Kawasaki disease in ghana: case reports from Korle Bu teaching hospital.

Kawasaki disease, an acute febrile vasculitis, predominantly affects children under the age of 5 years and is thought to be a rare disease in the developing world. It has previously never been reported in Ghana. We report 3 cases from February, 2007 to February, 2008. This potentially serious disease has no definitive diagnostic test and it is not unusual for diagnosis to be delayed with serious consequences. Any child with irritability and persisting fever (>5 days) not responding to antipyretics and antibiotics, accompanied by a rash and non purulent conjunctivitis should be suspected to have Kawasaki disease.

Gallstones in Ghanaian children with sickle cell disease.

OBJECTIVE: This prospective, cross-sectional study was done to define the prevalence and age of onset of gallstones in Ghanaina children with Sickle Cell Disease (SCD) in steady state, using ultrasonography. MATERIALS AND METHOD: The study was conducted at the Paediatric SCD clinic, Korle Bu Teaching Hospital, Accra, Ghana. Three hundred and fifteen (315) children comprising 162 males and 153 females aged 2 to 13 years with a confirmed diagnosis of SCD of haemoglobin SS, (HbSS), Haemoglobin SC, (HbSC) or Haemoglobin S-betathalassemia (SbetaThal) genotype whose parents/guardians gave informed conset, were recruited consecutively. The main outcome measure was the detection of gallstones in the gall bladder or common bile duct by ultrasonography. RESULTS: Thirteen children, 12 males and 1 female had gallstone, giving an overall prevalence of 4%. The youngest was aged 6. Four children had sludge only. Peak age of prevalence was 12 years. All patients under 12 years with gallstone were males (92.3%). The very high male: female ratio in these sickle cell disease children is at variance with the normal male: female ratio of 1:4.6. Although twenty percent of all the patients were genotype SC, only one SC patient had gallstones, giving a prevalence rate of 0.3%, and a prevalence ratio of stone in SS: SC of 12:1. Twenty patients had no spleen detectable clinically or on ultrasoound examination and none of them had gallstones. CONCLUSION: Gallstones occur at an early age in children with sickle cell disease in Ghana.

Low plasma concentrations of interleukin 10 in severe malarial anaemia compared with cerebral and uncomplicated malaria.

BACKGROUND: Severe anaemia is a major complication of malaria but little is known about its pathogenesis. Experimental models have implicated tumour necrosis factor (TNF) in induction of bone-marrow suppression and eythrophagocytosis. Conversely, interleukin 10 (IL-10), which mediates feed-back regulation of TNF, stimulates bone-marrow function in vitro and counteracts anaemia in mice. We investigated the associations of these cytokines with malarial anaemia. METHODS: We enrolled 175 African children with malaria into two studies in 1995 and 1996. In the first study, children were classified as having severe anaemia (n=10), uncomplicated malaria (n=26), or cerebral anaemia (n=41). In the second study, patients were classified as having cerebral malaria (n=33) or being fully conscious (n=65), and the two groups were subdivided by measured haemoglobin as normal (>110 g/L), moderate anaemia (60-90 g/L), and severe anaemia (<50 g/L). IL-10 and TNF concentrations were measured by ELISA in plasma samples from all patients. FINDINGS: IL-10 concentrations were significantly lower in patients with severe anaemia than in all other groups. In 1995, geometric mean plasma IL-10 in patients with severe anaemia was 270 pg/mL (95% CI 152-482) compared with 725 pg/mL (465-1129) in uncomplicated malaria and 966 pg/mL (612-1526) in cerebral malaria (p<0.03). In 1996, fully conscious patients with severe anaemia also had significantly lower IL-10 concentrations than all other groups, including cerebral-malaria patients with severe anaemia and all patients with moderate anaemia (p<0.001). In both studies, TNF concentrations were significantly higher in cerebral malaria than in fully conscious patients (p<0.01). By contrast, the ratio of TNF to IL-10 was significantly higher in fully conscious patients with severe anaemia than in all other groups (p<0.001). INTERPRETATION: Our findings identify severe malarial anaemia as a distinct disorder in which insufficient IL-10 response to high TNF concentrations may have a central role.

Rapid reemergence of T cells into peripheral circulation following treatment of severe and uncomplicated Plasmodium falciparum malaria.

Frequencies and absolute numbers of peripheral T-cell subsets were monitored closely following acute Plasmodium falciparum malaria in 22 Ghanaian children from an area of hyperendemicity for seasonal malaria transmission. The children presented with cerebral or uncomplicated malaria (CM or UM, respectively) or with severe malarial anemia. For all patients the frequencies and absolute numbers of peripheral T cells were lower than normal during the acute stage of disease. This lowering was most pronounced in the CM group and least pronounced in the UM group. Of particular interest, the CM patients showed markedly reduced frequencies of CD4+ cells, the number of which also normalized slower than in the other clinical groups. In all patients, the T-cell frequencies gradually approached normal values after the initiation of therapy, whereas the absolute numbers rapidly reverted from lower than normal to higher than normal before returning to steady-state levels. Furthermore, the initially reduced T-cell surface density of the T-cell receptor/CD3 complex, which rapidly normalized, was a general finding for all three clinical groups, suggesting a state of peripheral T-cell hyporesponsiveness during acute malaria. The data presented suggest a rapid therapy-induced reemergence of T cells that had been temporarily removed from the peripheral circulation as a consequence of the malaria attack and that the degree of the disease-induced T-cell reallocation correlates with disease severity.

Reversible suppression of bone marrow response to erythropoietin in Plasmodium falciparum malaria.

To study the importance of bone marrow inhibition in the pathogenesis of malarial anaemia, haematological and parasitological parameters were followed in patients with acute malaria. Three patient categories were studied, severe malarial anaemia (SA), cerebral malaria (CM) and uncomplicated malaria (UM). Red cell distribution width (RDW) was used as a surrogate marker of release of young erythrocytes and reticulocytes. Initially RDW was low in all patients in spite of markedly increased concentrations of erythropoietin (EPO). 3 d after institution of treatment and coinciding with parasite clearance RDW increased dramatically, reaching the highest levels 1-2 weeks later. Although severe anaemia was corrected by blood transfusion during the first 3 d of treatment, the peak RDW correlated significantly with the initial EPO levels. This suggests that Plasmodium falciparum infection causes a rapidly reversible suppression of the bone marrow response to EPO. Furthermore, the inhibition of bone marrow response was a general finding irrespective of initial haemoglobin levels suggesting that the severity of anaemia depends upon the degree of peripheral erythrocyte destruction in patients with suppressed bone marrow response to EPO.

The gamma/delta T-cell response to Plasmodium falciparum malaria in a population in which malaria is endemic.

Frequencies and absolute numbers of peripheral gamma/delta T cells have been reported to increase after episodes of Plasmodium falciparum malaria in adults with limited or no previous malaria exposure. In contrast, little is known about the gamma/delta T-cell response to malaria in children from areas where malaria is endemic, who bear the burden of malaria-related morbidity and mortality. We investigated the gamma/delta T-cell response in 19 Ghanaian children from an area of hyperendemic, seasonal malaria transmission. The children presented with cerebral malaria (n = 7), severe malarial anemia (n = 5), or uncomplicated malaria (n = 7) and were monitored from admission until 4 weeks later. We found no evidence of increased frequencies of gamma/delta T cells in any of the patient groups, whereas one adult expatriate studied in Ghana and three adults admitted to the hospital in Copenhagen, Denmark, all with uncomplicated, primary P. falciparum malaria, showed increased gamma/delta T-cell frequencies similar to those previously reported. All patients had lowered absolute numbers of peripheral gamma/delta T cells at admission, changing to increased numbers by days 7 to 14 and then returning to normal levels. The study raises questions regarding age and degree of previous exposure as determinants of malaria-induced gamma/delta T-cell responses.

Acute respiratory infections in young children comparative findings in emergency rooms in Accra, (Ghana) and Harare (Zimbabwe).

A descriptive study of the emergency room outcome of Acute Respiratory Infections (ARI) in children aged 0-3 years in the department of Child health of the Korle Bu Teaching Hospital (KBTH), Ghana and Parirenyatwa Hospital (PH), Zimbabwe was undertaken in June-July 1993. Each hospital's emergency room received over one thousand patients during the period with ARI contributing 22.4% to 45.5% of all admissions. KBTH had the lower incidence of ARI; probably as a result of the general lack of knowledge of ARI, resulting in late case of identification and referral for treatment. In PH, the colder environmental temperatures in June/July, the comprehensive ARI control programme and the HIV/AIDS and Tuberculosis epidemic could in part explain the relatively high attendance of patients with ARI to the emergency room. Our study shows an appreciable decline in the severer forms of ARI from the first to the third year of life, confirming the noted importance of younger age as a universal risk factor in ARI outcome. Lower respiratory infections, mainly pneumonia and bronchiolitis were more prevalent in both countries, while the chance of a child dying from ARI was higher in KBTH. Ghana urgently needs a comprehensive national ARI control programme based on the WHO case control programme guidelines with antibiotics permissible at all levels of the health service.

Neurodevelopmental problems in Ghanaian children: Part I. Convulsive disorder.

Children with convulsive disorder made up 3% of new patients seen in the paediatric department over a ten year period and 51.5% of children subsequently enrolled in the paediatric neuro-developmental clinic of the Korle Bu Teaching Hospital in Accra, Ghana. Generalised tonic-clonic seizures were the commonest type of seizure (76.5%), followed by complex seizures (14.8%) and temporal lobe seizures (3.4%). Majority of patients had no definable cause and normal neurological examination. 47.7% of electroencephalographs had diagnostic abnormalities. Most patients responded well to conventional antiepileptic drugs (AEDs) leading to discontinuation of drug therapy in 48 (7.1%) patients who remained seizure-free for two or more years. Adverse drug reactions and laboratory test abnormalities were rather uncommon. Discontinuation of antiepileptic therapy after effective long-term control is discussed.

Childhood deaths from anaemia in Accra, Ghana.

Severe anaemia has remained a major cause of morbidity and mortality in children of Southern Ghana since the early 1960s. 71.1% of 15450 children attending the Korle Bu Teaching Hospital, Accra referred to the laboratory for haematological studies had haemoglobin (HB) levels below 11.0 Gm/dl while 27.7% of anaemic patients had Hb levels below 7.0 gm/dl. Indeed, 71.1% of children with severe anaemia had Hb levels below 5.0 gm/dl, thus requiring urgent blood transfusion. Though the Department of Child Health alone utilised 32.2% of total blood processed by the National Blood Transfusion Service at Korle Bu, as many as 259 (58.1%) of the 554 deaths in the emergency rooms per annum in children beyond the neonatal period were related to severe anaemia. Iron deficiency was the commonest cause of anaemia and contributed further to the anaemias of sickle cell disease and protein--energy malnutrition. In the light of the significant decline in the prevalence of childhood anaemia in the developed world following improved counseling in nutrition, fortification of foods with iron, and iron supplementation to infants and school children, and the documented attendant improvement in growth velocity and intellectual performance we support the planned national anaemia survey and recommend for early consideration iron supplementation to older infants and pre-school children at risk.

PIP: Severe anemia has remained a major cause of morbidity and mortality in children of Southern Ghana since the early 1960s. Cases of anemia and anemia-associated mortality in the Korle Bu Teaching Hospital (KBTH), Accra, that occurred from January to December 1991 were reviewed. Data on hemoglobin levels, hypochromia, and malaria parasitemia of children referred from January to December 1991 were collected and analyzed to determine the prevalence of moderate/severe malaria parasitemia, anemia, and severe anemia. 10,989 (71.1%) of 15,450 children attending KBTH referred to the laboratory for hematological studies had hemoglobin (Hb) levels below 11.0 g/dl; while 3049 children (27.7%) of anemic patients had Hb levels below 7.0 g/dl. Of these 3049 children with severe anemia, 2185 (71.7%) had Hb levels below 5.0 g/dl, thus requiring urgent blood transfusion. Though the Department of Child Health alone utilized 32.2% of total blood processed by the National Blood Transfusion Service at KBTH, as many as 259 (58.1%) of the 554 deaths (306 male and 248 female) in the emergency room in children beyond the neonatal period were related to severe anemia. The main causes were nutritional anemia (n = 135), anemia associated with severe malaria (n = 56), anemia associated with sickle cell disease (n = 28), anemia associated with protein-energy malnutrition (n = 22), and 18 cases of anemia complicating gastroenteritis, pneumonia, meningitis, and convulsions. 108 (19.5%) deaths occurred because of neonatal sepsis, severe neonatal hyperbilirubinemia, meningitis and bronchopneumonia, severe anemia secondary to hemorrhage of the newborn, and faulty cord ligation. A significant decline occurred in the prevalence of childhood anemia in the developed world following improved counseling in nutrition, fortification of foods with iron, and iron supplementation to infants and schoolchildren with the attendant improvement in growth velocity and intellectual performance. A planned national anemia survey and early consideration of iron supplementation to older infants and preschool children at risk are recommended.

Measles in southern Ghana: 1985-1993.

Measles continues to be a significant cause of morbidity and mortality among children in Southern Ghana although at a much lower level than a decade earlier. The major indications for measles admissions and the mortality associated factors of pneumonia, malnutrition, and diarrhea complicated by dehydration, however remain the same. The majority of measles admissions were in children without primary immunization resident in the more densely populated inner city of Accra and the peri-urban areas inhabited by lower-income recent immigrants. Our data show uncomfortable increases in the number of children aged 3-8 months as well as school age children (> or = 60 months), thus reopening the perennial discussion on the measles immunization programme i.e. what to do with younger infants with doubtful maternally-derived protection as well as the children who have missed their primary immunization at 9 months or those with immunization failure. The advantages of the 2-dose measles immunization programme need urgent consideration by national programme directors in African countries. The second dose is especially advocated to address the attendant problems of the cold chain system, vaccine efficacy, vaccine failure and diagnostic errors as older school-going age children.

Drug compliance among parents and guardians of children in Accra, Ghana.

Through a structured questionnaire, 523 parents and guardians who received prescription to collect medicine for their wards at the pharmacy of the Department of Child Health, Korle Bu Teaching Hospital were interviewed during the months of March and April, 1993. The objectives were to determine to what extent they remembered prescription instructions for their wards and to find out any other factors that contributed to drug non-compliance. A large percentage (about 80%) were able to recount instructions given correctly. It was however worrying, that quite a sizeable number could not recount instructions given. This obviously contributed to non-compliance. Other factors that were found and which could have contributed to non-compliance were: poor economic standing, non-availability of drugs at the hospital pharmacy, availability of similar drugs at home and patients getting well before the scheduled period of treatment is over. Of particular concern was the response by some parents/guardians that they would double the dosage to their wards to make up for a missed one should they forget any of the scheduled doses. Workers at pharmacy shops need to use simple practical means of giving prescription instructions, especially to illiterate patients.

Bacterial meningitis in children in southern Ghana.

One hundred and three children (1% of seriously ill children referred to the Korle Bu Teaching Hospital in Accra) were admitted with bacterial meningitis over a 17 month period. 43 of these children had been ill for more than 4 days before arrival at our centre. The main causative organisms were S. pneumoniae (47.9%), Neisseria meningitides (38.4%) and Haemophilus influenzae (9.6%). All bacterial isolates were highly sensitive to ceftriaxone. Resistance to penicillin and chloramphenicol was however present in 5-17% of isolates. All cerebrospinal fluid samples were sterilised within 48 hours of antibiotic treatment. Case fatality rate was 22% with the majority of deaths occurring within hours of admission and closely related to S. pneumoniae infection. Neurological complications occurred in 22%; mild diarrhoea in 33% and secondary fever in 14.8% of survivors. No significant difference was noted among the three treatment regimens of ceftriaxone alone, penicillin plus chloramphenicol, and ceftriaxone alone for 48 hours followed by penicillin/chloramphenicol combination. Our overall outcome would have been better if patients had been started on appropriate antibiotic treatment within the earlier hours of the infection. Furthermore, the latter generation cephalosporins, including ceftriaxone, must be given consideration as antibiotics of first choice world wide.

PIP: Between November, 1991, and March, 1993, in Accra, Ghana, physicians admitted 103 children, 2 months to 12 years old, to the Korle Bu Teaching Hospital with suspected bacterial meningitis. They constituted 1.04% of all children presenting at the emergency rooms. Late referral to the hospital was likely responsible for the high case fatality rate within the 1st 24 hours of admission (59.1% of all deaths). 42.7% of all cases presented more than 96 hours after the onset of symptoms. 7 children died immediately after admission, allowing physicians no time to begin antibiotic treatment. The overall case fatality rate was 21.4%. Streptococcus pneumonia was isolated from the cerebrospinal fluid (CSF) in 53.8% of the early deaths and 55% of all 73 mortality cases from which bacteria were isolated. Leading causative organisms were $. pneumoniae (47.9%), Neisseria meningitides (38.4%), and Hemophilus influenza (9.6%). All bacterial isolates were sensitive to ceftriaxone. 5-17% of all isolates were resistant to penicillin and chloramphenicol. No bacteria were isolated in the CSF of any children within 48 hours of antibiotic treatment. The leading complications and sequelae of the 81 survivors were mild diarrhea (33%), neurological complications (22%), and secondary fever (14.8%). Even though the chloramphenicol/penicillin treatment regimen had the highest survivor outcome results (43%), its results were not significantly different than those of ceftriaxone alone for 48 hours followed by chloramphenicol/penicillin and ceftriaxone alone (24% and 20%, respectively; p =.6). These results suggest that health workers at less than optimum health facilities should administer the 1st dose of ceftriaxone to children suspected of having meningitis before transferring them to a tertiary facility for further management. This should greatly reduce case fatalities and sequelae. Health workers worldwide, even those in malaria endemic areas, should consider meningitis as a significant cause of fever.

Pediatric cerebral malaria in Accra, Ghana.

Characteristics of pediatric cerebral malaria, including specificity of clinical diagnosis, efficacy of antimalarial regimens, and the influence of drug resistance remain poorly defined in many parts of the world. The utility of the Glasgow coma scale and quantitative assessment of parasitaemia levels as diagnostic and prognostic indices in cerebral malaria were determined in this study. Thirty-one pediatric patients with admission diagnoses of cerebral malaria in the emergency ward at Korle Bu Hospital, Accra, Ghana were evaluated. Mean age was 4.8 years. The initial diagnosis of malaria was confirmed in 65 per cent of patients; 16 per cent ultimately received another diagnosis including pneumonia, meningitis or encephalitis. In 19 per cent the diagnoses were inconclusive. Mean initial blood parasitaemia level was 10(4.6) parasites per mm3, and mean initial Glasgow coma score was 10.4. The initial Glasgow score was a better predictor of length of stay (Pearson correlation coefficient r = 0.66) than initial parasitaemia level (r = 0.17). For most treated patients parasitaemia levels decreased a mean of 1.3 logs per day of therapy; however, in 33 per cent parasitaemia continued to rise or fluctuate. High parasitaemia levels were associated with deep levels of coma, but only when both parameters were assessed throughout the hospital stay. Both deaths in this series occurred in patients who had persistently negative blood smears for malaria parasites, but showed autopsy findings consistent with cerebral malaria.

The nutritional status and feeding practices among sick urban pre-school children admitted to a major hospital in Accra, Ghana.

In a prospective study of 652 sick pre-school children only 33% were found to be adequately nourished. Among the malnourished, 54.3% had first degree malnutrition while 32.3% and 13.4% had second and third degree malnutrition respectively. The majority of malnourished children (72.4%) had undernutrition: kwashiorkor (14.2%), marasmus 7.3%) and marasmic kwashiorkor (6.1%) was relatively less common. Furthermore, 58% of the underweight children were stunted, indicating malnutrition of some considerable duration. Malnutrition was essentially of postnatal origin and closely related to a high incidence of malnutrition-associated illnesses: diarrhoea (74%), measles (51%) and intestinal parasites (54%). Though breast feeding was universal and of adequate duration, milk production was mostly inadequate because of too early supplementation with low-energy cereal gruels with little or no protein-enrichment. The majority of children came from low socio-economic homes (61%) with mostly illiterate or semi-literate mothers. It is essential that newer methods of teaching be employed in the health education of these unfortunate mothers. Health institutions other than well-baby clinics need to have integrated units for nutritional and immunization surveillance and also for serving as avenues for the supply of free supplementary food items to children with poor weight gain, especially those from poor homes. Clinical Nutrition Units are needed to ensure that inpatients receive nutrients sufficient for continuing and catch-up growth.

Measles in Ghana--1973-1982.

Admissions of children with measles constituted 8.8% of all admissions to the paediatric medical service of the Korle Bu Teaching Hospital, Accra, over the ten-year-period 1973-1982. Measles remains endemic in urban Accra as in the towns of other developing nations. The peak of admissions occurred in the age range seven to 12 months. Complications were frequent, with a high mortality (16.86%). Bronchopneumonia, the commonest complication (63.9%) was also the commonest cause of death in 51.5% of cases. Comparative national case-mortality rates were, however, surprisingly low and should be accepted with caution. There is an urgent need for intensification of immunization efforts through amalgamation of the preventive and curative services of Ghana, especially for children attending health centres for medical care. Vaccination should be administered before the peak age of admission, preferably at six months of age, with a second dose administered as soon after one year of age as possible.