Diagnostic utility of cerebrospinal fluid studies in patients with clinically suspected tuberculous meningitis.

OBJECTIVE: To compare yields of cerebrospinal fluid (CSF) studies in the diagnosis of tuberculosis meningitis (TBM). DESIGN: Prospective laboratory study, Kenyatta National Hospital, Kenya. STUDY POPULATION: Consecutive patients with 1) headache, neck stiffness and altered consciousness for more than 14 days, 2) above features plus evidence of tuberculosis elsewhere in the body, and 3) on standard antimeningitic drugs for one week without response, were included. Those with contraindications to lumbar puncture, confirmed causes of meningitis (except TB) and on anti-tuberculosis treatment were excluded. METHODS: CSF cell counts, glucose and protein were assayed. CSF was stained on ZN, cultured on LJ and BACTEC and subjected to PCR and LCR for Mycobacterium tuberculosis DNA sequences. Positive tests for M. tuberculosis were classified as definite and the rest as probable TBM. RESULTS: Fifty-eight patients with a mean age of 33.0 years were recruited. Mean CSF cell count was 71/microl and CSF lymphocyte count up 67%. Mean CFS protein and glucose were 2.10 g/l and 2.05 mmol/l, respectively. BACTEC was positive in 20 cases, LJ 12, LCR eight, and PCR and ZN one each. Twenty-six patients had definite and 32 probable TBM. Patients with definite TBM had significantly higher CSF protein, lower CSF glucose, higher CSF cell count and lower CSF lymphocytes. CONCLUSION: TBM can be confirmed in half of clinically suspected cases. More sensitive tests for confirmation of TBM are required.

The Kidney: An important target for HIV infection.

HIV-infected patients may present with a variety of patterns of renal involvement. Acute renal failure is common and most often a result of sepsis, hypotension and nephrotoxic agents. It is potentially avoidable, and support through the period of renal failure may lead to resolution of the renal dysfunction. HIV-associated nephropathy is a unique pattern of sclerosing glomerulopathy that ranges in prevalence form 1 to 10 per cent of the HIV infected population in different geographic locales. This complication of HIV infection will likely present a growing challenge to the medical community as HIV infection continues to spread worldwide. Deciphering the pathogenitic mechanisms of this most rapidly progressive form of focal segmental glomerulosclerosis is not only clinically relevant, but will hopefully provide valuable insights into the medication of the more common idiopathic form of the disease. The potential for improved renal survival of patients with HIV-associated nephropathy ahs become more realistic with the development and the use of antiretroviral agents, as well as studies on the role of immunosuppression and Angiotensin Converting Enzyme (ACE) inhibition in this population.

Urinalysis and electrolyte profiles in patients with acquired immunodeficiency syndrome.

One hundred and twenty six patients diagnosed as having AIDS had their urinalysis and electrolyte profiles studied. The commonest electrolyte abnormalities were a low serum bicarbonate in 56% of the patients and hyponatraemia in 48%. Possible aetiological factors are discussed. Significant pyuria was found in 10% of the patients and significant bacteriuria in 13%. Escherichia coli was the commonest isolated organism (56% of all the culture positive cases). Proteinuria above the upper limit of normal was detectable in 13% of the patients; of these, 25% had proteinuria in the nephrotic range. Of the patients 3% had clinical and biochemical evidence of renal insufficiency. It is concluded that significant bacteriuria occurs commonly in AIDS and that renal insufficiency and nephrotic syndrome may be associated with the disease. It is also noted that other electrolyte and acid-base abnormalities, in particular hyponatraemia and low bicarbonate levels may contribute to the morbidity and mortality in patients suffering from AIDS.

Seroprevalence of hepatitis B and C in maintenance dialysis in a public hospital in a developing country.

BACKGROUND: Patients with end-stage renal disease (ESRD) on maintenance dialysis are predisposed to hepatitis B virus (HBV) infection for a number of reasons. In a similar way, the prevalence of anti-hepatitis C virus (HCV) antibodies among patients on chronic haemodialysis and peritoneal dialysis is consistently higher than in healthy populations. There are few published data on these diseases in patients undergoing maintenance dialysis in sub-Saharan Africa. OBJECTIVE: To determine the seroprevalence of HBV and HCV in patients on maintenance dialysis. SETTING: Renal Unit, Kenyatta National Hospital, the largest public referral and teaching hospital in Kenya. DESIGN: Cross-sectional descriptive study. STUDY POPULATION: All 100 patients on maintenance dialysis during the 9-month study period were evaluated. METHOD: The following information was obtained from all the patients: socio-demographic data, date of diagnosis of ESRD and commencement of dialysis, and number of blood transfusions. Additionally, a history suggestive of hepatitis in spouses was looked for and physical examination for tattoos and other scars was carried out. Laboratory investigations included urea, electrolytes and serum creatinine, liver enzymes, hepatitis B surface antigen (HBsAg), immunoglobulin M anti-hepatitis B core antibody (IgM anti-HBc), hepatitis B e antigen (HBeAg) and anti-HCV antibodies. Student's t-test was used to assess the significance of the data collected. RESULTS: The results were expressed as mean (+/- SD). Fifty-seven males and 43 females were studied. Mean age was 44.3 +/- 14.6 years. Ten patients (10%) had elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (> 40 U/l for both). HBsAg was found in 8 patients (8%), IgM anti-HBc in 2%, and HBeAg in none. Anti-HCV antibody was found in 5%. Six of the HBsAg-positive patients were on haemodialysis, the other 2 on continuous ambulatory peritoneal dialysis (CAPD). There was no coexistence of HBV and HCV markers. Longer duration of dialysis and the number of blood transfusions were associated with an increased seroprevalence of HBV and HCV. CONCLUSION: There is a low seroprevalence of HBV and HCV in our dialysis population. This should not lead to complaisance in screening for these potentially lethal complications.