Haematology Consultations in a Tertiary Health Care Centre in Nigeria.

BACKGROUND AND OBJECTIVES: The ease with which investigations are done in this technological age increases the possibility of finding abnormal haematological values, which inevitably leads to haematologic consultations. The Department of Haematology at the University College Hospital (UCH), Ibadan provides a busy consultative service for in-patients and out-patients suspected of having a haematological disorder. This study reviewed the consultations received from different clinical departments to Consultant Haematologists at our tertiary hospital. METHODS: Analysis of consultation requests on in-patients received in the Haematology department, UCH between June 2015 and January 2016 was done. During this period, the department had six Haematologists and nine resident doctors. SPSS version 22 was employed for the statistical analysis. RESULTS: A total of 285 consultation requests were received during the study period, with an average of 36 consults per month. The highest number was received in July 2015. The patients reviewed had a mean age of 36.9±19 years, and requests on female patients exceeded those on males, with a M:F ratio 1:1.5. Consultation for a presumptive diagnosis of sickle cell disease (SCD) were the commonest indication (17%). The highest consultation was from Obstetrics and Gynaecology (O&G) (25%) while the least was from Radiation Oncology (0.4%). CONCLUSION: There is an increasing role for the Haematologist in sub-Saharan Africa as evidenced by the high frequency of consultations observed in this review. The management team of each teaching hospital should bear in mind the need to have adequate number of Haematologists so as to ensure optimal haematological services.

Changes in mediators of inflammation and pro-thrombosis after 12 months of dietary modification in adults with metabolic syndrome.

OBJECTIVE: This study evaluated the effects of a 12-month dietary modification on indices of inflammation and pro-thrombosis in adults with metabolic syndrome (MS). MATERIALS AND METHODS: This longitudinal study involved 252 adults with MS recruited from the Bodija market, Ibadan and its environs. Participants were placed on 20%, 30% and 50% calories obtained from protein, total fat and carbohydrate respectively and were followed up monthly for 12 months. Anthropometry and blood pressure were measured using standard methods. Fasting plasma glucose (FPG), total cholesterol (TC), triglycerides (TG), high density lipoprotein-cholesterol (HDL-C), fibrinogen, plasminogen activator inhibitor-1 (PAI-1)], interleukin-6 (IL-6) and interleukin-10 (IL-10) were measured using spectrophotometric methods and ELISA as appropriate. Data was analysed using ANCOVA, Student's t-test, Mann-Whitney U and Wilcoxon signed-rank tests. P-values less than 0.05 were considered significant. RESULTS: After 6 months of dietary modification, there was a significant reduction in waist circumference (WC), while the levels of HDL-C, fibrinogen and PAI-1 were significantly increased when compared with the corresponding baseline values. However, WC and fibrinogen reduced significantly, while HDL-C and IL-10 significantly increased after 12 months of dietary modification as compared with the respective baseline values. CONCLUSION: Long-term regular dietary modification may be beneficial in ameliorating inflammation and pro-thrombosis in metabolic syndrome.

Current sickle cell disease management practices in Nigeria.

BACKGROUND: Although Nigeria has the highest burden of sickle cell disease (SCD) worldwide, there is still variable and poor utilisation of standard-of-care practices for SCD patients in the country. METHODS: This was a questionnaire survey of doctors in some dedicated SCD clinics in Nigeria in order to document the facilities available and common management practices. RESULTS: There were responses from 18 clinics based in 11 institutions. The number of patients being followed in each centre ranged from 15 to approximately 11 000. All clinics provided malaria prophylaxis and folic acid routinely to their patients. Only eight clinics prescribe penicillin prophylaxis. Eight prescribe hydroxyurea to patients who can afford it when indicated. All of the centres except three have electronic cell counters, but all had access to haemoglobin electrophoresis. Three had high-performance liquid chromatography machines installed but none was being routinely used. One institution had a functioning molecular biology laboratory. There is no official newborn screening programme in the country. All had access to microbiology and chemistry laboratories. Nine institutions had CT, six had MRI and three had transcranial Doppler facilities. CONCLUSION: The care available for SCD in Nigeria is still suboptimal and there is an urgent need for concerted effort to tackle the problem, but to make a significant impact on the burden of the disease would require more focus at the primary care level. Some steps to achieving this are outlined.

Metabolic alterations in different stages of hypertension in an apparently healthy nigerian population.

Metabolic syndrome (MS) amplifies hypertension (HTN) associated with increased risk of cardiovascular disease (CVD). MS components and other CVD risk measures were investigated in different stages of hypertension. 534 apparently healthy Nigerian traders aged 18-105 years were participants of a cohort study. The International Diabetes Federation (2005) and the National High Blood Pressure Education Program Coordinating Committee criteria were used for MS and HTN classifications, respectively. Anthropometric indices were obtained by standard methods. Levels of fasting plasma glucose (FPG), total cholesterol (TC), triglyceride (TG), and high-density lipoprotein cholesterol (HDLC) were determined by enzymatic methods, while low-density lipoprotein cholesterol (LDLC) was calculated. Data analysed statistically were significant at P < 0.05. 143 (26.8%), 197 (36.9%), and 194 (36.3%) of the traders had normotension, pre-HTN and HTN (stages 1 and 2), respectively. All indices tested except HDLC were significantly different among BP groups (P < 0.05). Waist to hip (WHR) and waist to height (WHT) ratios were significantly different between HTN groups (P < 0.05). HTN was associated with MS and female gender (P < 0.05). Metabolic alterations and significant HTN were observed. Treatment of the individual components of the syndrome and improvement of modifiable metabolic factors may be necessary to reduce MS and high BP.

Serum levels of copeptin, C-reactive protein and cortisol in different severity groups of sickle cell anaemia.

It is well known that individuals with SCA undergo constant physiological stress even, in steady state. However, there is little information on the relationship between the severity of sickle cell anaemia (SCA) and serum levels of biomarkers of stress. This study therefore determined the serum levels of copeptin, cortisol and CRP in adults with SCA in different severity groups. Sixty adults with sickle cell anaemia in steady state (27.1±6.3 years) and in vaso-occlusive crisis (24.9±4.9 years) were recruited into this cross-sectional study. Degree of severity (mild, moderate or severe) was determined using a scoring system incorporating annual number of blood transfusions, crisis and presence of anaemia, vaso-occlusive pain and organ complications. Standard methods were used for the determination of packed cell volume (PCV), total white blood cell count (WBC), blood pressure measurements and anthropometric indices. Serum levels of copeptin, cortisol and CRP were determined using ELISA with the ratios calculated accordingly. Data obtained were statistically analyzed using the Student's t-test, Mann Whitney U and Chi-square test as appropriate. P<0.05 was considered significant. The mean systolic blood pressure (SBP) and copeptin level were significantly higher in subjects with moderate SCA compared with those with mild SCA. Similarly SBP, pulse, WBC, copeptin and cortisol were significantly higher while body weight was significantly lower in subjects with severe SCA compared with subjects with mild SCA. However, WBC and cortisol-to-copeptin ratio were significantly higher in subjects with severe SCA compared with subjects with moderate SCA. There was progressive rise in serum levels of CRP from mild SCA through severe SCA but the differences were not statistically significant. Also, proportions of subjects with elevated SBP and WBC were higher than the proportion of subjects with lower SBP and WBC in the severe SCA group. Serum levels of cortisol, copeptin, and their ratio could differentiate severe SCA from mild or moderate SCA. Also, elevated systolic blood pressure and total white blood cell count are associated with severe sickle cell anaemia.

Therapy Outcome of a T-Cell-Rich-B-Cell Lymphoma (TCRBCL) Patient with R-CHOP in Ibadan, Nigeria: a Case Report.

T-cell-rich B-cell lymphoma (TCRBCL) is considered a rare variant of aggressive B cell lymphoma characterized by few neoplastic B cells and a large reactive infiltrate with striking similarities to nodular lymphocyte predominant Hodgkin's lymphoma.A case of a 46 year old man referred with a 5 months history of generalized lymphadenopathy, weight loss, low grade pyrexia and two separately reported lymph node histology consistent with TCRBCL is described.The clinical course was indeed aggressive because in spite of initial treatment with four cycles of CHOP combination chemotherapy, followed by R+CHOP(x 6 cycles), signs of tumor re-growth/infiltration were frequently observed. Also, recurrent infection was frequent, troublesome and eventually became overwhelming resulting to the loss of the patient.This case, being the first case of TCRBCL diagnosed by immunohistochemical confirmation and managed at this centre with R-CHOP, is presented to highlight the dilemma in making diagnosis, clinical challenges faced and rituximab therapy outcome especially in resource poor country. It will also serve to increase our index of suspicion and the need reinforce immunohistochemistry in the diagnosis of lymphoma.

Antioxidant Levels of Acute Leukaemia Patients in Nigeria

The incorporation of nutritional screening and comprehensive assessments of oxidative stress is increasingly recognised as imperative in the development of standards for quality care in oncology. This study evaluated the levels of nitric oxide (NO); some essential trace metals (Zn; Cu; Fe; and Se); superoxide dismutase (SOD) activity and malondialdehyde (MDA) in twenty five (25) patients with acute leukaemia and 25 apparently healthy controls. The mean levels of plasma Zinc (Zn); Iron (Fe) and Selenium (Se) were not significantly elevated (p 0.05) in leukaemia patients compared with controls. Also; slightly lower level of plasma Cu was observed in leukaemia patients compared with the controls. However; nitric oxide was significantly increased (p 0.05) in leukaemia patients compared with controls. The implication of the present finding is that intervention to increase antioxidant status in patients with Acute Lymphoblastic Leukaemia (ALL) should be considered

FOETAL HAEMOGLOBIN (HbF) STATUS IN ADULT SICKLE CELL ANAEMIA PATIENTS IN IBADAN, NIGERIA.

AIM: Elevated HbF, among other biological and environmental factors, is responsible for decrease in mortality in sickle cell anaemia (SCA). This study determined the levels of HbF in adult SCA patients in steady state compared with HbAA controls. HbF was discussed in line with the clinical course of the disease so as to emphasize the relevance of hydroxyurea in the management of adult SCA patients. MATERIALS AND METHODS: The HbF levels of 66 confirmed SCA patients and 31 HbAA controls were estimated using Betke method and HbF percentage was calculated using formula: %HbF percentage = A413 filtrate x 100A413 standard x 20. RESULT: A statistical significant difference in the mean of the levels of HbF in patients (5.16±4.04) compared to controls (1.04±0.44) (p = 0.000) was observed. The mean levels of HbF for males (4.71±3.49) compared to that of females (4.99) were statistically similar (p =0.773). It was also observed that the mean HbF level appears to be declining as age advances. SCA patients were classified to three categories viz: HbF <2% (21.2% SCA patients); HbF of 2.1% -10%, (68.2% SCA patients); and HbF of 10.1% -16%, (10.6% SCA patients). CONCLUSION: Substantial proportion of our patients actually will require treatment with hydroxylurea to stimulate HbF production especially those with HbF percentage of <2 and some with HbF percentage of 2.1 - 10%. HPFH may be considered rare since only 10. 6% had HbF at the range of 10.1-16%. This study showed that in treating our SCA patients in Nigeria we need to adopt and encourage the use of HbF activating agents like hydroxyurea or any other safe agent that will be found to stimulate HbF production in SCD patients.

Richter's syndrome: a case report.

OBJECTIVE: To report a case of Richter's syndrome found in one of the teaching hospitals in Nigeria in the context of sparse earlier reports of Richter's syndrome in western Africa. CLINICAL PRESENTATION AND INTERVENTION: A 52-year-old male had been diagnosed earlier as having chronic lymphocytic leukaemia (CLL) and treated for 6 months with chlorambucil, although compliance was poor and the patient eventually stopped treatment. He presented to our hospital 18 months later with clinical features in keeping with Richter's syndrome. The blood and bone marrow smear review, together with fine-needle aspiration cytology of the masses, showed diffuse large cells of non-Hodgkin lymphoma consistent with the Richter's syndrome stage of CLL. There was significant improvement in response to the first 4 cycles of CHOP chemotherapy (consisting of cyclophosphamide, doxorubicin, vincristine and prednisolone) instituted, but then there were features of relapse. CONCLUSION: The case report serves to increase awareness and improve the index of suspicion about the terminal phase of CLL and low-grade lymphoma. It equally emphasizes the great need to strengthen further the laboratory diagnosis of haematological malignancies in developing countries.

An Acute Leukaemia Masquerading as Immune Thrombocytopaenic Purpura (ITP)? A Case Report.

This is a case report of a 35 year old female with diagnosed Immune Thrombocytopaenic Purpura (ITP) that was strangely followed by acute myeloid leukaemia at 10 months post diagnosis of ITP. She was managed as ITP using prednisolone 45 mg daily for 10 months with good response. She also synchronously carried a pregnancy to term and safe delivery. Shortly after delivery, she represented with gingival bleeding and peripheral film review and subsequent bone marrow cytology was in keeping with AML-M4 subtype. She died shortly after diagnosis without being able to receive chemotherapy.

Multiple complications in a sickle cell disease patient: a case report.

Summary This case report illustrates the multiple complications experienced by a sickle cell anaemia patient. Although he enjoyed fairly good health till age 16 years; he subsequently suffered grade four bilateral femoral head necrosis, cerebella infarct and cerebral atrophy from cumulative effect of repetitive vasoocclussion, recurrent overwhelming septicaemia, fixed flexion deformities and decubitous ulcer as a sequelae of earlier complications. He eventually became bed ridden. Financial constraint seriously compounded these problems. The determinants, of which type of the wide-ranging complications of SCD a particular patient will eventually develop, remain elusive.

Essential trace elements and antioxidant status in relation to severity of HIV in Nigerian patients.

OBJECTIVES: This study was designed to determine the plasma levels of some antioxidants and trace elements in three severity groups of HIV patients compared with non-HIV-infected controls. METHODS: The plasma levels of antioxidants (total antioxidant, albumin, bilirubin and uric acid) and trace elements (Mg, Fe, Zn, Mn, Cu, Cr, Cd and Se) were estimated spectrophotometrically in controls and patients with CD4 counts of <200; 200-499 and > or =500 cells/microl. RESULTS: Uric acid and Zn were significantly higher, while vitamin E and all the trace elements (except Zn) were significantly lower in HIV-infected patients compared to healthy controls. The highest level of uric acid was observed in those with CD4 counts of <200 cells/microl. All the trace elements (except Zn) were higher in HIV subjects with a CD4 count of 200-499 cells/microl compared to >500 cells/microl. Only uric acid and Zn showed significant correlation with CD4 count. CONCLUSION: Based on the results of this study, we recommend routine assessment and appropriate supplementation of antioxidants/trace elements in HIV subjects. This supplementation is hoped to strengthen the immune system and reduce the adverse consequences of HIV- related oxidative stress.

Frequency of hepatomegaly and splenomegaly in Nigerian patients with sickle cell disease.

BACKGROUND: Hepatobiliary and splenic complications (amongst others) are common in sickle cell disease (SCD) as a consequence of the progressive injury resulting from repeated sickling of HbS red blood cells. OBJECTIVE: To determine the degree and the frequency of persistent hepatomegaly and splenomegaly in relation to determinants of clinical severity in patients with SCD. METHODS: Two hundred and twenty SCD patients in clinical steady state were assessed for the presence and the size of palpably enlarged spleen and liver. Patients with hepatomegaly or splenomegaly were re-assessed after three months. Average size was recorded as well as the electrophoresis pattern, age at asessment, sex and the haematocrit. These were compiled over one year RESULTS: The mean age of the SCD patients was 24.7 (8.7) years. HbS and female subjects predominated, constituting 89% and 57% respectively. Females had statistically significantly higher mean age of years than males, (p < 0.001). Splenomegaly was present in 46 (21%) of SCD patients, of which 39 (84.8%) were HbSS, with a mean splenic size of 8.7 (7) cm. Out of the 220 SCD patients, hepatomegaly was present in 59%, with a mean size of 7.6 (6.5) cm. However, higher frequency and a significantly bigger size of hepatomegaly were found in patients with HbS than in those with HbSC. The mean age of 27.2 (10.9) years and the mean of PCV of 24.1 (4.9) in the 82 (37%) patients without hepatomegaly and splenomegaly were significantly higher (p = 0.001) than the general population of SCD patients studied. CONCLUSION: Hepatomegaly of varying sizes occurs commonly in patients with HbS and probably connotes a severe clinical course. The aversions that there is predominance of HbS, survival advantage of females and the fact that HbSC fair better than HbS remain true.

Case report: extra pulmonary tuberculosis in sickle cell disease.

In apparently healthy individuals, tuberculosis (TB) affects mainly the lungs however, worsening immune status tend to predispose to an increased tendency for extra-pulmonary tuberculosis (EPTB). We report the case of a 22 year old known sickle cell anaemia (HBS) female student with three-month history of bilateral hip pain, weight loss and swelling of the left hip with multiple discharging sinuses, paraplegia and recurrent fever. There was no preceding history of trauma. Full Blood Count (FBC) revealed leukocytosis with neutrophilia, monocytosis, thrombocytosis and Packed Cell Volume (PCV) of 23%. Erythrocyte sedimentation rate (ESR) was 120mm/Hr (Western Green) and retroviral screening was negative. Bacteriologic culture of the discharging sinuses grew Escherichia coli and Staphylococcus aureus, both sensitive to sparfloxacin. Smear microscopy for acid-fast-bacilli (AFB) was negative. Chest X-Ray was reported normal but X-Ray of the pelvis showed loss of L4/L5 disc space and appearances suggestive of avascular necrosis of the femoral heads. Clinical and haematological profile of the patient started to improve by the second month on therapeutic trial of anti-TB regimen. She had nine-month course of therapy and later discharged to physiotherapy clinic. Management of EPTB requires a high index of clinical suspicion and well-equipped laboratory to support the diagnosis. Therefore, this case report highlights the need to upgrade TB-diagnostic facilities in this environment.

Acute phase proteins, trace elements in asymptomatic human immunodeficiency virus infection in Nigerians.

The natural history of Human Immunodeficiency Virus (HIV) infection is incompletely understood. Factors other than HIV infection alone may be required for the development of the profound immunosuppression that characterizes advanced HIV disease. Nutritional status plays an important role in maintaining normal immunity and thus may be one of these factors. The plasma concentrations of C-reactive protein, transferrin, selected trace elements (Mg, Zn, Fe, Cu, Cd, Se and Cr,), total protein and albumin were determined in 25 asymptomatic HIV-infected Nigerian subjects and 30 age matched HIV-seronegative controls using single radial immunodiffusion and spectrophotometric methods. The mean values of Cu (73.2 + 23.9 microg/dl), Mg (9.83 + 5.5 mg/dl), Fe (126 + 21 microg/L), Cd (24.6 + 7.2 microg/L), Se (22.0 + 12.2 microg/dl) and Cr (19.0 + 5.2 microg/L) were low in asymptomatic HIV-positive subjects when compared with the controls (Cu = 119.3 + 30.8 microg/dl; Mg = 14.5 + 4.6 mg/L; Fe = 155 + 8.8 microg/ dl; Cd = 33. 1 + 8.3 microg/L; Se = 30.9 + 8.3 microg/dl; Cr = 32.1 + 7.8 microg/ L). The level of Zn was similar in asymptomatic HIV-positive subjects (5.1 + 1.9 mg/dl) and the controls (4.6 + 1.7mg/dl). The value of albumin in asymptomatic HIV-positive subjects (3.43 + 0.7 g/dl) was significantly low when compared with the controls (4.04 + 0.52 g/dl). Significant correlation existed between albumin and Mg in asymptomatic HIV subjects (r = + 0.758, p < 0.001). The mean value of C-reactive protein was significantly higher in HIV-infected subjects compared with the controls while the level of transferrin in HIV-infected subjects (92.86 + 26.3 mg/dl) did not show any significant difference when compared with the controls (84.36 + 16.9 mg/dl). This study revealed the deficiencies of trace elements in asymptomatic HIV infection and therefore suggests dietary supplementation of these trace elements in the infected subjects.

Haematological profile of patients with pulmonary tuberculosis in Ibadan, Nigeria.

The haematological indices of sixty two pre-treatment, sputum-smear-AFB positive pulmonary tuberculosis patients were examined. Haematocrit, white cell count and differentials and erythrocyte sedimentation rates (ESR) were estimated by manual methods. The heamatological parameters were compared with age and sex matched control subjects. Statistically significant heamatologic abnormalities found include high erythrocyte sedimentation rate (ESR), anaemia occurred in 93.6%, leucocytosis in 22.3%, neutrophilia in 45.2% and lymphopaenia in 4.8% of the patients. Thrombocytosis occurred in 12.9%,while 8% had thrombocytopaenia. None of the patients had leucopaenia and only 8.4% had lymphocytosis.

Bone marrow findings in patients with pulmonary tuberculosis.

The cytology and culture of bone marrow aspirate in sixty-two newly diagnosed patients with pulmonary tuberculosis were studied. The findings were depressed erythroid activity in 69% of the patients, micronormoblastic changes in 18% and megaloblastic changes in 16.6%. Myeloid activity was increased in 65% of the patients. Normal looking plasma cells above 5% was found in 17.7% of the bone marrow aspirates while 12.9% had eosinophilic precursors above 5% in the marrow. None of the marrow smears showed granuloma formation or caseation necrosis. The bone marrow cultures yielded no growth of Mycobaterium tuberculosis while stainable iron in the marrow was found to be low or negative in 88.8% of the patients.