Mycobacterial diversity causing multi- and extensively drug-resistant tuberculosis in Djibouti, Horn of Africa.

On detecting a high prevalence of multidrug-resistant tuberculosis (TB) in Djibouti, 32 Mycobacterium tuberculosis isolates of patients hospitalised in the TB referral centre of the capital were genotyped. A high variety of M. tuberculosis lineages, including lineage 1, Indo-Oceanic, lineage 2, East-Asian, lineage 3, East-African Indian and lineage 4, Euro-American, were detected.

Profound reduction of CD4+ lymphocytes without HIV infection: two cases from the horn of Africa.

Idiopathic CD4+ lymphocytopenia is a disorder associated with low CD4+ T cell count and opportunistic infections resembling AIDS. Most cases are described in developed countries. We report two HIV-negative patients with idiopathic CD4+ lymphocytopenia and AIDS-defining events diagnosed in Djibouti. The first patient developed lesions of Kaposi's sarcoma and the second one presented with pulmonary tuberculosis. Both patients died with severe immunodepression. In poor resource-areas where HIV testing may not be available it is important to bear in mind that severe immunodepression and a clinical presentation compatible with AIDS do not necessary carry the diagnosis of AIDS.

Female genital mutilation in Djibouti.

The practice of female genital mutilation (we will use the latest definition adopted by WHO/UNFP: female genital mutilation/cutting or FGM/C) is still widespread in 28 African countries. The World Health Organisation (WHO) estimates that more than two million females undergo some form of genital mutilation every year. Its negative health impact and its ethical and human rights aspects have been discussed and attempts to eliminate it have been the objectives of several meetings promoted by national and international organisations thanks to an increased awareness related to FGM/C in those countries practicing it and also, maybe due to the number of Africans migrating to industrialized countries. We review the present situation in Djibouti, a small country in the Horn of Africa, where 98 % of the female population has suffered different forms of FGM/C.

Resistance to anti-tuberculosis medications in the Horn of Africa.

We performed drug susceptibility testing among chronic patients hospitalised in the tuberculosis (TB) referral centre of the capital of Djibouti. Among 36 patients tested, 27 had multidrug-resistant TB and four had extensively drug-resistant TB. National guidelines must be revised urgently and the administration of second-line TB medications strictly controlled.

Tuberculosis in rural Uganda.

BACKGROUND: St Francis Hospital, a health facility in the rural district of Mayuge, Uganda. OBJECTIVES: To evaluate the presentation, course and outcome of patients with tuberculosis hospitalized to receive the intensive phase of treatment. METHOD: Observational analytical study of all patients admitted during June 2002-March 2005. RESULTS: There were 680 patients. Their median age was 31 years (range 2-75); 364 (54 %) were male. There were 564 (83 %) new patients; 60 (9 %) defaulters; 35 (5 %) relapses; 14 (2 %) transfers; four chronic patients; and three treatment failures. Three hundred and thirteen patients (58 %) had moderate or severe malnutrition on admission. Among 102 patients tested for the human immunodeficiency virus, 68 (67 %) were positive. At the end of hospitalization 593 patients (87 %) were to be followed-up at St Francis Hospital or were transferred to another health facility, 31 (5 %) had absconded and 56 (8 %) had died. CONCLUSION: The severely limited resources of our patients and the human immunodeficiency virus co-infection are likely factors contributing to their late presentation and the severity of the disease. It is doubtful that in our setting tuberculosis can be effectively controlled without addressing and correcting these factors.

Multiorgan involvement due to Salmonella typhi: case report.

A 12-year-old male presented with osteomyelitis and poliarthritis; after hospitalisation he developed subcutaneous abscesses, endocarditis and pericarditis. The diagnosis of typhoid fever was made when blood cultures grew Salmonella typhi. The patient was cured with a regimen of ceftriaxone and ciprofloxacin.

Outcomes of individualised treatment for multidrug-resistant tuberculosis before DOTS-plus.

SETTING: A tuberculosis (TB) out-patient service in the city of Santa Cruz, Bolivia. OBJECTIVE: To evaluate the outcomes of patients with TB resistant to isoniazid and rifampicin (multidrug resistance [MDR]) treated in a resource-poor area before the introduction of the DOTS-Plus initiative. DESIGN: Retrospective cohort study of MDR-TB patients treated with individualised regimens between January 1983 and December 1993. RESULTS: Among 143 patients studied, 73 (51%) were males; the mean age was 33.9 years. Forty (28%) were new patients and 103 (72%) were previously treated patients. The treatment regimen had to be modified in 122 (85%) patients. A successful outcome was achieved in 41 (28%) patients; 68 (48%) defaulted, 18 (13%) died, and 14 (10%) were still under treatment in 1996. CONCLUSIONS: The treatment approach described had dismal results. The capacity for performing drug susceptibility testing and the availability of several second-line anti-tuberculosis drugs were not sufficient to achieve cure in more than one third of the patients treated. Other factors, such as a set of standard procedures, clear guidelines for the treatment and follow-up of patients and the administration of directly observed treatment, must be included in a programme for treating MDR-TB, to obtain better treatment results.

[Prognosis of mono- and polydrug resistant pulmonary tuberculosis in the city of Santa Cruz, Bolivia]. / Pronóstico de la tuberculosis pulmonar mono y polirresistente en la ciudad de Santa Cruz (Bolivia).

OBJECTIVE: To evaluate the results of treatment in patients with pulmonary tuberculosis (TB) resistant to one antituberculosis drug (single drug resistance [SDR]) or to more than one drug (polyresistance [PDR]), excluding patients with resistance to the combination of isoniazid and rifampicin (multidrug resistance). PATIENTS AND METHOD: Retrospective review of all the records of patients with pulmonary TB diagnosed in an outpatient clinic in Santa Cruz, Bolivia, from 1983 through 1993 whose first cultures were SDR or PDR and who were started on treatment in the clinic. RESULTS: We identified 368 patients: 276 (75%) with SDR TB and 92 (25%) with PDR TB. There were 164 new patients among the SDR cases (59%) and 41 (45%) among the PDR cases (P<.05). The mean (SD) age of PDR patients was 31.5 (14.2) years and there were 165 (68%) males. The mean age of SDR patients was 29.4 (13.4) years and there were 50 (54%) males. Eleven patients (3%) experienced a change in the type of resistance (SDR: 7 [3%]; PDR: 4 [4%]) and in 119 cases (32%) the initial treatment regimen was changed (SDR: 84 [30%]; PDR: 35 [38%]). One hundred ninety-six SDR patients (71%) and 56 PDR patients (61%) were cured (P>.05). There were no significant differences in the cure rates in either of the 2 groups between new patients and patients with a history of previous treatment. Seventy-three SDR (26%) and 35 PDR patients (38%) failed to complete treatment (P<.05). CONCLUSIONS: The cure rates among patients who presented with SDR TB and PDR TB were similar to those of drug-sensitive patients; there were no significant differences between new and previously treated patients. The low cure rates were due to the high number of patients who abandoned treatment. Unless a system of therapy administered under supervision is set up it is not likely that these figures can be improved in Santa Cruz, Bolivia.

Patients hospitalised in Bolivia with pulmonary tuberculosis: risk factors for dying.

SETTING: The adult tuberculosis ward of a public hospital in the city of Santa Cruz, Bolivia. OBJECTIVES: To identify risk factors for dying among adult patients hospitalised with pulmonary tuberculosis. DESIGN: Hospital-based cross-sectional study of patients admitted consecutively with pulmonary tuberculosis during the period November 1993-February 1996. RESULTS: A total of 466 patients were admitted to the study. There were 305 (65%) males, and the mean age was 33.1. Seventy-five patients (16%) died during hospitalisation. Multiple logistic regression analysis identified the following predicting variables for death: associated pathology (odds ratio [OR] 2.88; 95% confidence interval [CI] 1.48-5.36), female sex (OR 2.08; 95%CI 1.23-3.52), and number of lobes affected (OR 1.48; 95%CI 1.23-1.79). CONCLUSIONS: These three variables predicting death allow us to identify patients with a diagnosis of pulmonary tuberculosis who should have priority for receiving hospital care. In Bolivia, physicians faced with a shortage of hospital beds should determine the presence or absence of this group of variables when evaluating patients for possible admission.

Treatment of tuberculosis in a rural area of Haiti: directly observed and non-observed regimens. The experience of H pital Albert Schweitzer.

SETTING: Artibonite Valley, a rural area in Haiti. OBJECTIVE: To evaluate a tuberculosis control program in rural Haiti and to compare two strategies for treatment implemented in two areas that were not chosen at random: treatment delivered at the patients' homes observed by former tuberculosis patients (DOT), and non observed treatment (non-DOT). DESIGN: Retrospective analysis of the clinical records of adult patients diagnosed with tuberculosis at H pital Albert Schweitzer in Deschapelles, Haiti, during 1994-1995. RESULTS: There were 143 patients in the non-DOT group and 138 patients in the DOT group. The results of treatment were significantly different: in the non-DOT group 29% defaulted, 12% died and 58% had a successful outcome; in the DOT group 7% defaulted (P < 0.01), 4% died (P = 0.01) and 87% had a successful outcome (P < 0.01). These differences are also significant when considering only human immunodeficiency virus (HIV) infected patients (defaulted P < 0.01; died P = 0.09; successful outcome P < 0.01). CONCLUSION: Delivering treatment in patients' homes with direct observation by former tuberculosis patients can achieve good results, even in an area of extreme poverty and high rates of HIV infection. In this population the number of patients who are able to complete their treatment without observed administration is far from optimal.

[Diagnostic errors related with tuberculosis in hospitalized patients]. / Errores diagnósticos relacionados con la tuberculosis en enfermos hospitalizados.

OBJECTIVE: To assess whether diagnostic error could have been avoided for patients who were mistakenly hospitalized for tuberculosis (TB) when in fact TB was not present or who were mistakenly hospitalized for another disease when they in fact had TB. METHODS: This cross-sectional, descriptive study examined the medical records of all patients admitted to the TB ward of Hospital San Juan de Dios (SJD) in Santa Cruz, Bolivia over a period of 28 consecutive months. RESULTS: Sixty-four (9.8%) of the 650 patients admitted were diagnosed incorrectly. Upon admission, all relevant information was recorded in the medical histories of 10 patients (15.6%) and at the physical examination of 28 patients (43.8%). Taking of a full medical history, performing a complete physical examination, and correctly interpreting the chest film would have led to correct diagnosis for 34 patients (53.2%) and would have been suggestive for 23 (35.9%) more. Such information plus the results of a sputum smear examination could have established or ruled out the presence of TB for 32 patients (50.0%) and suggested the appropriate diagnosis in another 27 patients (42%). CONCLUSION: The careful use of basic diagnostic tools could prevent serious clinical errors related to TB before such patients are admitted to a specialized ward.

Patients with tuberculosis in Bolivia: why do they die?

The objective of this research was to analyze why patients with tuberculosis (TB) die and to evaluate whether there are factors contributing to their fatal outcome that could be corrected. A cross-sectional observational study was conducted of the patients with active TB or its sequelae admitted to the TB ward of the main public hospital in the city of Santa Cruz, Bolivia, over a 29-month period, from October 1993 through February 1996. The available records of the patients who died during hospitalization were reviewed. Out of 597 patients, 94 of them (15.7%) died. We examined the records of 90 of these 94 patients. Their mean age was 35.1 years (standard deviation, 16.7 years), and 45 of the patients (50.0%) were male. On admission 42 of the 90 patients (46.7%) had never been treated for TB or had received anti-TB treatment for less than one month, 23 (25.6%) had returned after having abandoned their TB treatment, 8 (8.9%) had had an erroneous diagnosis, 6 (6.7%) had tuberculosis sequelae, 6 (6.7%) were undergoing tuberculosis treatment, and 5 (5.6%) were known to have multidrug-resistant TB. Of the 90 patients, 83 (92.2%) had pulmonary tuberculosis (median lobes affected, 4), 6 (6.7%) had pleural tuberculosis, and 12 (13.3%) had extrapulmonary tuberculosis (some patients had more than one form of TB). Patients died a median of 5.5 days after entering the TB ward. The causes of death were: hemoptysis, 6 patients (6.7%); other tuberculosis-related causes, 65 patients (72.2%); drug reactions, 6 patients (6.7%); nontuberculosis causes, 6 patients (6.7%); and undetermined causes, 7 patients (7.8%). Factors possibly contributing to death were late diagnosis (38.9%), errors in follow-up (14.4%), and errors in treatment (24.4%). In conclusion, most patients with active or inactive TB admitted to our ward died as a consequence of tuberculosis. There were several factors possibly contributing to their fatal outcome that could be corrected.

A survey of prescribing patterns for tuberculosis treatment amongst doctors in a Bolivian city.

SETTING: A sample survey of knowledge about prescribing tuberculosis treatment among private physicians in the city of Santa Cruz, Bolivia. OBJECTIVES: To study the anti-tuberculosis regimens prescribed by private physicians and to assess the number of tuberculosis patients treated by them. DESIGN: Questionnaire survey of a random sample of 401 private physicians in Santa Cruz. RESULTS: Of the 401 physicians, 165 (41%) could not be located or did not want to participate. Among the 236 completed questionnaires, 137 physicians (58%) stated that they did not see patients with tuberculosis, 16 (7%) referred them to other centres and 83 (35%) treated them in their practice. Among 80 prescribed regimens that could be evaluated there were 58 different regimens: 17 (21%) followed the National Tuberculosis Control Programme's standard regimen, but overall 35 regimens (60%) were incorrect-18 regimens (31%) were non-curative and 17 (29%) could not be recommended. Frequent errors were the prescription of medications not available in the market (7%) or not included in the national regimen (34%), the prescription of insufficient medications (9%), or of only one in the continuation phase (16%), or for too short (9%), or too long (12%) a period. Eighty physicians estimated that they attended in their practice an average total of 404 patients with tuberculosis per month. CONCLUSIONS: A significant number of physicians in private practice did not adhere to the standard norms for prescribing anti-tuberculosis treatment. This study also suggests that in the city of Santa Cruz, Bolivia, there is a not insignificant number of patients with tuberculosis treated outside the National Tuberculosis Control Programme.