Undiagnosed diabetes mellitus and impaired glucose tolerance among hypertensive patients in Mulago Hospital, Kampala, Uganda

Both diabetes and impaired glucose tolerance (IGT) are rising globally, and are known to be associated with hypertension. We have assessed the prevalence of, and risk factors for, abnormal glucose tolerance (AGT) among hypertensive patients in Kampala, Uganda. A total of 320 randomly chosen hypertensive patients were studied, demographic and other data collected, and an oral glucose tolerance test (OGTT) carried out. AGT was found in 237 (74%) patents ­ 50% had IGT and 24% type 2 diabetes. The following factors were significantly associated with AGT: body mass index (BMI) over 28.0 kg/m2 (p=0.003), family history of diabetes (p=0.002), physical inactivity (p=0.001), alcohol consumption (p=0.01), and a systolic blood pressure (BP) over 140 mmHg. We conclude that diabetes and IGT are highly prevalent in hypertensive patients and screening for these conditions in such patients should be considered

Morbidity and mortality among diabetic patients admitted to Mulago Hospital, Uganda.

OBJECTIVES: To document the causes of admission, clinical presentation and outcome of patients admitted with diabetes mellitus to our medical wards. SETTING: Medical wards of Mulago Hospital, teaching hospital and national referral for the government of Uganda. STUDY DESIGN: Cross-sectional descriptive non-interventional study of diabetic medical admissions. RESULTS: During the study period 129 (4.2%) patients with diabetes mellitus out of 3103 total medical admissions were admitted. The commonest cause of admission was uncontrolled diabetes (48.3%) but infections were present in 27.7% of all the study patients. The commonest infections were pneumonia (15%) and urinary tract infections (11.8%). Diabetic ketoacidosis (DKA) was a cause of admission in 9.2% of all the study subjects. Glycaemic control was satisfactory among 50.6% (HbA1c less than 7) despite 84.5% of the study subjects being hyperglycaemic at admission (mean random blood sugar 20±9.0 mmol/L). Fifty-point seven of the subjects had long term complications of diabetes at admission with hypertension (53.8%) and peripheral neuropathy (38.3%) being the commonest. There were 13 deaths (10.8%) and 61.5% of the deaths were among patients admitted with infections. The average length of hospitalisation was 9.5±4 days. CONCLUSION: The results show that the commonest causes of admission were uncontrolled diabetes and infections. The mortality rate was 10.8%.

Disseminated aspergillus fumigatus infection: case report.

A case of disseminated aspergillus fumigatus infection is reported in a 43 year old Ugandan female with no known immune system disorder(not neutropenic and HIV-1 sero negative). She presented with multiple cutaneous ulcers, recurrent empyema thoracis, a past history of intra-abdominal abscess and bowel infarction. Empirical treatment for tuberculosis was previously given without improvement. A diagnosis of aspergillus fumigatus based on a combination of tissue wet potassium hydroxide preparation, fungal culture and tissue histologic typing was made. Despite antifungal therapy with intravenous amphotericin B infusion in 5% dextrose, after a normal baseline renal function test, the patient died in the second week of admission. Autopsy showed disseminated aspergillosis involving the pleural space, pericardium, spleen, and meningitis in addition to the cutaneous sites. Disseminated aspergillus fumigatus infection in a non-immunocompromised is rare antemortem diagnosis. This case highlights the difficulty in making a diagnosis in the face of many endemic conditions with similar presentation.

Renal glycosuria treated as diabetes mellitus: case report.

A case of renal glycosuria is reported. A 55 year old female was diagnosed and treated in an upcountry hospital for diabetes mellitus. She developed symptoms of hypoglycaemia while on an oral hypoglycaemic agent, leading to her admission in Mulago Hospital. Persistent glycosuria was noted despite treatment and normal serum glucose. Oral glucose tolerance test and timed urine glucose showed a normal curve but high urine sugar. A diagnosis of renal glycosuria was made, oral hypoglycaemic therapy was stopped, patient improved and was discharged. Though renal glycosuria is a benign condition, mistaken diagnosis for diabetes mellitus puts patients at risk of hypoglycaemia due to treatment. Diagnosis of the condition requires physicians' awareness of its existence in our community and the use of Marbles' criteria obviates confusion with diabetes mellitus though it does not absolutely exclude Fanconi syndrome.

The presentation of newly-diagnosed diabetic patients in Uganda.

We assessed the clinical characteristics of newly-diagnosed diabetic patients presenting to the Mulago Hospital Diabetic Clinic for the first time between 1 January 1993 and 10 August 1994. There were 252 patients: 117 men and 135 women. Mean age at onset of diabetes was 45 years (range 2-87 years) and peak incidence was at 40-49 years. Body mass index (BMI) was available in only 71 patients, of whom 53.5% (33.8% female, 19.7% male) were overweight (BMI > 25 in women, in > 27 men) and 11.3% (8.5% men, 2.8% women) were underweight (BMI < 20). Obesity was more marked in young women. Almost all patients presented with the classical symptoms of diabetes, and the majority were severely hyperglycaemic. A family history of diabetes was identified in 16%. Concurrent illnesses at diagnosis of diabetes were unusual. Sepsis was commonest (11.9%), followed by malaria (7.8%), tuberculosis (1.2%), AIDS (1.2%) and pancreatitis (0.8%). Peripheral neuropathy was present in 46.4% of patients, hypertension (BP > 150/100) in 27.3%, impotence in 22.2% of the men, proteinuria in 17.1%, ischaemic heart disease in 4.8%, foot ulcers in 4.0% and cataracts in 3.2%. Insulin was the most commonly prescribed treatment (52.8%); 31% of patients received oral hypoglycaemic agents, only 15.1% were managed on diet only, and 1.2% opted for herbal medicine.

Tuberculous lymphadenitis associated with human immunodeficiency virus (HIV) in Uganda.

Sixteen adults presented with lymphadenopathy which was tuberculous on biopsy; they were all seropositive for human immunodeficiency virus (HIV-1), but none had the clinical criteria of the acquired immunodeficiency syndrome (AIDS). The biopsy specimen showed caseating tuberculosis, with scanty or no visible acid fast bacilli in seven cases; the remaining nine had a poor cellular reactivity with numerous bacilli. Antituberculous chemotherapy for two months reduced the lymphadenopathy. Two patients subsequently developed AIDS. Mycobacterial cultures were not performed, but the infection was almost certainly Mycobacterium tuberculosis. The space-time clustering of tuberculous lymphadenitis now seen in Kampala, and the unusual non-reactive histopathology, are typical of the impairment of cellular immunity induced by HIV infection.

PIP: Tuberculosis is not among the infections currently included in the clinical case description of AIDS. However, tuberculous lymphadenitis is emerging as an increasingly common concomitant infection associated with HIV-1 seropositivity in Africa. 16 HIV-positive patients presenting at Mulago Hospital, Kampala, in 1986, with lymphadenopathy were studied. Lymph node biopsies were done on all 16, but only 7 of the histopathologic specimens showed a normal immune response to tubercle bacilli. The remaining 9 showed numerous bacilli but absent or weak cellular immune response. All patients responded to standard antituberculosis drug therapy; 2 patients developed clinical AIDS. Since HIV seropositivity seems to predispose to nontypical tuberculosis, it is recommended that in future cultures be done on tuberculous tissues from HIV-positive patients in Africa.