Diverse blood exposures associated with incident HIV infection in Calabar, Nigeria.

Few types of blood exposures have been assessed in relation to incident HIV infection in sub-Saharan Africa, despite evidence that penile-vaginal sex cannot account for the epidemic in the region. To investigate correlates of incident HIV infection in Calabar, Nigeria, we surveyed clients at voluntary HIV counselling and testing centres. Participating clients who tested multiple times were generally similar to those testing only once in terms of demographic characteristics, sexual and blood exposures and HIV prevalence. Blood exposures were common. Serial testers had a 10% annual incidence of HIV infection. Seroconverters and seronegative serial testers were similar on most demographic characteristics and sexual exposures. However, seroconverters were more likely than seronegatives to report blood exposures during the test interval, both for most specific exposures as well as summary measures of blood exposures. In particular, seroconverters were substantially more likely to report one of a set of blood exposures that cannot be explained as a consequence of unprotected vaginal sex or of health care for symptoms of HIV infection (adjusted odds ratio = 6.6, 95% confidence interval = 1.2-38). The study design we used is an inexpensive approach for describing the local epidemiology of HIV transmission and can also serve as the foundation for more definitive investigations that employ contact tracing and sequencing of HIV DNA.

Kaposi's sarcoma and HTLV-III: a study in Nigerian adult males.

Sera from 37 adult Nigerian men with Kaposi's sarcoma (KS), 30 contemporaneous controls bearing primary cell carcinoma of the liver (PCL), and 150 healthy non-tumour-bearing negative controls were tested for antibody to human T-cell lymphotropic virus type III/lymphadenopathy associated virus (HTLV-III/LAV) by enzyme-linked immunosorbent assays (ELISA). Certain immunocellular functions were also measured: the chemotactic locomotion of peripheral blood monocytes towards casein, delayed-type cutaneous hypersensitivity reaction to tuberculoprotein and opportunistic infection with the fungus Candida albicans. Sera from all these groups were also tested for markers of previous infections with the viruses cytomegalovirus (CMV), Epstein-Barr virus (EBV), hepatitis B (HBV) and hepatitis A (HAV). All serum samples tested were reproducibly and consistently negative for anti-HTLV-III/LAV. Peripheral blood monocytes from both KS and PCL patients showed profound depression of chemotaxis; similarly all tumour patients gave markedly depressed cutaneous reactivity to tuberculoprotein and uniformly exhibited seropositivity to CMV, EBV, HBV and HAV. A great majority showed evidence of infection with Candida albicans. It is concluded that tropical African KS is not associated with HTLV-III/LAV infection.

PIP: Sera from 37 Nigerian men with Kaposi's sarcoma were examined for evidence of infection with human T-cell lymphotropic virus type III (HTLV-III), cytomegalovirus (CMV), Epstein-Barr virus (EBV), hepatitis B virus (HBV), hepatitis A virus (HAV), and Candida albicans. For comparison purposes, sera from 30 patients with primary cell liver carcinoma and 150 health young adults were also assessed. The Kaposi's sarcoma patients were in poor general condition, with severe anemia and gross sepsis. In each case, cutaneous disease affected only the limbs-- a finding that is in contrast with the visceral organ involvement seen in most black African victims. The serologic testing provided clear evidence that tropical African Kaposi's sarcoma is not associated with HTLV-III infection; non of the 217 serum samples analyzed from the 3 study groups showed antibodies to this virus. A widespread pattern among the Kaposi's sarcoma and liver carcinoma patients was depression of peripheral blood monocyte chemotaxis and a diminished, delayed-type hypersensitivity reaction to tuberculin. All patients in these 2 groups demonstrated circulating antibodies to CMV, EBV, HBV, AND HAV. Candida albicans was isolated from 30 of the 37 Kaposi's sarcoma patients and all 30 liver carcinoma patients compared with none of the health controls. These findings suggest that endemic tropical African Kaposi's sarcoma is a different disease than the epidemic AIDS-linked Kaposi's sarcoma reported from the US, and it is probable that different etiologic agents are involved in each case.

Prospective evaluation of simple suture in the surgical treatment of perforated peptic ulcer.

In a prospective study aimed at evaluating a safe treatment for perforated peptic ulcer in tropical African conditions 205 patients who presented with perforation of a peptic ulcer in South-Eastern Nigeria during the ten year period January 1973 to December 1982 were treated by simple suture. The ulcers were classified at operation from appearance and feel as acute in 155 patients (75.6%), and chronic in the remaining 50 patients (24.4%). Of this number 21 patients (10.2%) died post-operatively. All 21 patients had chronic pyloroduodenal ulcers which were complicated by haemorrhagic in 10 patients (5.0%) and extensive scarring of the duodenum and pyloric stenosis in 9 patients (4.4%). By way of contrast, no patient with acute pyloroduodenal ulcer died and none was known to suffer from recurrent dyspepsia at 6 months to 1 year follow-up. These results clearly show that simple suture is adequate and safe treatment for perforated acute pyloroduodenal ulcer; however, this form of treatment carries an unacceptably high mortality in those patients with perforated chronic pyloroduodenal ulcers. These patients should, where feasible, be treated by definitive ulcer - curative surgery.

Inhibition of macrophage chemotaxis by supernatant fluid from malignant cell lines.

The chemotactic locomotion of peritoneal macrophages in vitro was measured in the presence of supernatant fluid from 27 different tumour cell lines. All the tumour-derived cells tested caused profound depression of macrophage chemotaxis towards the chemo-attractant casein. Conversely, supernates from rapidly dividing non-malignant cells uniformly failed to depress macrophage migration. This confirms the results of a previous investigation and provides further evidence that malignant tumours depress the functions of the reticuloendothelial system of the host animal in vivo.

Tropical surgical abdominal emergencies: acute intestinal obstruction.

In a prospective evaluation of acute intestinal obstruction in emergency surgery, 3550 consecutive patients were studied. In the vast majority of patients (75%), obstruction was due to the external hernia, the inguinal hernia being by far the commonest type. However, the ascaris worm in children, volvulus of the sigmoid colon in adults, and intussusception in both children and adults, were significant causes of the disorder, and together accounted for 18% of the patients. Obstruction by the ascaris worm is easy to diagnose (by stool microscopy), and effective treatment (with antihelminthics) is readily available and cheap. A large number (90%) of the volvulus patients required resection for gangrene of the colon, thus arguing a strong case in support of laparotomy and inspection of the colon whenever feasible. A significant (41%) proportion of intussusception cases were adult, and in 33% of this group the lesion was associated with a tumour of the small bowel. The chief reason for death (10%) was late reporting to hospital.

Perforated peptic ulcer in south-eastern Nigeria 1973-1982.

In a prospective study aimed at evaluating a safe treatment for tropical African conditions 205 patients who presented with perforation of a peptic ulcer in South Eastern Nigeria during the ten year period January 1973 to December 1982 were treated by simple suture. The ulcers were classified at operation from appearance as acute in 155 patients (75.6%), and chronic in the remaining 50 patients (24.4%). Of this number 21 patients (10.2%) died post-operatively. All 21 patients had chronic pyloroduodenal ulcers which were complicated by haemorrhage in 10 patients (5.0%) and extensive scarring of the duodenum and pyloric stenosis in 9 patients (4.4%). In contrast, no patient with acute pyloroduodenal ulcer died and none was known to suffer from recurrent dyspepsia at 6 months to 1 year follow-up. These results show that simple suture is an adequate and safe treatment for perforated acute pyloroduodenal ulcer but this treatment is, however, followed by an unacceptably high mortality in patients with perforated chronic pyloroduodenal ulcers in whom were feasible, a definitive ulcer--curative surgery should be performed.

Prevalence of dysglycemia in Calabar: a cross-sectional observational study among residents of Calabar, Nigeria.

OBJECTIVE: Population data on dysglycemia are scarce in West Africa. This study aimed to determine the pattern of dysglycemia in Calabar city in South East Nigeria. DESIGN: This was a cross-sectional observational study. METHODS: 1134 adults in Calabar were recruited. A multistage sampling method randomly selected 4 out of 22 wards, and 50 households from each ward. All adults within each household were recruited and an oral glucose tolerance test was performed. Dysglycemia was defined as any form of glucose intolerance, including: impaired fasting glucose (blood glucose level 110-125 mg/dL), impaired glucose tolerance (blood glucose level ≥140 mg/dL 2 h after consuming 75 g of glucose), or diabetes mellitus (DM), as defined by fasting glucose level ≥126 mg/dL, or a blood glucose level ≥200 mg/dL, 2 h after a 75 g glucose load. RESULTS: Mean values of fasting plasma glucose were 95 mg/dL (95% CI 92.1 to 97.5) for men and 96 mg/dL (95% CI 93.2 to 98.6) for women. The overall prevalence of dysglycemia was 24%. The prevalence of impaired fasting glucose was 9%, the prevalence of impaired glucose tolerance 20%, and the prevalence of undiagnosed DM 7%. All values were a few percentage points higher for men than women. CONCLUSIONS: The prevalence of undiagnosed DM among residents of Calabar is similar to studies elsewhere in Nigeria but much higher than the previous national prevalence survey, with close to a quarter of the adults having dysglycemia and 7% having undiagnosed DM. This is a serious public health problem requiring a programme of mass education and case identification and management in all health facilities. TRIAL REGISTRATION NUMBER: CRS/MH/CR-HREC/020/Vol.8/43.

Antibody to the AIDS virus in Kaposi's sarcoma in Nigeria.

The present study has investigated whether Kaposi's sarcoma (KS) in Nigeria is associated with infection with the AIDS virus variously called human T-cell lymphotropic virus type III (HTLV-III), lymphadenopathy/AIDS virus (LAV), and AIDS-associated retrovirus (ARV). Serum samples from 40 KS patients, 30 patients with malignant melanoma of the foot (contemporaneous controls), and 50 normal nontumour-bearing controls were tested for anti-AIDS virus antibody by enzyme-linked immunosorbent assay (ELISA). The assay consistently and reproducibly failed to show seropositivity in all the patients and controls. These results show that Kaposi's sarcoma in Nigeria is not associated with infection with the AIDS virus and that the virus is not endemic in this region.

PIP: In an investigation of the possible association of human T-cell lymphotropic virus type III (HTLV-III) to Kaposi's sarcoma (KS) in Nigeria, no association was found. Kaposi's sarcoma (KS) is a disease that is highly endemic in the Equatorial African countries of Zaire, Uganda and Zambia. The few cases reported in North America demonstrate the tendency of KS to affect older men. However, increasingly KS has been found among younger men with AIDS. Thus a study, examining the serum of 120 men divided into 3 groups, was set up to determine any relationship between the diseases. The physical effects of Kaposi's sarcoma are discussed. Although KS is frequently found in AIDS patients, the possible connection between the 2 diseases is not uniformly reported. The results of the study showed that none of the 40 patients with KS, the 30 patients with malignant melanoma or the 50 normal controls had antibody against AIDS.

Tropical surgical abdominal emergencies: acute appendicitis.

In a prospective 5-year investigation of acute appendicitis 603 consecutive patients with the disorder were studied in detail. Of this number 388 (64.3%) were female and 215 (35.7%) male giving a female: male ratio of 1.8:1. The patients were aged 4-65 years with a median age of 23.1 years; females with a median age of 22.1 years were younger than males with a median age of 25.4 years. Patients presented to hospital late: 3-7 days (median 5 days) from the onset of symptoms; the strikingly most common of these was abdominal pain seen in all the patients, and tenderness, local or with rebound was uniformly elicited. Supportive laboratory and radiological services were not regularly available; however, when white cell count was obtainable leucocytosis with a left shift was a useful finding. At operation 422 (70%) patients had an acutely inflamed appendix, 121 (20%) gangrenous or perforated appendicitis and 18 (3%) an appendix abscess; an appendix mass was palpable in 42 (7%) patients and these were treated conservatively. Wound infection complicated surgery in 18 (3%) patients; there were no operative deaths. Acute appendicitis was the second commonest surgical abdominal emergency during the period under study, and the results of treatment compare favourably with series from the developed countries of the West.

Benign breast tumours in an African population.

A detailed prospective clinical study of 238 women presenting with benign breast swellings in the South Eastern equatorial rainforest of Nigeria clearly shows that 94% of lesions were due to two disorders, fibroadenomas and bacterial infections, and that they affected mostly young women in the peak of their reproductive life. Fibroadenoma which accounted for disease in no less than 69% of the women was multiple in 8%, bilateral in 11%, and was considered giant in size in 5% of the cases; by contrast, fibroadenosis was rare, accounting for swellings in only eight patients. Bacterial infections, chronic pyogenic mastitis and tuberculosis together caused breast swellings in 25% of the women studied. In tropical Africa, multiple chronic discharging sinuses suggest tuberculosis of the breast.

Wrist and hand ganglion treatment with hyaluronidase injection and fine needle aspiration: a tropical African perspective.

In an attempt to provide an alternative non-invasive treatment to surgical excision of ganglion cysts of the hand, and as part of the departmental audit resulting from the prevailing economic depression, 340 consecutive patients with 349 ganglia were treated in a prospective investigation by intralesional injection of hyaluronidase (up to 150 units in 1 ml) followed by fine needle aspiration (FNA) of the cyst to dryness. Pressure was applied over a piece of gauze and maintained with a crepe bandage for 24 h. Of the 340 patients treated in this way, the vast majority (323 or 95.0%) were considered to be cured on clinical examination at 6-month follow-up; only 17 patients (5.0%) exhibited recurrence during this period and these were successfully treated by re-aspiration. To the knowledge of this author, this is the first report of the use of the enzyme hyaluronidase as an adjunct to FNA in the treatment of ganglion cysts of the hand. The results clearly show that this method of treatment is a safe, fast, well accepted and cost-effective alternative to surgical excision, which is relatively expensive and is known to be associated with certain complications, including hypertrophic scars and cheloids.

Hepatocellular carcinoma, hepatic cirrhosis, and hepatitis B virus infection in Nigeria.

A total of 200 consecutive patients bearing histologically confirmed primary hepatocellular carcinoma (PHC) were studied at University of Calabar Teaching Hospital (CTH), Calabar, Nigeria in 5 years and compared with 150 patients with metastatic hepatic carcinoma (MHC). Four hundred symptomless non-icteric nontumor-bearing individuals were noncontemporaneous controls. Sera (a total of 750) were assayed for markers of hepatitis B virus (HBV) infection; hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), and hepatitis B surface antibody (anti-HBs). Specimens which were positive for HBsAg also were examined for hepatitis E antigen (HBeAg) and antibody (anti-HBe). The results show that PHC was associated with HBV seropositivity in 80% of patients, and postnecrotic (macronodular) cirrhosis of the liver in 90% clearly indicating a strong association between primary liver cancer and HBV infections and liver cirrhosis. The main factor associated with seropositivity among normal controls was a large number of therapeutic injections. Seropositives received over twice as many injections as seronegatives. Public health measures are urgently required to prevent parenteral transmission of HBV in Nigeria.

Biphasic pattern of activation of the reticuloendothelial system by anaerobic coryneforms in mice.

Macrophage activation as measured by increased rates of clearance of carbon was explored in five inbred and two outbred strains of mice pretreated with anaerobic coryneform bacilli. Constant differences were found according to strain from DBA (lowest response) to Sha-Sha (highest response). The investigation was continued with mice of CBA strain which also provided highly reproducible and high-level responses. In this strain activation occurred in two phases: an early activation which reached maximum levels at 2 days and attributable to a lipid component of the bacteria, and a late phase reaching maximum at 14 days which appeared to coincide with greatly increased weight of the liver and spleen, due to infiltration by mononuclear cells. Evidence is provided that the early phase of macrophage activation is due to a lipid extract from the anaerobic coryneforms with chemotactic activity.

Alterations of mononuclear phagocyte function induced by Lewis lung carcinoma in C57BL mice.

The function of the reticulo-endothelial system in mice bearing Lewis lung carcinomas has been measured by(1) the rate of clearance of carbon particles from the circulation in vivo and calculation of the phagocytic index K; (2) chemotactic locomotion of macrophages in vitro in the presence or absence of serum or tumour supernate. The ability of the bone marrow to develop macrophage colonies in vitro in the presence or absence of sera from tumour-bearing mice has also been tested. A clear depression of macrophage locomotion and macrophage colony formation in vitro was found in the presence of sera or tumour supernates from tumour-bearing mice as early as 24 to 72 h after tumour inoculation. Similarly, tumour-bearing mice showed marked depression of carbon clearance in tests repeated throughout the first 72 h after tumour inoculation. This early depression of macrophage function may be an important step in allowing escape of tumour cells from host resistance.

Characterization of breast cancer subgroups in an African population.

A detailed prospective study of 58 consecutive breast cancer patients and contemporaneous controls, using age, duration of tumour and presence or absence of poor prognostic signs as clinical parameters, clearly showed that the patients fell into three distinct groups. Group A accounted for 30 per cent of cancers and consisted of young women (21-45 years) with advanced cancers, a short history (3 months or less) and poor prognostic signs; these patients had fast-growing tumours. Group B, to which nearly 60 per cent of patients belonged, was made up of menopausal women (46-50 years) with advanced disease, a history of from 3 months to 1 year and poor prognostic signs; their tumour growth rate was intermediate. Group C made up slightly more than 10 per cent of cases and consisted of postmenopausal women (50 years and above) who gave a long history (1 year or more), and had resectable tumours without poor prognostic signs. Thus, although advanced breast cancer in tropical Africa is due to late presentation in the majority of cases, a small but significant proportion of women have advanced disease in spite of early presentation, attributable to fast tumour growth rate.