Clinical features of tuberculosis among adults in sub-Saharan Africa in the 21st century.

Although tuberculosis was unknown in sub-Saharan Africa before the 19th century, rapid spread of infections due to Mycobacterium tuberculosis occurred during the 20th century and could be found in up to 50% of the adult population by the 1950s. Owing to changes in age structure, rapid urbanization associated with overcrowding living conditions, increasing poverty and the HIV epidemic a 300-400% increase in tuberculosis cases and deaths has been reported from sub-Saharan Africa. Persons dually infected with HIV and tuberculosis may have active tuberculosis with typical or atypical clinical features and/or involving multiple organ systems. In addition, mycobacteraemia associated with non-specific clinical features is common among HIV-infected persons, especially if they are severely immunocompromised. Because of the atypical clinical features these patients are easily misdiagnosed and are therefore likely to die from what is otherwise a curable illness. Consequently there is a need to better characterize the clinical features of all forms of tuberculosis, especially in the presence of HIV infection.

Fatal Mycobacterium tuberculosis bloodstream infections in febrile hospitalized adults in Dar es Salaam, Tanzania.

Causes of community-acquired bloodstream infections (BSIs) in sub-Saharan Africa are unknown with regard to mycobacteria and fungi. We prospectively studied 517 consecutive febrile (axillary temperature, > or =37.5 degrees C) adults (> or =15 years of age) admitted to one hospital in Tanzania. After hospital admission and informed consent, blood was drawn for culture (of bacteria, mycobacteria, and fungi), determination of human immunodeficiency virus type 1 (HIV-1) status, and malaria smears. Malaria smears were prepared for a control group of 150 afebrile patients. One hundred and forty-five patients (28%) had BSI. Of these 145 patients, 118 (81%) were HIV-1-infected. HIV-positive patients were more likely than HIV-negative ones to have BSI (118 of 282 vs. 27 of 235; P < .0001). The three most frequently isolated pathogens were Mycobacterium tuberculosis (60 [39%]), non-typhi Salmonella species (29 [19%]), and Staphylococcus aureus (13 [8.3%]). The incidence of malaria parasitemia was similar in study and control patients (9.5% vs. 8%). In this patient population with high prevalence of HIV-1 infection, M. tuberculosis has become the foremost cause of documented BSI.

Chest radiography and beta-2-microglobulin levels in HIV-seronegative and HIV-seropositive African patients with pulmonary tuberculosis.

To examine the relationship between radiographic features, serum beta-2-microglobulin (beta-2-M) levels, results of sputum-smear microscopy and outcome, we performed a retrospective study of 99 HIV-seropositive and 162 HIV-seronegative patients with pulmonary tuberculosis (TB) in Dar es Salaam, Tanzania. Radiographic features of primary TB were more common and features of postprimary TB less common in HIV-seropositive compared to seronegative patients (50% vs 31%, p < 0.002; and 40% vs 63%, p < 0.001), respectively). HIV infection had a strong independent effect on the beta-2-M levels. Among HIV-infected patients radiographic findings of primary TB were significantly more often associated with beta-2-M levels of > 4 mg/l than features of postprimary TB (71.1% vs 44.4%, p < 0.02). In patients with features of postprimary TB, acid-fast bacilli were more often detected in sputum smears than in patients with primary TB (65% vs 47%, p > 0.05, in HIV-seropositive patients; and 63% vs 31%, p < 0.001) in seronegative patients). The observed mortality was too low to identify radiographic predictors of survival. We conclude that HIV-infected patients with features of primary pulmonary TB are likely in an advanced stage of HIV infection and deserve close supervision during anti-tuberculous therapy.

PIP: A retrospective study enrolled 99 HIV-seropositive and 162 HIV-seronegative patients with pulmonary tuberculosis (TB) in Dar es Salaam, Tanzania, during July-October 1991 in order to examine the relationship between radiographic features, serum beta-2-microglobulin (beta-2-M) levels, results of sputum-smear microscopy and outcome. 179 (68.6%) were male. Radiographic features of primary TB were more common and features of postprimary TB were less common in HIV-seropositive compared to seronegative patients (50% vs. 31%, p 0.002; and 40% vs. 63%, p 0.001), respectively. HIV infection had a strong independent effect on the beta-2-M levels. Among HIV-infected patients, radiographic findings of primary TB were significantly more often associated with high beta-2-M levels of 4 mg/l than features of postprimary TB (71.1% vs. 44.4%, p 0.02). Serum was available for measurement of beta-2-M concentrations in 83 HIV-infected patients. Patients who presented with primary TB had high beta-2-M levels significantly more often than patients with postprimary TB (27/38 vs. 16/36, p 0.02). 6 of 9 patients with indeterminate TB had beta-2-M levels of 4 mg/l. Type of infiltration also showed a trend to be associated with beta-2-M levels, as 14 of 31 with patchy type, 19 of 29 with reticulonodular type, and 8 of 9 with homogenous consolidation had increased beta-2-M levels of 4 mg/l. In patients with features of postprimary TB, acid-fast bacilli were more often detected in sputum smears than in patients with primary TB (65% vs. 47%, p 0.05, in HIV seropositive patients; and 63% vs. 31%, p 0.001, in seronegative patients). The observed mortality was too low to identify radiographic predictors of survival. In conclusion, HIV-infected patients with features of primary pulmonary TB are likely in an advanced stage of HIV infection and deserve close supervision during anti-tuberculous therapy.

Cutaneous findings associated with HIV disease including AIDS: experience from Sub Saharan Africa.

Cutaneous manifestations are common in patients with HIV infection and tend to be more frequent as immunodeficiency progresses. In the initial stage of HIV infection a transient maculopapular-rash may appear. During the otherwise asymptomatic phase that follows, patients may develop seborrhoeic dermatitis, persistent genital ulcer disease, pruritic papular eruption and/or a variety of scaling dermatoses. The most frequent skin tumour associated with HIV disease is Kaposi's sarcoma. Skin manifestations of adverse reactions to a variety of drugs occur more frequently in patients with HIV disease than in immunocompetent patients. In general most skin diseases that occur in association with HIV disease respond well to standard treatment regimens. However relapses, and/or recurrences are frequent in this group of patients.

PIP: Cutaneous manifestations are common in patients infected with HIV and tend to be more frequent as immunodeficiency progresses. It remains, however, unclear which or how many with HIV-1 infection will develop skin disease. This paper presents and describes the commonly reported skin diseases occurring in people with HIV-1 infection. Observed infections include herpes zoster, herpes simplex, chancroid, syphilis, condylomata acuminata, oral hairy leukoplakia, molluscum contagiosum, candidiasis, bacterial infections, dermatophytosis, and scabies. Noninfective conditions such as pruritic papular eruption, seborrhoeic dermatitis, psoriasis, and others may also present. Regarding disease etiology, a transient maculopapular rash may present in the initial stage of HIV infection. Seborrhoeic dermatitis, persistent genital ulcer disease, pruritic papular eruption, and/or a variety of scaling dermatoses may then be observed during the otherwise asymptomatic phase. Kaposi's sarcoma is the most frequent skin tumor associated with HIV disease. It is also observed that skin manifestations of adverse reactions to drugs occur more frequently in patients with HIV disease than in immunocompetent patients. In closing, most skin diseases associated with HIV disease respond well to standard treatment regimens. Relapses and/or recurrences are, however, frequent among these patients.

Radiological features of pulmonary tuberculosis in patients infected with human immunodeficiency virus.

We tested 120 consecutive admissions with sputum positive pulmonary tuberculosis for antibodies to the human immunodeficiency virus type I (HIV-1). Pre-treatment chest x-ray appearances were recorded. Seventy one patients (59%) were males and 49 (41%) were females. 43 (35.8%) patients were seropositive for HIV, and were all in the age range 16-45 years. The seropositivity for the 56 males and 44 females in the age range 16-45 years were 53 and 26 percent respectively. Atypical x-ray features were found in 21 of 43 cases compared to 15 of 57 referents (p less than 0.025). Radiographic features typical of reactivation pulmonary tuberculosis in the adult were found in 73% and 51% of referents and cases respectively (P less than 0.025). Pulmonary lesions localized to the mid and or lower zones were seen in 20 percent of cases and 3.3% of referents (P = 0.01). Mediastinal and or hilar adenopathy alone or with pulmonary infiltrates occurred more frequently among cases but the results were not significant. Our findings indicate that radiological appearances of pulmonary tuberculosis in patients seropositive for HIV-1 antibodies tend to be atypical in type of lesion and or anatomic distribution, even for patients from communities with high prevalence rates of tuberculosis.

PIP: The authors tested 120 consecutive admissions with sputum positive pulmonary tuberculosis for antibodies to the human immunodeficiency virus type I (HIV-1). Pretreatment chest x-ray appearances were recorded. 71 patients (59%) were males and 49 (41.9%) were females. 43 (35.8%) patients were seropositive for HIV, and were all between the ages of 16-45. The seropositivity for the 56 males and 44 females in this age ranger were 53% and 26%, respectively. Atypical x-ray features were found in 21 of 43 cases compared to 15 of 5 referents (p 0.25). Radiographic features typical of reactivation pulmonary tuberculosis in the adult were found in 73% and 51% of the referents and cases, respectively (p0.025). Pulmonary lesions localized to the middle or lower zones were seen in 20% of cases and 3.3% of the referents (p=0.01). Mediastinal or hilar adenopathy alone or with pulmonary infiltrates occurred more frequently in cases but the results were not significant. These findings indicate that radiological appearances of pulmonary tuberculosis in patients positive for HIV-1 antibodies tend to be atypical in type of lesion and/or anatomic distribution, even for those patients from communities with high prevalence rates of tuberculosis.

Clinical presentation of HIV infection and AIDS in Tanzania

Several new syndromes; a typical presentation of well known diseases as well as increase in endemic opportunistic infections have become common in the recent past following advent of HIV. HIV can be said to have replaced syphilis as the greatest imitator

Clinical presentation of HIV infection and AIDS in Tanzania

Several new syndromes; atypical presentation of well known diseases as well as increase in endemic opportunistic infections have become common in the recent past following advent of HIV. HIV can be said to have replaced syphilis as the greatest imitator

Survival time of patients with acquired immune deficiency syndrome: experience with 274 patients in Dar-es-Salaam.

To determine the survival time once acquired immune deficiency syndrome (AIDS) has developed, we analysed case records of 274 patients confirmed to have died of the disease. Of the 274 patients 193 were males and 81 females (M:F 2:1). The duration of symptoms ranged from a few weeks to two years but over 70% had apparently enjoyed good health until 2-3 months before diagnosis. Weight loss, severe weakness, chronic diarrhoea, prolonged fevers and oro-pharyngeal candidosis were the commonest features. Kaposi's sarcoma (KS) was the presenting feature in 2 (0.7%) patients. Frequent concurrent illnesses included tuberculosis (19%), unspecified (23%) and skin lesions other than KS (24%). In 31 (11.3%) patients no concurrent illness was detected. The survival after one week was 63.5% and 7.5% at the end of three months. These results indicate that due to a combination of factors survival of AIDS patients in developing countries is much shorter than in developed countries.

PIP: To determine the survival time once acquired immune deficiency syndrome (AIDS) has developed, we analyzed case records of 274 patients confirmed to have died of the disease. Of the 274 patients 193 were males and 81 females (M:F 2:1). The duration of symptoms ranged from a few weeks to 2 years but over 70% had apparently enjoyed good health until 2-3 months before diagnosis. Weight loss, severe weakness, chronic diarrhea, prolonged fevers and oro-pharyngeal candidosis were the commonest features. Kaposi's sarcoma (KS) was the presenting feature in 2 (0.7%) patients. Frequent concurrent illness included tuberculosis (19%), unspecified (23%) and skin lesions other than KS (24%). In 31 (11.3%) patients no concurrent illness was detected. The survival after 1 week was 63.5% and 7.5% at the end of 3 months. These results indicate that due to a combination of factors survival of AIDS patients in developing countries is much shorter than in developed countries. (Author's).

One point dilution enzyme-linked immunosorbent assay (ELISA) for Toxoplasma gondii seroepidemiological surveys.

A one point dilution enzyme-linked immunosorbent assay (ELISA) procedure suitable for determining immunoglobulin G (IgG) antibody levels to Toxoplasma gondii (T. gondii) in community seroepidemiological surveys is described. A two-fold serial dilution ELISA procedure was first used to determine the IgG titers in 56 and 83 sera earlier screened by the Sabin-Feldman dye test (DT) and the indirect hemagglutination test (IHA), respectively. The regression rate of the results by the DT and ELISA was 0.92. Comparison of the results by the IHA and the two-fold serial dilution ELISA gave regression coefficient of 0.92. Using the absorbance values for the test sera at dilutions of 1:20, standard curves made by plotting the optical density versus the corresponding dilution factor of a control sera were used to estimate the antibody levels. The regression coefficient of the results by the two-fold serial dilution method and those by the curves for sera with titers of up to 1:320 was 0.97. The curves could not, however, estimate accurately the antibody level in sera with titers above 1:320. The one point dilution ELISA described is a useful epidemiological tool for the screening of IgG antibody to Toxoplasma gondii in the community. However, larger series are required to confirm our observations.

Treatment of diabetic coma in a tropical environment.

Fourteen patients admitted to Muhimbili Medical Centre, Dar es Salaam in diabetic coma were treated according to a management plan based on the hourly administration of low doses of soluble insulin. The use of this treatment plan resulted in a significant fall in mortality. Three patients died. While these results are still unsatisfactory, the study has shown that combining the treatment plan with enthusiastic and constant medical and nursing care, the results of treatment of diabetic coma in the tropics can approach those of the developed world. The treatment plan is described in detail, since we believe that it can be used in hospitals with only basic facilities.