Clinical presentation and short-term outcomes of multisystemic inflammatory syndrome in children in Lagos, Nigeria during the COVID-19 pandemic: A case series.

Background: Multisystemic inflammatory syndrome in children (MIS-C) has increasingly been documented globally with the progression of the COVID-19 pandemic and a significant proportion of cases have been noted in children of Black descent. There has been a noticeable discrepancy in the presentation and outcomes of COVID-19 infection in sub-Saharan Africa compared to the rest of the world. We documented the demography, clinical features, laboratory and imaging findings, therapeutic management, and short-term outcomes of paediatric patients with MIS-C diagnosed during the COVID-19 pandemic in Lagos, Nigeria. Methods: We carried out a retrospective review of MIS-C cases seen in nine public and private hospitals in Lagos from July 10, 2020 to July 30, 2021. Data on clinical presentation, laboratory investigations, therapy as well as outcomes at 2 weeks, 6 weeks, 3 months and 6 months were analyzed. Findings: 28 children and adolescents with median age of 7·5 (IQR 2·3 - 9·4) years were diagnosed with MIS-C. MIS-C was suspected in 24 patients (85·7%) at initial clinical evaluation and mucocutaneous, gastrointestinal and cardiovascular manifestations were identified in 75·0%, 71·4% and 89·3% of patients respectively. Acute kidney injury and aseptic meningitis were noted in 32·1% and 17·9% of patients respectively. Cardiac manifestations at presentation included coronary dilatation and pericardial effusion in 46·4% each, ventricular dysfunction (32·1%), atrioventricular valve regurgitation (25·0%), prolonged QTc interval (40·0%) and first-degree atrioventricular block (16·0%). Therapy included aspirin in 89·3%, steroids in 75·0% and intravenous immunoglobulin (IVIG) infusion in 60·7%. All patients survived and were discharged after a mean of 11·14 (SD 5·65) days. Frequency of coronary dilatation had reduced from 46·4% to 7·1% by 3 months follow up and prolonged QTc interval persisted until the 6 week follow up in 4.5% of patients. Echocardiogram and electrocardiogram findings were normal in all patients assessed at 6 months follow up. Interpretation: MIS-C is an important diagnosis in children presenting with prolonged fever during the COVID-19 pandemic. Cardiovascular manifestations occurred in several children with MIS-C and improved by 6 months follow up. Early diagnosis and prompt institution of a combination of antiplatelet therapy, steroids and IVIG appear to be beneficial. Funding: None.

Assessment of the utility of a screening tool for COVID-19 diagnosis in an accident and emergency department in Lagos, Nigeria: A pilot study.

The use of reverse transcription-polymerase chain reaction (RT-PCR) is the gold standard laboratory test for diagnosing SARS-CoV-2 infection. However, it has the disadvantage of a long turnaround time and cost. The Nigeria Centre for Disease Control (NCDC) formulated a case definition for COVID-19. We sought to determine the utility of a 14-item, point-weighted clinical screening questionnaire adapted from the NCDC case definition in identifying patients more likely to have the disease. This was to aid prompt clinical decision-making. Methods: We retrospectively reviewed the data of 113 non-surgical patients presenting to the Accident and Emergency Department (A and E) of Lagos University Teaching Hospital, Lagos, Nigeria. Patients were stratified based on screening scores into low (0-2), moderate (3-5) and high (6) pre-test categories. Patients with low and high scores ≥6 were admitted to the A and E and the COVID-19 holding ward, respectively, while the moderate group had chest computed tomography scans to aid further decision-making, pending the outcome of their RT-PCR results. The validity of the triage score as compared to the RT-PCR test result was calculated and the kappa score of agreement was utilised to evaluate the concordance between two triage scores. The optimum cut-off score was also obtained based on the maximal Younden's index. Results: The frequencies of low, moderate and high pre-test scores were 34 (30%), 43 (38.1%) and 36 (31.9%), respectively. Overall, 38.1% (43/113) were RT-PCR positive. RT-PCR was positive in 26.5% (9/34) with low screening scores, 55.8% (24/43) with moderate scores and 27.8% (10/36) with high scores. The sensitivity and specificity of a high score of 6 were 25% and 92.86%, while the lower score of 3 had sensitivity and specificity of 62.5% and 58.6%, respectively. Conclusion: The screening tool showed a high specificity in its initial design, which suggests that anyone with a low score using this tool has a high probability of testing negative. We recommend a cut-off score of 4 (score A) or 6 (score B) of the current screening tool be used to increase the chances of identifying persons with COVID-19 for RT-PCR testing.

The feasibility and effect of a nurse-led, patient-centered asthma education program in a Nigerian context.

RATIONALE, AIMS AND OBJECTIVES: Insufficient asthma education is an unmet need in Nigeria. We aimed to assess the feasibility of a nurse-led asthma education program and its effect on asthma knowledge and outcomes in Lagos, Nigeria. METHODS: Using a quasi-experimental study design, we recruited participants ≥12 years with physician diagnosed asthma. We assessed asthma knowledge, asthma control, medication adherence, health related quality of life and inhaler technique and also measured lung function. A trained nurse delivered asthma education sessions during the regular clinic visits and demonstrated correct inhaler technique. All assessments were repeated at 3-month. Data was analyzed with descriptive and inferential statistics. A p-value of <0.05 was considered significant for all associations. RESULTS: Of the 80 participants at baseline, 42 (52.5%) completed the follow-up assessment and were included in the outcome analysis. Their ages ranged from 12 to 75 years, 35 (83.3%) were ≥18 years old and 30 (71.4%) were females. There was significant improvement in knowledge score immediately post intervention (15.48 ± 3.05 versus 18.33 ± 2.21, p < 0.001) and at 3 months (17.52 ± 2.63, p < 0.001). Those with uncontrolled asthma (Asthma Control Test score ≤19) had a meaningful (3.8-point) change in ACT score at follow-up. The improvement in the mean score on the Morisky Medication Adherence Scale was significant (p = 0.03), but a change of 0.48 was not considered meaningful. There was significant (p < 0.001) and meaningful (1.08) improvement in Mini Asthma Quality of Life score at 3 months. Pre-bronchodilator FEV1% predicted and scores on the inhaler technique check list for the Diskus and pressurized meter dose inhaler did not significantly change at follow-up (p = 0.38, 0.26 and 0.80 respectively). CONCLUSION: It is practicable for nurses to deliver effective asthma education during regular clinic visits in our practice setting. This training could meaningfully improve asthma control and health related quality of life.

Inflammatory Bowel Disease in Children: Experience and Constraints in a Resource-limited Setting.

INTRODUCTION: Inflammatory bowel disease (IBD), though well described in the Caucasian population, is rarely encountered in the black African children. The aim of this study was to increase the awareness of this emerging condition in African children and highlight the constraints of management in a resource-limited setting like Nigeria. METHODS: This study included an audit of children with IBD who were seen between January 2015 and February 2020 at the Lagos University Teaching Hospital (LUTH). The clinical records of children aged one to 16 years who presented with recurrent abdominal pain, weight loss, and gastrointestinal (GI) bleeding with clinical suspicion of IBD were reviewed. Clinical features, endoscopic findings, histopathologic findings, and treatment were documented. RESULTS: Eight children with IBD were seen during the study period. The median age was 12.0 years (range: five to 15 years). The most common reported concerns in the children were chronic abdominal pain [seen in four patients (50%)] and bloody diarrhea [seen in three patients (42.30%)]. Weight loss and arthritis were seen in three (37.5%) and one (12.5%) children, respectively. Endoscopy confirmed two cases of Crohn's disease (CD), three cases of ulcerative colitis (UC), and three cases of indeterminate colitis (IC). The children with CD were treated with steroids and exclusive enteral nutrition, with one patient receiving methotrexate, while the UC and IC patients received 5-aminosalicylate therapy. CONCLUSION: Although IBD is uncommon in Nigeria, a high index of suspicion is vital to enable early diagnosis and appropriate treatment. Management in the African setting is severely constrained by limited access to endoscopy facilities and nonavailability of other effective treatment options such as biologic agents.

A rare case of an isolated aneurysmal supravalvar mitral ring in a young Nigerian adult: a cor-triatriatum mimic.

Supravalvar mitral ring is a rare congenital abnormality characterized by a ridge of connective tissue located above the mitral valve. It is a cause of congenital mitral stenosis typically presenting in childhood and usually associated with other cardiac abnormalities. We report the rare case of a 24-year-old male presenting with an isolated aneurysmal supravalvar mitral ring. He presented at the emergency room with a 2-week history of worsening heart failure symptoms and antecedent effort intolerance of 4 years duration. He was referred from a primary care facility with an echo diagnosis of cor-triatriatum. Echocardiography done at our centre revealed an isolated aneurysmal supravalvar mitral ring of the intramitral variant. This report highlights the unusual isolated presentation of a supravalvar mitral ring in a young adult and the need to carefully differentiate it from cor-triatriatum, a possible close mimic.