Chronic lymphocytic leukaemia (CLL) in Central Africans.

OBJECTIVE: To document the clinical and haematological features of chronic lymphocytic leukaemia (CLL) in Central Africans. DESIGN: Prospective descriptive analysis. SETTING: Tertiary referral teaching hospitals. SUBJECTS: 48 Zimbabweans and 27 Malawians formed the basis of this analysis. RESULTS: There were 75 patients (40 males and 35 females) studied and their ages ranged from 32 to 78 years with a mean +/- s.d. of 56.8 +/- 10.1 years. The peak age incidence of 26.7% occurred between 60 to 64 year old and 21.3% were below 50 years. The major clinical findings included: splenomegaly (68%); hepatomegaly (37.3%); anaemia (34.7%); lymphadenopathy (33.3%) and nine (12%) patients were diagnosed incidentally. The majority of patients (78.7%) had Rai stage III and IV and only seven (9.3%) patients were in stage 0. Of the 32 patients treated with chemotherapy, 25.9% and 59.3% achieved complete or partial remissions respectively. Six patients were still alive after a follow up period of a mean +/- s.d of 39.3 +/- 24.4 months; five were lost to follow up after a mean +/- s.d period of 28.6 +/- 18.8 months and 16 were dead after a mean +/- s.d. period of 25.7 +/- 19.1 months. The main causes of death in the treated group were septicaemia in six, pneumonia in four and tuberculosis in three. In the untreated group of 43 patients, two refused therapy, four died shortly after diagnosis and 37 were lost to follow up. CONCLUSIONS AND RECOMMENDATIONS: Although the study has disclosed that CLL is not rare in central Africans and its presentations are similar to cases reported in the literature, the majority of patients seek medical treatment late. Optimal therapy is impossible due to lack of chemotherapy and supportive services..Therefore, it is recommended that tertiary referral centers in African health systems should be equipped for better management of CLL patients.

Chronic myeloid leukaemia in central Africans.

OBJECTIVES: To document the pattern of presenting clinical and haematological features of chronic myeloid leukaemia (CML) in central Africans and evaluate the clinical consequences of treating the disease with chemotherapy. DESIGN: Prospective descriptive analysis of clinical and haematological data. SETTING: Departments of Haematology of tertiary referral centres and teaching hospitals. MATERIALS AND METHODS: Prospective clinical and haematological data were collected on 150 central Africans (90 Zimbabweans and 60 Malawians) using modern Coulter counters and standard up-to-date haematological procedures and the results analysed using predetermined criteria and the top-desk Scientific Calculator Model HP 48GX, Texas Instruments, USA. RESULTS: There were 150 CML patients studied. Males predominated in a ratio of 1:5:1. The youngest patient was 10 years and the oldest 77 years with a mean +/- s.d. of 38.9 +/- 14.7 years. The peak age incidence of 47.3% occurred between 21 to 40 years. The Ph chromosome was found in 19 of the 20 patients studied. Although complaints attributed to splenic enlargement were the most common symptoms, several unusual clinical features were encountered viz: hepatomegaly (26%), bleeding (12%), significant lymphadenopathy (11.3%), purpura (3.3%), skin infiltration (2.7%), cardiac failure (2.7%) and 14.7% were diagnosed incidentally. Symptoms such as fatigue, headaches and weight loss were associated with greater degrees of leucocytosis, severe to gross splenomegaly and lower haemoglobin levels. The severe to gross splenomegaly which occurred in 68(45.3%) suggests that patients in this part of the world seek medical advice rather late in the disease. The median survival times of 65,47 and 39 months respectively for alpha interferon, hydroxyurea and busulphan are in agreement with those of previous larger series from other parts of the world. CONCLUSIONS: The study has revealed that the presenting pattern of clinical and haematological features of CML is changing probably due to the advent of modern clinical practice coupled with increased physician density, greater awareness of disease among clinicians besides other reasons. However, optimal treatment is not possible for the majority of patients due to lack of chemotherapeutic agents and supportive care. RECOMMENDATION: Referral centres in African health systems should be equipped for better management of CML patients.

Leukaemia at Queen Elizabeth Central Hospital in Blantyre, Malawi.

OBJECTIVES: To determine the patterns of leukaemias seen in Malawians at Queen Elizabeth Central Hospital (QECH) and to compare the findings with those from elsewhere. An overview of the problems encountered in the management of leukaemia in developing countries especially those in sub-Saharan Africa are highlighted. DESIGN: Retrospective descriptive analysis of consecutive leukaemia cases seen from January 1994 through December 1998. RESULTS: Of the 95 leukaemia patients diagnosed during the study period, childhood (0-15 years) leukaemia occurred in 27 (28.4%) patients while adulthood (above 15 years) leukaemia accounted for 68 (71.6%) patients. The main leukaemia types were: acute lymphoblastic leukaemia (ALL) 14 (14.7%), acute myeloblastic leukaemia (AML) 25 (26.3%), chronic myeloid (granulocytic) leukaemia (CML) 32 (33.7%), chronic lymphocytic (lymphatic) leukaemia (CLL) 22 (23.2%) and hairy cell leukaemia (HCL) two (2.1%) patients. Most of the acute leukaemia (AL) cases occurred in the six to 15 year age bracket with a male preponderance. In ALL, lymphadenopathy was the commonest presenting feature followed by pallor (92.9%) while in the AML group, pallor occurred in 80% of cases. Abdominal swelling (87.5%) due to splenomegaly (81.3%) were the main clinical features in the CML group whereas lymphadenopathy (63.6%) followed by splenomegaly (59.1%) were the dominant presenting features in CLL. Haematologically, although leucocytosis characterised both acute and chronic leukaemias, most cases of acute leukaemia presented with more severe anaemia (Hb < 7 g/dl) and marked thrombocytopenia (Platelet count < 50 x 10(9)/l) than the chronic leukaemias. CONCLUSIONS AND RECOMMENDATIONS: The study shows that leukaemias are not rare in Malawi and cases which were diagnosed in this series probably only represent the tip of the iceberg. While there is need to increase diagnostic awareness among clinicians and laboratory staff, the severe chronic shortage of cytotoxic drugs and lack of supportive care facilities commonly encountered in developing countries should be realistically addressed through cost-sharing, cost recovery, adequate government subvention and donations from charitable organisations.

The use of sputum induction for establishing a diagnosis in patients with suspected pulmonary tuberculosis in Malawi.

SETTING: There has been a marked increase in notified cases of smear-negative pulmonary tuberculosis in Malawi since 1986. One reason for this may be related to the difficulties of getting adequate samples of expectorated sputum from patients. Sputum induction with nebulized hypertonic saline may be a simple way of obtaining a better specimen. OBJECTIVE: To examine the value of sputum induction for detecting cases of smear-positive tuberculosis. DESIGN: Sputum induction was performed on 82 adults presenting to the Queen Elizabeth Central Hospital, Blantyre, Malawi with clinically suspected pulmonary tuberculosis who were expectorated sputum smear-negative or unproductive of sputum. The induced sputum smear was examined for acid-fast bacilli and cultured for mycobacteria. RESULTS: Sputum was successfully induced from 73 of the 82 patients (26 previously smear-negative and 47 previously unproductive). The induced sputum was smear-positive in 18 patients (5 previously smear-negative and 13 unproductive). Cultures were positive for Mycobacterium tuberculosis in the 18 smear-positive patients and a further 12 that had been smear-negative. 94 cases of smear-positive pulmonary tuberculosis were notified during the study period. 18 (19%) were as a result of sputum induction. CONCLUSION: Sputum induction is a useful technique for improving the case detection rate of smear-positive tuberculosis in Malawi.