Stroke in Nigerian children with sickle cell disease.

We reviewed our records over a 15-year period to determine whether or not the impression that stroke complicating sickle cell disease was less common than reported in North America. Records of children aged 16 years and below with a diagnosis of stroke seen at the University College Hospital, Ibadan, Nigeria between 1988 and 2002 were examined. Thirty-nine such patients were identified but only 31 had detailed records available for study. Twenty-seven of these had sickle cell disease, 26 with haemoglobin genotype SS and 1 with Hb S+C. Sickle cell disease was therefore responsible for 87% of stroke seen in children at our centre. With an average clinic population of about 500 patients with sickle cell disease, the hospital frequency of stroke among these patients is estimated at 5.4%. The mean age of occurrence of the first stroke was 6.8 years ranging from 17 months to 11 years. Of the 7 patients who had CT scans of the brain done, 5 had evidence of cerebral infarction while 2 had intracerebral haemorrhage. While only 2 deaths occurred among the cases reviewed, morbidity was significant with only 6 patients achieving complete recovery. Recurrent stroke occurred after an average of 25.6 months in 8 of 13 patients who were followed up (61.5%). The incidence of stroke among African children with sickle cell disease appears to be not as high as reported in patients from North America.

A comparison of visual function scores in hydrocephalic infants with and without lumbosacral myelomeningocoele.

PURPOSE: The cerebrum is frequently malformed in children with myelomeningocoele. This anomaly renders them potentially susceptible to cerebral visual impairment. In these patients, hydrocephalus is an important and frequent complicating lesion which compromises intellectual function and may also cause cerebral visual impairment. In this study, we determined whether hydrocephalic patients with lumbar myelomeningocoele (HLM) are at a greater risk of visual impairment than hydrocephalic patients without this lesion (H). METHODS: In this prospective study, we assessed five parameters of visual function in 20 hydrocephalic children with lumbar myelomeningocoele and compared the total visual function scores (TVFS) obtained with those from hydrocephalic children without overt spinal dysraphism, but similar in age, sex and ventricular size. The parameters, which were assessed with the aid of a quantitative grading scale, were pupillary size and reaction, optic atrophy, visual fixation and tracking. RESULTS: The age and sex distributions of the patients in the two groups were similar. The anterior and posterior dimensions of the lateral ventricles were also similar. The mean (SD) of the TVFS were 24.25 (3.63) and 24.20 (3.47) respectively for the two groups (P = 0.90). CONCLUSIONS: The results suggest that, in hydrocephalic infants with lumbar myelomeningocoele, visual function is not further diminished by the associated dysraphism and that ventricular dilatation is the major determinant of visual impairment.

Deficiencies in tetanus prophylaxis in wound management in Ibadan, Nigeria.

In a review of 94 paediatric patients treated for post-neonatal tetanus over a period of 11 years at the University College Hospital, Ibadan, Nigeria, reliable data regarding the care received for wounds that eventually resulted in tetanus was available in 58 patients. Seventeen of these patients had orthodox medical care for their wounds before developing tetanus. While some of the patients had received antibiotics and/or tetanus toxoid, no patient received antitetanus serum despite the fact that most of them had no previous immunization against tetanus. All the 3 victims of road traffic accidents were given tetanus toxoid but none of the 6 patients with chronic suppurative otitis media had any form of tetanus prophylaxis. The findings highlight the adverse consequences of failure to adhere to basic guidelines for management of the tetanus-prone wound.

HIV-assocated lymphoma: a case report.

We report the case of a 3(1/2) year old boy who presented with sudden onset of headache. Fever and swelling of the left eye. He had complete opthalmoplegia of the left eye and 6th cranial nerve paralysis in the right eye. He was thought to have cavenous sinus thrombosis but CT findings suggestive of lymphoma led to the correct diagnosis of HIV associated Lymphoma It view of the rising incidence of HIV infection and the protein clinical manifestations, it is advised that all patients with disseminated tumour masses should be screened for the HIV virus, and CT examination should be made available to patients.

Atypical presentations in children with post-neonatal tetanus in Ibadan, Nigeria.

In a retrospective review of 73 children with post-neonatal tetanus seen over an 11-year period at University College Hospital, Ibadan, Nigeria, atypical portals of entry of the causative agent were recorded in nine and five developed unusual complications during the course of treatment for tetanus. Localized tetanus was encountered in seven children; this involved the cephalic region in one and one lower limb in each of the remaining six. Among these six children, the portal of entry of the organism included intramuscular injections into the buttock in five and an infected insect bite on the buttock in one case. Another unusual portal of entry, observed in two children, was through an impacted foreign body in the ear in the absence of otitis media. Arthritis of large joints was encountered in three children and two had episodes of severe bronchospasm which responded to bronchodilator treatment. The findings in this study significantly widen the reported spectrum of presentations and complications of tetanus in third-world children.

Injection-induced sciatic nerve injury in Nigerian children.

OBJECTIVES: A retrospective study of all children with a diagnosis of sciatic nerve injury managed at the University College Hospital, Ibadan, Nigeria over a 12 year period was carried out in order to determine predisposing factors to the nerve injury and highlighting practical preventive measures. DESIGN: The necessary data was collected from the case files of children seen at the hospital with a diagnosis of sciatic nerve injury, from 1988 to 1999. RESULTS: There were 27 children aged five months to 12 years with a diagnosis of sciatic nerve injury. Twenty (74%) of the children were aged five years or less. While seven patients (26%) presented within two weeks of development of foot drop consequent on intramuscular (i.m.) injection given on the buttock, 20 patients (74%) presented much later. Fever was the most common complaint for which the injection had been given. The identity of the drugs given was not known in 10 patients. In the remaining 17 patients drugs administered were specified and included Chloroquine, Novalgin, Paraldehyde, Procaine penicillin, and Sulfadoxine-Pyrimethamine. Most of the patients had received the injections in privately owned medical facilities where staff with minimal training are often allowed to administer i.m. injections. CONCLUSION: It is suggested that the i.m. route for injection be strongly discouraged when a drug can be given by other routes. Only trained staff should be allowed to administer i.m. injections. Giving i.m. injections at sites other than the buttock maybe advantageous in children particularly those aged five years and below.

Hyperventilation-precipitated cerebrovascular accident in a patient with sickle cell anaemia.

Hyperventilation exercise during electroencephalography precipitated a recurrence of right hemiplegia and aphasia in a patient with Hb SS disease. Although recovery of function started within hours of the event, full recovery has not occurred six months after. Hyperventilation provocative test during electroencephalography should be discouraged in patients with sickle cell anaemia.

The influence of racial and environmental factors on EEG photoparoxysmal responses in Zimbabwe.

OBJECTIVE: This study examined the influences of environmental and racial factors on the incidence of EEG photoparoxysmal responses (PPRs) to intermittent photic stimulation (IPS) in a multi-racial population exposed to seasonal variations in sunshine intensity. MATERIALS AND METHODS: The records of patients referred for EEG examination in Harare, Zimbabwe were screened for the presence of PPRs to IPS. The age, sex and racial classification of patients manifesting PPRs were studied. The relationship between sunshine duration and intensity and the frequency of PPRs was also studied. RESULTS: EEG records of 16,496 patients referred for EEG examination were studied. Of these, 136 patients (0.8%) showed PPRs to photic stimulation. The highest age-specific PPR (2.0%) occurred in the 16-20 year age group. The race-specific PPRs were 1.5% for white patients, 1.18% for Asian patients, 0.36% for colored patients and 0.09% for black patients (chi3[2] = 95.21, P = 0.001). The incidence of PPRs did not show any significant variation with the mean monthly sunshine duration (P = 0.8254) or with the mean monthly sunlight radiation (P = 0.2631). CONCLUSION: The findings of this study support a role for genetic rather than environmental factors in the relative rarity of PPRs in black Zimbabweans.

The relationship between ventricular size and visual function in children with hydrocephalus.

We examined the relationship between ventricular size and visual function in 50 children (36 males and 14 females) with hydrocephalus. The third and lateral ventricular sizes and the visual function scores did not significantly differ between the sexes. Ventricular enlargement was most pronounced at the trigones and least at the level of the foraminae of Monro. The visual function score correlated inversely with the size of the lateral ventricle measured at the levels of the anterior horn and the trigone and expressed as coronal diameter and "Modified" Evans' ratio (r = 0.49; P = 0.001 and r = -0.38, P = 0.01 for the anterior horn; r = 0.48, P = 0.001 and r = -0.35, P = 0.001 for the trigone). The size of the third ventricle did not correlate with visual function score. A "modified" anterior Evans ratio of 0.60 and a trigonal Evans ratio of 0.73 were associated with very low visual function score. Furthermore, there was significant inverse correlation between occipitofrontal circumference (OFC) and visual function (r = -0.6379, P = 0.001), but OFC was not valuable for predicting visual function before the onset of head enlargement.

Electroencephalographic photosensitivity among Zimbabwean youths.

To clarify the factors associated with electroencephalographic (EEG) photosensitivity, the records of patients who had EEG examinations in the city of Harare, Zimbabwe between 1968 and 1996 were studied. EEG photosensitivity was confirmed in 107 of a total of 9082 youths (aged 0-25 years), giving an overall photosensitivity prevalence of 1.17% in the study population. Photosensitivity occurred more frequently in females than in males, and the peak age period for its occurrence was during adolescence. A significantly higher prevalence of photosensitivity was recorded among Whites and Asians than among Blacks, while the Coloured population had an intermediate prevalence. The monthly and seasonal incidence of photosensitivity in the present study showed no correlation with the prevailing mean monthly or seasonal temperatures, sunshine duration and sunlight intensity in Harare during the period covered by the study. These findings indicate that sunshine-related factors do not play a dominant role in the occurrence of photosensitivity, thereby negating previous opinions which attributed the relative rarity of photosensitivity in black Africans to high levels of exposure to sunshine in tropical Africa. Our findings therefore corroborate the view that photosensitivity depends primarily on genetic rather than environmental factors.

Low birth weight and its correlates among Nigerian twins.

The incidence and correlates of low birth weight (LBW) among an index population of 525 newborn Nigerian twins and a control population of 363 singletons were studied. The incidence of LBW among the twins (53.9%) was significantly higher than the incidence of 11.8% among the singletons (P < 0.001). Smallness for gestational age (SGA) was also higher (14.3%) among the twins compared with 1.4% among the singletons (P < 0.001). Morbidity factors frequently associated with LBW among the twins were perinatal asphyxia, hypothermia, neonatal seizures, and intracranial haemorrhage. Intrapartum asphyxia was particularly common in those preterm LBW twins who were also SGA. This raises serious concern because of the known higher risks of SGA preterm babies for severe neurologic sequelae. Low socioeconomic status (SES) of mothers was an important predisposing factor to LBW and SGA as well as to premature deliveries among the twins. Improved SES of the maternal population and increased awareness by health practitioners of the risks LBW twins face, should improve their immediate and later outcome. Furthermore, there is a need for the development of an intrauterine growth chart for Nigerian twins to enhance accurate diagnosis of LBW and SGA among newborn twins.

Neonatal jaundice, aflatoxins and naphthols: report of a study in Ibadan, Nigeria.

This study set out to investigate the prevalence of naphthols and aflatoxins in the sera of babies with neonatal jaundice and their mothers in order to determine whether they contribute to the occurrence of unexplained neonatal jaundice in Ibadan. Blood was obtained from 327 jaundiced neonates and 80 of their mothers, and 60 non-jaundiced controls and seven of their mothers admitted to hospital between April 1989 and April 1991. Blood group, bilirubin concentration, erythrocyte G6PD status, aflatoxin and naphthol concentrations in blood were measured. Altogether, 30.9% of the jaundiced neonates were G6PD-deficient, compared with 13.3% of controls (chi 2 = 6.88; p = 0.009). Aflatoxins were detected in 27.4% of jaundiced neonates, 17% of their mothers, 16.6% of controls and 14.4% of control mothers. Naphthols were detected in 7.2% of jaundiced babies, 6.3% of their mothers, 6.25% of control babies and 14.4% of their mothers. Analysis of the data revealed that either G6PD deficiency or the presence of any serum aflatoxin is a risk factor for neonatal jaundice; odds ratio were 2.97 (95%) confidence intervals (CI): 1.31-6.74) and 2.68 (CI: 1.18-6.10), respectively. This study demonstrates that G6PD deficiency and/or the presence of serum aflatoxins are risk factors for neonatal jaundice in Nigeria. Aflatoxins are an additional risk factor not previously reported.

Placental transfer of tetanus toxoid antibodies in Nigerian mothers.

The aim of this study was to assess the efficacy of the tetanus toxoid immunization programme in Nigeria, specifically the placental transfer of antibody to newborn Nigerian babies. Tetanus toxoid antibody levels were measured in 39 mother-baby pairs in Ibadan, Nigeria and compared with 78 British mother-baby pairs. Geometric means of the ratios of cord/mother (sequestration index SI) were 0.776 for Nigerian pairs and 1.306 for British pairs, indicating a limitation in the placental transfer of tetanus toxoid in the Nigerian population. These findings confirm that there is a block in the placental transfer of anti-tetanus toxoid antibodies in African populations which will affect current immunization programmes and requires further investigation.

PIP: In 1989, in Ibadan, Nigeria, clinicians collected sera samples from 39 mothers and their full-term infants born at the Adeoyo Maternity Hospital and the University College Hospital to determine the placental transfer of tetanus toxoid antibodies and to compare the tetanus toxoid antibody levels with those of 78 UK mother-infant pairs. The primary aim of the study was to evaluate the efficacy of the tetanus toxoid immunization program. The protective antitetanus toxoid level was greater than 0.01 IU/ml in all the Nigerian infants and mothers. 59% of Nigerian infants had a tetanus toxoid antibody level lower than that of their mothers compared with 12% of UK infants (p .0001). In fact, the concentration of tetanus toxoid antibodies of the Nigerian infants was lower than that of their mothers (1.930 vs. 2.374 IU/ml). On the other hand, the concentration of tetanus toxoid antibodies of the UK infants was higher than that of their mothers (1.532 vs. 1.113 IU/ml). The geometric mean of the ratio of cord blood to maternal antibody levels for Nigerian pairs was lower than that of the UK pairs (0.776 vs. 1.306), suggesting a flaw in the transplacental transfer of antibodies. Possible mechanisms involved in blocking placental transfer of tetanus toxoid antibodies may be high maternal IgG levels and heavy malarial placental infection. This block of placental transfer of antibodies affects current immunization programs and necessitates further study.

Detection of naphthols and aflatoxins in Nigerian cord blood.

Widespread use of napthol-containing compounds and frequent contamination of foods by aflatoxins occurs in Nigeria. Napthols cause haemolysis and aflatoxins are hepatotoxic. A study was carried out to determine the extent of fetal exposure to these compounds and their influence on birthweight. Cord blood samples were collected at delivery from 625 babies and their sera were analysed for aflatoxins and naphthols. Mothers' histories and babies' weights were recorded. Naphthols were detected in 6.9% and aflatoxins in 14.6% of serum samples. No correlation was found between the presence of either compound and birthweight. Reported exposure to naphthalene-containing compounds was not related to detection of serum naphthol. Results show considerable fetal exposure to these potentially toxic compounds in Ibadan, Nigeria.

Pediatrics inpatients at the King Khalid University Hospital, Riyadh, Saudi Arabia, 1985-1989.

A review of admissions into the pediatric wards of the King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia, over a four-year period (1985-1989) indentified perinatal problems, acute respiratory infections, congenital anomalies and diseases of the central nervous system, as the major disorders. With the notable exception of nutritional rickets, manlnutrition was rare. The age distribution showed a preponderance of neonates and infants who represented 42.1% and 53.6% of all admissions, respectively. There was a seasonal variation with more patients being admitted during the cool months of November-April than the hot months of May-October, and acute respiratory infections were found to be mostly responsible for this seasonality. Genetic and heredofamilial factors features prominently in the pathogenesis of many of the disorders for which the children were admitted. It is therefore recommended that increased attention be given to neonatology and to genetics and genetic counselling as important components of medical practice in the country. The establishment of a National Institute for Human Genetics is also highly desirable.

Antecedents and outcome of simple and complex febrile convulsions among Saudi children.

Of 215 Saudi children seen with their first febrile convulsion (FC) at the King Khalid University Hospital, Riyadh, between January 1984 and December 1988, the index FC was simple for 133 children and complex for the remaining 82. History of adverse antecedent factors, particularly perinatal asphyxia, birth injuries and pre-existing neurological deficits, were significantly more associated with complex FC, as was occurrence of first FC before the age of 12 months. Recurrence of FCs and development of epilepsy were also more common among the group of children with complex FC. Complex FCs were less benign in the present study population than has been reported in some Western studies.

Childhood bacterial meningitis in Al-Baha province, Saudi Arabia.

A retrospective review of 71 paediatric patients admitted with bacterial meningitis to the King Fahad Hospital at Al-Baha, Saudi Arabia, during an 8-year period revealed a preponderance of males (67.6%) and young subjects with 88.7% being below 24 months of age. The commonest cerebrospinal fluid pathogens in the series were Haemophilus influenzae type B (HIB), Streptococcus pneumoniae and Group B-beta haemolytic streptococcus, which were responsible for 47.3, 34.5 and 9.1% of cases respectively. Neisseria meningitidis which is a major cause of meningitis in most other reports was uncommon in the present series, and was isolated from only two patients. All the children with Group B-beta haemolytic streptococcal meningitis were below 3 months of age while 96.2% of the children with HIB meningitis were younger than 2 years. Mortality was highest (40%) among the infants with Group B-beta haemolytic streptococcal meningitis. Six (23.1%) of the HIB isolated were resistant to ampicillin and two (7.7%) were resistant to both ampicillin and chloramphenicol. There is a need for greater emphasis on prevention through the use of available vaccines including the newly introduced conjugate vaccines against HIB which are capable of eliciting immune responses in infants as young as 2 months.

Subacute sclerosing panencephalitis in Riyadh, Saudi Arabia.

The clinical features and outcome of disease in 14 cases of subacute sclerosing panencephalitis (SSPE) diagnosed at the King Khalid University Hospital, Riyadh during an 8-year period are similar to those described elsewhere. Therapy was associated with arrest of deterioration for 2.5 years in one patient, and with survival after diagnosis for 2-7 years in four others. Many of the cases had initial misdiagnoses because of the frequently bizarre modes of presentation. It is thought that many more cases of SSPE occur in Saudi Arabia and also in many other tropical countries than are currently recognized. The establishment of national SSPE registries is advocated to improve early identification and management of cases.

Septicaemia in febrile neutropenic children with cancer in Saudi Arabia.

The pattern of sepsis among 56 children admitted for various forms of cancer to the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia during a 6-year period, was retrospectively reviewed. A total of 148 febrile neutropenic episodes occurred and 55 of these, in 40 patients, were associated with positive blood cultures. The isolates were Gram-positive bacteria in 54% of instances, Gram-negative bacteria in 39.4% and Candida in 6.6% and polymicrobial sepsis occurred in five patients. Profound neutropenia (neutrophil counts less than 0.1 x 10(9) l-1) significantly predisposed to Gram-negative sepsis (P less than 0.02), which was responsible for about one-third of deaths in this series. Central venous catheters were present prior to 49% of the septicaemic episodes, but were not significantly associated with either increased Gram-negative or Gram-positive bacterial sepsis. However, all four cases of candidaemia occurred in patients with a central venous catheter in situ, and it is recommended that early empirical treatment for candida be considered in all febrile neutropenic cancer patients with central venous catheters.