Ventricular silent rupture leading to sudden death: Navigating diagnostic challenges in a resource-constraint setting.

Key Clinical Message: Ventricular myocardial rupture is a rare complication of myocardial infarction. It occurs within hours to weeks after an infarction. Mortality is high. Antemortem diagnosis is a challenge in low-resource settings, leading to potential misdiagnosis. Abstract: Left ventricular myocardial rupture is a potentially fatal yet common complication in acute myocardial infarction patients. Rupture can occur as early as hours after an infarction. However, rupture may also occur later in the first week in the setting of myocardial necrosis and neutrophilic infiltration. Patients may survive several days to weeks before rupture occurs, and cardiac tamponade may present subacutely with a slow or repetitive clinical course. Sudden death can be attributed to ventricular rupture, more commonly during this time frame. Myocardial rupture can also occur as a result of trauma, infections, or cancer. Mortality is exceedingly high if surgical intervention is delayed. In most patients, myocardial rupture manifests as a catastrophic event within days of a first, small, uncomplicated acute myocardial infarction. Acute onset of shortness of breath, chest pain, shock, diaphoresis, unexplained emesis, cool and clammy skin, and syncope may herald the onset of ventricular septal rupture after acute myocardial infarction. Sudden death from myocardial rupture during acute myocardial infarction in patients with no apparent previous symptoms of myocardial ischemia represents a challenge for medical examiners, law enforcement officers, and society as a whole. An autopsy is critical for establishing the cause of death. We present the case of a 54-year-old male whose body was found beside the road after a trivial quarrel a day before. Further medical information about the deceased was not available. The preliminary cause of death was presumed to be traumatic. No evidence of trauma was seen during the autopsy. Massive pericardial blood collection compressing the heart and concealed left ventricular myocardial rupture were noted. Histopathological examination of the heart demonstrated myocardial infarction with a tear associated with bleeding that was contained in the pericardial sac. We ruled cardiac tamponade as the cause of death due to an infarcted myocardial rupture. Antemortem diagnosis of myocardial rupture can be challenging in low-resource settings, leading to potential misdiagnosis and negative impacts such as community conflicts.

Immunological factors linked to geographical variation in vaccine responses.

Vaccination is one of medicine's greatest achievements; however, its full potential is hampered by considerable variation in efficacy across populations and geographical regions. For example, attenuated malaria vaccines in high-income countries confer almost 100% protection, whereas in low-income regions these same vaccines achieve only 20-50% protection. This trend is also observed for other vaccines, such as bacillus Calmette-Guérin (BCG), rotavirus and yellow fever vaccines, in terms of either immunogenicity or efficacy. Multiple environmental factors affect vaccine responses, including pathogen exposure, microbiota composition and dietary nutrients. However, there has been variable success with interventions that target these individual factors, highlighting the need for a better understanding of their downstream immunological mechanisms to develop new ways of modulating vaccine responses. Here, we review the immunological factors that underlie geographical variation in vaccine responses. Through the identification of causal pathways that link environmental influences to vaccine responsiveness, it might become possible to devise modulatory compounds that can complement vaccines for better outcomes in regions where they are needed most.

The haunting diagnosis of malignancy in women with treatable reproductive system tuberculosis.

This study reports a case of female genital tuberculosis in a 46-year-old woman who presented to emergency department with abdominal pain and progressive abdominal distension. The patient was initially thought to have ovarian cancer based on clinical diagnosis and elevated cancer antigen-125 (CA-125) levels. Intra-operatively, no obvious ovarian tumor was encountered instead; disseminated creamy white patches on the uterus and left adnexa were seen. About 4500-mL straw-colored ascitic fluid and disseminated creamy white patches were also found on the bowels and omentum giving an impression of carcinomatosis. However, histopathology of the fallopian tube and ovary confirmed the diagnosis of female genital tuberculosis as the underlying cause. Female genital tuberculosis often mimics tumors in its clinical appearance and symptoms, leading to misdiagnosis and unnecessary treatment. The key to diagnosing female genital tuberculosis is being suspicious as it is challenging to diagnose through laboratory tests or radiology. The mainstay of treatment for female genital tuberculosis is a combination of four antituberculosis drugs. Consideration of female genital tuberculosis as a differential diagnosis in women presenting with symptoms mimicking reproductive tumors is highly recommended as highlighted in this case report.

An incidental finding of duodenal GIST in a patient with penetrating abdominal trauma: A case report.

INTRODUCTION AND IMPORTANCE: Duodenal Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors of the digestive tract. The tumors are derived from interstitial cells of Cajal and usually they present as gastrointestinal bleeding or non-specific abdominal pain, but they can also be asymptomatic even when they have reached considerable size. CASE PRESENTATION: We report a case of a 40-year-old male presented to our emergency department after sustaining a stab wound on the abdomen. Abdominal imaging tests weren't done; instead an emergency laparotomy was undertaken upfront in an attempt to catch up with a "golden hour". Intra-operatively, an incidental solid mass measuring 4 × 5 cm was noted on the third/fourth portion of the interior duodenal flexure. Histopathologically, the lesion demonstrated spindled shaped cells which were immunopositive for positive CD117. The patient fared well postoperatively and during subsequent follow up visits. CLINICAL DISCUSSION: High-risk GISTs have malignant potential. In some cases, GIST is diagnosed as incidentally finding, mostly during surgical procedure, upper endoscopy or radiological studies related to GI tract. Surgical resection is recommended curative option and its extension depends on different factors. Tyrosine kinase inhibitors are of the utmost importance in high-risk and metastatic disease. CONCLUSION: Even considerably large duodenal GISTs can be asymptomatic, thus incidentally found during an abdomino-pelvic imaging tests. Histopathological evaluation of the operative specimen plays a key role in assessing the need of adjuvant therapy, with a significant impact on the patients' survival.

Non-Hodgkin lymphoma of bone of the femur and humerus: a case report and review of the literature.

Lymphoma of bone is a rare neoplasm composed of malignant lymphoid cells, producing a tumefactive lesion within bone. We report a 13-year-old male who presented with progressively increasing swellings at the right shoulder and right mid-thigh for one month. Radiological images revealed lytic destructive lesions associated with soft tissue masses in both sites and a pathological fracture on the right humerus. The patient had no significant medical history. Histological, immunohistochemical and fluorescent in-situ hybridization assessment of biopsies from the lesions confirmed the diagnosis of primary non-Hodgkin lymphoma of bone. Unfortunately, due to coronavirus disease 2019 outbreak, the patient was unable to follow-up treatment and died shortly after establishment of the diagnosis. Delay in diagnosis and treatment is of serious concern when it comes to improve the prognosis of patients with this disease.

Placental pathology and maternal factors associated with stillbirth: An institutional based case-control study in Northern Tanzania.

OBJECTIVE: To determine the placental pathologies and maternal factors associated with stillbirth at Kilimanjaro Christian Medical Centre, a tertiary referral hospital in Northern Tanzania. METHODS: A 1:2 unmatched case-control study was carried out among deliveries over an 8-month period. Stillbirths were a case group and live births were the control group. Respective placentas of the newborns from both groups were histopathologically analyzed. Maternal information was collected via chart review. Mean and standard deviation were used to summarize the numerical variables while frequency and percentage were used to summarize categorical variables. Crude and adjusted logistic regressions were done to test the association between each variable and the risk of stillbirth. RESULTS: A total of 2305 women delivered during the study period. Their mean age was 30 ± 5.9 years. Of all deliveries, 2207 (95.8%) were live births while 98 (4.2%) were stillbirths. Of these, 96 stillbirths (cases) and 192 live births (controls) were enrolled. The average gestational age for the enrolled cases was 33.8 ±3.2 weeks while that of the controls was 36.3±3.6 weeks, (p-value 0.244). Of all stillbirths, nearly two thirds 61(63.5%) were males while the females were 35(36.5%). Of the stillbirth, 41were fresh stillbirths while 55 were macerated. The risk of stillbirth was significantly associated with lower maternal education [aOR (95% CI): 5.22(2.01-13.58)], history of stillbirth [aOR (95%CI): 3.17(1.20-8.36)], lower number of antenatal visits [aOR (95%CI): 6.68(2.71-16.48), pre/eclampsia [aOR (95%CI): 4.06(2.03-8.13)], and ante partum haemorrhage [OR (95%CI): 2.39(1.04-5.53)]. Placental pathology associated with stillbirth included utero-placental vascular pathology and acute chorioamnionitis. CONCLUSIONS: Educating the mothers on the importance of regular antenatal clinic attendance, monitoring and managing maternal conditions during antenatal periods should be emphasized. Placentas from stillbirths should be histo-pathologically evaluated to better understand the possible aetiology of stillbirths.

Ovarian malignant mixed Müllerian tumor: a rare case report from Tanzania.

Malignant mixed Müllerian tumor of the ovary is rare aggressive tumor that is histologically defined by the presence of malignant epithelial and stromal components. We report a 37-year-old woman who consulted our facility complaining of abdominal distention and a painful palpable mass over her lower abdomen. Physical examination including computerized tomography revealed a complex cystic mass lesion on the left ovary with extensive omental involvement. Ovarian cancer was suspected and the patient underwent debulking surgery. The histopathology of the specimen revealed a high-grade tumor composed of both malignant epithelial and sarcomatous elements. Both epithelial and stromal components stained positive for p53 immunostaining. Before the initiation of chemotherapy, on 5th day postoperation, the patient was found unresponsive. The stage of the disease seems to be the most important prognostic factor, thus emphasis should be made to identify it in earlier stages.

Diagnosis of primary osteosarcoma of the urinary bladder in a resource-limited setting: a case report and review of the literature.

Extraskeletal osteosarcoma is a rare malignant mesenchymal soft tissue tumor without attachment to the bone and is able to produce osteoid or cartilaginous matrix. Rendering a definitive diagnosis may pose a challenge particularly in a resource-limited setting. We report a case of primary osteosarcoma of the urinary bladder presenting with hematuria, dysuria and positive history of schistosomal contact. Computed tomography intravenous urogram revealed a large heterogeneous mass at the right superolateral aspect of the urinary bladder. Morphological evaluation of the biopsy and a minimal panel of immunohistochemical antibodies of vimentin and cytokeratin 20 ruled out potential differentials and thus confirmed the diagnosis of osteosarcoma.

Schistosomiasis and cancer: Experience from a zonal hospital in Tanzania and opportunities for prevention.

Schistosomiasis infection is endemic in many parts of Tanzania. The morbidity due to Schistosomiasis and its association with cancer remains to be of great concern and poses greater challenge that needs to be assessed. Cancer is an increasing public health problem in most sub-Saharan African countries, and yet, cancer control programs and the provision of early detection and treatment services are limited despite this increasing burden. This article aims to discuss case series of patients diagnosed with urinary bladder, prostate and colorectal cancer together with Schistosoma infection. We further highlight the opportunities for combating new Schistosomiasis infection, a potential to reduce its oncological complications particularly in low-resource setting.

Missed opportunity of deworming a Maasai boy from nomadic family leading to life threatening intestinal obstruction.

Mass deworming against soil-transmitted helminthiasis, including Ascaris lumbricoides (AL), is one of the largest public health interventions in low- and middle-income countries. The prevalence of A. lumbricoides in Tanzania is 6.8%. We present a 3-year-old male of a known Tanzanian nomadic tribe (Masaai tribe) with history of missed deworming, who was brought to the emergency department with a 3-day history of constipation, nonprojectile, bilious vomiting, generalized abdominal distension and pain.He was diagnosed with intestinal obstruction by the use of a plain abdominal X-ray, which revealed marked gaseous distension of the stomach and bowels without significant air-fluid levels. He was initially treated with intravenous ceftriaxone 50 mg/kg, metronidazole 15 mg/kg and acetaminophen 15 mg/kg. An explorative laparotomy was then performed. Intraoperative findings demonstrated a dense collection of A. lumbricoides worms in the gangrenous proximal jejunum and duodenum. Thorough abdominal lavage was carried out and abdomen was closed.

Seroprevalence of hepatitis B virus infection and associated factors among healthcare workers in northern Tanzania.

BACKGROUND: Hepatitis B virus infection is a global health problem with the highest prevalence in East Asia and Sub-Saharan Africa. The majority of infected people, including healthcare workers are unaware of their status. This study is aimed to determining seroprevalence of hepatitis B virus infection and associated factors among healthcare workers in northern Tanzania. METHODS: This cross-sectional study included 442 healthcare workers (HCWs) from a tertiary and teaching hospital in Tanzania before the nationwide hepatitis B vaccination campaign in 2004. Questionnaire- based interviews were used to obtain detailed histories of the following: demographic characteristics; occupation risks such splash and needle stick injuries or other invasive procedure such as intravenous, intramuscular or subcutaneous injections; history of blood transfusion and surgeries, as well as HCWs'knowledge of HBV. Serological markers of HBV were done using Laborex HBsAg rapid test. Serology was done at zero months and repeated after six months ( bioscienceinternational.co.ke/rapid-test-laborex.html HBsAg Piazzale-milano-2, Italy [Accessed on November 2017]). Chi-square (χ2) tests were used to compare proportion of HBV infection by different HCWs characteristics. Multivariable logistic regression was used to determine factors associated with HBV infection. RESULTS: A total of 450 surveys were sent out, with a 98.2% response rate. Among the 442 HCWs who answered the questionnaire, the prevalence of chronic hepatitis B virus infection was 5.7% (25/442). Only 50 (11.3%) of HCWs were aware of the HBV status. During the second HBsAg testing which was done after six months one participant sero-converted hence was excluded. Adjusted for other factors, history of blood transfusion significantly increased the odds of HBV infection (OR = 21.44, 95%CI 6.05, 76.01, p < 0.001) while HBV vaccine uptake was protective against HBV infection (OR = 0.06, 95%CI 0.02, 0.26, p < 0.001). The majority of HCWs with chronic HBV infection had poor to fare knowledge about HBV infection but this was not statistically significant when controlled for confounding. CONCLUSIONS: Prevalence of HBV among health care workers was 5.7% which is similar to national prevalence. Although the response rate to take part in the study was good but knowledge on HBV infection among HCWs was unsatisfactory. History of blood transfusion increased risks while vaccine uptake decreased the risk of HBV infection. This study recommends continues vaccinating HCWs together with continues medical education all over the country. We also recommend documentation of vaccination evidence should be asked before employment of HCWs in order to sensitize more uptakes of vaccinations. Although we didn't assess the use of personal protective equipment but we encourage HCWs to abide strictly on universal protections against nosocomial infections.

ABO and Rhesus blood group distribution and frequency among blood donors at Kilimanjaro Christian Medical Center, Moshi, Tanzania.

OBJECTIVE: This study aims to determine the distribution of blood groups and the demographic background of blood donors in a referral hospital in Northern Tanzania. RESULTS: The most common blood group was O (52.3%) and the least common was AB (3.18%). 97.7% of the blood donors were Rh positive and the rest were Rh negative. Most donors were young adults, representing the age group of 19-29. The majority of donors were male (88.1%) and the majority (90.8%) were replacement while the remainder was voluntary donors.

Seroprevalence and Knowledge of Hepatitis B Virus Infection Among LaboratoryWorkers at Kilimanjaro Christian Medical Centre in Moshi, Tanzania.

BACKGROUND: Hepatitis B Virus (HBV) is transmitted through blood, infected body fluids, and unsterile needles and surgical equipment. We first determined the current seroprevalence of HBV and vaccination coverage, then assessed knowledge on risk factors for hepatitis B virus infection among medical laboratory workers at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. METHODS: A cross-sectional study was conducted from January to June 2014, involving health care workers (HCWs) from KCMC. Eligibility for participation in the study was determined by length on employment, provision of consent, and willingness to complete a questionnaire. Recruitment was non-randomised; a simple and consecutive sampling of 85 eligible HCWs was conducted at the hospital during study period. Structured questionnaires were self-administered and consenting participants allowed blood samples to be tested for HBV infection. Blood (4 mL) was obtained by vene-puncture from all participants using sterilised disposable 5 mL syringes and 20 gauge needles. All collected blood was tested for HBsAg using enzyme linked immunosorbent assay according to manufacturer's guidelines. A cut-off point of 10% (P>0.1) was used to select variables to be included in the further analysis. RESULTS: Out of the 76 HCWs eligible to participate in the study, only 8 (10.5%) were vaccinated against HBV. Of the 68 unvaccinated laboratory workers, 9 (11.8%) tested positive for HBsAg. Knowledge about HBV infection and its associated risks was high among medical personnel - where 36.4% scored above 65% - compared with non-medical personnel, none of whom scored as high as 65%. CONCLUSION: Seroprevalence of HBsAg among laboratory workers at KCMC was 11.8%. Low knowledge of risks for HBV infection placed HCWs at great risk of occupational exposure. Low vaccination coverage among HCWs increases the risk of acquiring HBV infection following occupational exposure.