Secondary polycythaemia with elevated carbon monoxide levels due to hookah pipe smoking: A public health concern.

Hookah pipe (HP) smoking is perceived as a harmless activity, enjoyed by young adults and high school-going children. Awareness of the health impact of recreational habits, and their intersection with new social norms in the COVID-era, requires critical review. We describe a case series of young HP smokers presenting with secondary polycythaemia with significant clinical sequelae necessitating extensive work-up. HP smoking may lead to acute and chronic carbon monoxide intoxication, with resultant secondary polycythaemia and complications including provoked thrombosis.

HIV-related bronchiectasis in children: an emerging spectre in high tuberculosis burden areas.

BACKGROUND: Human immunodeficiency virus (HIV) infected children have an eleven-fold risk of acute lower respiratory tract infection. This places HIV-infected children at risk of airway destruction and bronchiectasis. OBJECTIVE: To study predisposing factors for the development of bronchiectasis in a developing world setting. METHODS: Children with HIV-related bronchiectasis aged 6-14 years were enrolled. Data were collected on demographics, induced sputum for tuberculosis, respiratory viruses (respiratory syncytial virus), influenza A and B, parainfluenza 1-3, adenovirus and cytomegalovirus), bacteriology and cytokines. Spirometry was performed. Blood samples were obtained for HIV staging, immunoglobulins, immunoCAP®-specific immunoglobulin E (IgE) for common foods and aeroallergens and cytokines. RESULTS: In all, 35 patients were enrolled in the study. Of 161 sputum samples, the predominant organisms cultured were Haemophilus influenzae and parainfluenzae (49%). The median forced expiratory volume in 1 second of all patients was 53%. Interleukin-8 was the predominant cytokine in sputum and serum. The median IgE level was 770 kU/l; however, this did not seem to be related to atopy; 36% were exposed to environmental tobacco smoke, with no correlation between exposure and CD4 count. CONCLUSION: Children with HIV-related bronchiectasis are diagnosed after the age of 6 years and suffer significant morbidity. Immune stimulation mechanisms in these children are intact despite the level of immunosuppression.

Meningococcal infections in hospitalised patients in Pretoria.

We report on 13 patients diagnosed with meningococcal infections in patients attending state-owned hospitals serving an indigent population in Pretoria in 2009. The case fatality rate was 27%. Ceftriaxone was the main antibiotic (9 out of 13 patients) for therapy. Five isolates (39%) were serogroup B and 4 (31%) serogroup W135. Most isolates (12/13) were fully susceptible to penicillin (MIC range 0.016 - 0.047 µg/ml). A single isolate was intermediately resistant to penicillin (MIC, 0.125 µg/ml) while all isolates were uniformly susceptible to ceftriaxone, ciprofloxacin and rifampicin. This pattern reveals a shift in serogroups with an increase of serogroup B disease in the Pretoria region, and the need for ongoing monitoring of antimicrobial susceptibility profiles and the value of ceftriaxone for favourable therapeutic outcome.

Case series of the long-term psychosocial impact of drug-resistant tuberculosis in HIV-negative medical doctors.

BACKGROUND: Health care workers (HCWs) are at greater risk for tuberculosis (TB), including multidrug-resistant TB (MDR-TB), compared to the general population. The psychosocial impact of nosocomial TB on HCWs has received little attention in the literature. METHODS: A retrospective medical record review from 1999 to 2003 found 15 HCWs who were treated for drug-resistant TB at a specialist hospital in South Africa. Five human immunodeficiency virus (HIV) negative doctors with no predisposing factors for drug resistance are included in this case series. We collectively present their clinical case histories based on medical records from 2000 to 2005, and explore the long-term psychosocial impact of TB from interviews conducted in 2009. RESULTS: Four doctors had primary MDR-TB and one had primary resistance to multiple first-line drugs. Time from symptom onset to commencement of effective treatment ranged from 8 to 39 weeks. Time for bacteriological confirmation of drug-resistant TB ranged from 6 to 24 weeks. All were cured within 3 years of initial presentation. Content analysis of follow-up interviews revealed five main themes: 1) prolonged morbidity, 2) psychological impact, 3) poor infection control, 4) weak support structures and 5) attrition from the field. CONCLUSION: Themes emergent from this case series encourage prioritisation of TB infection control education and practice to minimise HCW morbidity and prevent HCW attrition from high-burden resource-constrained settings.

Atopy in HIV-infected children in Pretoria.

INTRODUCTION: The development or aggravation of a pre-existing atopic state in patients with human immunodeficiency virus (HIV) has not been thoroughly investigated in South Africa. HIV-infected adults have been shown to have a higher prevalence of atopy in some international studies, but this has not been documented in children. METHODS: A prospective convenience sample of 50 children aged between 3 months and 12 years attending the Tshwane District Hospital Paediatric HIV Clinic in Pretoria was recruited. Their personal and family histories of atopy, World Health Organization (WHO) HIV clinical staging and Centers for Disease Control (CDC) immunological staging with CD4 counts were documented. An age- and sex-matched control group of 50 HIV-negative children was included. Skin prick tests (SPTs) to identify common aeroallergens were conducted on all patients. RESULTS: One hundred children were enrolled, with 50 in each group. Ten per cent of the HIV-infected patients compared with 16% of controls had positive SPTs to aeroallergens. A higher percentage of the HIV-infected patients had chronic rhinitis and eczema (60% and 68%, respectively). There was no relationship between CD4 count and positive SPTs (p = 0.61), mean log CD4 count and presence of reported asthma (p = 0.71), and CD4 count and presence of reported dermatitis (p = 0.84). The CD4 count was not statistically different between children with and without a family history of atopy (p = 0.68). CONCLUSION: It appears that the stage of HIV disease does not influence the development or expression of allergy. There is a high prevalence of dermatitis and chronic rhinitis in HIV-infected children, probably not atopic in origin.

Montelukast inhibits tumour necrosis factor-alpha-mediated interleukin-8 expression through inhibition of nuclear factor-kappaB p65-associated histone acetyltransferase activity.

BACKGROUND: Montelukast is a potent cysteinyl leukotriene-1 receptor antagonist possessing some anti-inflammatory effects although the molecular mechanism of these anti-inflammatory effects is unknown. In this study, we aimed to investigate the effect of montelukast on nuclear factor (NF)-kappaB-associated histone acetylation activity in phorbol myristate acetate (PMA)-differentiated U937 cells. METHODS: We examined the inhibitory effects of montelukast on TNF-alpha-induced IL-8 production in PMA-differentiated U-937 cells. U-937 cells were exposed to PMA (50 ng/mL) for 48 h to allow differentiation to macrophages. Macrophages were then exposed to TNF-alpha (10 ng/mL) in the presence or absence of montelukast (0.01-10 microm) for 24 h. After this time, the concentration of IL-8 in the culture supernatant was measured by sandwich-type ELISA kit. The effect of signalling pathways on TNF-alpha-induced IL-8 release was examined pharmacologically using selective NF-kappaB/IKK2 (AS602868, 3 microm), (PD98059, 10 microm) and p38 mitogen activated protein kinase (MAPK) (SB203580, 1 microm) inhibitors. NF-kappaB DNA binding activity was measured by a DNA-binding ELISA-based assay. NF-kappaB-p65-associated histone acetyltransferase (HAT) activity was measured by immunoprecipitation linked to commercial fluorescent HAT. RESULTS: TNF-alpha-induced IL-8 release was suppressed by an NF-kappaB inhibitor but not by MEK or p38 MAPK inhibitors. Montelukast induced a concentration-dependent inhibition of TNF-alpha-induced IL-8 release and mRNA expression that reached a plateau at 0.1 microm without affecting cell viability. Montelukast did not affect NF-kappaB p65 activation as measured by DNA binding but suppressed NF-kappaB p65-associated HAT activity. CONCLUSION: Montelukast inhibits TNF-alpha-stimulated IL-8 expression through changes in NF-kappaB p65-associated HAT activity. Drugs targeting these enzymes may enhance the anti-inflammatory actions of montelukast.

The potential role for arachidonic and docosahexaenoic acids in protection against some central nervous system injuries in preterm infants.

The risk of central nervous, visual, and auditory damage increases from 2/1000 live births in the normal birthweight to > 200/1000 as birthweight falls below 1500 g. Such babies are most likely to be born preterm. Advances in infant care have led to increasing numbers of very-low-birthweight, preterm infants surviving to school age with moderate to severe brain damage. Steroids are one of the current treatments, but they cause significant, long-term problems. The evidence reported here suggests an additional approach to protecting the very preterm infant by supporting neurovascular membrane integrity. The complications of preterm, very-low-birthweight babies include bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular hemorrhage, periventricular leukomalacia, and necrotizing enterocolitis, all of which have a vascular component. Arachidonic acid (AA) and DHA are essential, structural, and functional constituents of cell membranes. They are especially required for the growth and function of the brain and vascular systems, which are the primary biofocus of human fetal growth. Molecular dynamics and experimental evidence suggest that DHA could be the ligand for the retinoid X receptor (RXR) in neural tissue. RXR activation is an obligatory step in signaling to the nucleus and in the regulation of gene expression. Very preterm babies are born with minimal fat stores and suboptimal circulating levels of these nutrients. Postnatally, they lose the biomagnification of the proportions of AA and DHA by the placenta for the fetus. No current nutritional management repairs these deficits. The placental biomagnification profile highlights AA rather than DHA. The resultant fetal FA profile closely resembles that of the vascular endothelium and not the brain. Without this nourishment, cell membrane abnormalities would be predicted. We present a scientific rationale for a common pathogenic process in the complications of prematurity.

Lithopedion: a case report.

An 80-year-old Black, South African woman presented in the outpatient department with severe abdominal pain. Ultrasound examination revealed a large echogenic mass (20 x 20 cm) in the right upper quadrant. An abdominal x-ray demonstrated the skeleton of a fully developed extrauterine fetus. It is presumed from the patient's history that this fetus was present for at least 40 years. Radiography revealed a fetus shrouded in a mantle of calcification. The fetus was hyper-flexed with other signs of "intrauterine" death. Fetal dentition charts dated the fetus at 34 weeks, the epiphyses being obscured by extensive calcification. In addition to subcutaneous calcification there was extensive visceral and intracranial calcification.

Incidence and bedside diagnosis of haemodynamically significant right ventricular infarction.

The incidence, diagnosis and clinical course of haemodynamically significant right ventricular infarction (RVI) were assessed prospectively in 90 patients with their first acute inferior myocardial infarction. The haemodynamic criteria for RVI were defined as a mean right atrial pressure of 10 mmHg or more and a mean right atrial pressure equal to or greater than the mean pulmonary capillary wedge pressure. Twenty-six patients (29%) had haemodynamic evidence of RVI (group A) whereas 64 (71%) did not meet the criteria (group B). ST-segment elevation in lead V4R was observed in 25 patients (96%) with haemodynamic evidence of RVI and in 15 (23%) without (P less than 0.001). The jugular venous pressure (JVP) was found to be elevated in 24 of the 26 group A and in 7 of the 64 group B patients (P less than 0.001). Kussmaul's sign was present in 21 group A and 3 group B patients (P less than 0.001). Of the clinical signs, elevation of the JVP with clear lung fields on the chest radiograph had the best predictive value (92%) for haemodynamically significant RVI. The ECG was highly sensitive (96%) but less specific (77%) and had a low predictive value (63%) for haemodynamically significant RVI. Hypotension and complete atrioventricular block occurred more frequently in group A patients (P less than 0.001 and P less than 0.01 respectively). The hospital mortality rate was similar in both groups.

Risk factors in young Indian males with myocardial infarction.

Risk factors were assessed in 108 young Indian males with myocardial infarction. The mean age was 36 years (range 21-40 years). Cigarette smoking was the most common risk factor (79% of patients). Serum cholesterol levels were above 6.5 mmol/l in 50% and serum triglyceride levels were above 2.0 mmol/l in 53% of patients. High-density lipoprotein cholesterol levels below 0.83 mmol/l were found in 52% of patients. Ninety-six per cent of patients had one or more of the following risk factors: a history of cigarette smoking, hypercholesterolaemia, hypertension, and abnormal glucose tolerance. Thus, in young Indian males with myocardial infarction, one or more risk factors are usually present.

Neural deficits, intelligence, maladjustment and family response in children with the nephrotic syndrome.

An intensive psychomedical study of a small number of children suffering from the nephrotic syndrome is reported. Significant organic and psychological sequelae exist in the nephrotic child. The patient's family also appears to need specialist psychological attention. The urgent need for well-organised liaison psychiatric services in non-psychiatric medical departments is emphasised.

Congenital heart block detected in utero. A case report.

Fetal heart movement and fetal heart rate are easily observed with real-time ultrasonography. Certain aspects of fetal cardiac disorders can thus be further evaluated by M-mode echocardiography. Congenital heart block and associated connective tissue disorders are discussed.

Simulation of posterior fossa cyst by normal, hypo-echoic white matter on cranial ultrasonography.

Ultrasonography in the diagnosis of fetal abnormalities is well documented, and improvements in technology have made possible detailed visualization of the intracranial anatomy. Ten per cent of major fetal abnormalities involve the head and neck. A case of simulation of a posterior fossa cyst by normal, hypoechoic white matter on cranial ultrasonography is presented. Potential pitfalls and the differential diagnosis of intracranial abnormalities in utero are discussed.

Ovarian hyperstimulation syndrome. A case report.

An iatrogenic disease resulting from the induction of ovulation is described. It would appear that it is uncommon in southern Africa.

Unusual displacement of an intra-uterine contraceptive device. A case report.

Since its introduction in 1959 the plastic intra-uterine contraceptive device (IUCD) has been accepted as a safe and convenient means of preventing conception. Nevertheless, use of the IUCD has been attended by complications, notably perforation of the uterus by the device. An unusual case of translocation of an IUCD--the device was located within the lumen of the appendix--is presented.