Cryptococcus neoformans meningoencephalitis in African children with acquired immunodeficiency syndrome.

BACKGROUND: The number of children with AIDS in Africa is high. Such children may be at risk for cryptococcal meningoencephalitis, but data are scarce regarding this disease in our population. METHODS: We examined records of HIV-infected children (< or =16 years) diagnosed with cryptococcal meningoencephalitis in Harare, Zimbabwe, between 1995 and 2000. To elucidate features unique to pediatric disease, the children were compared with adult patients with HIV-associated cryptococcal meningoencephalitis. RESULTS: Thirteen children presented to our institution with headache (85%), nuchal rigidity (69%), vomiting (46%), impaired mental status (38%), convulsions (38%) and focal neurologic signs (23%). The mean duration of symptoms before diagnosis was 9 days. Cerebrospinal fluid examination revealed normal white blood cell counts in 64%, protein value in 67% and glucose concentration in 57% of patients. Children were more likely than adults to have seizures (38% vs. 11%, P = 0.02) and normal cerebrospinal fluid protein (67% vs. 10%, P < 0.01). The in-hospital mortality was 43%. Convulsions (P = 0.05) and impaired mental status (P < 0.01) were associated with increased mortality CONCLUSIONS: Cryptococcal meningoencephalitis in African children presents acutely or subacutely, can have a fulminant picture and is consistent with progressive meningoencephalitis.

Rapid emergence of resistance to penicillin and trimethoprim-sulphamethoxazole in invasive Streptococcus pneumoniae in Zimbabwe.

Pneumococcal pneumonia and meningitis are common infectious disease problems in people who are HIV seropositive in southern Africa. For many years two inexpensive antibiotics, penicillin and trimethoprim-sulphamethoxazole (TMP-SMX) had been effective in treatment, but recently resistance to these agents has been reported from many parts of the world. This study was designed to determine the antimicrobial resistance patterns in invasive pneumococci from hospital patients in Harare, Zimbabwe. A total of 160 isolates of Streptococcus pneumoniae from blood cultures and CSF cultures were examined. The isolates came from adults and children in hospital in Harare between 1994 and 2000. The majority of isolates came from HIV positive adults (74%) and children (75%). Isolates of pneumococci with an MIC of 1.0 mg/l or more were first seen in 1997 and by 2000 they made up 35% of all isolates. Significantly more isolates from HIV seropositive patients (50%) showed reduced susceptibility to penicillin compared with isolates from HIV seronegative patients (16%), and high level resistance (MIC 1.0 mg/l or higher) was found in 16% isolates from HIV positive patients compared with 6% isolates from HIV seronegative patients. Resistance to TMP-SMX was common, with more than 50% isolates from HIV positive and HIV negative patients having reduced susceptibility to this antibiotic combination.

Neurological complications of human immunodeficiency virus infection in Zimbabwe-2005.

Zimbabwe is a high prevalence area for HIV infection, and provides opportunities for studying complications of AIDS in both antiretroviral naive and treated groups of patients. Figures for HIV prevalence are among the highest in the world, but the number of people receiving treatment is very small. Economic and political factors contribute to this important health crisis. Opportunistic diseases as a whole and their relative frequencies of presentation in southern Africa are discussed, emphasizing the lead role of tuberculosis. The limited data that do exist regarding neurological complications in Zimbabwe are summarized, and combined with anecdotal experience from practicing clinicians. Opportunistic infections in the nervous system are very common, the most important being cryptococcal meningitis, causing half of all adult meningitis in the country. Tuberculous and bacterial meningitis have also become more common and carry a high mortality in HIV-infected people in Zimbabwe. Intracranial mass lesions, including tuberculoma, bacterial abscesses and toxoplasmosis encephalitis are less common and difficult to diagnose in the absence of stereotactic biopsy. Spinal tuberculosis and transverse myelitis are the most frequent causes of spinal cord opportunistic infections. Peripheral neuropathy is probably similar in presentation to that seen elsewhere, whereas dementia is less frequently recognized.

The surgeon and human immunodeficiency virus.

The moral dilemmas faced by surgeons worldwide who treat patients infected with the human immunodeficiency virus (HIV) can be viewed against the background of experience in sub-Saharan countries, where the community prevalence is in excess of 25% (90% of hospital inpatients). When seeking consent for an HIV test before surgery, frank communication regarding the surgeons' perspective of risks to themselves and the patient is helpful. When consent for a test must be obtained from a substitute decision-maker, the surgeon should consider if the patient would want the decision-maker to know the result. Understanding the natural history of HIV in the surgical setting can help deal with the uncertainties encountered and should be a research priority for developing countries. International professional organizations are useful platforms for the exchange of ideas when surgeons encounter uncertainty by increasing access to journals and creating opportunities for discussion. Although supervisory bodies in some parts of the world prevent HIV-infected surgeons from putting patients at risk by offering surgery, the withdrawal of their services in developing countries can cause more harm than good. Surgeons in that position may be entitled to offer surgery but only with full disclosure of the risk of HIV infection to the patient. The decision-making process known as "accountability for reasonableness" allows surgeons to determine fairness, legitimacy, and acceptability when making resource allocation decisions involving patients with HIV.

Priority setting in a hospital critical care unit: qualitative case study.

OBJECTIVE: To describe priority setting for admissions in a hospital critical care unit and to evaluate it using the ethical framework of "accountability for reasonableness. DESIGN: Qualitative case study and evaluation using the ethical framework of accountability for reasonableness. SETTING: A medical/surgical intensive care unit in a large urban university-affiliated teaching hospital in Toronto, Canada. PARTICIPANTS: Critical care unit staff including medical directors, nurses, residents, referring physicians, and members of a hospital committee that formulated an admissions policy. INTERVENTIONS: Modified thematic analysis of documents, interviews with participants, and direct observation of critical care unit rounds. Evaluation using the four conditions of Daniels and Sabin's accountability for reasonableness: relevance, publicity, appeals/revisions, and enforcement. MEASUREMENTS AND MAIN RESULTS: We examined key features and participants' views about the priority setting process. Decisions to admit patients involve a complex cluster of reasons. Both medical and nonmedical reasons are used, although the nonmedical reasons are less well documented and understood. Medical directors, who are the chief decision makers, differ in their reasoning. Admitting decisions and reasons are usually explained to referring staff but seldom to patients and families, and nonmedical reasons are seldom surfaced. A hospital critical care admissions policy exists but is not used and is not known to all stakeholders. A formal appeals/revisions process exists, but appeals usually involve informal negotiations. The existence of priority programs in the hospital (e.g., transplantation) adds complexity and heightens disagreement by stakeholders. CONCLUSION: We have described and evaluated admissions decision making in a hospital's critical care unit. The key lesson of our study is not only the specific findings obtained here but also how combining a case study approach with the ethical framework of "accountability for reasonableness" can be used to identify good practices and opportunities for improving the fairness of priority setting in intensive care.