Undifferentiated systemic connective tissue disease-"overlap' in Zimbabwe.

OBJECTIVE: To define the clinical characteristics of the overlapping, undifferentiated systemic connective tissue disease in one of the tropical African countries. DESIGN: A descriptive retrospective study of records of patients registered on a special rheumatology clinic between 1989 and 1994. SETTING: Harare Central Hospital Rheumatology Clinic, Zimbabwe. SUBJECTS: All registered patients with systemic connective tissue diseases. MAIN OUTCOME MEASURES: Numbers of patients, laboratory and clinical features of undifferentiated overlapping connective tissue disease. RESULTS: The distribution for those who satisfied internationally accepted criteria for classification/diagnosis were: 48(52.8pc) rheumatoid arthritis (RA), 17(18.7pc) systemic lupus erythematosus (SLE), 10(11pc) juvenile chronic arthritis (JCA), four (4.4pc) polymyositis/dermatomyositis (PMD) and 11 (12.1pc) overlapping connective tissue disease (overlap) and one unclassified disease. No pure progressive systemic (PSS) was registered. Among the overlap patients, five had SLE-RA, three SLE-PSS and one each for SLE-RA-PSS, RA-PSS and SLE-PDM overlapping clinical features respectively. In two patients with SLE-PSS, the criteria of each of the individual connective tissue disease were satisfied. Similarly, in one patient with SLE-RA and another with RA-PSS features, the criteria of individual disease were also satisfied. CONCLUSION: In undifferentiated overlapping connective tissue diseases-overlaps occur in tropical Africa, the SLE-RA overlapping features predominate and are moderately severe diseases.

Gout and hyperuricaemia.

We have recounted the remarkable story of gout and hyperuricaemia in the indigenous populations of the Pacific and noted the recent identification of the same problem in communities in rural Indonesia. Gout is increasingly recognized in African populations, especially in urban centres. There is no doubt that gout is 'alive and well' and presents a continuing challenge to future generations in developing countries.

The clinical, serologic and radiologic features of rheumatoid arthritis in ethnic black Zimbabwean and British Caucasian patients.

OBJECTIVE: To compare the clinical, serologic and radiologic expression of rheumatoid arthritis (RA) in UK Caucasian and ethnic black patients from Zimbabwe. METHODS: Standardized protocols and assessment criteria were used to study 84 black patients with no non-Bantu antecedents and 84 UK Caucasian patients with RA (matched for disease duration, sex and age). RESULTS: Articular manifestations of RA were less severe in the black patients with RA from Zimbabwe as shown by less early morning stiffness (p = 0.001), fewer patients with > or = 3 active joints (p = 0.01), fewer joint deformities (p = 0.004) and better grip strength (p = 0.001) in comparison to the white patients with RA from the UK. Caucasian patients had a higher frequency of extraarticular manifestations (p = 1 x 10(-6)) including rheumatoid nodules (p = 0.0001), Raynaud's (p = 0.01) and Sicca syndrome (p = 0.001). Toxic effects from disease modifying antirheumatic drugs occurred less frequently in black patients (p = 0.0002). More white patients had Ro and La antibodies. The radiologic changes in the black patients were less severe than those in the white patients. The distribution of erosions in hands and feet were different in the 2 groups of patients studied. There were no differences between the urban and rural black patients but a more detailed study involving a large number of patients is required to confirm this observation. CONCLUSION: Black patients with RA from Zimbabwe have a disease that is clinically and radiologically less severe with fewer extraarticular features when compared to UK white patients.

Sequence-specific oligonucleotide typing in Shona patients with rheumatoid arthritis and healthy controls from Zimbabwe.

Seventy-two patients with rheumatoid arthritis (RA) and 82 controls have been typed with the XI Histocompatibility Workshop DRB1 and DQB1 sequence-specific oligonucleotide probes. The increase of DRB1*04 corresponds to an increase of the serologically defined DR4, previously found in a small group of Zimbabwean RA patients and we now show that this increase is due to the subtype DRB1*0405 in association with DQB1*0302. In addition there is a clearcut increase of DRB1*1001 equivalent to the serologically defined DR10. There was no increase amongst RA patients of DRB1*0102 which was the predominant DR1 sub-type amongst controls. In the course of our investigation, we observed a DRB1*04 variant which corresponds to DRB1*0412, newly defined in the XIth Histocompatibility Workshop.

Gout: an experience from Zimbabwe.

Twenty three patients with gout treated and followed up in Zimbabwe over a five year period were analysed. Men were afflicted 6.7 times more than women. Their mean age at diagnosis was 44 +/- 8 years and the mean serum uric acid level was 588 +/- 138 mumol/l. The disease was diagnosed late with 30.4 pc of all patients presenting with tophi. Associated alcohol excess was universal and the shoulder, a proximal big joint, was also affected in 21.7 pc of all patients. There is a need for serum uric acid levels for the different localities in Africa to be mapped out and alcohol excess to be curtailed.

A clinical assessment of the consequences of alcohol consumption in 'communal' drinkers in the Zimbabwean Midlands.

The study was undertaken to clinically assess the consequences of alcohol consumption in 'communal' drinking patients whose levels of alcohol consumption could not be determined accurately in grams of alcohol. The level of alcohol consumed by 100 adult 'communal' drinking medical patients per drinking session was scored on a scale 0-10. The score was based on a qualitative impression of how much alcohol was drunk, level of consciousness, behaviour and gait. The frequency of drinking days in a week was scored on a 0-7 scale. The duration of drinking in years prior to registration at the clinic was also recorded. The pattern of diseases among the drinkers was compared to that of 70 adult non-drinkers. The individual diseases were ranked to association with alcohol consumption by the Kruskal-Wallis Test. The drinkers attained a mean level score of 5.75 +/- 2.16, a frequency of 4.75 +/- 2.4 days but the duration of prior drinking varied greatly. Gout, dilated cardiomyopathy, epilepsy and hypertension ranked highest in that order to alcohol usage. Rheumatic heart disease and Diabetes mellitus ranked low. The probability significance were, for level score p = 0.005, frequency p = 0.016 and duration p = 0.001. This method was able to identify the morbid chronic medical diseases associated with alcohol usage in 'communal' drinkers. There is a need to evaluate it against a known screening instrument like the Alcohol Use Disorders Identification Test (AUDIT).

Complications of seasonal adult malaria at a central hospital.

Recently introduced chloroquine resistant malaria has altered the clinical picture and complicated the overall management of malaria. 113 adults with proved malaria admitted at Harare Central Hospital, Zimbabwe, were evaluated to determine the incidence, nature, relationship to morbidity and mortality and response to treatment of the complications due to malaria. 47.7 pc (52 of 109) patients had relatively chloroquine resistant malaria. 87.4 pc (99 of 113) had complications whose percentage frequency of occurrence were: Anaemia 51.2 pc, diarrhoea and/or vomiting 42.2 pc, cerebral malaria +/- fits 39.2 pc, renal insufficiency +/- hyperkalaemia 26.4 pc, hypoglycaemia 15.6 pc, jaundice 15.2 pc, neuro-psychiatric 15.0 pc, shock 10.6 pc, concurrent sepsis 8.9 pc, pulmonary oedema 3.5 pc and hyperpyrexia 1.7 pc. Multiple complications in the same patient were common. The combination of cerebral malaria and renal insufficiency had the worst mortality (p less than 0.001). All patients dialysed, however, survived. Non-iron deficiency anaemia, 91.7 pc (51 of 55) and diarrhoea and/or vomiting, were common, worsened morbidity but not mortality (p = 0.555). A seriously-ill patient with malaria should be suspected of having complications and chloroquine resistance and should be referred promptly to a centre with facilities for dialysis. Anti-malaria drugs should be mixed in a dextrose solution and iron supplements should not be given routinely.

Acute pulmonary oedema caused by lightning.

A case of a 35-year-old housewife who developed acute pulmonary oedema due to the blast effect of lightning is reported. The literature is reviewed and the general effects of lightning are discussed.

Experience on follow-up of registered rheumatic fever patients in the Zimbabwean Midlands.

A total of 75 patients with rheumatic fever, 49 acute (ARF) and 26 acute-on-chronic (A-C-RF), registered in the Zimbabwean Midlands during a 7 year period [1973-1980], followed up for 1-12 years where each one had a potential of follow-up of at least 5 years, were reviewed. Their mean age at diagnosis was 13.2 +/- 7.9 (range 3-39) years and 5 of them were over thirty years old. Thirty five percent were followed up regularly although only 20% realised the full potential. 12% of ARF who initially had no carditis, developed it on a recurrence. The disease was more florid among defaulters than among regulars; chronic valvular lesions being clinically established in 2.8 +/- 1.8 (range 1-6) years; chronic heart failure developing in 5.2 years and death occurring in relatively young patients aged 10.9 +/- 3.0 years old. There were more recurrences among defaulters than among regulars (p less than 0.001). The follow-up was better in those with clinically established valvular lesions, worse in the asymptomatic ones and it was unrelated to age or residence. In addition to improving social-economic conditions, parenteral penicillin prophylaxis should be continued until one is at least 40 years old.

Chronic inflammatory rheumatic diseases in black Zimbabweans.

The pattern of chronic inflammatory rheumatic diseases seen in 52 black Zimbabweans was determined. These diseases constituted 2% of all treatable chronic endemic medical diseases registered around Gweru City. Rheumatoid arthritis (RA) and gout were the commonest, 38.8% and 28.8% of the total respectively. Systemic lupus erythematosus (SLE), polymyositis, progressive systemic sclerosis, mixed connective tissue disease, ankylosing spondylitis, and Reiter's diseases were seen less frequently. While the rarity of ankylosing spondylitis was not surprising, that of SLE was striking. RA seen in Zimbabwe was as severe as in East Africa, with a mean age of onset of 43.6 (SD 9.6) years, mean ESR 67 (SD 33) mm/h, seropositivity 78%, subcutaneous nodules 10%, and overall deformities in 35% of all cases. Gout was as seen elsewhere, with a mean age of onset 41.5 (SD 7.95) years, M:F ratio 6.5:1, mean male serum uric acid 10.8 (SD 2.69) mg/dl (0.64 +/- 0.16 mmol/l). Alcohol as a precipitating and aggravating factor was supported by a high mean drunkenness score of 10.3 (SD 3.89) out of a maximum of 17. Unawareness and underdiagnosis of these diseases are still likely problems in this part of the world.