Medicine and Health Sciences Commons^™

Longitudinally Extensive Transverse Myelitis: A Sub-Saharan Conundrum, Antonina Obayo, Sylvia Mbugua, Sayed Karar

Internal Medicine, East Africa

Spinal cord schistosomiasis is a rare, underdiagnosed manifestation of schistosomiasis. We present the case of a 36-year-old male who presented to our institution with a one-week history of low back pain with rapidly progressive lower limb weakness, loss of sensation, and flaccid paraparesis. An MRI of the spine showed a longitudinally extensive transverse myelitis from T6 to L1, with enhancement at the cauda equina region. Further review of the images and serological tests eventually led to diagnosis of spinal schistosomiasis. He was treated with praziquantel and high-dose steroids, with minimal improvement in his symptoms.

Adverse Health Effects Associated With Household Air Pollution: A Systematic Review, Meta-Analysis, And Burden Estimation Study, Kuan Ken Lee, Rong Bing, Joanne Kiang, Sophia Bashir, Nicholas Spath, Dominik Stelzle, Kevin Mortimer, Anda Bularga, Dimitrios Doudesis, Michael Chung

Internal Medicine, East Africa

Background: 3 billion people worldwide rely on polluting fuels and technologies for domestic cooking and heating. We estimate the global, regional, and national health burden associated with exposure to household air pollution.

Methods: For the systematic review and meta-analysis, we systematically searched four databases for studies published from database inception to April 2, 2020, that evaluated the risk of adverse cardiorespiratory, paediatric, and maternal outcomes from exposure to household air pollution, compared with no exposure. We used a random-effects model to calculate disease-specific relative risk (RR) meta-estimates. Household air pollution exposure was defined as use of polluting fuels (coal, wood, …

Reliability And Validity Of The Rs14 In Orphaned And Separated Adolescents And Youths In Western Kenya, Sarah C. Sutherland, Harry S. Shannon, David Ayuku, David L. Streiner, Olli Saarela, Lukoye Atwoli, Paula Braitstein

Internal Medicine, East Africa

Purpose: The 14-item Resilience Scale (RS14) is a tool designed to measure psychological resilience. It has been used effectively in diverse populations. However, its applicability is largely unknown for Sub-Saharan adolescent populations and completely unknown for orphaned and separated adolescents and youths (OSAY), a highly vulnerable population for whom resilience may be critical. This study assesses the RS14's psychometric properties for OSAY in Uasin Gishu County, Kenya.

Methods: Survey responses from a representative sample of 1016 OSAY (51.3% female) aged 10-25 (mean = 16; SD = 3.5) living in institutional and home-based environments in Uasin Gishu County were analyzed. The …

Adult Secondary Hemophagocytic Lymphohistiocytosis, Antonina Obayo, Karishma Sharma, Caroline Mithi, Riyat Malkit, Anne Mwirigi

Internal Medicine, East Africa

Background: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation. HLH carries a very high mortality, and while delays in patients’ presentation to hospital, time to suspicion of HLH, investigation, and initiation of therapy all play a part, mortality remains high even with timely diagnosis and treatment. Classical manifestations of HLH include persistent fever, cytopenias, and liver dysfunction.

Case presentation: We present four cases of secondary HLH, highlighting the demographic and clinical characteristics of these patients, underlying triggers (including systemic lupus erythematosus, lymphoproliferative disorders, and leishmaniasis), together with challenges associated with the …

Follow-Up Care For Breast And Colorectal Cancer Across The Globe: Survey Findings From 27 Countries, Michelle A. Mollica, Deborah K. Mayer, Kevin C. Oeffinger, Youngmee Kim, Susan S. Buckenmaier, Sudha Sivaram, Catherine Muha, Nur Aishah Taib, Elisabeth Andritsch, Asim Jamal

Internal Medicine, East Africa

Purpose: The purpose of this study was to describe follow-up care for breast and colorectal cancer survivors in countries with varying levels of resources and highlight challenges regarding posttreatment survivorship care.

Methods: We surveyed one key stakeholder from each of 27 countries with expertise in survivorship care on questions including the components/structure of follow-up care, delivery of treatment summaries and survivorship care plans, and involvement of primary care in survivorship. Descriptive analyses were performed to characterize results across countries and variations between the WHO income categories (low, middle, high). We also performed a qualitative content analysis of narratives related to …

Substance Use Service Availability In Hiv Treatment Programs: Data From The Global Iedea Consortium, 2014-2015 And 2017, Angela M. Parcesepe, Kathryn Lancaster, E. Jennifer Edelman, Raquel Deboni, The Foundation For Aids Research, Bangkok, Thailand, Lukoye Atwoli

Internal Medicine, East Africa

Background: Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes.

Methods: We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014–2015 …

Out-Patient Neurological Disorders In Tanzania: Experience From A Private Institution In Dar Es Salaam, Philip Adebayo, Omar Aziz, Rose E. Mwakabatika, Mandela Makakala, Mugisha Clement, Shabbir Adamjee, Noureen Mushi, Ahmed Jusabani, Eric Aris

Internal Medicine, East Africa

Background and introduction: Low and middle-income countries (LMIC) have a considerable burden of neurological disorders. Available profile of neurological disorders in our environment is biased towards neurological admissions. There is a paucity of data on out-patient neurological conditions in sub-Saharan Africa.

Objective: To determine the frequency and demographic data of neurological illnesses being managed at the adult out-patient neurology clinic of the Aga Khan Hospital, Dar es Salaam (AKHD).

Materials and methods: The electronic medical records of all cases with neurological diseases who presented to the adult neurology clinic of the AKHD between January 2018, and December 2019 were retrospectively …

Qualitative Approach To Understanding Barriers To Delivering Difficult News In Sub Saharan Africa, Karishma Sharma, Jasmit Shah, Sayed Karar

Internal Medicine, East Africa

Communication, especially delivery of difficult news (DDN), remains a key part of clinical practice. Despite its importance, many medical providers lack the skill and ability to effectively DDN to their patients. Due to lack of data specific to sub-Saharan Africa and to help us develop an appropriate training tool for this geographical area, we sought to explore what challenges and barriers residents at our institution faced when they deliver difficult news to their patients.

Randomized Control Trial Of Advanced Cancer Patients At A Private Hospital In Kenya And The Impact Of Dignity Therapy On Quality Of Life, John Weru, Miriam Gatehi, Alice Musibi

Internal Medicine, East Africa

Background: Palliative care is a modality of treatment that addresses physical, psychological and spiritual symptoms. Dignity therapy, a form of psychotherapy, was developed by Professor Harvey Chochinov, MD in 2005.The aim of the study was to assess the effect of one session of dignity therapy on quality of life in advanced cancer patients.

Methods: This was a randomized control trial of 144 patients (72 in each arm) randomized into group 1 (intervention arm) and group 2 (control arm). Baseline ESAS scores were determined in both arms following which group 1 received Dignity therapy while Group 2 received usual care only. …

Covid-19 And Stroke In Sub-Saharan Africa: Case Series From Dar Es Salaam, Philip Adebayo, Nadeem Kassam, Omar Aziz, Ahmed Jusabani, Samina Somji, Mugisha Clement

Internal Medicine, East Africa

Low and middle-income countries including those in sub-Saharan (SSA) Africa are experiencing a steady increase in the number of COVID-19 cases. To the best of our knowledge, reports of COVID-19 related strokes are scarce in SSA. The peculiar situation of stroke care in SSA makes COVID-19 associated stroke a bothersome entity as it adds other dynamics that tilt the prognostic balance. We present a case series of COVID -19 related stroke in 3 patients from Tanzania. We emphasized protected code stroke protocol.

Postoperative Myocardial Injury In A Patient With Left Ureteric Stone And Asymptomatic Covid-19 Disease, Nadeem Kassam, Omar Aziz, Ally Zain Ismail, Rodgers Swai, Samina Somji, Robert Mvungi, Mustaafa Bapumia, Ali Akbar Zehri, Salim Surani

Internal Medicine, East Africa

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified on 8thDecember 2019 in Wuhan, Hubei, China, and has since spread globally to become an emergency of international concern. Patients infected with SARS-CoV-2 may be asymptomatic or present with symptoms ranging from mild clinical manifestations: such as fever, cough, and sore throat to moderate and severe form of the disease such as pneumonia and acute respiratory distress syndrome (ARDS). In some patients, SARS-CoV-2 can affect the heart and cause myocardial injury which is evidenced either by electrocardiographic (ECG) changes …

Invasive Liver Abscess Syndrome Caused By Klebsiella Pneumoniae: First Tanzanian Experience, Nadeem Kassam, Omar Aziz, Samina Somji, Zainab Yusuf Fidaali, Salim Ramzan Surani

Internal Medicine, East Africa

Over the past 20 years there has been growing awareness of community-acquired primary liver abscess caused by strains of Klebsiella pneumoniae (K. pneumoniae) especially in patients of Asian descent, a minority of which are characterized by metastatic spread. A common and frequent destructive complication is endophthalmitis as well as the involvement of the central nervous system (CNS), causing suppurative meningitis or brain abscess. Here we report a case of invasive liver abscess caused by K. pneumoniae in an Asian patient who presented to our hospital in Tanzania with bilateral lower limb swelling for 6 weeks with acute onset of difficulty …

Post-Vaccination Pharyngeal-Cervical-Brachial Variant Of Guillain-Barré Syndrome, Funmilola T. Taiwo, Daniel E. Ezuduemoih, Philip Adebayo

Internal Medicine, East Africa

The pharyngeal-cervical-brachial (PCB) variant of Guillain-Barré syndrome (GBS) is very rare. It is characterized by weakness of the upper extremities associated with bulbar symptoms and facial diplegia. Documented cases were post-infectious, a post-vaccination occurrence has not been documented in the available literature. Even rarer is the occurrence of any variant of GBS following the mumps measles rubella (MMR) vaccine. The neurophysiological hallmark of PCB variant of GBS is a combination of myelinopathy and axonopathy, hence, its consideration as a subtype of the acute motor axonal neuropathy (AMAN) variant. It should be suspected in any case of acute-onset flaccid symmetrical weakness …

Furrowed Tongue, Fatten Lip And Facial Droop, Philip Adebayo, Hanifa Mbithe

Internal Medicine, East Africa

No abstract provided.

Cardiospecific Overexpression Of Atpgd1 (Carnosine Synthase) Increases Histidine Dipeptide Levels And Prevents Myocardial Ischemia Reperfusion Injury, Jingjing Zhao, Daniel J. Conklin, Yiru Guo, Xiang Zhang, Detlef Obal, Luping Guo, Ganapathy Jagatheesan, Kartik Katragadda, Liqing He, Jasmit Shah

Internal Medicine, East Africa

Background: Myocardial ischemia reperfusion (I/R) injury is associated with complex pathophysiological changes characterized by pH imbalance, the accumulation of lipid peroxidation products acrolein and 4-hydroxy trans-2-nonenal, and the depletion of ATP levels. Cardioprotective interventions, designed to address individual mediators of I/R injury, have shown limited efficacy. The recently identified enzyme ATPGD1 (Carnosine Synthase), which synthesizes histidyl dipeptides such as carnosine, has the potential to counteract multiple effectors of I/R injury by buffering intracellular pH and quenching lipid peroxidation products and may protect against I/R injury.

Methods and Results: We report here that β-alanine and carnosine feeding enhanced myocardial …

Endobronchial Tuberculosis: A Rare Presentation, Nadeem Kassam, Omar M. Aziz, Samina Somji, Grace Shayo

Internal Medicine, East Africa

Endobronchial tuberculosis (EBTB) is an infection of the tracheobronchial tree by Mycobacterium tuberculosis. It is common among young females. Patient can present with fever, cough, wheeze, with or without any constitutional symptoms. It presents as a diagnostic dilemma, as patient sputum smear can be false negative. CT scan may or may not show any abnormality, or any endobronchial lesion. Bronchoscopy with bronchoalveolar lavage and biopsy offers the diagnostic choice. We hereby report a case of a young immunocompetent Asian female who was found to have endobronchial pathology, leading to diagnosis and timely therapy.

Cytopenia Among Cml Patients On Imatinib In Kenya: Types, Grades, And Time Course, Angela Mcligeyo, Jamilla Rajab, Mohammed Ezzi, Peter Oyiro, Yatich Bett, Andrew Odhiambo, Matilda Ong’Ondi, Sitna Mwanzi, Mercy Gatua, Naothieno Abinya

Internal Medicine, East Africa

Background: Imatinib mesylate is the gold standard for the treatment of all phases of Philadelphia-positive chronic myeloid leukemia. Patients on imatinib treatment may develop cytopenia due to drug toxicity. This study aimed to determine the types, grades, and time course of cytopenia in CML patients on imatinib at a Nairobi hospital.

Methods: This was a cross-sectional descriptive study of adult patients aged ≥18 years followed up at the Glivec International Patient Access Program (GIPAP) clinic from 2007 to 2015. Patients who developed cytopenia within 12 months of initiating imatinib were eligible. Clinical and hematologic data were retrieved from the patients’ …

Disseminated Carcinomatosis Of Bone Marrow In An African Man With Metastatic Descending Colon Carcinoma, Harrison Chuwa, Nadeem Kassam, Casmir Wambura, Omar Sherman, Salim Surani

Internal Medicine, East Africa

Colorectal cancer (CRC) is ranked third worldwide and seventh in Tanzania. The liver and lungs are the most commonly involved sites. Disseminated carcinomatosis of the bone marrow (DCBM) from colorectal carcinoma is rare and typically indicates widespread disease and poor prognosis. We report a case of a 40-year-old African male, who presented to us with abdominal distension, weight loss, fever and change in bowel habit over the past month. He underwent colonoscopy which revealed a necrotic mass in the descending colon. Biopsies were taken, and histopathology confirmed the presence of poorly differentiated mucin-producing adenocarcinoma. The patient suffered a colonic perforation …

Benign Recurrent Intrahepatic Cholestasis (Bric): An African Case Report, Adil Salyani, Linda Barasa, Allan Rajula, Sayed Karar

Internal Medicine, East Africa

Benign recurrent intrahepatic cholestasis (BRIC) is a rare disorder characterised by recurrent episodes of cholestatic jaundice. First described in 1959, BRIC has been reported in patients all over the world including of African descent. Here, we describe a case of a 21-year-old male with recurring episodes of cholestatic jaundice where we diagnosed BRIC and terminated an episode with rifampicin. To our knowledge, this is the first case report of BRIC diagnosed in Africa.

Adequacy Of Hemodialysis And Its Associated Factors Among Patients Undergoing Chronic Hemodialysis In Dar Es Salaam, Tanzania, Samina Somji, Pascal Ruggajo, Sibtain Moledina

Internal Medicine, East Africa

The worldwide prevalence of maintenance hemodialysis continues to rise. An adequate delivery of hemodialysis dose as measured by Kt/V or urea reduction ratio is a crucial determinant of clinical outcome for chronic hemodialysis patients. )e aim of this study was to assess the adequacy of hemodialysis and its associated factors among patients undergoing chronic hemodialysis in Dar es Salaam. )is was a cross-sectional study done on patients undergoing chronic hemodialysis in four dialysis centers in Dar es Salaam. Sociodemographic information and treatment characteristics were collected. Urea reduction rate and single-pool Kt/V were calculated to determine the adequacy of hemodialysis. )e …

Long-Term Outcomes And Factors Associated With Mortality In Patients With Moderate To Severe Pulmonary Hypertension In Kenya, Mzee Ngunga, Abdulaziz Mansur Abeid, Jeilan Mohamed, Anders Barasa

Internal Medicine, East Africa

Background: Pulmonary hypertension is poorly studied in Africa. The long-term survival rates and prognostic factors associated with mortality in patients with moderate to severe pulmonary hypertension (PH) in Africa are not well described.

Objectives: To determine the causes of moderate to severe PH in patients seen in contemporary hospital settings, determine the patients’ one-year survival and the factors associated with mortality following standard care.

Methods: A retrospective review of patients diagnosed with moderate to severe PH at Aga Khan University Hospital (AKUHN) from August 2014 to July 2017 was carried out. Clinical and outcome data were collected …

Menstrual-Related Headaches Among A Cohort Of African Adolescent Girls, Philip Adebayo, Folajimi M. Otubogun, Rufus O. Akinyemi

Internal Medicine, East Africa

Introduction: Migraine attacks associated with menstruation are generally perceived as more severe than attacks outside this period.

Aim and Objective: The study aimed at determining the frequency of menstrual-related headaches among a cohort of senior secondary school girls in Abeokuta, Nigeria. We also determined its burden among these school girls.

Methodology: This study was cross-sectional using a validated adolescent headache survey questionnaire. A self-administration of the instrument was done during a school visit. A headache was classified using the ICHD-II criteria.

Results: Of the 183 students interviewed, 123(67.2%) had recurrent headaches. Mean age ±SD, 16.18± 1.55 (range 12– …

Pre-Treatment Hiv-Drug Resistance Associated With Virologic Outcome Of First-Line Nnrti-Antiretroviral Therapy: A Cohort Study In Kenya, Ingrid A. Beck, Molly Levine, Christine J. Mcgrath, Steve Bii, Ross S. Milne, James M. Kingoo, Isaac So, Nina Andersen, Sandra Dross, Michael Chung

Internal Medicine, East Africa

Background: Pre-treatment HIV-drug-resistance (PDR) to WHO-recommended 1st-line non-nucleoside reverse transcriptase inhibitors (NNRTI)-based antiretroviral treatment (ART) is increasing in low-resource communities. We evaluated the risk of PDR on treatment failure if detected at single or multiple codons, at minority (2–9%) or higher (≥10%) frequencies during efavirenz- vs. nevirapine-ART.

Methods: We conducted a pooled analysis across three cohorts of Kenyans initiating 1st-line NNRTI-ART between 2006 and 2014. Mutations K103N, Y181C, G190A, M184V and K65R were detected by an oligonucleotide ligation assay (OLA) and confirmed by Sanger and next-generation sequencing (NGS). PDR was defined as detection of any mutation by OLA when confirmed …

Case Report Of Kikuchi-Fujimoto Disease From Sub-Saharan Africa: An Important Mimic Of Tuberculous Lymphadenitis, Karishma Sharma, Fredrick Otieno, Reena Shah

Internal Medicine, East Africa

Kikuchi-Fujimoto disease (KFD) is a rare form of painful lymphadenopathy, usually cervical, which is more common in Southeast Asia and rarely reported from Africa. Symptoms are usually nonspecific (fever, night sweats, etc.), and can mimic more common diseases such as tuberculosis (TB) in endemic areas. We report a case of a 29-year-old black African woman who was admitted with headache, neck pain, fever, and lymphadenopathy. She was found to have aseptic meningitis, eventually attributed to TB based on cervical node biopsy, although further histology suggested KFD. Blood tests for systemic lupus erythematosus (SLE) were negative; she had already been commenced …

The Impact Of Scaling Up Cervical Cancer Screening And Treatment Services Among Women Living With Hiv In Kenya: A Modelling Study, Pablo Noel Perez-Guzman, Michael Chung, Hugo De Vuyst, Shona Dalal, Kennedy K. Mutai, Karanja Muthoni, Bartilol Kigen, Timothy B. Hallett, Mikaela Smit

Internal Medicine, East Africa

Introduction: We aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18–65 in Kenya.

Methods: Mathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, …