Diagnostic role of video-assisted thoracoscopy in the management of indeterminate pleural effusion.

Background: The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients. Aim: To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center. Patients and Methods: Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed. Results: Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis. Conclusion: Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.

Microbiological profile and antibiotic resistance pattern of empyema thoracis in Calabar, Nigeria.

Targeted empirical antibiotic therapy based on local microbiology and antibiotic resistance patterns is essential for the treatment of empyema thoracis. Our retrospective review of 105 pleural empyema culture and sensitivity reports aimed at determining the causative microorganisms and their antimicrobial resistance pattern. Of 105 pleural aspirate samples, 46 (43.8%) were positive on culture. Gram-negative organisms (n = 43) were the predominant isolates, the commonest of which was Klebsiella pneumoniae. It was concluded that empyema thoracis is predominantly caused by Gram-negative organisms in our locality. This should guide protocols on the initiation of empirical therapy.

ADVANCED BRONCHOGENIC CARCINOMA PRESENTING WITH SKIN NODULES - A CASE REPORT.

Bronchogenic cancer can metastasize to several organs of the body. Metastases to skin and subcutaneous tissue are uncommon. We present our experience with the management of a patient with an unusual presentation of bronchogenic carcinoma with multiple skin nodules. In patients with bronchogenic cancer, metastasis to the skin and subcutaneous tissues could heighten the index of suspicion of advanced disease. The nodules should be histologically assessed and if confirmed metastatic, only palliative therapies are indicated.

ADVANCED BRONCHOGENIC CARCINOMA PRESENTING WITH SKIN NODULES - A CASE REPORT.

Bronchogenic cancer can metastasize to several organs of the body. Metastases to skin and subcutaneous tissue are uncommon. We present our experience with the management of a patient with an unusual presentation of bronchogenic carcinoma with multiple skin nodules. In patients with bronchogenic cancer, metastasis to the skin and subcutaneous tissues could heighten the index of suspicion of advanced disease. The nodules should be histologically assessed and if confirmed metastatic, only palliative therapies are indicated.

Recurrent pericardial effusion associated with hypothyroidism in Down Syndrome: a case report.

BACKGROUND: The complex of Down Syndrome-hypothyroidism-pericardial effusion is largely unreported in sub-Sahara. OBJECTIVE: To present and highlight an unusual manifestation of hypothyroidism. METHODS: A 16-year-old girl with confirmed Down Syndrome presented with complaints of generalised body swelling of eight months' duration. Her work-up consisted of full clinical and laboratory evaluation including ECG and echocardiography. RESULTS: The patient was diagnosed of Down's Syndrome at birth but was lost to follow-up after at eight years of age. Body swelling was associated with clinical features of heart failure. Echocardiography showed massive pericardial effusion. Serum l-thyroxine was less than 0.5mg/dl and TSH >40iu/l. The heart failure and menstrual irregularities responded to l-thyroxine therapy. CONCLUSION: This appears to be the first report of the complex of Down syndrome, hypothyroidism and pericardial effusion in a Nigerian child. Thyroid function test is therefore recommended as a part of baseline investigation for Nigerian children with Down syndrome as is the practice.

Discrete subaortic stenosis in an adult Nigerian: a case report.

BACKGROUND: Cases of discrete subaortic stenosis are rare in adults. To our knowledge, no case has been reported in Nigerian literature. Cases are thus likely to be missed or wrongly managed. OBJECTIVE: To present a case of discrete membranous subaortic stenosis in an adult Nigerian with a view to creating awareness of the existence of this entity in our milieu. METHODS: The patient a 46-year-old Nigerian presented with symptoms of angina pectoris and near syncope. Transthoracic 2-Dimensional / M-mode echocardiography demonstrated thickened and calcific aortic valves and laboratory investigations showed that he also had artherogenic dyslipidaemia. He was initially managed as a case of severe valvular aortic stenosis of rheumatic origin with associated dyslipidaemia and was referred for further evaluation and management abroad. RESULTS: On further assessment at the referral centre, the diagnosis was reviewed to subaortic stenosis with severe left ventricular outflow tract obstruction (LVOTO) arising from a fibro muscular subaortic membrane after a repeat 2-D/M-mode and Doppler echocardiography. Coronary angiography showed normal coronaries. He had excision of the membrane with marked reduction in gradient across the left ventricular outflow tract. He has remained symptom free and stable thereafter. CONCLUSION: Discrete membranous subaortic stenosis though rare in adults should be suspected in patients with clinical features of valvular aortic stenosis. Doppler echocardiography is thus mandatory in the evaluation of these patients.

Gunshot injuries in Calabar, Nigeria: an indication of increasing societal violence and police brutality.

BACKGROUND: Gunshot injuries were rare in Calabar before the Nigerian civil war. This has changed in subsequent years and has reached a near epidemic proportion in the last three years. These are caused by civil violence, police brutality and armed robberies. OBJECTIVE: To evaluate the incidence, pattern and causes of gunshot injuries in this region and draw the attention of Nigerians and the Government to the above problems for a possible solution. METHODOLOGY: Records of patients admitted into the University of Calabar Teaching Hospital (UCTH) with gunshot wounds between April 2002 and May 2004 were extracted. Parameters analyzed included patients' biodata, sources of injury, anatomical site (s) of injury, modalities of treatment and the outcome RESULT: There were 51 injuries in 49 patients as follows: The lower limbs 25 (51'), upper limbs 6 (12.4'), upper limbs/ chest 2 (4.1'), chest 4 (8.2'), abdomen 7(14.1') and head/neck 5(10.2'). Male/female ratio was 48:1. Twenty-four (49') sustained their injuries from either accidental discharge or deliberate shooting by the police while armed robbers wounded 10 (20.4') and cultists, 2 (4.1'). Two patients had amputations and mortality was 8.2'. CONCLUSION/RECOMMENDATIONS: The police should be cautious with guns;they and the Government should be alert to the menace of robbery, political violence, cultism and communal clashes. Good Governance, creation of employment, eradication of corruption and political violence may help.

Chronic foot ulcer complicating a traumatic arteriovenous fistula

Background: Chronic foot ulcers could be a complication of traumatic arteriovenous (A-V) fistulation. We report a rare case of chronic foot ulcer and deformity resulting from arteriovenous fistula of the anterior tibial artery. Method: The clinical presentation and the outcome of treatment in a patient treated at the University of Calabar Teaching Hospital (UCTH) Calabar are reported. The relevant literature on this subject matter is briefly reviewed. Result: A case of chronic foot ulcer and oedema secondary to traumatic arteriovenous fistula of the anterior tibial artery was managed by the authors at the University of Calabar Teaching Hospital. The diagnosis was mainly clinical as sophisticated equipment was not readily available and satisfactory healing was achieved by exploration; quadruple ligation; skin grafting and cast application. Conclusion: Prompt diagnosis and treatment of difficult cases should warrant sophisticated equipment to make diagnosis