Plasma Exchange for Refractory Pruritus Due to Drug-Induced Chronic Cholestasis Following Azithromycin Misuse in COVID-19 Infection.

Azithromycin can result in severe cholestatic liver disease. We describe two cases of intractable pruritus secondary to drug-induced cholestatic liver injury, unresponsive to symptomatic medical therapy, necessitating and responding well to therapeutic plasma exchange (TPE). The first is a case of a 60-year-old male known to have stable chronic lymphocytic leukemia (CLL) and benign prostatic hyperplasia, and the second is a 46-year-old female known to have primary biliary cirrhosis (PBC) who presented at six weeks and two weeks, respectively, post-mild-COVID-19 pneumonia. Their drug histories were positive for over-the-counter (OCT) azithromycin use during the COVID-19 pneumonia period. They presented with a two-week history of severe itching, associated with sleep deprivation and impaired quality of life. Liver function tests revealed a cholestatic pattern of liver injury. Pruritus remained refractory to multiple lines of treatment including bile acid sequestrants and antihistamines. Rapid and long-lasting relief of the patient's symptoms was observed after three sessions of TPE. Our cases highlight medically recalcitrant cholestatic pruritus as an adverse effect of antibiotic misuse during the recent COVID-19 pandemic. Sustained symptomatic improvements were seen after TPE.

The New Creatinine-Based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 Equation: Potential Impact on Screening for Chronic Kidney Disease in an Asymptomatic Black African Population.

BACKGROUND: In 2021, a new Chronic Kidney Disease Epidemiology (CKD-EPI) Collaboration equation was introduced that excluded race correction. We set out to compare estimated glomerular filtration rate (eGFR) determined using the creatinine-based CKD-EPI 2009 and 2021 equations and the reclassification of chronic kidney disease (CKD) eGFR staging to explore the potential ramifications of adopting the 2021 equation on reported eGFR and CKD staging. METHODS: We analyzed secondary data previously utilized to determine reference intervals among Black African individuals residing in urban towns in Kenya. Serum creatinine was measured using a standardized modified Jaffé kinetic method on a Beckman AU5800 analyzer. Glomerular filtration rate (GFR) was estimated using both the 2009 and 2021 CKD-EPI creatinine equations. Classification of CKD based on eGFR was performed using the Kidney Disease: Improving Global Outcomes (KDIGO) practice guidelines. RESULTS: Using 533 study samples, the median eGFR was highest when determined using the race-corrected CKD-EPI 2009 equation. The CKD-EPI 2021 equation yielded a median eGFR that was similar to the non-race-corrected CKD-EPI 2009 equation. The race-corrected CKD-EPI 2009 equation classified 93.6% of participants into CKD stage G1 compared with 85.6% by the CKD-EPI 2021 equation. The CKD-EPI 2021 equation classified 14.3% of participants into CKD stage G2 compared to 6.4% by the race-corrected CKD-EPI 2009 equation. CONCLUSIONS: The CKD-EPI 2021 equation gave a comparable eGFR to the non-race-corrected CKD-EPI 2009 equation and its implementation in laboratories reporting eGFR in Kenya will help in identifying patients with an appropriate decrease in renal function.

Associated Factors and Outcomes of Acute Kidney Injury in COVID-19 Patients in Kenya.

Background: Corona Virus Disease 2019 (COVID-19), an infection caused by the SARS-CoV-2 virus, has been the largest global pandemic since the turn of the 21st century. With emerging research on this novel virus, studies from the African continent have been few. Corona Virus Disease 2019 has been shown to affect various organs including the lungs, gut, nervous system, and the kidneys. Acute kidney injury (AKI) is an independent risk factor for mortality and increases the health care burden for patients with persistent kidney dysfunction and maintenance dialysis. Sub-Saharan Africa has a high number of poorly controlled chronic illnesses, economic inequalities, and health system strains that may contribute to higher cases of kidney injury in patients with COVID-19 disease. Objectives: The objective of this study was to determine the incidence, associated factors, and outcomes of AKI in patients hospitalized with COVID-19 in Kenya. Methods: This retrospective cohort study included 1366 patients with confirmed COVID-19 illness hospitalized at the Aga Khan University Hospital in Nairobi, Kenya, between April 1, 2020 and October 31, 2021. Data were collected on age, sex, the severity of COVID-19 illness, existing pregnancy and comorbid conditions including human immunodeficiency virus (HIV), diabetes mellitus, hypertension, and functioning kidney transplant patients. Univariate analysis was carried out to determine the association of clinical and demographic factors with AKI. To determine independent associations with AKI incidence, a logistic regression model was used and the relationship was reported as odds ratios (ORs) with a 95% confidence interval (CI). The outcomes of AKI including the in-hospital mortality rate, renal recovery rate at hospital discharge, and the duration of hospital stay were reported and stratified based on the stage of AKI. Results: The median age of study patients was 56 years (interquartile range [IQR] = 45-68 years), with 67% of them being male (914 of 1366). The AKI incidence rate was 21.6% (n = 295). Patients with AKI were older (median age = 64 years vs 54 years; P < .001), majority male (79% of men with AKI vs 63.6% without AKI; P < .001), and likely to have a critical COVID-19 (OR = 8.03, 95% CI = 5.56-11.60; P < .001). Diabetes and hypertension, with an adjusted OR of 1.75 (95% CI = 1.34-2.30; P < .001) and 1.68 (95% CI = 1.27-2.23; P < .001), respectively, were associated with AKI occurrence in COVID-19. Human immunodeficiency virus, pregnancy, and a history of renal transplant were not significantly associated with increased AKI risk in this study. Patients with AKI had significantly higher odds of mortality, and this effect was proportional to the stage of AKI (OR = 11.35, 95% CI = 7.56-17.03; P < .001). 95% of patients with stage 1 AKI had complete renal recovery vs 33% of patients with stage 3 AKI. Of the patients with stage 3 AKI (n = 64), 10 underwent hemodialysis, with 1 recovery in renal function and 3 patients requiring ongoing dialysis after discharge. Conclusions: This study was conducted at a single private tertiary-level health care facility in Kenya and only up to the time of hospital discharge. It is one of the first large studies from sub-Saharan Africa looking at the associated factors and outcomes of AKI in COVID-19 and forms a foundation for further analysis on the long-term consequences of COVID-19 on the kidneys. A major limitation of the study is the lack of baseline pre-admission creatinine values for most patients; thus, the impact of chronic kidney disease/baseline creatinine values on the incidence of AKI could not be established.

A Case Report of Concurrent Cryptococcal and Tuberculous Meningitis in an Immunosuppressed Renal Transplant Patient.

Infections after renal transplant are a common cause of morbidity and are commonly due to Cytomegalovirus (CMV), Cryptococcus, Mycobacterium tuberculosis, and Aspergillus. Concurrent infections with both cryptococcal and tuberculous aetiologies are rare within the central nervous system (CNS). We present a case of a 67-year-old male patient who presented with three weeks of headaches, confusion, unsteady gait, and seizures. He had type 2 diabetes mellitus and hypertension. He had a kidney transplant three years prior and was on three immunosuppressive agents. He was HIV-negative. He was evaluated and found to have cryptococcal meningitis and received appropriate treatment with liposomal amphotericin B, flucytosine, and serial lumbar punctures. He also had treatment for CMV viremia with valganciclovir. Three weeks later, after an initial good clinical response, he deteriorated with worsening confusion and persistent seizures. We re-evaluated him and found him to have brain imaging suggestive of tuberculosis. We started him on anti-tuberculous medication, and he improved significantly and was alert and seizure free at discharge home one month later. This case highlights that concurrent CNS infections with cryptococcus and tuberculosis do occur especially in patients who are severely immunosuppressed such as after a renal transplant. Failure to improve while on treatment for one CNS opportunistic infection should prompt one to investigate for other concurrent causes.

Plasma Exchange for the Treatment of Severe Hypertriglyceridemic Pancreatitis With Diabetic Ketoacidosis: A Case Report From Sub-Saharan Africa.

The triad of acute pancreatitis, diabetic ketoacidosis, and hyperlipidemia is exceedingly rare. Case reports describing this uncommon triad have successfully been managed with insulin infusions only. Herein, we highlight the challenges in making this diagnosis and present Sub-Saharan Africa's first experience with therapeutic plasma exchange in the management of hypertriglyceridemic pancreatitis associated with diabetic ketoacidosis, which was initially refractory to insulin infusion alone.

A Case of Oxalate Nephropathy in a Known Diabetic Patient following Acute Alcoholic Pancreatitis.

This was a case of a 39-year-old gentleman known to have diabetes mellitus since February 2021 on insulin glargine (Lantus) 16 units nocte and sitagliptin/metformin 50/500 mg once a day who presented to a tertiary teaching hospital in Kenya in May 2021 with a three-week history of vomiting and diarrhea. He had been previously admitted to a different facility with acute alcoholic pancreatitis. His examination was nonremarkable except for mild dehydration and pallor. He had moderate metabolic acidosis and deranged renal function. Prior to this, his creatinine was normal. As part of the evaluation for the rapid deterioration of renal function, a kidney biopsy performed revealed oxalate nephropathy. He was started on renal replacement therapy with hemodialysis.

Perceived Barriers to Peritoneal Dialysis Among Kenyan Nephrologists: A Cross-Sectional Descriptive Study.

Background: Peritoneal dialysis (PD) is a well-recognized technique of renal replacement therapy (RRT), with similar efficacy as well as survival outcomes as hemodialysis (HD). Despite its advantages including prolonged preservation of residual renal function, potentially lower cost and advances with automated techniques, and commercialization of more biocompatible solutions, the overall prevalence of patients treated with PD is still very low in developed countries and even more so in Africa and low-middle income countries like Kenya. According to our knowledge, no local studies have been done on prevalence of peritoneal dialysis or on potential barriers to utilization of PD as an RRT modality. Objective: To explore perceptive barriers of nephrologists to PD utilization. Methodology: A computer-base, 22-question questionnaire was formulated using the Delphi technique and sent out to all the nephrologists via emails. There were 30 nephrologists, in clinical practice in Kenya, at the time when the study was conducted. This is according to the registry maintained by the Kenya Renal Association (KRA). Their contacts were obtained from the registry. Design: A cross-sectional descriptive study. Setting: A computer based 22-question questionnaire was administered to 23 nephrologists in Kenya. Results: Among the total number of 23 nephrologists, 39% reported to be looking after patients maintained on PD despite 59% of them reporting that they think patients should be maintained on PD. Only 21% of respondents felt limited training in PD limited their use of PD and only 23% felt poor personal experience contributed to limited use. Other barriers that came up with a relative majority of the respondents included lack of nursing expertise, concerns with PD catheter placement, concerns about long-term viability of continuous peritoneal dialysis, concerns about technique failure and peritonitis, lack of facility support for PD, and lack of dialysis education programs. Conclusion: A significant proportion of nephrologists in this survey felt PD, as a modality of RRT, was underutilized and reported systemic and technical factors as being potential barriers.

Contexte: La dialyze péritonéale (DP) est une modalité bien connue de thérapie de suppléance rénale (TSR) qui présente une efficacité et des résultats de survie similaires à ceux de l'hémodialyse (HD). Malgré ses avantages, notamment la préservation prolongée de la fonction rénale résiduelle, les coûts potentiellement inférieurs, les avancées des techniques automatisées et la commercialisation de solutions plus biocompatibles, la prévalence globale des patients traités par DP demeure très faible dans les pays développés, et plus encore en Afrique et dans les pays à revenu faible et intermédiaire comme le Kenya. À notre connaissance, aucune étude locale n'avait été réalisée sur la prévalence de la DP ou sur les obstacles potentiels à son utilization comme modalité de TSR. Objectif: Explorer les obstacles perçus par les néphrologues quant à l'utilization de la DP. Méthodologie: Un questionnaire informatisé de 22 questions a été formulé à l'aide de la technique Delphi et envoyé à tous les néphrologues par courrier électronique. Il y avait 30 néphrologues, en pratique clinique au Kenya, au moment où l'étude a été menée. C'est selon le registre tenu par la Kenya Renal Association (KRA). Leurs contacts ont été obtenus à partir du registre. Conception: Étude transversale et descriptive. Cadre: Un questionnaire informatisé de 22 questions a été distribué à 23 néphrologues kenyans. Résultats: Parmi les 23 néphrologues sondés, 39 % ont déclaré s'occuper de patients traités par DP. Une majorité des répondants (59 %) était d'avis qu'au moins 20% des patients devraient être traités par DP. Seulement 21 % des répondants estimaient que le peu de formation en matière de DP limitait son utilization, et seulement 23 % jugeaient que leur mauvaise expérience personnelle avait contribué à l'utilization limitée de la DP. Les autres obstacles rapportés par une majorité relative de répondants étaient le manque d'expertise en soins infirmiers, des préoccupations concernant le placement des cathéters, des préoccupations sur la viabilité à long terme de la DP en continu, des préoccupations concernant la péritonite et l'échec de la modalité, le manque de soutien des établissements en lien avec la DP, et le manque de programs d'éducation en dialyze. Conclusion: Une bonne proportion des néphrologues sondés estimait que la DP était sous-utilisée comme modalité de TSR. Plusieurs ont par ailleurs rapporté des facteurs systémiques et techniques comme obstacles potentiels à son utilization.

Bleeding complications in patients on new oral anticoagulants for venous thromboembolism in Kenya.

BACKGROUND: The incidence of bleeding complications in patients with venous thromboembolism (VTE) on new oral anticoagulants (NOACs) has not been widely studied in contemporary clinical practice in Africa. The purpose of this study was to determine the rates of major bleeding, clinically relevant non-major bleeding (CRNM) and minor bleeding associated with NOAC use. METHODS: A retrospective review was carried out of patients diagnosed with venous thromboembolism and treated with NOACs at the Aga Khan University Hospital, Nairobi, from January 2014 to December 2019. Clinical and outcome data were collected from medical records and the hospital mortality database. All patients with VTE aged > 18 years and initiated on NOACS were recruited. Patients with missing information were excluded. They were followed up from the time of commencement of oral anticoagulation to completion of therapy, or to the time of the first major bleed, CRNM or minor bleeding. Data on bleeding were obtained from the hospital database and through telephone interviews. Unadjusted rates of the first major bleeding event or CRNM were calculated as the number of bleeding events per 100 person-years. RESULTS: Two hundred and forty-three patients with VTE were recruited and 222 (91.4%) were initiated on rivaroxaban, 12 (4.9%) on dabigatran and nine (3.7%) on apixaban, with a median follow up of 213 [interquartile range (IQR): 119-477] days. The median age of the patients was 57 (IQR: 45-71) years. A total of 64 bleeding events were identified in 50 (20.6%) patients. Overall, the incidence rate for bleeding events was 17.24 per 100 patient-years. The incidence rate of major bleeding was 3.79 per 100 person-years. Gastrointestinal bleeding was the most common major bleeding site. There were more females with bleeding events (70.7%) compared to males. Anaemia and the use of aspirin and other antiplatelets were associated with a higher incidence of major and CRNM bleeding [relative risk (RR) = 3.77, confidence interval (CI) = 1.37-10.39, p = 0.005 and RR = 8.89, CI = 2.06-38.33, p = 0.0003, respectively]. CONCLUSIONS: Most of these bleeds were minor, with the gastrointestinal tract being the most common source of major bleeding and menorrhagia being the commonest cause of bleeding. Anaemia and the use of aspirin were associated with a higher incidence of major bleeding.

Association between dialysate sodium concentration and interdialytic weight gain in patients undergoing twice weekly haemodialysis.

BACKGROUND: Chronic kidney disease is highly prevalent across the globe with more than 2 million people worldwide requiring renal replacement therapy. Interdialytic weight gain is the change in body weight between two sessions of haemodialysis. Higher interdialytic weight gain has been associated with an increase in mortality and adverse cardiovascular outcomes. It has long been questioned whether using a lower dialysate sodium concentration during dialysis would reduce the interdialytic weight gain and hence prevent these adverse outcomes. METHODS: This study was a single blinded cross-over study of patients undergoing twice weekly haemodialysis at the Aga Khan University Hospital, Nairobi and Parklands Kidney Centre. It was conducted over a twelve-week period and patients were divided into two groups: dialysate sodium concentration of 137 meq/l and 140 meq/l. These groups switched over after a six-week period without a washout period. Univariate analysis was conducted using Fisher's exact test for categorical data and Mann Whitney test for continuous data. RESULTS: Forty-one patients were included in the analysis. The mean age was 61.37 years, and 73% were males. The mean duration for dialysis was 2.53 years. The interdialytic weight gain was not significantly different between the two groups (2.14 for the 137 meq/l group and 2.35 for the 140 meq/l group, p = 0.970). Mean blood pressures were as follows: pre-dialysis: DNa 137 meq/l: systolic 152.14 ± 19.99, diastolic 78.99 ± 12.20, DNa 140 meq/l: systolic 156.95 ± 26.45, diastolic 79.75 ± 11.25 (p = 0.379, 0.629 respectively). Post-dialysis: DNa 137 meq/l: systolic 147.29 ± 22.22, diastolic 77.85 ± 12.82 DNa 140 meq/l: systolic 151.48 ± 25.65, diastolic 79.66 ± 15.78 (p = 0.569, 0.621 respectively). CONCLUSION: There was no significant difference in the interdialytic weight gain as well as pre dialysis and post dialysis systolic and diastolic blood pressures between the two groups. Therefore, using a lower dialysate sodium concentration does not appear useful in altering the interdialytic weight gain or blood pressure although further studies are warranted with a larger sample size, taking into account residual renal function and longer duration for impact on blood pressures.

Eligibility and patient barriers to peritoneal dialysis in patients with advanced chronic kidney disease.

INTRODUCTION: The burden of chronic kidney disease (CKD) is increasing in Kenya and is a significant cause of morbidity and mortality. While definitive treatment is renal transplantation, many patients require kidney replacement therapy with haemodialysis (HD) or peritoneal dialysis (PD). The predominant modality utilized in Kenya is currently HD. There is a need to explore why PD remains underutilized and whether patient factors may be contributory to barriers that limit the uptake of PD. METHODS: This was a descriptive cross-sectional study where patients with advanced CKD were assessed by a multidisciplinary team for PD eligibility using a standardized tool. Contraindications and barriers to the modality were recorded as was the presence or absence of support for the provision of PD. Demographic and clinical data were recorded using a standardized questionnaire. The impact of support on PD eligibility was determined. RESULTS: We found that 68.9% patients were eligible for PD. Surgery-related abdominal scarring was the most common contraindication. Barriers to PD were identified in 45.9% and physical barriers were more common than cognitive barriers. Presence of support was associated with a significant increase in PD eligibility (p < 0.001). CONCLUSION: The rate of eligibility for PD in this study was similar to that found in other populations. Surgical-related factors were the most commonly identified contraindication. Physical and cognitive barriers were commonly identified and may be overcome by the presence of support for PD.

Phenytoin Toxicity Treatment with Haemodialysis in Epilepsy due to Glioblastoma Multiforme: Case Report and Review of the Literature.

Phenytoin is one of the most commonly used anticonvulsants in the developing world, but lack of monitoring and concurrent medications can easily lead to toxicity. We report the case of a 35-year-old female on phenytoin for symptomatic epilepsy due to previously treated glioblastoma multiforme, who presented with status epilepticus 1 week after being treated for a urinary tract infection. She was loaded with phenytoin and levetiracetam as per emergency protocol but had a persistently low level of consciousness, and her preloading phenytoin level result came back in the toxic range. She was managed conservatively, but after 4 days with no change she was dialyzed and her level of consciousness improved within 24 h, allowing for safe discharge home shortly after. Our case illustrates the option of haemodialysis in phenytoin-toxic patients who do not improve with conservative measures or who may need urgent reduction due to potentially fatal complications of phenytoin toxicity.

A delay in diagnosis: thrombotic thrombocytopenia purpura occurring in systemic lupus erythematous.

Thrombotic thrombocytopenia purpura (TTP) in the background of systemic lupus erythematous (SLE) remains rare with an incidence of about 2%. Both conditions have overlapping features and can thus be difficult to differentiate and diagnose. A careful review of the peripheral blood smear remain essential often providing many clues. The diagnosis of TTP is a medical emergency and therapy should be instituted immediately. We present one such challenging case where a delay in diagnosis due to limited resources could have proven fatal for our patient.

Treatment of steroid-resistant focal segmental glomerulosclerosis with rituximab: A case report and review of literature.

Various immunomodulating agents have been tried for the treatment of steroid-resistant focal segmental glomerulosclerosis (FSGS) in the native kidney. A few case series and small studies have reported mixed results with the use of Rituximab for this indication. We report on the case of a 76-year-old male with steroid-resistant FSGS successfully treated with rituximab and remained in remission at the end of six months. A review of the literature highlights the paucity of data on this subject. We conclude that rituximab is a potentially useful treatment for steroid resistant FSGS and larger controlled studies are needed to further define its role in this setting.

A case of refractory thrombotic thrombocytopenic purpura treated with plasmapheresis and rituximab.

 Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disorder with no prevalence or incidence studies in sub-Saharan Africa. Acquired TTP has several causes, all of which lead to decreased activity of von Willebrand factor cleaving protease (ADAMTS13) due to autoantibodies that are directed towards ADAMTS13. We report a case of a 46-year-old man who presented with most of the classic clinical manifestations of TTP.

A prospective cohort conversion study of twice-daily to once-daily extended-release tacrolimus: role of ethnicity.

BACKGROUND: Tacrolimus is a widely used calcineurin inhibitor in kidney transplantation. It is available as twice-daily Prograf® (Tac-BID) and once-daily Advagraf® (Tac-OD). Although therapeutically equivalent, some patients require dose adjustments to achieve similar trough concentrations [C0] after conversion. Tacrolimus exposure is affected by ethnicity in the de novo setting but the role of ethnicity in determining dose requirements and adjustments after conversion is unknown. METHODS: In this study, 496 renal transplant recipients (RTRs) were prospectively converted from Tac-BID to Tac-OD, with dose adjustments targeted to achieve similar [C0] at 12 months post-conversion. Renal function, acute rejection and Tac dose adjustments by ethnicity were analyzed. RESULTS: There were similar numbers of recipients from living and deceased donors. The mean transplant duration was 7 years. Of the RTRs, 60% were Caucasian and 40% were identified as belonging to an ethnic minority. There was no change in estimated renal function (eGFR) post-conversion to Tac-OD. At 12 months, 35/488 (7%) RTRs were receiving a reduced dose, 101/488 (21%) required a dose increase of which 77 (16%) were receiving at least a 30% increase in dose over baseline. The percentage of those in ethnic groups requiring a dose increase of >30% varied from 8.0% for South Asians to 27.5% for East Asians (P = 0.03), despite East Asians having a similar baseline dose of Tac-BID (3.59 mg/day) compared to the entire cohort (3.53 mg/day). CONCLUSIONS: Ethnicity may play an important role in dosing requirements when converting from Tac-BID to Tac-OD, unrelated to baseline dose. Further investigation is required to determine the reasons for ethnic variability when patients are converted between tacrolimus preparations.

Dialysis therapies in older patients with end-stage renal disease.

Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.

Helicobacter pylori eradication: A randomised comparative trial of 7-day versus 14-day triple therapy.

Background. Helicobacter pylori is associated with several upper gastrointestinal conditions including chronic gastritis, peptic ulcer disease, and gastric malignancy. Proton pump inhibitor-based triple therapies are considered the standard regimens for H. pylori eradication, but the optimal duration of therapy is controversial. To prevent infection and complications, local studies should be undertaken to evaluate H. pylori eradication rates in a country. Objectives. We compared 7-day and 14-day regimens to determine the optimum duration of triple therapy for H. pylori eradication. Methods. We undertook a prospective randomised comparative trial of 7-day and 14-day triple therapy regimen for H. pylori eradication at the Aga Khan University Hospital, Nairobi; 120 patients with dyspepsia and H. pylori infection were randomised to receive esomeprazole, amoxicillin and clarithromycin for either 7 days (EAC 7) or 14 days (EAC 14). Compliance and side-effects were assessed 2 weeks after the start of therapy and H. pylori eradication was assessed by stool antigen tests 4 weeks after treatment. Results. Both the intention-to-treat (ITT; N=120) and per protocol (PP; N=97) analyses showed no significant differences between the eradication rates of EAC 7 (ITT 76.7%; PP 92%) and EAC 14 (ITT 73.3%; PP 93.6%) (ITT p=0.67; PP p=0.76). Poor compliance was reported in one patient in the EAC 14 group. The incidence of adverse events was comparable in the two groups. Conclusion. One-week and 2-week triple treatments for H. pylori eradication are similar in terms of efficacy, safety and patient compliance.

Fanconi syndrome and lactic acidosis associated with stavudine and lamivudine therapy.

We report a case of the nucleoside reverse transcriptase inhibitors, stavudine and lamivudine inducing Fanconi syndrome in a patient. The presence of simultaneous lactic acidosis suggests mitochondrial toxicity within the proximal renal tubular cells as the likely pathogenesis. We recommend that both the above nucleosides be added to the list of antiretroviral drugs that can induce Fanconi syndrome and that patients on stavudine and lamivudine be monitored carefully for early signs of Fanconi syndrome.

Neurofibromatosis type II presenting as vertical diplopia.

Neurofibromatosis type II (NF II) is rare and most commonly presents with hearing loss, tinnitus and/or vestibular disturbance in the third decade of life. The authors describe a rare case presenting with NF II with vertical diplopia due to IV(th) nerve palsy. The patient was otherwise asymptomatic despite multiple extensive lesions on MRI.