Hepatitis B and C infection at a large public sector hospital clinic: is it a burden?

BACKGROUND: Co-infections have become significant causes of morbidity and mortality in Human Immunodeficiency Virus (HIV) infected people. Due to shared routes of transmission, co-infection of HIV with Hepatitis B (HBV) and/or Hepatitis C (HCV) should be expected. In Zimbabwe, screening for both viruses in HIV infected people prior to treatment is not routinely practised despite the World Health Organisation (WHO) guidelines (2013) prioritising treatment where these co-infections exist. OBJECTIVE: To determine the prevalence of HBV and HCV infection in HIV infected adults at a public sector HIV clinic in Zimbabwe and to determine risk factors associated with these infections. DESIGN AND SETTING: An analytical cross-sectional survey carried out among systematically randomly sampled HIV infected patients coming for treatment between March and July 2012 at Parirenyatwa Hospital Opportunistic Infection Clinic. MATERIALS AND METHODS: Blood samples were tested for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibodies (anti-HCV). Demographic data and exposure to risk factors were collected. RESULTS: 228 antiretroviral therapy (ART) naive adults were enrolled. 7.9% (18/228) were HBsAg positive and 0.9% (2/228) were anti-HCV positive. None of the participants were infected with both viruses. CONCLUSIONS: The prevalence of HBV has not changed during this HIV era and there is no significant HCV infection in this public sector clinic which serves quite a large sector of the population that lives in Harare, Zimbabwe. Based on these results, there is no need for HCV screening but HBV screening prior to ART initiation may be required. -

Acquired epidermodysplasia verruciformis due to multiple and unusual HPV infection among vertically-infected, HIV-positive adolescents in Zimbabwe.

BACKGROUND: We have previously described the presentation of epidermodysplasia verruciformis (EV)-like eruptions in almost a quarter of hospitalized adolescents with vertically-acquired human immunodeficiency virus (HIV) infection in Harare, Zimbabwe, a region with a high prevalence of HIV infection. METHODS: We performed a clinical case note review and skin biopsy from affected sites in 4 HIV-infected adolescents with EV-like lesions in Harare. Biopsies were processed for histology and for human papillomavirus (HPV) typing. RESULTS: All patients had long-standing skin lesions that pre-dated the diagnosis of HIV by several years. The histology of skin biopsies from all patients was consistent with EV. In each biopsy, EV-associated ß-HPV type 5 was identified (additionally, type 19 was found in 1 biopsy). Cutaneous wart-associated HPV types 1 and 2 were detected in all biopsies, together with genital lesion-associated HPV types 6, 16, and 52, (as well as ≥3 other genital lesion-associated HPV types). Despite immune reconstitution with combination antiretroviral therapy (cART), there was no improvement in EV-like lesions in any patient. CONCLUSIONS: EV is a disfiguring and potentially stigmatizing condition among this patient group and is difficult to treat; cART appears to have no impact on the progression of skin disease. Among adolescents with longstanding HIV-induced immunosuppression and with high levels of sun exposure, close dermatological surveillance for potential skin malignancy is required.

Renal dysfunction among anti-retroviral therapy naïve HIV infected patients in Zimbabwe.

BACKGROUND: The prevalence and determinants of renal dysfunction among HIV infected adults in the outpatient in Zimbabwe setting is unknown. OBJECTIVE: To determine the proportion of patients with evidence of renal dysfunction among anti-retroviral treatment naive HIV infected patients in a tertiary outpatient setting. DESIGN: Cross sectional study. SETTING: HIV outpatients' clinic (Family Care Centre) at Parirenyatwa hospital. SUBJECTS: 159 Anti-retroviral therapy (ART) naive HIV infected adults. METHODS: A cross-sectional study was carried out on ART-naive HIV infected willing adult participants, > or = 18 years old. WHO clinical staging was conducted on all participants. Urine was examined using urinary dipsticks and proteinuria quantification by calculating its protein: creatinine ratio. Serum creatinine and CD4 cell counts were measured. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault formula. MAIN OUTCOME MEASURES: The primary endpoint was renal dysfunction defined as CrCl < 60 ml/min. Protenuria, defined as > or = + dipstick positive and/or protein to creatinine ratio > 20 mg/mg was a secondary outcome. RESULTS: Renal dysfunction defined as CrCl < 60 ml/min was found in 7.5% [95% CI 3.4-11.7] (12/159) of the participants. Risk factors for renal dysfunction were age [OR 1.14, (95% CI 1.06-1.22)], BMI [OR 0.77 (95% CI 0.61-0.94)] andproteinuria [OR 7.45 (95% CI 1.58-35.26)]. Proteinuria was common, occurring in 45.9% of the participants. CONCLUSIONS: [corrected] A high prevalence of proteinuria (45.9%) was found in this study, while the prevalence of reduced creatinine clearance was relatively low (7.5%). Screening for proteinuria is strongly recommended in ART naive HIV infected patients and should be complemented by measurement of serum creatinine and calculation ofcreatinine clearance.

The prevalence of diabetic nephropathy in adult patients with insulin dependent diabetes mellitus attending Parirenyatwa Diabetic Clinic, Harare.

OBJECTIVE: The objective of this study was to determine the prevalence of diabetic nephropathy in a diabetic clinic in a tertiary hospital setting in Zimbabwe. DESIGN: Descriptive cross sectional study. SETTING: Diabetic clinic in a tertiary hospital. SUBJECTS: 75 insulin dependent diabetic consenting adults aged over 18 years. METHODS: Consecutive sampling of 75 insulin dependent consenting subjects presenting at the Parirenyatwa Diabetic Clinic was conducted over a four month period. Patients were tested for proteinuria using dipsticks and were divided into dipstick positive and dipstick negative. The dipstick positive samples were sent to the laboratory for protein quantification. The dipstick negative samples were tested for microalbuminuria. Urine albumin creatinine ratios were utilised to quantify the proteinuria. MAIN OUTCOME MEASURES: Prevalence of overt proteinuria and the prevalence of microalbuminuria. RESULTS: Overt proteinuria was found in 16 (21%) patients. Microalbuminuria was found in 9 (12%) of the patients. Nephropathy was, therefore, found in 25 (33%). CONCLUSION: There is a high prevalence of diabetic nephropathy in adult patients with insulin dependent diabetis mellitus attending Parirenyatwa Diabetic Clinic.

Clinical, Virologic, Immunologic Outcomes and Emerging HIV Drug Resistance Patterns in Children and Adolescents in Public ART Care in Zimbabwe.

OBJECTIVE: To determine immunologic, virologic outcomes and drug resistance among children and adolescents receiving care during routine programmatic implementation in a low-income country. METHODS: A cross-sectional evaluation with collection of clinical and laboratory data for children (0-<10 years) and adolescents (10-19 years) attending a public ART program in Harare providing care for pediatric patients since 2004, was conducted. Longitudinal data for each participant was obtained from the clinic based medical record. RESULTS: Data from 599 children and adolescents was evaluated. The participants presented to care with low CD4 cell count and CD4%, median baseline CD4% was lower in adolescents compared with children (11.0% vs. 15.0%, p<0.0001). The median age at ART initiation was 8.0 years (IQR 3.0, 12.0); median time on ART was 2.9 years (IQR 1.7, 4.5). On ART, median CD4% improved for all age groups but remained below 25%. Older age (≥ 5 years) at ART initiation was associated with severe stunting (HAZ <-2: 53.3% vs. 28.4%, p<0.0001). Virologic failure rate was 30.6% and associated with age at ART initiation. In children, nevirapine based ART regimen was associated with a 3-fold increased risk of failure (AOR: 3.5; 95% CI: 1.3, 9.1, p = 0.0180). Children (<10 y) on ART for ≥4 years had higher failure rates than those on ART for <4 years (39.6% vs. 23.9%, p = 0.0239). In those initiating ART as adolescents, each additional year in age above 10 years at the time of ART initiation (AOR 0.4 95%CI: 0.1, 0.9, p = 0.0324), and each additional year on ART (AOR 0.4, 95%CI 0.2, 0.9, p = 0.0379) were associated with decreased risk of virologic failure. Drug resistance was evident in 67.6% of sequenced virus isolates. CONCLUSIONS: During routine programmatic implementation of HIV care for children and adolescents, delayed age at ART initiation has long-term implications on immunologic recovery, growth and virologic outcomes.

An uncommon presentation of cysticercosis.

This is a report of a sudden death which turned out to be an unexpected case of neurocysticercosis. Most doctors nowadays expect cerebral cysticercosis to present with seizures and have forgotten its other clinical manifestations.

Serum albumin concentrations in rural Zimbabweans.

Primary infections, protein malnutrition or simply poor food intake which decrease albumin synthesis often prevail in rural Zimbabwe. Therefore, we postulated that serum albumin levels in rural folk may not compare with published values. To investigate this, blood samples were collected from 1,502 consenting participants aged between 16 and 90 years from randomly selected rural areas in Mashonaland West, Midlands, Matebeleland South and Matebeleland North provinces in Zimbabwe. The effects of smoking, alcohol consumption and pregnancy on serum albumin levels were also investigated. The mean age in years did not differ significantly between females and males (32.5 +/- 0.44, n = 943 vs 33.84 +/- 0.62, n = 559). Serum preserved with sodium azide at -4 degrees C was analyzed for albumin using a Quick Lab 2 Analyzer (Ames Quick Lab) by the bromocresol green dye binding method. Only small differences of albumin concentrations (means +/- S.E.M.) were noted for each studied area and results were pooled. The normal serum albumin ranges were 27 to 52 g/L for females and 26 to 52 g/L for males and were different from those reported for developed countries. The albumin levels in females were significantly (p < 0.01) lower than in males (39.29 +/- 0.20 g/L, n = 943 vs 40.09 +/- 0.25 g/L, n = 559). However, the concentrations of the protein in males who smoked (38.66 +/- 0.38 g/L, n = 174) were significantly low (p < 0.01) by comparison with non smokers. Smoking did not alter albumin levels in females (38.27 +/- 0.53 g/L, n = 87) perhaps because they smoked fewer cigarettes.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of oral chloroquine administration on kidney function.

The effects of 3 consecutive days of oral chloroquine (1 mg/100 g body weight) on kidney function and blood pressure were studied in male Sprague-Dawley rats that were challenged with hypotonic saline infusion 24 h after the last chloroquine administration. The rats were anesthetized with Inactin [5 ethyl-5-(1'-methylpropyl)-2-thiobarbiturate, Byk Gulden] and continuously infused with 0.077 M NaCl for 8 h; urine flow and electrolyte excretion rates were monitored during the last 5 h. Blood pressure and glomerular filtration rates were also measured. Kidney function was compromised in chloroquine-treated rats, which retained significantly more of the infused Na+ and Cl- by comparison to control-vehicle-treated rats. Throughout the experimental period, chloroquine-treated rats exhibited low blood pressure (80 mm Hg vs. 127 mm Hg) which was associated with low glomerular filtration rate. The plasma aldosterone concentrations were significantly (p < 0.01) elevated in rats pretreated with chloroquine at the end of the 8-h infusion of hypotonic saline, but corticosterone levels were significantly (p < 0.01) lower in the treated rats. It is concluded that chloroquine administration impairs kidney function, resulting in inappropriate Na+ and Cl- retention. This effect is likely to be mediated via chloroquine-induced increases in plasma aldosterone concentration and lowering of GFR.

Renal fluid and electrolyte handling in streptozotocin-diabetic rats.

Male Sprague-Dawley rats (300-400 g) were made diabetic by an i.p. injection of streptozotocin (STZ, 60 mg/kg in citrate buffer, n = 8) to examine renal function in well-established diabetes mellitus. Vehicle-injected animals (n = 8) acted as controls. The mean weekly total amounts of food taken by control and STZ-diabetic rats did not differ, but diabetic rats exhibited diarrhea and drank more water. STZ-diabetic rats progressively lost weight from the first to the third week but gained weight in the fourth week. At 5 weeks the weight stabilized, plasma glucose concentration was elevated, and this was associated with increased kidney weight. The weekly urine volume from STZ-diabetic rats was elevated throughout the 5-week period of study and this was associated with significantly lower urinary outputs of Na+ and higher outputs of K+ than those of control animals. After 5 weeks of STZ diabetes, plasma corticosterone and aldosterone concentrations in unanesthetized rats did not differ significantly from values seen in controls. To examine renal function in more detail, groups of Inactin-anesthetized 5-week STZ-diabetic rats (n = 7) and control rats (n = 7) were placed on continuous jugular infusion of 0.077 M NaCl at 150 microL/min for 8.5 h. Following a 3.5-h equilibration period, urine flow and Na+, K+, and Cl- outputs were determined for the subsequent 5-h period, with mean arterial pressure and glomerular filtration rate (GFR). STZ-diabetic rats voided significantly less of the infused fluid and the urinary excretions of Na+ and K+ were lower than those of controls. Mean arterial blood pressure and GFR values in STZ-diabetic rats did not differ statistically from those seen in controls. Following hypotonic saline infusion for 8.5 h the levels of aldosterone were elevated significantly (p < 0.01) in STZ-diabetic rats by comparison with control animals (5.36 +/- 1.58 nmol/L, n = 7 vs. 2.36 +/- 0.12 nmol/L, n = 7). It is concluded that a challenge of hypotonic saline load to rats with 5 weeks of STZ diabetes mellitus elevates plasma aldosterone to reduce the ability to excrete Na+.

Interaction of aldosterone and oxytocin to influence renal sodium excretion in rats.

The possibility of an interaction between oxytocin and aldosterone to influence renal Na+ excretion was investigated in Inactin-anaesthetized male Sprague-Dawley rats. Endogenous plasma concentrations of aldosterone were suppressed by either adrenalectomy or bicarbonate infusion. The effects of 2 h intravenous administration of oxytocin (0.04 pmol/min) and/or aldosterone (42 pmol/min) on renal Na+ handling were studied in 0.077 M NaCl-infused adrenalectomized (Adx) rats and groups of intact animals that were infused with 0.077 M NaHCO3. Aldosterone alone significantly (P < 0.01) reduced Na+ excretion from pretreatment peak value of 5.0 +/- 1.0 to 1.5 +/- 0.4 mumol/min in Adx animals (n = 8) and 9.2 +/- 1.2 to 5.2 +/- 1.2 mumol/min in NaHCO3-infused rats (n = 8) by 2 h after the start of administration. However, combined administration of aldosterone and oxytocin was associated with a significantly (P < 0.01) increased Na+ excretion rate from a peak pretreatment value of 6.8 +/- 0.7 mumol/min to a peak value of 11.5 +/- 1.1 mumol/min by 1 h 40 min after the start of treatment in Adx rats (n = 7). In bicarbonate-infused rats (n = 8) Na+ excretion rose within 20 min of the start of treatment from a pretreatment peak of 9.0 +/- 0.8 mumol/min to a peak value of 13.5 +/- 0.8 mumol/min in response to combined hormone administration. In conclusion, we have shown that concomitant administration of aldosterone and oxytocin increased the rate of excretion of Na+ in two different preparations, which supports the idea of an interaction between the steroid and oxytocin to promote Na+ loss.

Acute chloroquine administration increases renal sodium excretion.

The effect of a 2-hour intravenous chloroquine infusion (0.015, 0.030 and 1.25 micrograms min-1) on renal fluid and electrolyte handling was investigated in the saline infused, Inactin anaesthetized rat. Blood pressure and glomerular filtration rate were not affected by chloroquine administration, remaining around 128 mmHg and 2.4 ml min-1, respectively throughout the 5-hour post-equilibration period. Chloroquine produced an increase in Na+ and Cl- excretion without affecting the urine flow. By 1 hour after the start of treatment (0.03 micrograms chloroquine min-1) the Na+ excretion rate had increased to 14.5 +/- 2.1 mumol min-1 (n = 6), and was significantly (P < 0.01) greater than in control animals (8.6 +/- 1.0 mumol min-1) at the corresponding time. Parallel but lesser increases in Cl- excretion rates were also observed. The plasma aldosterone and corticosterone levels following either 10, 30 or 120 minutes infusion of chloroquine at 0.03 micrograms min-1 did not differ statistically from each other or from control values. It is concluded that acute chloroquine administration induces an increase in Na+ excretion. The mechanism of this natriuresis cannot be established from the present study, but is likely to involve altered tubular handling of Na+.