Glycemic control and complications of type 1 diabetes among children in Tanzania.

INTRODUCTION: Knowledge on Type 1 Diabetes (T1D) in sub-Saharan Africa is scarce. This study aimed at assessing microvascular complications of Type 1 diabetes in young patients. METHOD: A retrospective study based on medical recordings from 2010-2016 was done. 604 children and young adults with T1D were recruited from five hospitals with pediatric diabetes clinics. 559 patients aged 2-35 years with known date of birth were included. Clinical data on retinopathy and neuropathy were analyzed. There was no information on renal function/ nephropathy. RESULTS: Most data were missing. There was documentation on HbA1C, plasma glucose and complications in less than half of the patient files. Of those with registered HbA1c values (42.2%), 36% had HbA1c > 12.5%. There was high prevalence of retinopathy (21.5%) and neuropathy (29.4%) in spite of short mean duration of diabetes (6.2 ± 4.1 years). CONCLUSION: Many patients with T1D in Tanzania have poor metabolic control. Microvascular complications are common already after a short duration of diabetes, but the results have to be interpreted with great caution because of study limitations. Better pediatric diabetes care as well as increased awareness of diabetes is needed. Studies in resource-poor countries need careful planning, if possible with prospective design.

Incidence, prevalence and clinical manifestations at onset of juvenile diabetes in Tanzania.

Better knowledge on incidence, prevalence and clinical manifestations is needed for planning diabetes care in Sub Saharan Africa. AIMS: To find a crude incidence/prevalence of diabetes in children and young adults in a low resource setting, classify the diabetes and audit the health record keeping. METHODS: A retrospective observational study based on medical recordings 2010-2016. Target population was children and adolescent registered in Changing Diabetes in Children (CDiC) or Life for a Child (LFAC) programs for children with T1DM and diagnosed at 5 diabetes clinics in three geographical regions of Tanzania. 604 patients' files were available from five hospitals. RESULTS: 336/604 files covered patients <15 years of age at diagnosis. The prevalence of diabetes <15 years of age ranged from 10.1 to 11.9 per 100,000 children and the annual incidence 1.8-1.9/100,000 children, with peak incidence at 10-14 years. A lot of data were missing. The great majority of the patients presented with typical signs and symptoms of T1D, 83.7% with plausible ketoacidosis (DKA). CONCLUSIONS: Diabetes incidence and prevalence is still low. T1D seems to dominate with very high frequency of DKA at diagnosis. Increased awareness of diabetes both in health care and community is needed.

Management of diabetic ketoacidosis in children and adolescents in sub-Saharan Africa: a review.

BACKGROUND: Diabetic ketoacidosis (DKA) is a complex metabolic state of hyperglycaemia, ketosis, and acidosis. Diabetes in sub-Saharan Africa is, in many patients a serious disease with a poor prognosis. Most deaths, however, are due to preventable causes. OBJECTIVE: To improve knowledge on the management of DKA in sub-Saharan Africa. DATA SOURCES: Literature review from different published sources. DATA SYNTHESIS: Health systems in sub-Saharan Africa are currently organised for the treatment of episodes of illness and not long-term conditions like diabetes. Therefore the high rates of DKA is essentially due to lack of training of health professionals, lack of facilities in most hospitals, lack of public awareness as well as lack of health education to individual patients/families. In addition erratic insulin supply coupling with infections, low parental education, poor insulin storage and lack of facilities for self monitoring of blood glucose. CONCLUSION: A complex unfavourable social and economic environment is the basis of the high prevalence of DKA in sub-Saharan Africa. Several episodes of DKA can be prevented by effective public awareness programmes and education to healthcare providers.

Estimation of CD4 T-lymphocyte counts from percent CD4 T-lymphocyte determinations in HIV-1-infected subjects in sub-Saharan Africa.

The relationship between CD4 percent and CD4 count has been reported to be different in industrialized countries compared to sub-Saharan Africa, where often only the former is reliable. CD4 determinations from an open cohort of hotel workers in Dar es Salaam followed between 1990 and 1998 were evaluated. T-lymphocyte determinations were offered once a year to 190 HIV-1 seropositive, 80 seroconverters and 495 sex and age matched HIV-seronegative subjects. After log transformation of the CD4 percent and CD4 counts a good fit to a linear regression curve was found, R(2) 0.697. The CD4 percent corresponding to a CD4 count of 200 cells/mm(3) was found to be 9.8%. CD4 percent determination can be useful to estimate CD4 counts, but needs to be locally standardized. The CD4 percent in Africa corresponding to AIDS defining CD4 counts seems to be lower than in the industrialized world.

Lymphocyte subset enumeration in HIV seronegative and HIV-1 seropositive adults in Dar es Salaam, Tanzania: determination of reference values in males and females and comparison of two flow cytometric methods.

The level of CD4(+) T-lymphocytes represents a useful marker with which to monitor the progression of HIV infection. Sex and geographical differences in the reference values of lymphocyte subsets have been reported. We have compared two flow cytometric methods (MultiSET and SimulSET) for the quantification of lymphocyte subsets using whole blood from 92 HIV seropositive and 241 seronegative adults, and determined the reference values of lymphocyte subsets in HIV seronegative Tanzanian subjects. In seronegative Tanzanian subjects, the percentages of CD3(+) and CD4(+) T-lymphocytes and the CD4(+):CD8(+) T-lymphocyte ratios were lower while the percentage of natural killer cells was higher compared to the levels of the corresponding parameters reported for Europeans. Seronegative Tanzanian females had significantly higher levels of CD3(+) and CD4(+) T-lymphocytes and CD4(+):CD8(+) T-lymphocyte ratios compared to seronegative males. The correlation coefficients of CD3(+), CD4(+) and CD8(+) T lymphocyte counts and percentages obtained by the two flow cytometric methods were high. The median values of the number of CD4(+) T-lymphocytes obtained by the two methods were not significantly different. In conclusion, determination of the reference values of lymphocyte subsets in HIV seronegative Tanzanian adults showed significant sex differences and differences in percentage values compared to those reported in certain other geographical areas. There was acceptable agreement in the levels of CD4(+) T-lymphocyte values obtained by the two flow cytometric methods.

The effect of Phyllanthus amarus aqueous extract on blood glucose in non-insulin dependent diabetic patients.

The glycaemic response to 124.5 +/- 9.3 (mean +/- SD) g of pancakes was monitored in 21 non-insulin dependent diabetic (NIDDM) patients while on oral hypoglycaemics, after a 1-week washout period and after a 1-week twice daily treatment with 100 mL of an aqueous extract from 12.5 g of powdered aerial parts of Phyllanthus amarus. After the 1-week washout period, the fasting blood glucose (FBG) and postprandial blood glucose increased significantly compared with treatment on oral hypoglycaemics ( p < 0.05). After a 1-week herbal treatment no hypoglycaemic activity was observed. Both FBG and postprandial blood glucose remained very similar to that recorded after the washout period ( p > 0.05). Both liver and renal functions based on alanine transaminase (ALAT) and serum creatinine, respectively, were not significantly affected by the use of the extract. Although the lymphocyte and monocyte levels were significantly decreased ( p < 0.05) and the granulocyte level was significantly increased after treatment ( p < 0.05) the overall total white blood cell (WBC) count and haemoglobin (Hb) were not significantly affected by the 1 week herbal treatment. We conclude that 1 week treatment with the aqueous extract of Phyllanthus amarus was incapable of lowering both FBG and postprandial blood glucose in untreated NIDDM patients.

Prevalence of HIV type 1 infection, associated clinical features and mortality among hospitalized children in Dar es Salaam, Tanzania.

The aim of this study was to determine the prevalence of HIV-1 infection, the clinical spectrum of HIV-1-associated conditions and HIV-1-associated mortality among children hospitalized in the medical paediatric wards at Muhimbili Medical Centre (MMC), Dar es Salaam, Tanzania. All children admitted to the medical paediatric wards of MMC between August 1995 and January 1996 were eligible for the study. Testing for HIV antibodies was done using 2 consecutive enzyme linked immunosorbent assays (ELISAs). ELISA-reactive samples from children aged 18 months and below were further tested by a recently developed heat-denatured p24 antigen assay. The prevalence of HIV-1 infection among the 2015 children studied was 19.2%. When present for 14 days or more, fever, cough, diarrhoea, ear discharge, oral ulcers and skin rash were all significantly more common in HIV-1-infected than in HIV-uninfected children (p < 0.001). In the multivariate analysis cough, ear discharge, oropharyngeal ulcers and skin rash were found to be the most important symptoms. Clinical signs found to be significantly associated with HIV-1 infection in the univariate analysis were wasting, stunting, hair changes, oral thrush, oropharyngeal ulcers, lymphadenopathy, lung consolidation and lung crepitations (p < 0.001). In the multivariate analysis, oral thrush, lung crepitations, cervical lymphadenopathy, wasting and inguinal lymphadenopathy were found to be the most important signs. The 3 most common diagnoses in HIV-1-infected children were acute respiratory infection (ARI) (39.4%), malnutrition (38.1%) and tuberculosis (19.3%), while in HIV-uninfected children they were malaria (47.0%), ARI (25.0%) and malnutrition (16.1%). The mortality rate was 21.4% in HIV-1-infected children and 8.4% in HIV-uninfected children (p < 0.001). In conclusion, the prevalence of HIV-1 infection among hospitalized children at the main hospital in Dar es Salaam was high and associated with high mortality. Many symptoms and signs are indicative of HIV-1 infection, but appropriate laboratory testing is required for diagnosis.

The prevalence and incidence of HIV-1 infection and syphilis in a cohort of police officers in Dar es Salaam, Tanzania: a potential population for HIV vaccine trials.

OBJECTIVES: To assess the suitability of a cohort of police officers in Dar es Salaam for HIV vaccine trials by determining the prevalence and incidence of HIV-1 infection, active syphilis and their associated factors. DESIGN AND SETTING: An open cohort study of police officers in Dar es Salaam, Tanzania. METHODS: Recruitment of police officers began in 1994. A standardized questionnaire was completed at enrolment and subsequent visits. HIV antibodies were determined using two consecutive enzyme-linked immunosorbent assays. Samples repeatedly discordant on the two tests were tested by a Western blot assay. Treponema pallidum antibodies were first determined by Venereal Disease Research Laboratory (VDRL) test and reactive sera were confirmed by Treponema pallidum hemagglutination test. RESULTS: At the end of 1996 a total of 2850 police officers had been recruited of whom 2733 (96%) consented to be tested for HIV. The overall HIV-1 seroprevalence at recruitment was 13.8% (378 of 2733). Females had a significantly higher HIV-1 seroprevalence, 18.0% (55 of 306), as compared to males, 13.3% (323 of 2427), P< 0.05. From a total of 2215 married police officers, 585 (26.4%) responded to a question on extramarital sex within the previous 3 months of whom 36.2% (212 of 585) admitted to have had at least one extramarital sexual intercourse. Condoms were not used during these encounters by 178 of 212 (84.0%). As of 31st December 1998, among the 1524 males observed for 2553 person-years (PYAR), 50 had seroconverted and among 200 females observed for 357 PYAR, eight had seroconverted. The overall crude HIV-1 incidence was thus 19.9/1000 PYAR; 19.6 and 22.4/1000 PYAR for males and females, respectively. The overall prevalence and incidence of active syphilis were 3.1% (88 of 2850) and 8.6/1000 PYAR (26 of 3149), respectively. Males had a higher prevalence of active syphilis, 84 of 2525 (3.3%) than females, five of 325 (1.5%), P = 0.09. CONCLUSIONS: There was high risk sexual practice including low condom use in this cohort of police officers. The incidence and prevalence of HIV infection were high. Police officers in Dar es Salaam are therefore a potential population group for HIV vaccine evaluation.

Bancroftian filariasis on Pemba Island, Zanzibar, Tanzania: an update on the status in urban and semi-urban communities.

Cross-sectional clinical, parasitological and entomological surveys for bancroftian filariasis were conducted in Konde, Chake Chake and Kengeja, three urban and semiurban communities on Pemba Island, and the results were compared with similar surveys done 15 years earlier. The overall prevalences of clinical manifestations among males aged 15 years or more (n = 614) was remarkably similar to those recorded 15 years earlier: elephantiasis 1.4% in 1975 and 1.1% in 1990; hydrocele, 22.4% and 21.8%, respectively. However, when the communities were compared individually, there was a reduction in the hydrocele prevalence in Konde from 22.4% to 11.5% and an increase in Kengeja from 27.0% to 35.5%. The overall microfilarial prevalence found during night blood surveys of all individuals aged 1 year or more (n = 2687) was 9.7%, compared to 14.2% recorded in 1975. The reduction was most pronounced in Konde. Of 1052 female mosquitoes caught with CDC light traps, 95% were Culex quinquefasciatus and 5% Anopheles gambiae s.l. Infective larvae of Wuchereria bancrofti were found only in the former. The filariasis situation in urban and semiurban communities on Pemba Island appears not to have changed considerably over the last 15 years.

Diagnosis of tuberculosis in sputum negative patients in Dar es Salaam.

OBJECTIVE: To determine diagnostic criteria for tuberculosis among sputum smear acid fast bacilli negative patients with chronic cough, based on symptoms, signs and simple laboratory tests. DESIGN: A two-month prospective follow up study. SETTING: Muhimbili Medical Centre, Dar es Salaam, Tanzania. SUBJECTS: One hundred and seventy- eight consecutive patients admitted between 1st November, 1994 and 31st March, 1995 with chronic productive cough. MAIN OUTCOME MEASURES: Sputum smear acid fast bacilli (AAFB) negative with TB, discriminating ability of clinical and laboratory parameters. RESULTS: Forty three (24.2%) were sputum smear positive for acid fast bacilli (AAFB). In 90 (50.6%) patients, AAFB could be isolated in specimen other than sputum and in 45 (25.3%) no AAFB could be isolated. In a univariate analysis of all symptoms, signs and laboratory test results, cough of four or more weeks, haemoptysis, oral candidiasis, chest consolidation, pleural effusion, mid zone and upper zone chest x-ray opacities were significantly different between sputum AAFB negative TB and non TB patients. Discriminant analysis revealed six highly significant variables: Mantoux reaction, pleural effusion, Kaposi's lesion, cervical lymphadenopathy, matted lymph node, mid zone and upper zone CXR infiltrates. From these variables an equation was derived to calculate the probability that a sputum smear negative patient had tuberculosis. Then a scoring system was developed that classified correctly 84% of cases of sputum AAFB negative patients into tuberculosis or non tuberculosis. CONCLUSION: In sputum smear AAFB negative patient clinically suspected to have tuberculosis, Mantoux reaction, cervical lymphadenopathy, matted lymph nodes, absence of mid lower zone infiltration on CXR and presence of pleural effusion could be used for presumptive diagnosis, but they would not make a therapeutic trial unnecessary.

Insulin resistance and hypertension in non-obese Africans in Tanzania.

Insulin sensitivity was assessed using a glucose-insulin infusion test in 15 newly diagnosed non-obese hypertensive black Tanzanians with normal glucose tolerance and in 15 normotensive control subjects matched for age, sex, and body mass index. The steady-state blood glucose and metabolic clearance rate of glucose (MCR) were used as measures of insulin sensitivity. The mean MCR (glucose) was significantly reduced (7.12+/-0.57 versus 9.50+/-0.69 micromol/kg per minute; P<.05) and mean steady-state blood glucose was significantly elevated (5.0+/-0.3 versus 3.7+/-0.3 mmol/L; P<.01) in subjects with hypertension compared with the normotensive group. For all subjects there was a significant inverse correlation between MCR (glucose) and systolic (P=.003) and diastolic (P=.005) blood pressure; and a positive correlation was found between fasting serum insulin levels and systolic (P=.005) and diastolic (P=.004) blood pressure. These observations were independent of body mass index and serum lipid levels. These data indicate a strong association between insulin mediated glucose uptake and blood pressure in this population of normal weight untreated urban Africans.

The relationship of concentrations of insulin and proinsulin-like molecules with coronary heart disease prevalence and incidence. A study of two ethnic groups.

OBJECTIVE: To define the potential role of proinsulin-like molecules as risk factors for cardiovascular disease. RESEARCH DESIGN AND METHODS: Fasting concentrations of proinsulin, des-31,32-proinsulin, and insulin, and of insulin 2 h after a 75-g glucose load, were measured in 1,034 nondiabetic europid subjects and 257 south Asian subjects and related to prevalent coronary heart disease (Minnesota-coded electrocardiographic criteria or ischemic chest pain). In 137 south Asian subjects, the fasting concentrations were related to incident coronary heart disease over a 6.5-year follow-up. RESULTS: The standardized odds ratios for prevalent coronary heart disease were as follows: fasting insulin, 1.29 (1.11-1.49), P = 0.0006; 2-h insulin, 1.25 (1.08-1.45), P = 0.003; proinsulin, 1.23 (0.99-1.53), P = 0.058; and des-31,32-proinsulin, 1.32 (1.03-1.69), P = 0.026. The odds ratios were similar in the two ethnic groups. These relationships became insignificant when controlling for age, sex, and BMI. The standardized odds ratios for incident coronary heart disease were as follows: fasting insulin, 0.99 (0.63-1.55), P = 0.97; proinsulin, 1.13 (0.72-1.78), P = 0.59; and des-31,32-proinsulin, 1.00 (0.61-1.63), P = 1.00. CONCLUSIONS: We have found similar relationships between concentrations of proinsulin-like molecules and prevalent coronary heart disease, as are observed for insulin in these nondiabetic subjects, although these molecules comprise only approximately 10% of all insulin-like molecules. It appears biologically implausible that these relationships represent cause and effect.

Evaluation of the efficacy of thiamine and pyridoxine in the treatment of symptomatic diabetic peripheral neuropathy.

The clinical response to therapeutic doses of two vitamins were determined in diabetic patients with symptomatic peripheral neuropathy. Of 200 consecutive patients, 100 were randomly allocated to treatment with both thiamine (25 mg/day) and pyridoxine (50 mg/day) group A and the rest group B to treatment with an identical tablet containing 1 mg/day each of thiamine and pyridoxine. Pain, numbness, paraesthesia and impairment of sensation and ankle in the legs were graded into none, mild, moderate or severe. Blood thiamine levels were measured using HPLC fluorimetry. Four weeks after starting treatment the grade was less than on the first visit in 88.9%, 82.5% and 89.7% of those whose worst symptoms were pain, numbness and paraesthesia respectively for group A compared with 11.1%, 40.5% and 39.4% respectively for group B. The severity of signs of peripheral neuropathy decreased in 48.9% of patients in group A compared with 11.4% in group B. The mean (s.e.) pre-treatment whole blood thiamine levels decreased with increasing severity of symptoms: 64.2 (2.81), 57.7 (3.25) and 52.2 (2.14) micrograms/l for those with mild, moderate and severe symptoms respectively (analysis of variance, p = 0.03). Diabetic peripheral neuropathy in Dar es Salaam is associated with thiamine deficiency. Dietary guidelines for diabetic patients should emphasize a balanced diet.

High frequency of sexually transmitted diseases among pregnant women in Dar es Salaam, Tanzania: need for intervention.

In order to determine the prevalence and characteristics of sexually transmitted diseases (STDs) in pregnant women (PW) attending a primary health care antenatal clinic (ANC) in metropolitan Dar es Salaam, Tanzania, a randomly selected sample of PW in their second or third trimesters were invited to participate at their first visit. They were interviewed using a questionnaire and underwent genital examination. Genital swabs were obtained for microscopy and/or culture isolation of Candida albicans, Trichomonas vaginalis, and Neisseria gonorrhoeae. Blood specimens were also obtained for serological testing for syphilis and for antibodies to the human immunodeficiency virus (HIV). A total of 777 PW aged 14 to 40 years were seen. Parities ranged from 0 to 10. Prevalence of syphilis, trichomoniasis, gonorrhoea and HIV infection were 4.0%, 22.7%, 3.6% and 15.2%, respectively. At least one acute STD (excluding HIV infection) was found in 32.8% of the PW. The prevalence of multiple STDs (excluding HIV infection) was higher in teenagers (45.3%, 77/170) than in PW in other age groups (29.2%, 177/607) (p < 0.001). The prevalence of HIV infection in teenage PW was 10.0%. Most STDs were least prevalent in PW who were married monogamously. Of the 732 PW who had one or more genital infections (including infection with Candida species), 669 (91.4%) had one or more genital complaints. However, most of the genital complaints were not disease specific. Since this study has shown that the prevalences of acute STDs were high in PW, especially in teenagers, it is recommended that all PW in Tanzania should be screened for STDs syndromically including the use of appropriate clinical and laboratory examination whenever possible.

PIP: A survey of 777 randomly selected pregnant women attending an antenatal clinic in Dar es Salaam, Tanzania, in 1993 revealed a high prevalence of sexually transmitted diseases (STDs), particularly among teenagers. The median age of survey respondents was 23.6 years (range, 14-40 years); 170 women (22%) were teenagers and 439 (56.7%) were married. 320 women (41.2%) had 1 or more STDs (excluding human immunodeficiency virus (HIV) infection); in 32.7%, there was active infection. STD prevalence was 45.3% in teenagers compared with 29.2% in adults. In the overall sample, the prevalences of syphilis, trichomoniasis, gonorrhea, and HIV were 4.0%, 22.7%, 3.6%, and 15.2%, respectively. 80 women (10.3%) showed serologic evidence of past syphilis infection and 4% had active syphilis. Syphilis was most prevalent in pregnant women aged 35 years and above (13.8%), while trichomoniasis was most common in teenagers (34.3%). Of the 732 pregnant women with genital infections, 63 (8.6%) were asymptomatic; when symptoms did exist, they were generally not disease-specific. The most significant risk factor for STDs, including HIV, was single marital status. These findings suggest a need for the introduction of essential clinical and laboratory facilities for STD detection to antenatal clinics in Tanzania.

Serum iron, zinc, copper and bromine in malnourished children in Dar es Salaam, Tanzania.

We measured the serum concentration of iron, zinc, copper and bromine in fifty malnourished children and twenty one healthy controls using energy dispersive X-ray fluorescence spectrometry. The mean ages for the study group and controls were 27.06 and 29 months respectively. The mean weights of the study and control groups were 7.32 and 12.05 +/- 3.07 kilogrammes respectively. The serum iron, zinc, copper and bromine mean levels in the study and control groups were Fe 14.6 (9.9) Zn 12.5 (11.9) Cu 16.5 (21.2) and Br 59.1 (63.0) micromoles per litre. Analysis of variance between the study group and controls showed a significant fall in copper levels even when adjusted for age sex and weight differences (F = 4.6586 p < 0.05). The wide distribution of concentrations of Iron noted in the malnourished children is probably due to haemolysis and rapid catabolism. The role of bromine in nutrition is yet to be established.

Predictive markers of survival in HIV-seropositive and HIV-seronegative Tanzanian patients with extrapulmonary tuberculosis.

SETTING: Prediction of survival in Tanzanian patients with extrapulmonary tuberculosis (TB). OBJECTIVE: To evaluate the prognostic value of clinical and laboratory parameters on survival in human immunodeficiency virus (HIV) seropositive and HIV seronegative patients with extrapulmonary TB. DESIGN: Over an 8-month period 192 consecutive patients with extrapulmonary TB, admitted to a major referral centre in Tanzania, were enrolled in the study. Their symptoms, signs and PPD skin test were noted. Their sera were tested for HIV and analyzed for beta-2-microglobulin content. Univariate risk factors for 12 months' survival after the start of anti-TB chemotherapy were entered into a stepwise Cox regression model. Survival probabilities were estimated according to the number of risk factors. RESULTS: Of the 192 patients 126 (65%) were HIV-infected, and 29.7% had disseminated TB. Thirty-five patients, of whom 24 (68.6%) were HIV-positive, withdrew from the study immediately after hospital discharge. For survival analysis 157 patients remained. Within 12 months' follow-up after initiation of anti-TB therapy, the case fatality rate of the 102HHIV-infected patients was 22% and of the 55 HIV seronegative patients 2% (P < 0.001). In the HIV seropositive patients the following independent risk factors were significantly associated with a decreased probability of survival: peripheral lymphadenopathy (Hazard Rate Ratio (HRR) 5.2, 95% Confidence Interval [CI] 1. 7-16.2), a decreased activity score (bedridden > 50%/day (HRR 4.5, 95% CI 1.7-11.7), lymphopenia of < 1000/microL (HRR 4.4, 95% CI 1.7-11.8), and mycobacteraemia (HRR 4.0, 95% CI 1.2-13-.1). An anergic PPD skin test reaction proved to be another independent risk factor when the analysis was performed on 89 patients with available Mantoux test results. In the HIV seropositive patients, the 12 months' survival probabilities were 93%, 86%, 54% and 0% for presence of 0, 1, 2, and > 2 risk factors respectively. CONCLUSION: Estimation of survival probabilities in patients with extrapulmonary TB may be possible without performing CD4 cell counts.

PIP: This study sought to evaluate the prognostic value of clinical and laboratory parameters on survival in human immunodeficiency virus (HIV) seropositive and HIV seronegative patients with extrapulmonary tuberculosis (TB) from Tanzania. Over an 8-month period 192 consecutive patients with extrapulmonary TB, admitted to a major referral center in Tanzania, were enrolled in the study. Their symptoms, signs, and PPD skin test results were noted. Their sera were tested for HIV and analyzed for beta-2-microglobulin content. Univariate risk factors for 12 months' survival after the start of anti-TB chemotherapy were entered into a stepwise Cox regression model. Survival probabilities were estimated according to the number of risk factors. Of the 192 patients, 126 (65.6%) were HIV-infected, and 29.7% had disseminated TB. 35 patients, of whom 24 (68.6%) were HIV-positive, withdrew from the study immediately after hospital discharge. For survival analysis 157 patients remained. Within 12 months' follow-up after initiation of anti-TB therapy, the case fatality rate of the 102 HIV-infected patients was 22% and of the 55 HIV seronegative patients 2% (p 0.001). In the HIV seropositive patients the following independent risk factors were significantly associated with a decreased probability of survival: peripheral lymphadenopathy (Hazard Rate Ratio [HRR] 5.2, 95% confidence interval [CI] 1.7-16.2), a decreased activity score (bedridden 50%/day) (HRR 4.5, 95% CI 1.7-11.7), lymphopenia of 1000/mcl (HRR 4.4, 95% CI 1.7-11.8), and mycobacteremia (HRR 4.0, 95% CI 1.2-13.1). An anergic PPD skin test reaction proved to be another independent risk factor when the analysis was performed on 89 patients with available Mantoux test results. In the HIV seropositive patients, the 12 months' survival probabilities were 93%, 86%, 54%, and 0% for the presence of 0, 1, 2, and 2 risk factors respectively. The conclusion is that estimation of survival probabilities in patients with extrapulmonary TB may be possible without performing CD4 cell counts. (author's modified)

Clinical features of HIV seropositive and HIV seronegative patients with tuberculous lymphadenitis in Dar es Salaam.

SETTING: The medical wards of a referral hospital in Dar es Salaam, Tanzania. OBJECTIVE: To investigate the impact of HIV infection on clinical features in tuberculous lymphadenitis. DESIGN: A prospective clinical study of HIV seropositive and HIV seronegative patients with lymphadenopathy. RESULTS: Of 128 patients with peripheral lymphadenopathy, 24 had no tuberculosis (TB) and in 10 patients TB was found only in other organs. The remaining 94 patients, of whom 76% were HIV seropositive, formed our study population. TB lymphadenitis was considered proven in 89 and probable in 5 patients. Disseminated TB (both TB adenitis and TB in other organs) was diagnosed more often in HIV seropositive than in HIV seronegative patients (52% versus 26%, P < 0.03). 59% of the 71 HIV-infected patients compared to only 4% of the 23 patients without HIV infection were over 30 years of age (P < 0.02). The following clinical features were significantly associated with HIV infection: dyspnoea, respiratory rate > 20/min, low motility score (bedridden), neurological abnormalities, hepatomegaly, splenomegaly, lymph node size < 2.5 cm, negative PPD skin test, lymphopenia (< 1000/cm3) and presence of pleural fluid. CONCLUSION: Co-infection with HIV influences several clinical and laboratory features in patients with tuberculous lymphadenitis.

Blood pressure changes in diabetes in urban Tanzania.

Little is known of the natural history of blood pressure (BP) levels in diabetic patients from sub-Saharan Africa. BP levels were therefore recorded in such patients in Dar es Salaam, Tanzania, over 2, 5, and 7 years. Hypertension was found in 5% of insulin-treated diabetes mellitus (IDDM) and 29.2% of non-insulin-dependent diabetes mellitus (NIDDM) patients at presentation with diabetes. Hypertension developed in a further 2 IDDM (3.7%) and 27 NIDDM (15.6%) patients at 2 years, and in 3 IDDM (13.0%) and 9 NIDDM (9.8%) patients at 5 years. Seven NIDDM (18.4%) patients had developed hypertension by 7 years. In NIDDM patients with normal BP initially, the mean systolic BP rose from 131 to 141 mmHg (P < 0.001) 2 years later (n = 146); from 131 to 138 mmHg (P < 0.001) for those followed for 5 years (n = 82); and from 131 to 138 mmHg (P < 0.05) for those followed for 7 years (n = 31). The mean diastolic BP was 83 mmHg initially and 84 mmHg (NS) for those followed for 2 years (n = 146). There was no observed rise in mean diastolic BP at 5 or 7 years of follow-up. In IDDM patients without hypertension, only the systolic BP rose significantly by 5 years, from 124 to 132 mmHg (P < 0.001; n = 20). These changes were independent of age, sex, body mass index, and proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)