Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients.

OBJECTIVE: To determine the effect of adjunctive prednisolone on morbidity, pericardial fluid resolution, and mortality in HIV seropositive patients with effusive tuberculous pericarditis. DESIGN: Double blind randomised placebo controlled trial. SETTING: Two medical school affiliated referral hospitals in Harare, Zimbabwe. PATIENTS: 58 HIV seropositive patients aged 18-55 years with tuberculous pericarditis. INTERVENTIONS: All patients received standard short course antituberculous chemotherapy and were randomly assigned to receive prednisolone or placebo for six weeks. MAIN OUTCOME MEASURES: Clinical improvement, echocardiographic and radiologic pericardial fluid resolution, and death. RESULTS: 29 patients were assigned to prednisolone and 29 to placebo. After 18 months of follow up there were five deaths in the prednisolone treated group and 10 deaths in the placebo group. Mortality was significantly lower in the prednisolone group (log rank chi(2) = 8. 19, df = 1, p = 0.004). Resolution of raised jugular venous pressure (p = 0.017), hepatomegaly (p = 0.007), and ascites (p = 0.015), and improvement in physical activity (p = 0.02), were significantly more rapid in the prednisolone treated patients. However, there was no difference in the rate of radiologic and echocardiographic resolution of pericardial effusion. CONCLUSIONS: Adjunctive prednisolone for effusive tuberculous pericarditis produced a pronounced reduction in mortality. It is suggested prednisolone should be added to standard short course chemotherapy to treat HIV related effusive tuberculous pericarditis.

Endomyocardial fibrosis in Zimbabwe--how rare is it? A report of two cases.

In Africa endomyocardial fibrosis (EMF) is rare outside countries where it is endemic, such as Uganda, Mozambique and Ivory Coast. The only published case in Zimbabwe was in 1957. We describe two female patients aged 22 and 19 years who presented within seven months of each other with typical clinical, electrocardiographic and echocardiogaphic features of right ventricular EMF. We would like to suggest that EMF exists in Zimbabwe and needs to be considered in the differential diagnosis of patients presenting with suggestive clinical features.

Acute myocardial infarction in Zimbabwe: the changing scene of coronary artery disease.

From 1988 to 1993 (six years), 127 suspected cases of acute myocardial infarction (AMI) were admitted to the Parirenyatwa Hospital coronary care unit. AMI was confirmed in 76 cases, 37 were Black, 27 White, six Indian and six Coloured. For Blacks the male to female ratio was 5:1. The clinical and laboratory features and complications of AMI were similar in all ethnic groups. Compared to other groups, Blacks presented to hospital late, an observation which has important implications for thrombolytic therapy. With the increasing number of cases of AMI now being seen among Black Zimbabweans, the time has come for the evaluation of the changing risk factor profile and the initiation of education and intervention programmes which could contain this rise before it spirals into a major health problem.

Epitrochlear lymph nodes as marker of HIV disease in sub-Saharan Africa.

PIP: Because serological testing for HIV infection is expensive and hard to obtain in Africa, diagnosis often depends upon clinical evaluation. A study was undertaken, therefore, to determine whether the rate of occurrence of enlarged lymph nodes and variations in their size and distribution could provide useful diagnostic markers. Of 260 eligible adult patients admitted to a hospital in Zimbabwe, 259 agreed to take part in the study. 146 (56%) were diagnosed with HIV using serological tests. A doctor who was blinded to these results scored lymph node size in the epitrochlear, submandibular, and axillary regions. Enlargement of axillary and submandibular lymph nodes by or= 1 cm gave positive predictive values of 91 and 89%, respectively, and specificities of 95 and 96%, respectively, but the negative predictive values and sensitivities were all 60%. Thus, the presence of enlarged lymph nodes was a strong marker of HIV disease, but their absence was unhelpful, and they were only occasionally present (in 24 and 12% of patients, respectively). When the criterion for enlargement was or= 0.5 cm, the number of patients with palpable nodes increased, but positive prediction and specificity were poor. Enlargement of the epitrochlear nodes by or= 0.5 cm resulted in a positive predictive value of 85%, a specificity of 81%, and a sensitivity of 84%. Also, these nodes were palpable in 47% of patients. Larger epitrochlear nodes (or= 1 cm) improved specificity to 90% but reduced positive prediction and sensitivity dramatically. A combination of the 2 regions improved positive predictive value to 90% but caused a noticeable fall in sensitivity. These predictive values must not be extrapolated beyond the setting in which they were derived (one of high prevalence). The predictive value of epitrochlear nodes in other clinical settings remains to be determined, but the clinical importance of these nodes deserves attention.^ieng

Comparison of the Tru-cut biopsy needle with the Abrams punch for pleural biopsy.

In a prospective study pleural biopsy specimens obtained with a Tru-cut needle were compared with those obtained with an Abrams pleural biopsy punch from 36 patients in Zimbabwe judged to have an effusion of at least 1.5 litres; one patient had two biopsies. Both instruments were used on each patient, the Abrams punch being followed by the Tru-cut needle. There were no serious complications. The diagnoses determined by biopsy were: tuberculosis (11); carcinoma (12); chronic inflammation (9); and pleural fibrosis (4); one biopsy showed nothing abnormal. In 23 (62%) patients both biopsy needles produced adequate diagnostic material; in eight the Tru-cut needle alone produced diagnostic material and in six the Abrams punch alone. Thus diagnostic material was obtained in 31 patients from the Tru-cut needle and in 29 from the Abrams punch. The Tru-cut needle was useful and safe for pleural biopsy in this series and appeared to be particularly useful when the pleura was thickened.