Myasthenia Gravis with Toxic Goiter: Challenges with Management in a Low-Resource Setting in Africa; Review of Literature and Case Report.

ABSTRACT: Myasthenia gravis (MG) is an antibody-mediated autoimmune disease with the cardinal feature being exertional voluntary skeletal muscle weakness and fatigability. It can be an isolated finding or in association with other autoimmune conditions such as Hashimoto's thyroiditis, Graves' disease, systemic lupus erythematosus (SLE), or rheumatoid arthritis. Thymectomy is recommended for most patients with MG whose symptoms begin before the age of 60 years. Patients with thymoma or thymic hyperplasia do respond to thymectomy compared to those without thymoma or enlarged thymus. Those with enlarged goiter would benefit from thyroidectomy. The management of these patients requires a multidisciplinary approach as performed in a low-resource setting. We are reporting the case of a 24-year-old who presented with MG with toxic goiter and had good control on medication. A computed tomography scan of the chest showed a superior mediastinal mass and a soft tissue scan of the neck was done which showed a diffusely enlarged thyroid gland. She subsequently had thymectomy and subtotal thyroidectomy with a satisfactory outcome. We highlight this case to show that MG with thymoma and goiter could coexist. Reports of such findings are infrequently reported in our environment.

FOETUS-IN-FETU, A PAEDIATRIC RARITY IN AN INFANT AT IRRUA SPECIALIST TEACHING HOSPITAL, IRRUA, NIGERIA.

Introduction: Fetus in fetu is a paediatric rarity. It involves the presence of a mass resembling a fetus inside the body of a child or an adult. It is described as a twin growing inside the body of the other. It can be located in different parts of the body but commonly the retroperitoneum. It is usually benign. Case presentation: The patient was a 4 month old male infant who presented to the hospital with complaints of abdominal distention. The distention was noticed two months prior to presenting to our hospital. The distension was generalized and has been progressively increasing until presentation (1). There was no associated abdominal pain and no other abdominal symptoms. Conclusion: Treatment is by complete excision for histological examination.

Management of a huge intrathoracic goitre in a rural specialist hospital in Nigeria-Case report and review of literature.

Retrosternal goiter is expectedly a common presentation in rural African communities due to long periods of neglect. The treatment of choice is surgical - commonly via a trans-cervical incision. A few require an extra-cervical surgical approach and multidisciplinary management as reported in this case performed in a rural specialist hospital in Nigeria.

A Five-Year Review of Perforated Peptic Ulcer Disease in Irrua, Nigeria.

BACKGROUND: Peptic ulcer perforation is a common cause of emergency admission and surgery. This is the first study that documents the presentation and outcome of management in Irrua, Nigeria. PATIENTS AND METHOD: This is a prospective study of all patients operated on for perforated peptic ulcer between April 1, 2010, and March 31, 2015. A structured questionnaire containing patients' demographics, operation findings, and outcome was filled upon discharge or death. RESULTS: There were 104 patients. 81 males and 23 females (M : F = 3.5 : 1). The age range was between 17 years and 95 years. The mean age was 48.99 years ± SD 16.1 years. The ratio of gastric to duodenal perforation was 1.88 : 1. Perforation was the first sign of peptic ulcer disease in 62 (59.6%). Pneumoperitoneum was detectable with plain radiographs in 95 (91%) patients. 72 (69.2%) had Graham's Omentopexy. Death rate was 17.3%. CONCLUSION: We note that gastric perforation is a far commoner disease in our environment. Perforation is often the first sign of peptic ulcer disease. We identify fasting amongst Christians as a risk factor for perforation.

Hémorragie du post-partum immédiat : technique de méchage

Le Méchage intra-utérin (MIU) est une technique d'étape importante pour stopper l'Hémorragie du post-partum (HPP); il est pratiqué après l'inefficacité des moyens médicaux et avant l'étape chirurgicale. Les préalables pour une PEC efficace sont évoqués puis une description détaillée de la technique de méchage est faite, terminée par une étude portant sur 265 cas d'HPP sur 7 ans dont 119 cas de méchage. Avec 93,3% de taux de succès et un coût très faible, le MIU est très efficace dans la PEC de l'HPP. Aucune complication à court ou long terme n'est constatée dans la cohorte présentée. 58 cas de grossesses spontanées sont constatés par la suite

Motorcycle Related Injuries among Rural Dwellers in Irrua, Nigeria: Characteristics and Correlates.

Background. The escalating use of motorcycle for commercial transportation of commuters and goods has resulted in an increase in morbidity and mortality from road traffic injuries. Objectives. To study the characteristics of motorcycle injuries seen in Irrua, Nigeria. Materials and Methods. This is a one-year prospective study of all patients seen from January 1, 2009, to December 31, 2009. A structured proforma was filled for all consecutive crash victims involving a motorcycle. Results. Motorcycle injuries accounted for 11.6% of attendance in surgical emergency room (142 out of 1,214); 76.8% were males. Amongst victims 47.1% were riders, 42.9%, passengers, and 7.8% pedestrians. Extremity injury accounted for 42.2% while head injury occurred in 21.8%. There were 9 deaths (6.3%). In this study no victim used crash helmet. Conclusion. Banning of motorcycle for commercial use and the introduction of tricycles into rural/suburban comminutes may be an important preventive strategy.

A review of posttraumatic bowel injuries in ibadan.

Background. Bowel injuries are a leading cause of morbidity and mortality following trauma. Evaluating patients who sustained abdominal trauma with bowel injury may pose a significant diagnostic challenge to the surgeon. Prompt recognition and timely intervention is necessary to improve outcome. Aim. This study was undertaken to evaluate treatment and outcome of patients with bowel trauma. Methods. A 5-year retrospective study of all patients presenting with abdominal trauma requiring surgical intervention seen in the UCH Ibadan, Nigeria was undertaken. Results. There were 71 patients (59 males and 12 females). The majority of cases (70%) occurred between the 3rd and 5th decades of life. Some 37 patients (52%) sustained blunt abdominal injury, while 34 patients (48%) sustained penetrating abdominal injury. There were 27 patients with bowel injuries (38%). Isolated bowel injuries occurred in 19 patients (27%). The most common surgical operation performed was simple closure. There were 3 deaths in patients with bowel injuries. Conclusion. Most cases of bowel injury can be managed by simple closure, a technique that is not so technically demanding for surgeons in less-developed countries. This study has also incidentally identified a "rule of six" for patients with bowel injuries and abdominal trauma.

Anal carcinoma in a tropical low socio-economic population in the new millennium: What has changed?

The paper is a retrospective look at the clinicopathological presentation of carcinoma of the anal canal in a tertiary health institution in Nigeria. Sixty-five patients were diagnosed with anal carcinoma over a five-year period (2002-2006) from a total of 394 patients who had malignancies of the colon, rectum and anus. The male: female ratio was 1.2: 1 showing a slight male predominance; the average age was 48 years; tenesmus, bleeding per rectum and anal pain were the most common presenting features. None of the patients tested positive to HIV during the duration of their stay in hospital. The most predominant histopathological subtype was adenocarcinoma - a departure from the hitherto squamous cell cancer dominance. Thus, only a few patients benefited from chemo-radiation; the majority had abdominoperineal resection while quite a significant proportion of patients (27.7%) declined any form of treatment for socio-cultural reasons.

Colonic cancer in adolescents. A report of three cases.

Colorectal cancer is a common malignant neoplasm in adults, with a peak incidence of 60-79 years. About 1 million cases of the disease and half a million deaths associated with it are reported world-wide each year. Colorectal cancer, however, is very uncommon in children and adolescents. This is a presentation of 3 cases of colon cancer in Nigerians aged 17 and 19 years. Two of them were adenocarcinoma and the other leiomyosarcoma. The pathogenesis and aspects of management are discussed.

First Report of an Alternaria Leaf Spot Caused by Alternaria brassicae on Crambe abyssinicia in Australia.

Crambe abyssinicia Hochst. is grown sporadically worldwide for its value as a source of high erucic acid industrial oils and secondary commercial products. While there is increasing interest in cropping C. abyssinicia in Australia, for these potentials and also as a source of oil for biodiesel production, currently, there have been no commercial crops of this species. In September 2004, inspection of a small experimental field crop in Beverley, Western Australia indicated the presence of significant leaf spotting just prior to commencement of flowering. The symptoms of this disease included as many as 10 to 15 spot lesions per leaf that were generally rounded and varied between 0.5 to 11 mm in diameter. Clusters of these lesions were often associated with chlorosis of the region of leaves where they occurred. More than 95% of plants inspected showed these symptoms. When affected leaves were incubated in moist chambers, typical conidia of Alternaria brassicae (Berk.) Sacc. were observed. The description of these conidia matched that of the Commonwealth Mycological Institute for this pathogen (1) showing obclavate conidia 105 to 210 µm long and 20 to 30 µm thick, with 11 to 15 transverse septa and 0 to 3 longitudinal or oblique septa, predominantly with a pronounced beak 5 to 8 µm thick extending 0.3 to 0.5 µm of the length of the conidium. Single-spore isolations were made onto potato dextrose agar. Subcultures of these isolates were identified using a polymerase chain reaction (PCR)- based assay (2). This assay involved the use of two sets of A. brassicae-specific primers selected for conventional and real-time PCR. The colonies were confirmed to belong to A. brassicae. In a pathogenicity test to confirm Koch's postulates, single-spore isolates were inoculated onto cotyledons and leaves of 10-day-old C. abyssinicia seedlings. Symptoms on inoculated plants appeared within a period of 14 days of inoculation, matching those found on the affected plants in the field, and A brassicae was reisolated. A. brassicae causes an important worldwide disease of crucifers, for example, it can be a devastating disease of rapeseed and the other cruciferous crops in the United States and Canada. Since A. brassicae has already been reported on other species of crucifers Australia-wide, it may pose a threat to any potential Crambe spp. industry in this country. References: (1) M. B. Ellis No. 162 in: Descriptions of Pathogenic Fungi and Bacteria. CMI, Kew, England, 1966. (2) T. Guillemette et al. Plant Dis. 88:490, 2004.

Traditional bonesetters in south western Nigeria--friends or foes?

OBJECTIVE: To highlight the dangers inherent in the practice of traditional bone setting in south western Nigeria as evidenced by the preventable complications that accompany treatment of fractures, joint dislocations and limb deformities by traditional bonesetters (TBS). METHOD: Twenty-five consecutive patients with fractures, dislocations and limb deformities who had been previously managed by TBS and who subsequently presented to the University College Hospital, Ibadan (on account of complications from treatment at the TBS) between 15 October 1999 and 31st March 2000 were evaluated. RESULT: Fourteen patients had fracture non-union or malunion necessitating open reduction and internal fixation. Two patients with wet gangrene of the extremities had amputations. CONCLUSION: Traditional bone setting is an ancient trade practiced in Nigeria and most developing countries without government regulations and they lack guidance. The complications that accompany these practices are unacceptable and it is imperative that there should be legislation to curb their activities and save the unsuspecting public from further harm or even death.

[Management of severe orthostatic hypotension by head-up-tilt posture and administration of fludrocortisone]. / Súlyos fokú orthostaticus hypotonia kezelése "head-up-tilt" fektetéssel és fludrocortisonnal.

A case of a 66-year-old man with recurrent episodes of syncope is reported. The syncopal attacks started five years ago in sitting and standing positions. At the time of admission the fainting attacks occurred 2-3 times per day. The diagnostic tests revealed severe orthostatic hypotension. The medical treatment was started with salt enriched diet and fludrocortisone. The efficacy of the therapy was tested by using the tilt table test with a self developed computer system consisting of a non-invasive finger blood pressure monitor and ECG. The orthostatic tolerance improved with the medical therapy, however remained unsatisfactory for the patient's daily activity. Though the patient had less frequent symptoms, he had still sustained episodes of recurrent syncopes. The medical therapy was than combined with sleeping in the 15 degrees head-up-tilt position. The repeat tilt table test was performed two weeks after initiation of the 15 degrees head-up-tilt sleeping. The orthostatic tolerance was markedly improved. The patient became free of symptoms and during a four-week follow-up his condition remained stable. At the control the patient reported about deterioration of his symptoms as a result of the discontinuation of sleeping in "head-up-tilt" position for two weeks. The objective signs leading to aggravate his symptoms was documented by the tilt table test. We reinstituted the "head-up-tilt" sleeping in his therapeutic management.