eighteen ambulatory subjects with diabetes mellitus without active foot lesions. RESULTS: The prevalence of previous foot ulceration was 16% while that of previous amputation was 8%. Neuropathy was present in 42% of the study subjects and was significantly associated with age, male gender, duration of diabetes, random blood sugar, systolic blood pressure and the presence of foot deformity. Peripheral arterial disease was present in 12% and showed significant association with male gender. Foot deformities were observed in 46% of study subjects and were significantly associated with age, male gender, and presence of neuropathy. Subsequently 57% were categorised into IWGDF group 0--no neuropathy, 10% were placed in group 1--neuropathy alone, 16% were put in group 2--neuropathy plus either peripheral arterial disease or foot deformity and 17% were placed in risk group 3--previous foot ulceration/amputation. CONCLUSION: More than one third (33%) of diabetic patients were found to be at high risk for future foot ulceration (IWGDF groups 2 and 3). Published evidence exists that shows improved outcomes with interventions targeting individual patients with diabetes at high-risk of foot ulceration. Long term prospective studies to determine outcomes for the different risk categories should be carried out locally.

Fertility rate of epileptic women at Kenyatta National Hospital.

BACKGROUND: Reproductive health issues of women with epilepsy (WWE) are complex and multifaceted, and both epilepsy and antiepileptic drug (AEDs) use may alter fertility and pregnancy outcomes in these women. OBJECTIVE: To determine the fertility rate of women with epilepsy at Kenyatta National Hospital (KNH). DESIGN: Cross-sectional study. SETTING: Neurology clinic, KNH, Nairobi, Kenya, between October 2006 and March 2007. SUBJECTS: A total of 191 women with epilepsy (aged 15-49 years) who had been epileptic for at least one year were interviewed regarding their pregnancy and birth histories, and the information validated with medical records where available. RESULTS: The general fertility rate (GFR) for reproductive-aged epileptic women for the three-year period (2003-2006) preceding the study was 46 livebirths per 1000 women-years (95% CI 35.13-63.59). CONCLUSION: Fertility rate in epileptic women is decreased by two thirds (compared to that of general population of women in Kenya). Reasons for this are probably miltifactorial.

Primary intracerebral haemorrhage complicated by cerebral abscess: case report.

A case of primary intracerebral haemorrhage complicated by cerebral abscess is presented with a review of the literature.

Herpes zoster myelitis: report of two cases.

Two male patients aged 40 and 45 years with HIV infection and paraplegia are presented. The two had sub-acute onset paraplegia with a sensory level, which developed 10 days after herpes zoster dermatomal rash. They both had asymmetrically involvement of the lower limbs. Investigation including imaging of the spinal cord did not reveal any other cause of the neurological deficit. The two responded very well to treatment with acyclovir. Herpes zoster myelitis is a condition likely to rise with the upsurge of HIV infection and there is a need to identify the condition early. We also review the literature on the subject.

Steady-state anticonvulsant drug levels in epileptic patients.

Steady state concentrations of three anticonvulsant drugs (phenobarbitone, phenytoin and carbamazepine) were measured in plasma samples from fifteen patients (eight males and seven females; ages: 13-49 years; body weights: 44-70 kg), attending the outpatient Neurology Clinic at Kenyatta National Hospital. In addition, total protein and albumin levels were measured in plasma from patients taking phenytoin. Total protein levels were normal (range: 6.3-7.6 g/dl) in all patients except in one patient (10.7 g/dl). Albumin levels were also normal (range: 3.7-4.1 g/dl) in all patients except one (25.4 g/dl). One patient on phenobarbitone and three patients on phenytoin had no detectable drug levels in their plasma. In the remainder, phenobarbitone, phenytoin and carbamazepine steady state concentrations were 8.7-21.1 mg/L (N = 8), 9.3-27.3 mg/L (N = 6) and 10-19.7 mg/L (N = 5), respectively. The unbound fraction of phenytoin in plasma (fu) was normal(approximately 0.1) in six patients, but relatively high (0.2) in one patient. Most patients in the study complied with the prescribed treatment and their epilepsy was controlled. Cases where drug levels were undetectable probably arose from a lack of money to purchase all prescribed medicines rather than deliberate non-compliance. Routine monitoring of anticonvulsant drug levels may improve management of epileptic patients.

Peripheral neuropathy in AIDS patients at Kenyatta National Hospital.

Between June and December 1992 forty AIDS patients as defined by the CDC criteria, admitted to the medical wards of the Kenyatta National Hospital, were studied to determine the prevalence and pattern of peripheral neuropathy. Their mean age was 33 +/- 3 years with a range of 16 to 55 years. Clinical and laboratory assessment were carried out both to confirm peripheral neuropathy and exclude other causes of peripheral neuropathy apart from AIDS. All the patients had nerve conduction and electromyographic studies done. Eighteen patients were asymptomatic while fourteen had both signs and symptoms. The commonest symptom was painful paresthesiae of the limbs (35%) while the commonest sign was loss of vibration sense (60%). When symptoms, signs, and electrophysiological studies were combined, all the patients fitted the definition of peripheral neuropathy. The commonest type of peripheral neuropathy was distal symmetrical peripheral neuropathy (DSPN) (37.5%).

PIP: In Kenya, physicians evaluated 40 AIDS patients admitted to Kenyatta National Hospital during June-December 1992 to determine the prevalence and types of peripheral neuropathy in AIDS patients. 75% were 21-40 years old. 18 (45%) of the 40 AIDS patients had symptoms of peripheral neuropathy. Symptoms included increased sensitivity to stimulation (43%), hyperpathia (15%), and muscle or limb weakness (13%). 26 AIDS patients had signs of peripheral neuropathy, especially impaired sense of vibration (60%). 14 of these patients had both signs and symptoms. Electromyographic and nerve conduction velocity revealed peripheral neuropathy in 16 (40%) AIDS patients. The types of peripheral neuropathy included distal symmetrical peripheral neuropathy (37.5%), polyneuropathy, and mononeuritis multiplex. When the symptoms, signs, and electroneurophysiological test findings were considered, all 40 AIDS patients had evidence of peripheral neuropathy.

A comparative bioavailability of four Carbamazepine tablet formulations available in the Kenyan market.

The relative bioavailabilities of three carbamazepine tablet formulations available in the Kenyan market (Temporal(R), Taver(R) and Carbamazepine Lincoln) compared with the innovator formulation (Tegretol(R)) were evaluated in seven healthy African volunteers (5 males, two females; aged 22-36 years), according to a randomised fourway crossover study design, following oral administration of single 200 mg doses with a three week washout period. In vitro dissolution profiles of the tablets were also evaluated. Relative bioavailabilities ((F)rel) of Temporal(R), Taver(R) and Carbamazepine Linocoln were 101.2%, 82.2% and 71.6% respectively, compared with Tegretol(R). Percent drug content dissolved in vitro after I hour were 91.3%, 75.9% and 39.3% for Temporal(R), Taver(R) and Carbamazepine Lincoln, respectively. It was concluded that Temporal(R) was bioequivalent to Tegretol(R) while Taver(R) and Carbamazepin Lincoln were bioinequivalent to Tegretol(R). Administration of Taver(R) or Carbamazepine Lincoln might lead to poor control of epileptic seizures.

Neurological manifestations of human immunodeficiency virus infection and acquired immune deficiency syndrome: a review.

Neurological manifestations of HIV/AIDS is reviewed and discussed. It is noted that neurological manifestations are some of the commonest modes of clinical presentation of HIV/AIDS. At autopsy, the prevalence approaches 100%. These manifestations include: involvement of the higher functions, craniopathies, spinal cord disease, peripheral neuropathy and muscle disease. It is therefore stressed that the central nervous system must be particularly assessed in patients with HIV/AIDS and where the clinician is not sure of the neurological diagnosis, a referral to the neurologist is recommended as some of these are treatable.

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.

Human immunodeficiency virus- 1 in leprosy patients attending Kenyatta National Hospital, Nairobi.

The purpose of this study was to determine if Mycobacterium leprae is an opportunistic pathogen in immunosuppressed subjects with HIV infection. Ninety six leprosy patients at Infectious Diseases Hospital (IDH), Nairobi were screened for, HIV-1 antibody between January 1991 and June 1992. The patients included 15 who were diagnosed during the study period and 81 who were previously diagnosed and were on anti-leprosy treatment. Blood was screened for HIV antibody by first ELISA and double positive samples were confirmed by a second ELISA. The HIV seronegative patients were re-tested serologically every 3 months. Smears from skin slits were used to determine bacterial index and the patients were classified according to criteria described by Ridley and Jopling. The patients were re-assessed clinically monthly. The mean age of the patients was 40 years and ranged from 13 to 78 years. Forty seven percent had paucibacillary and 53% had multibacillary leprosy. The HIV seroprevalence was 8% in previously diagnosed patients and zero in the newly diagnosed patients. There were no changes in clinical spectrum in HIV seropositive patients during follow up period; neither reversal reactions nor erythema nodosum leprosum were observed. The study suggests that M. leprae may not be an opportunistic pathogen in immunosuppressed subjects with HIV infection.

Behavioural mechanisms in AIDS patients under stress.

Clinical observation at the Kenyatta National Hospital showed unusually rapid deterioration of patients testing seropositive to HIV infection and being moved to a side room for nursing. This pilot study tested the hypothesis that deterioration was at least partly, mediated by B-endorphins and other endogeneous opioids. The study design was a prospective and comparative study looking at 6 HIV seropositive and 10 control (HIV seronegative) patients matched for sex, age, and clinical status at time of study. The laboratory measures compaired were baseline, and daily serum B-endorphin and ACTH. A significant variation is noted between the two groups. The significance of this study is discussed.

PIP: From among patients hospitalized at Kenyatta National Hospital, 6 subjects diagnosed as HIV positive by at least one HIV ELISA antibody test and 10 HIV negative control patients were enrolled into a study and matched for age, sex, level of education, and ethnic group. A baseline blood sample was obtained from each patient at 2.00 p.m. for complete blood count biochemical assays for B endorphin and adrenocorticotropic hormone (ACTH) as well as an HIV ELISA test. HIV positive patients were informed of ELISA test results and transferred to isolation rooms. Blood was drawn on the next 3 consecutive days. Concentration of ACTH was measured by radio-immunoassay. B-endorphin assay was almost the same as for ACTH. Assay sensitivity was 5 pg/ml with a range of 5-500 pg/ml. Multivariate and univariate analyses of variance with repeated measures were used to evaluate the differences in biochemical responses between HIV positive (under stress) patients and HIV negative (with no stress) patients. (ACTH and B endorphin concentrations in plasma were obtained on the day of diagnosis and at different times 1 and 72 hours thereafter. Change scores (pre-post 72 hours) in plasma ACTH and B- endorphin concentrations support the hypothesis that patients diagnoses to have AIDS experience stress mediated biochemical changes. The change score distributions predominantly indicated elevated concentrations of each neurohormone. By contrast, HIV, negative patients exhibited more random patterns of change following diagnosis. The results could be used in situations of stress-induced immuno-incompetency. Identification of significant effect of stress on neuroendocrine response and immune competence in patients diagnoses as HIV positive may suggest methods of prolonging the life of patients who otherwise have no definitive treatment. B endorphin antagonists such as Naltrexone may exert beneficial effects in selected HIV positive patients by modifying the endogenous opioid systems.

Multiple sexually acquired diseases occurring concurrently in an HIV positive man: case report, diagnosis and management.

A case of an HIV positive man with multiple sexually acquired disease occurring concurrently is described. Risk behaviours that could have predisposed him to HIV infection are discussed. The factors which might have interacted to make the sexually acquired infections severe and difficult to treat are postulated.

PIP: The case of an HIV-seropositive man with gonorrhea, syphilis, genital warts, and chancroid is described. Multiple sexual partners, genital ulcer diseases, and lack of circumcision may have predisposed him to HIV infection. As indicated by his CD4/CD8 ratio of 0.5, his immunological status was not very compromised. Other factors were therefore probably behind these multiple sexually transmitted diseases (STD). This 30-year old man was inadequately treated for a long time for urethral discharge and genital ulcer disease, and ultimately collapsed on the job with a comprised central nervous system. Bacterial infection related to the multiple STDs could certainly have caused this collapse. The time demands of this man's work, the lack of medical facilities to diagnose and treat such conditions, his unprotected sexual behavior with multiple partners, and broader socioeconomic conditions which separate wage- earning males from their families in Africa conspire to produce multiply-afflicted cases such as these.

The pattern of neurological disease at Kenyatta National Hospital.

A retrospective survey of neurological disease seen at KNH in medical wards and medical outpatients clinics is presented. Neurological diseases constituted 7.5% of all medical conditions seen over that period. Infections especially meningitis were found to be the commonest. The 3 commonest diseases were meningitis (23.1%), epilepsy (16.6%) and cerebrovascular diseases (15.0%). Neurosyphilis, trypanosomiasis, and leprosy only infrequently seen (1-2 cases annually). Multiple sclerosis seen regularly through infrequently since 1981. The trend of the 3 commonest conditions is presented and a downward trend is noted. The mortality patterns for the 3 commonest diseases is also presented.

The experience with electroencephalography at the Kenyatta National Hospital, Nairobi.

Review of electroencephalography (EEG) requests at KNH over a 3 year period is presented. Majority of patients were aged between 0 and 10 years. None was older than 80 years. The epilepsies were the commonest reason for requesting EEG (58.5%). SSPE had the highest positivity rate of 91.7% followed by convulsive states of uncertain aetiology. The symptom of headache by itself was the least rewarding to study by EEG. It was more rewarding to first attempt to make a diagnosis of the headache. Hysteria had an EEG positivity rate of 40%, most of them being epilepsy. EEG picture for petit-mal, epilepsy focal seizure and generalized seizures are included in the text.

HIV and acute peripheral facial nerve palsy.

Between April and December 1989, 32 consecutive patients referred to the neurology clinic with acute peripheral facial paralysis were studied. Patients with traumatic facial palsy, parotid gland disease, otitis media and meningitis were excluded. Each of the patients selected had HIV test done by ELISA and the positive ones confirmed by Western blot. 8 (25%) of the patients tested positive for HIV antibodies. Their mean age was 34 +/- 13 years with an age range of 15-53 years. 4 (50%) of the 8 seropositive patients had generalized lymphadenopathy, one herpes zoster, one generalized pruritic rash, two of the patients were asymptomatic. The seroprevalence of HIV antibodies in patients with acute peripheral facial paralysis is much lower than that reported in other African countries.

PIP: Between April-December 1989, physicians at the neurology clinic of the Kenyatta National Hospital in Nairobi, Kenya recruited 32 patients who exhibited facial nerve palsy of lower motor neuron type and who did not have any trauma, inflammation of the middle ear, surgery, or disease of the parotid gland. 8 (25%) of the patients were HIV seropositive. Researchers did not retest any of the seronegative patients for HIV. 6 of the HIV seropositive cases had symptoms of early HIV infection: 4 generalized lymphadenopathy, 1 herpes zoster, and 1 generalized pruritic rash. The 2 other HIV seropositive patients did not have any symptoms other than facial paralysis. Several other studies have demonstrated an association between HIV infection and acute peripheral facial paralysis, especially in asymptomatic or AIDS related complex patients. In a study in Bangui, Central African Republic, HIV seroprevalence among patients with acute peripheral facial paralysis was 69%. The researchers could not identify the reason for the difference between the HIV seroprevalences of the 2 studies. Nevertheless physicians should expect to treat more cases of acute peripheral facial paralysis as the prevalence of HIV increases.

The management of cerebral malaria in a provincial general hospital in Kenya.

The practice of physicians at the Nakuru Provincial General Hospital (NPGH), Kenya, when dealing with cerebral malaria is reviewed over a 4-month period. The definition, management, and outcome of patients labelled to have cerebral malaria is presented and criticism of their practice offered in a manner applicable to other rural hospitals in Kenya.

Stroke at Kenyatta National Hospital.

Seventy two patients presenting with stroke to Kenyatta National Hospital were studied between January 1986 and January 1987. The majority were from the rural areas. There were about equal numbers between left and right sided hemipareses. The majority of the patients were in their 6th and 7th decades. 22 of the patients were hypertensive. Diabetes mellitus, cigarette smoking, alcohol consumption, and valvular heart disease were some of the other factors associated with strokes. 46% of the patients died while the remainder had residual neurological deficits.