Plasma L-Arginine in Sickle Cell Anaemia Patients in Crises and its Correlation with Markers of Severity of Disease.

INTRODUCTION/OBJECTIVES: Sickle Cell Anaemia (SCA) is a chronic haemolytic and inflammatory disorder characterized by repeated vaso-occlusive (VOC) and hyperhaemolytic crises (HC). These crises determine the quality of life of SCA patients. This study estimated the plasma L-arginine levels in SCApatients during crises (HC and VOC), and correlated these levels with the markers of inflammation in the patients. METHODS: A cross-sectional study comprising of 120 consenting adults (60 SCA patients and 60 HbAA controls). The SCA were grouped as SCA patients in VOC or SCA patients in HC and HbAA controls. All SCA patients presented at the emergency room or the daycare unit of Haematology Department, University College Hospital, Ibadan, Nigeria. Blood samples were collected and haematological parameters and plasma L-arginine levels were determined. RESULTS: There were 30 SCA patients in VOC, 30 SCA patients in HC, and 60 HbAA controls with age ranging from 18 to 58years. The controls had a higher haematocrit than the SCA patients (HbAA>SCA VOC> SCA HC, p<0.001) in each pair wise analysis. The VOC and the HC groups had higher mean White Blood Cell (WBC), platelet count, Absolute Neutrophil Count (ANC), Absolute Lymphocyte Count (ALC), Absolute Monocyte Count (AMC), and reticulocytes count than the HbAA controls. Similarly, the HC group had higher mean WBC, platelet count,ANC,ALC,AMC, and reticulocytes count, and a lower mean percentage irreversible sickle cell than the VOC group. The mean plasma L-arginine was significantly higher in the HbAA control group than those of SCA patients in crises (HbAA controls>SCAVOC>SCAHC, p < 0.001), and higher in the SCAVOC group than in the HC group. There was no significant correlation between plasma L-arginine levels, reticulocyte count, markers of VOC severity and markers of inflammations. CONCLUSION: The plasma L-arginine levels of SCA patients in VOC and HC were lower than those of the HbAA controls. The degree of reduction was however marked in patients in hyperhaemolytic crisis. There was no significant association between the plasma L-arginine levels and the markers of inflammation in the studied patients. The findings in this study buttress the need for consideration of L-arginine supplementation in patients with SCA, especially during acute hemolytic crises.

INTRODUCTION / OBJECTIFS: La SCA est un mal hémolytique et inflammatoire chronique caractérisé par des crises vaso-occlusives (COV) et hyperhémolytiques (HC) répétées, qui déterminent la qualité de vie des patients atteints de SCA. L'étude a estimé les taux plasmatiques de L-arginine chez les patients atteints de SCA pendant les crises (HC et COV), et a mis en corrélation ces taux avec les marqueurs de l'inflammation chez les patients. MÉTHODES: Une étude transversale comprenant 120 adultes consentants (60 patients SCA et 60 contrôles HbAA) regroupés en patients SCA en COV; Patients SCA à HC (tous les patients SCA présentés à la salle d'urgence ou à l'unité de garde du département d'hématologie, University College Hospital, Ibadan, Nigéria); et contrôles HbAA. Des échantillons de sang ont été prélevés et les paramètres hématologiques et les taux de L-arginine ont été déterminés. RÉSULTATS: Il y avait 30 patients SCA en COV, 30 patients SCA en HC et 60 contrôles HbAA avec un âge allant de 18 à 58 ans. Les témoins avaient un hématocrite plus élevé que les patients SCA (HbAA> SCA VOC> SCAHC, p <0,001) dans chaque analyse par paire. Les groupes VOC et HC avaient des taux moyens de globules blancs, de plaquettes, d'ANC, d'ALC, d'AMC et de réticulocytes plus élevés que les témoins HbAA. De même, le groupe HC avait un nombre moyen de globules blancs, de plaquettes, d'ANC, d'ALC, d'AMC et de réticulocytes plus élevés, et un pourcentage moyen de de drépanocytose irréversible plus faible que le groupe COV. La L-arginine plasmatique moyenne était significativement plus élevée dans le groupe témoin HbAA que chez les patients SCA en crise (contrôles HbAA> SCA VOC> SCA HC, p <0,001), et plus élevée dans le groupe SCA VOC que dans le groupe HC, p <0,001. Il n'y avait pas de corrélation significative entre les taux de L-arginine, le nombre de réticulocytes, les marqueurs de gravité des COV et les marqueurs d'inflammations. CONCLUSION: Les taux plasmatiques de L-arginine chez les patients SCAen COV et HC étaient inférieurs à ceux des contrôles HbAA, et le degré de réduction est cependant marqué chez les patients en crise hyperhémolytique. Il n'y avait pas d'association significative entre les taux plasmatiques de L-arginine et les marqueurs de l'inflammation chez les patients étudiés. Les résultats de cette étude renforcent la nécessité d'envisager une supplémentation en L-arginine chez les patients atteints de SCA, en particulier pendant les crises hémolytiques aiguës. MOTS CLÉS: anémie falciforme, L-arginine, crise vaso-oclussive, crise hyperhémolytique.

D-dimer as a Predictor of Altered Coagulation in HIV Patients in Nigeria.

Recent medical advances have improved the quality of life and correspondingly reduced the morbidity and mortality associated with HIV infection. However increased life expectancy has led to a relative rise in comorbidities and complications such as alterations in coagulation systems. This study is aimed at the evaluation of D-dimer level as a predictor of thromboembolic risk in HIV patients. A total of 152 HIV positive and negative subjects and control respectively attending the PEPFAR clinic UCH in Ibadan were recruited both for a questionnaire-based survey and a coagulation profile screening.  Activated Partial Thromboplastin Time (APTT), Prothrombin Time (PT), D-dimer level the viral load indices of the HIV   patients and their CD4 counts were also evaluated. In the subjects, the D-dimer level was significantly higher (193.6 ± 177.00ng/ml) than the controls (118.10 ± 140.58ng/ml) while a significantly lower APTT was also reported (36.22 ± 4.05 seconds) compared to the controls (41.14 ± 8.87 seconds). An evaluation of the coagulation profile in the Highly Active Antiretroviral Therapy (HAART) naïve and experienced group revealed only a significant increase (417.4) in the CD4 count whilst no difference was observed in the coagulation profile. In our study, a higher predisposition to a hypercoagulable state presenting as a short APTT was observed. This finding along with the higher D-dimer level underscores the relevance of the evaluation of this biomarker as an important predictor of thromboembolic event risk.

Awareness and distribution of ABO, Rhesus blood groups and haemoglobin phenotypes among medical undergraduates in a Nigerian university.

BACKGROUND: In the past two decades the Nigerian government and religious organisations have put more emphasis on knowing the haemoglobin electrophoresis of school children and intending couples respectively. Knowledge of the distribution of blood groups and haemoglobin electrophoretic patterns among young people is vital for the prevention of haemoglobinopathies in the population and for providing effective blood banking services. Therefore, this study was designed to assess the frequency and awareness of blood group and haemoglobinphenotypes among a new set of fourth year clinical medical and dental students of the University of Ibadan, Nigeria. METHODS: Data, including socio-demographics, self- reported blood group and haemoglobin phenotypes, were obtained from 155 students using a self-administered questionnaire. The ABO, Rhesus (Rh) blood groups and haemoglobin electrophoresis were determined by the tile (slide) technique and cellulose acetate at alkaline phrespectively. RESULTS: Only 43.9% of the participants knew their blood groups while less than a third (29.7%) knew their haemoglobin phenotypes. knowledge of both their blood groups and haemoglobin phenotypes was documented in as low as 20.6% of the respondents. The frequency of haemoglobin AA, AS, AC and. CC were 78.0%, 16.8%, 3.9% and 1.3% respectively. Similarly, the distribution of blood groups were: 0 RhD positive - 47.8%;0 RhD negative- 1.9%;ARhD positive- 21.9%; A RhD negative - 1.3%; B RhD positive - 23.2%; B RhD negative -1.3% and AB RhD positive - 2.6%. No participant was AB RhD negative. Participants who bad previously donated blood and those who were females were more likely to know their blood groups and haemoglobin phenotypes respectively (p<0.05). CONCLUSION: Awareness of blood groups and haemoglobin phenotypes among the medical and dental students was poor. Documentation and routine screening for haemoglobinphenotypes as well as blood grouping, accompanied by appropriate counseling should be institutionalised in Nigeriantertiary institutions.

Abdominal Pain in Adult Sickle Cell Disease Patients: A Nigerian Experience

Background: Abdominal pain is a relatively frequent occurrence in sickle cell disease. The aetiology of abdominal pain in sickle cell disease is often difficult to diagnose clinically. Despite the frequent occurrence; diagnostic dilemma; and the need for an accurate; early diagnosis; abdominal pain in sickle cell disease has not been rigorously studied. Objective: We therefore sought to describe the different presentations and patterns of abdominal pain in persons with sickle cell disease. Methods: A prospective case series of 20 patients was done in which data was collected on demographic characteristics; hemoglobin electrophoresis patterns; a description of the abdominal pain including sites; severity; and type of pain; packed cell volume and the provisional and final diagnosis. Results: Haemoglobin S patients were 17 in number constituting eightyfive percent (85) of our study population whilst the rest 3 were Hb S+C. Most patients (70) had one site of abdominal pain. The pain was mainly colicky or tightening; moderate to severe in nature and; in some cases; associated with vomiting. We did not find any significant difference between the steady state PCV and the PCV during the acute abdominal pain episodes. The final diagnosis showed that only 38.8of the patients had vasoocclusive crises and the reliability index between the provisional diagnosis and the final diagnosis was 67. Conclusion: Abdominal pain in sickle cell disease may present in different ways and it is important to recognize that the possible diagnoses are numerous. Not all cases are due to vasoocclusive crises. Early diagnosis and prompt treatment can be life saving

Pattern, indications and review of complications of neonatal blood transfusion in ibadan, southwest Nigeria.

BACKGROUND AND OBJECTIVES: There is a huge need for blood transfusion in the newborn particularly due to the reduced marrow activity in the neonatal period. Despite widely use of blood products in the neonatal period, there is paucity of local data on the pattern, indications and reactions to blood transfusions in Nigerian newborns. This study evaluates the blood transfusion indications and patterns in special care baby unit and C1(2nd) of University College Hospital, Ibadan, Nigeria. METHODOLOGY: A cross sectional study was carried on the recruited newborns and structured questionnaires were used to obtain bio data, medical problems, indications for blood transfusion, type of blood products transfused and clinical signs. Urinalysis was performed out before and after the transfusion. RESULTS: A total of 100 neonates were recruited into the study with a male: female ratio of (M: F= 1:1). The age range was 2-34 days and their weight ranged between 0.8kg to 3.6 kg with a mean weight of 1.64 kg. The main indications for transfusion were anaemia from prematurity & neonatal sepsis(NNS) 46%; (red cell replacement), NNS, Disseminated intravascular coagulation(DIC) & anaemia 24%; (partial exchange + top up + Fresh frozen plasma), neonatal jaundice(NNJ) & anaemia 14%; (whole blood), NNJ, NNS + anaemia 6%(Blood transfusion + Fresh frozen plasma), NNS + anaemia 10% (whole blood). CONCLUSION: Blood transfusion is still frequent in the study area and prematurity, neonatal sepsis and jaundice rank high in the indications. Transfusion reactions are rare in the evaluated neonates.

Abdominal pain in adult sickle cell disease patients: a nigerian experience.

BACKGROUND: Abdominal pain is a relatively frequent occurrence in sickle cell disease. The aetiology of abdominal pain in sickle cell disease is often difficult to diagnose clinically. Despite the frequent occurrence, diagnostic dilemma, and the need for an accurate, early diagnosis, abdominal pain in sickle cell disease has not been rigorously studied. OBJECTIVE: We therefore sought to describe the different presentations and patterns of abdominal pain in persons with sickle cell disease. METHODS: A prospective case series of 20 patients was done in which data was collected on demographic characteristics, hemoglobin electrophoresis patterns, a description of the abdominal pain including sites, severity, and type of pain, packed cell volume and the provisional and final diagnosis. RESULTS: Haemoglobin S patients were 17 in number constituting eightyfive percent (85%) of our study population whilst the rest 3 were Hb S+C. Most patients (70%) had one site of abdominal pain. The pain was mainly colicky or tightening, moderate to severe in nature and, in some cases, associated with vomiting. We did not find any significant difference between the steady state PCV and the PCV during the acute abdominal pain episodes. The final diagnosis showed that only 38.8% of the patients had vasoocclusive crises and the reliability index between the provisional diagnosis and the final diagnosis was 67%. CONCLUSION: Abdominal pain in sickle cell disease may present in different ways and it is important to recognize that the possible diagnoses are numerous. Not all cases are due to vasoocclusive crises. Early diagnosis and prompt treatment can be life saving.

Pattern; Indications and Review of Complications of Neonatal Blood Transfusion in Ibadan; Southwest Nigeria

Background and objectives: There is a huge need for blood transfusion in the newborn particularly due to the reduced marrow activity in the neonatal period. Despite widely use of blood products in the neonatal period; there is paucity of local data on the pattern; indications and reactions to blood transfusions in Nigerian newborns. This study evaluates the blood transfusion indications and patterns in special care baby unit and C12nd of University College Hospital; Ibadan; Nigeria. Methodology: A cross sectional study was carried on the recruited newborns and structured questionnaires were used to obtain bio data; medical problems; indications for blood transfusion; type of blood products transfused and clinical signs. Urinalysis was performed out before and after the transfusion. Results: A total of 100 neonates were recruited into the study with a male: female ratio of (M: F= 1:1). The age range was 2-34 days and their weight ranged between 0.8kg to 3.6 kg with a mean weight of 1.64 kg. The main indications for transfusion were anaemia from prematurity et neonatal sepsis(NNS) 46; (red cell replacement); NNS; Disseminated intravascular coagulation(DIC) et anaemia 24; (partial exchange + top up + Fresh frozen plasma); neonatal jaundice(NNJ) et anaemia 14; (whole blood); NNJ; NNS + anaemia 6(Blood transfusion + Fresh frozen plasma); NNS + anaemia 10(whole blood). Conclusion: Blood transfusion is still frequent in the study area and prematurity; neonatal sepsis and jaundice rank high in the indications. Transfusion reactions are rare in the evaluated neonates

Pattern of contraceptive use among women with sickle cell disease in Ibadan, South-west Nigeria.

A cross-sectional study was conducted at the University College Hospital, Ibadan, Nigeria between January and April 2009. The purpose of this study was to determine the pattern of contraceptive use among females of reproductive age, with sickle cell (SC) disease, attending various clinics at the University College Hospital, Ibadan, Nigeria. It is evident in this study that even although contraceptive awareness in this group of patients is high, the prevalence of contraceptive use is very low which is comparable with the general population. This is largely due to perceived fear of real and imagined side-effects associated with some contraceptive methods and also relative lack of access to commodity sources. It is therefore suggested that there is need for effective enlightenment and health education targeted at this vulnerable group of women to dissipate unreal fears about contraception. Also, the provision of a contraceptive-friendly environment, especially at various clinics attended by sickle cell disease patients, to facilitate their access to contraceptive commodities will go a long way to enhance their uptake of contraception while preventing unwanted pregnancies along with other benefits in this susceptible group of women. The need for child spacing as well as limiting family size among sickle cell disease patients cannot be over emphasised.

Blood banking in a malaria-endemic area: evaluating the problem posed by malarial parasitaemias.

The emergence and wide dissemination of drug-resistant malarial parasites underscore the need to prevent post-transfusion malaria. In Nigeria, as in most of sub-Saharan Africa, however, blood donors are not routinely screened for malarial infection. Recently, 391 consecutive potential blood donors in a malaria-endemic area of south-western Nigeria were each checked for malarial parasitaemia using three methods: microscopy (all samples), OptiMAL (315 samples) and/or the Clinotech Malaria Cassette (142 samples). OptiMAL detects parasite-specific lactate dehydrogenase whereas the Clinotech test detects the surface proteins of merozoites and sporozoites. Microscopy revealed parasitaemias in 79 (20.2%) of the potential donors, the levels of parasitaemia varying from 34 to 6289 asexual parasites/microl (mean=445/microl). The prevalence of malarial parasitaemia, as detected by microscopy, was significantly higher during the rainy season than in the dry season (27.3% v. 5.5%; P<0.0001). There was no significant association between patent parasitaemia and fever (i.e. an axillary temperature > or =37.5 degrees C), blood group, gender or anaemia. The corresponding prevalences of malarial parasitaemia detected using the rapid diagnostic tests were 3.8% (12/315) for OptiMAL and 57.8% (82/142) for the Clinotech. With the results of the microscopy used as the 'gold standard', OptiMAL gave a sensitivity of only 16.0% but a specificity of 98.5%. The corresponding values for the Clinotech tests were 69.2% and 50.0%, respectively. It would clearly be beneficial to include screening for malaria parasitaemia in the routine investigation of potential blood donors in Nigeria, especially during the rainy season, when the risk of transfusion-transmitted malaria appears relatively high.

A case of human bite by an 11-year old HIV positive girl in a paediatrics ward.

Biting is a possible mode of transmission of HIV infection, though the risk of such transmission is believed to be low. Children infected with HIV are at risk of psychological complications as a result of direct or indirect effects associated with the disease. We report the case of an 11 year old HIV positive girl with clinical stage IV disease, who was involved in multiple disputes while on admission on the ward. During one of the disputes she inflicted a deep bite injury on a 10-year old boy, HIV post-exposure prophylaxis (PEP) was commenced 6 hours after the bite and he has remained HIV negative 12 months later. What is peculiar about this case is that the incident occurred in a hospital setting and biting is not usually expected among children of this age. In the era of HIV/AIDS, it is recommended that persons involved in childcare be aware of this potential risk during interactions among children. It is also essential for health care personnel to have sufficient knowledge about PEP in order to reduce the risk of HIV transmission in similar settings. In addition, a multidisciplinary approach to the management of children living with HIV is important in order to identify and address psychosocial factors that may influence symptoms and medical treatment outcome. The risk of transmission of HIV through human bites and the psychosocial impact of the disease on children are also discussed.

Increased plasma manganese, partially reduced ascorbate, 1 and absence of mitochondrial oxidative stress in type 2 diabetes mellitus: implications for the superoxide uncoupling protein 2 (UCP-2) pathway.

Oxidative stress is an important component of diabetes and its complications. Manganese (Mn), the key component of the Mitochondrial antioxidant (MnSOD), plays a key role in the superoxide uncoupling protein 2 (UCP-2) pathway in inhibiting of glucose-stimulated insulin secretion (GSIS). The interactions of Mn with ascorbate and other components of this pathway have not been defined in type-2 diabetes. Fifty established type 2 diabetics (30 males, 20 females) and 30 non-diabetics (controls; 18 males, 12 females) matched for age and sex were investigated. Dietary intake, particularly of micronutrients as assessed by 24-h dietary recall was similar between diabetics and controls. Weight and height of all subjects were determined and body mass index (BMI) computed after clinical assessment. Fasting plasma glucose, manganese, ascorbic acid, creatinine and K+ levels were determined; K+ was to assess the K+ channels, whereas creatinine was to assess probability of oxidative stress nephropathy. Body mass index was greater in DM than in controls (p < 0.001). Fasting plasma glucose and Mn levels (p < 0.00 and p < 0.01, respectively) were higher in diabetes than in the controls. Manganese level was greater than twice the levels in controls. Ascorbic acid was not significantly different (p > 0.05), but was 50% lower than the level in non-diabetics. Potassium like Mn and glucose was significantly higher in diabetes mellitus (DM) than in controls (p < 0.001). Creatinine was not significantly different between diabetics and controls (p > 0.05). Correlations among all parameters were not significantly different. These findings suggest absence of significant oxidative stress in the mitochondria, probably excluding a role for UCP-2-superoxide pathway in the inhibition of glucose-stimulated insulin secretion (GSIS), calling for caution in the precocious conclusion that interruption of UCP-2 activity may provide a viable strategy to improve beta-cell dysfunction in type 2 diabetes mellitus.

Decreased thiamine and magnesium levels in the potentiation of the neurotoxicity of lead in occupational lead exposure.

The relationship between blood lead (Pb) and serum levels of calcium and of neural nutrients such as thiamine and magnesium (Mg) has been determined in a Nigerian population that is occupationally exposed to Pb. Forty-seven male Pb workers were recruited as test subjects and 25 males unexposed to Pb served as controls. The test subjects were classified into three groups, based on severity of exposure to Pb. Blood lead (BPb) and the serum levels of Mg, thiamine, and calcium were determined in both test subjects and controls. The mean blood Pb level was not significantly higher in Pb workers. In contrast, Mg and thiamine levels were significantly decreased (p<0.05; p<0.01, respectively). However, the calcium level was not significantly lower in test subjects than in controls. Also, there was a significant negative correlation between serum thiamine and blood Pb levels (r=-0.50; p<0.01). Furthermore, there was a significant negative correlation between serum calcium and BPb levels (r=-0.41; p<0.01). This study has shown that relatively low BPb levels can enhance Pb absorption and also potentiate Pb neurotoxicity in the presence of decreased serum thiamine and Mg levels.

Haematological profile of healthy pregnant women in Ibadan, south-western Nigeria.

There is a dearth of information on the reference values for haematological indices particularly according to the relevant trimesters of pregnant women in Nigeria. The objective of this study was to provide reference values for Nigerian pregnant women. The study took place at the Adeoyo Maternity Hospital and the University College Hospital, both in Ibadan. This descriptive study was carried out over a period of 8 months. Subjects were apparently healthy pregnant women that satisfied the inclusion and exclusion criteria. The mean values (and 95% confidence intervals, CI) of haematological indices were as follows -- First trimester: Haemoglobin (Hb) 112.44 (101.64 - 123.25) g/l, haematocrit (hct) 35 (32 - 38)%, WBC 5.488 (4.025 - 6.950) x 10(9)/l and platelet counts 227.56 (165.21 - 289.90) x 10(9)/l;Second trimester: Hb 100.39 (97.85 - 102.92) g/l, hct 29.3 (28.5 - 30.1)%, WBC 6.57 (6.19 - 6.95) x 10(9)/l, platelet count 229.56 (211.86 - 247.26); and the Third trimester: Hb 98.06 (96.12 - 100.00) g/l, hct 29.4 (28.7 - 29.9)%, WBC 6.92 (6.53 - 7.30), platelet count 186.52 (177.67 - 195.38) x 10(9)/l. These results were compared with those of 52 non-pregnant age matched women volunteers as controls whose mean haematological indices and 95% CI were: Hb 120.51 (116.61 - 124.41) g/l, hct 36 (25 - 48)%, WBC 5.28 (2.9 - 8.7) x 10(9), platelet count 330.87 (176 - 538) x 10(9)/l. The following haematological indices: WBC, platelet counts, RBC, PCT, and PDW, of women between the trimesters showed statistical significance (p value < 0.001 in each case). The WBC is inversely proportional to the PCT and the MCV in the pregnant women was slightly raised. In this study, pregnancy is characterised by lowest values of haemoglobin parameters in trimester three and there are statistically significant differences between the WBC, platelet counts, RBC, PCT, and PDW of women between the three trimesters.

Coagulation profile in Nigerian children with cerebral malaria.

OBJECTIVES: To determine the screening coagulation tests - PT, PTT(k), TCT, fibrinogen and absolute platelet counts. MATERIALS AND METHODS: There were 97 children with 35 cerebral malaria (CM) and two control groups 30 acute malaria (AM) and 32 healthy controls aged 6 months--11 years. This is the first documented report of coagulation profile in Nigerian children above 6 months. RESULTS: The means of the PT in the three groups were normal. There was no significant difference between the means of PTT(k) and fibrinogen, p values 0.51 and 0.20 respectively. Nine of the CM group had deranged PT while eleven had elevated PTT(k). Four of the thrombocytopaenic CM patients were hypercoagulable. Three CM patients had bleeding episodes without laboratory evidences of DIC. Thrombocytopaenia occurred in 46% of the CM group compared with 23% of the AM. The role of hypercoagulable state observed amongst the thrombocytopaenic CM group could not be determined. CONCLUSION: We suggest close monitoring of platelet count and coagulation profile in those with haemorrhagic complications.

A case of IgA multiple myeloma: Nutritional perspective in diagnostic testing.

A 64-year-old security guard and longstanding known hypertensive presented with hypertensive heart disease (HHD), weight loss, an enlarged prostate, and a spontaneously fractured rib. Malignancy of the prostate with possible metastases to the ribs was strongly suspected. Biochemical profiling revealed a paraprotein. Other biochemical and hematological correlates that were on hand before serum protein electrophoresis were rather atypical. Paraprotein studies by immunofixation revealed IgA myelomatosis. Unlike previous reports from Caucasians there was normocalcaemia, normal protein level, microcytic hypochromia, low MCHC, cholesterol level at the lower limit of the reference range and normal urea level (in the face of markedly raised creatinine level). Nutritional modulation of the classical laboratory features of this disease may account for the fairly atypical laboratory picture.The need to appreciate the influence of nutritional status on the laboratory (especially biochemical) features of a disease and thus interpretation of diagnostic tests appears of exceptional current importance, given the widening gap in socioeconomic status and the level of poverty between the resource poor and developed countries from which the classical, clinical and laboratory features of most diseases were first described.This case report reminds of the need not only to recognize theoretically the impact of nutritional status on the laboratory characteristics of a disease but of the practical application of the nutritional perspective in the interpretation of diagnostic investigations, especially in nutritionally disadvantaged communities.

Hodgkin's disease after treatment for Burkitt's lymphoma: case report.

Hodgkin's disease and non-Hodgkin's lymphomas are interrelated disorders which have been reported to occur either simultaneously or sequentially in the same patient. We report here the development of nodular sclerosing type Hodgkin's disease in a patient two decades after successful treatment for Burkitt's lymphoma with cyclophosphomide and abdominal resection (AR). While the onset of symptoms after treatment for Burkitt's lymphoma was seven years definitive diagnosis of Hodgkin's disease was only made 22 years after the initial diagnosis of Burkitt's lymphoma. The recurrent and solitary nature ofthe lymphadenopathy and the fact that it was initially reported as reactive hyperplasia is typical of nodular lymphocyte predominant Hodgkin's disease. We believe that there was a transitory period of the malignancy as nodular lymphocyte predominant Hodgkin's disease.