Profile of suicide in Dar es Salaam.

OBJECTIVE: To investigate individual socio-demographic characteristics of suicides, the reasons, methods and means employed to commit suicide. DESIGN: A descriptive prospective study of suicides. A structured questionnaire was employed to enquire the details of the itemised objectives. SETTING: Muhimbili National Hospital--in urban Dar es Salaam. SUBJECTS: Fifty three males and 47 females consecutive suicides aged 15 to 59 years RESULTS: The mean age for suicides was found to be 28.2 years. Males were more than females and were ten years older. Sixty two percent of the subjects were single, 30% married. Seventy two percent had primary school education, 19% secondary education. Main reasons for committing suicide were established in 61 cases of which 57.3% (35/61) were due to severe marital and family conflicts, overwhelming disappointments in love affairs and unwanted pregnancies. Eleven subjects with chronic somatic illnesses killed themselves due to unbearable physical pain and overwhelming economic deprivations motivated ten subjects to take their lives. Sixty nine subjects poisoned themselves predominantly using anti-malarials and pesticides while 27 hanged themselves. A third of the suicides consumed alcohol frequently and a quarter of the suicides were HIV positive, a rate twice the national prevalence for sexually active adults. CONCLUSION: Comparatively, women became vulnerable to suicide at a younger age. Dysfunctional social networks played a predominant role among suicides. Family and marital conflicts need closer social attention and timely counseling. Patients with chronic medical conditions and frequent alcohol use need effective exploration concerning suicidal ideation to avert self-annihilation. A policy to control prescriptions of toxic drugs including pesticides is overdue.

Breast cancer during the HIV epidemic in an African population.

Both human immunodeficiency virus (HIV) infection and certain malignancies including breast cancer occur predominantly in premenopausal women in an African population. Cancers that are associated with HIV infection are Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL) and invasive cervical carcinoma. Recently, cases of breast cancer have been reported in patients with HIV infection but an association between breast cancer and HIV infection has yet to be determined. The present study investigated for association between HIV infection and breast cancer. Among the 101 patients studied, 50 were cases with breast cancer while the remaining 51 were referents with conditions other than mammary cancer. Patients with breast cancer 30 years of age and below recorded in the Cancer registry during 1974-1987 constituted 8% while those recorded during the ongoing AIDS epidemic amounted to only 2%. When a similar comparison was undertaken among patients below 50 years there was also an overall decrease in the proportion of patients from 76.1 to 58.0%. Conversely, in the age groups above 50 years the breast cancer cases increased from 33.9 to 42% respectively (chi2=1.83 on 1df, p=0.18). The overall prevalence of HIV infection among the control group was 35.5% (95% CI=22.2-48.4) while among breast cancer patients it was 6% (95% CI=0.6-12.6). Women below 50 years of age with breast cancer were less likely to be HIV positive; OR=0.18: (95% CI=0.04-0.76) chi2=5.95; p=0.01. However, there is no basis to suggest that HIV infection is protective against this malignancy. AIDS associated mortality commonly occurs in the second and third decades of life and probably these deaths have changed the demographic of the disease in an African population. The impact of AIDS associated mortality on cancer registries needs attention.

Expression of oestrogen and progesterone receptors, Ki-67, p53 and BCL-2 proteins, cathepsin D, urokinase plasminogen activator and urokinase plasminogen activator-receptors in carcinomas of the female breast in an African population.

OBJECTIVE: To determine the expression of oestrogen (ER) and progesterone receptor (PgR), Ki-67, p53, bcl-2 proteins and the proteolytic enzymes cathepsin D (CD), urokinase-plasminogen activator (uPA) and its receptor (uPA-R) in primary carcinomas of the breast from indigenous Tanzanian female patients by immunohistochemistry. DESIGN: Prospective cross-sectional study. SETTING: Muhimbili Medical Centre, Dar es Salaam, Tanzania. SUBJECTS: Sixty patients admitted between 1995 and 1997. RESULTS: Markers were found to be expressed as follows: ER (33.3%), PgR (18.3%), p53 (30%), bcl-2 (43.5%) and the median proliferation rate of Ki-67 was 15%. Proportion of tumours positive for ER, PgR and bcl-2 initially decreased to 12 months disease duration, after which it increased. The observed proliferation rate approaches that reported in developed countries. p53 expression did not influence the proliferation rate nor did bcl-2 expression. ER, PgR and bcl-2 were strongly co-expressed. CD was predominantly expressed in stromal macrophages than in cancer cells. CONCLUSION: The low expression of ER and PgR and their strong co-expression with bcl-2 might negatively influence response to hormonal therapy. The influence of bcl-2 on tumour response to anti-cancer therapy in patients with long disease duration requires urgent clarification. Determination of CD in stromal macrophages rather than in cancer cells may have greater prognostic significance in patients of this region.

Toxoplasma encephalitis in HIV: case report.

In Tanzania, no data are available on the prevalence of brain infection by toxoplasma in HIV-infected patients. A case of a 35-year old man with fulminant toxoplasma encephalitis (TE) is reported for the first time. TE was not suspected clinically in our patient who presented with a one week history of severe headache and treated empirically with antimalarial drugs. TE was diagnosed postmortem histologically by haematoxylin-eosin and immunohistochemical stain with P30 antibody for toxoplasma antigen. The findings in our case support the suggestion that a high index of suspicion for TE should be maintained in HIV-infected patients presenting with focal neurological symptoms. The case highlights the importance of autopsy studies in not only documenting a toxoplasma brain lesion but also in increasing the awareness for its diagnosis in HIV-infected patients in Tanzania and other developing countries.

Expression of estrogen and progesterone receptors in carcinomas of the female breast in Tanzania.

In Africa breast cancer has been reported to occur frequently in young females and to show an aggressive histological and clinical picture, suggesting that this malignancy might have a different biology from this disease in Western females. To investigate this, the present study assessed by immunohistochemistry the expression of estrogen receptors (ER) and progesterone receptors (PgR) in 60 fresh frozen breast cancer tissues from indigenous Tanzanian patients. This prospective study collected tissues from routine patients treated at the Muhimbili Medical Center, Dar es Salaam, Tanzania. These markers have not been previously investigated in indigenous sub-Saharan females with breast cancer. Patients in this study expressed lower frequencies of ER (33%) and PgR (18%) as compared to literature reports including those about African-Americans. Expression of these markers, however, correlated with the demographic, clinical and histological characteristics in a similar way as observed elsewhere. A compounding effect of younger patients' age, advanced disease or late stage at hospital presentation and race in this geographical region could be responsible for the poor expression of hormonal receptors in the majority of patients as observed in this study. A surprising finding was that the proportion of hormonal receptor positive tumors increased with disease duration. In view of the low frequency of expression of hormonal markers, only 26.7% of the patients would be expected to benefit from hormonal therapy based on their expression of the hormone receptors. There is great need to undertake an inter-African study that would evaluate the hormonal status of more African women with breast cancer in different geographical regions of sub-Saharan Africa and document the true picture of their hormonal status. The outcome of these results could be important for treatment strategies for the second most common cancer among African women.

Neuropathology of human immunodeficiency virus 1 infection. Significance of studying in forensic autopsy cases at Dar es Salaam, Tanzania.

OBJECTIVE: In sub-Saharan Africa, only a few studies of neurologic complications of human immunodeficiency virus 1 (HIV-1) infection have been done. The authors studied neuropathology of HIV-1 infection in Tanzania. DESIGN: Forensic autopsy study at Dar es Salaam, Tanzania. SETTING: A joint research project between Dar es Salaam, Tanzania, and Kumamoto, Japan. PATIENTS: Thirty patients with risk factors for HIV-1 infection. MAIN OUTCOME MEASURES: Human immunodeficiency virus 1 infection was evaluated by HIV-1 antibody test on postmortem serum samples. The brains of HIV-1-infected persons were studied histopathologically. RESULTS: Infection with HIV-1 was identified on postmortem serum samples in 10 of 30 forensic autopsy cases. Neuropathologic changes of the brain were observed in 8 of the 10 HIV-1-infected persons; these changes consisted of lymphocytic meningitis, bacterial meningoencephalitis, cryptococcal meningoencephalitis, tuberculous meningitis with brain abscesses, and intracerebral hemorrhage. CONCLUSIONS: Because none of the persons studied was suspected to have had brain diseases before autopsy, the results suggest that brain diseases of HIV-1-infected patients are likely to go unrecognized in Tanzania. In addition, the high incidence of neuropathologic findings in HIV-1-infected persons indicates that HIV-1-related brain diseases are common in Tanzania, as they are in developed countries. Further forensic autopsy study will determine the range and prevalence of brain complications and have immediate impact on the management of HIV-1-infected patients in Tanzania and other developing countries.

Characterisation of benign lesions and carcinomas of the female breast in a sub-Saharan African population.

Carcinoma of the breast is the second most frequent tumour in African females. Breast carcinomas in African females appear about a decade earlier and follow a more aggressive clinical course than those in developed countries. To elucidate this difference we investigated 63 biopsied benign lesions of the female breast for their potential to malignant progression. We also performed histologic typing and grading of 184 female breast carcinomas received at the Muhimbili University Hospital in Dar es Salaam, Tanzania. Fibrocystic disease and fibroadenomas were the most frequent lesions. The majority of patients with fibrocystic disease had no proliferative lesion and thus were not at a significantly increased risk of developing breast carcinomas. For fibroadenomas, no indication for precancerous lesions was found. The vast majority of breast carcinomas investigated were invasive. As a striking feature, the majority of those studied (66%) were of the non-special type (NST), displaying a more aggressive behaviour than the remaining tumours of the special type (ST). In the group of ST tumours, cribriform types constituted 41% of the cases which may be a special feature of the carcinomas in African females. Among the NST, the tumours were either of grade II or grade III, whereas in ST, 25% of the cases were of grade I. Since histology observed in this study is comparable to that seen in patients from the Western society, late hospital presentation with advanced tumour stages may be a major reason for differences in clinical behaviour between African and Western females. A genetic factor, however, may be an important contributing factor.

Dermatofibrosarcoma protuberans: a clinicopathological study in an African population.

Dermatofibrosarcoma protuberans (DFSP) is a slow-growing, locally aggressive fibrous tumour which rarely metastasises to regional lymphnode or distant sites. The rarity, age pattern of occurrence and the male to female ratio of the tumour were found to correspond to reports elsewhere. But contrary to other reports, the lower limb and not the trunk was found to be the site of predilection of the tumour in Tanzania. This and the tendency of occurrence of the tumour on the scalp in females rather than at other sites in the head and neck region seem to implicate trauma as a predisposing factor. It is difficult to differentiate between DFSP, keloids and hypertrophi scars on the basis of clinical presentation without biopsy. The treatment of choice of this lesion is wide excision followed by skin grafting. It is emphasised that all hypertrophi scars and keloids should be histologically examined in order to rule out DFSP so that it is correctly treated in order to avoid recurrence.

Ploidy and proliferation rates in carcinomas of the breast in Tanzania.

Routinely collected, processed and stored breast cancer tissue blocks recovered from the archives of the Pathology laboratory in Dar es Salaam after storage of up to 3 years were analysed by a flow cytometry for DNA ploidy and S-phase fraction. Results showed that archival material stored in humid tropical conditions may be used for flow cytometric analysis. The mean age of the patients was rather low and aneuploidy was much rarer when compared to studies from Western countries, but the figures on S-phase fraction were comparable. The predominant histological type was infiltrating ductal carcinoma. These results seem to indicate that there may be some differences in the biology of breast cancer between Tanzania and other countries. Studies to confirm these preliminary findings are desirable.

Cutaneous squamous cell carcinoma in Tanzania.

The Tanzania Cancer Registry at Muhimbili Medical Centre, Dar es Salaam, Tanzania was reviewed for squamous cell carcinoma of the skin in non-albino African subjects. The data was analysed for age, sex, site and predisposing factors. Our results were then compared with studies previously carried out in Tanzania, elsewhere in Africa and also on Blacks in America. Squamous cell carcinoma of the skin was found to be a common malignancy, and the commonest skin cancer. Its peak was in the 40-49 years age group though it could occur in children under five years of age. The most affected site was the lower limb, followed by the head and the neck. The penis in the male and the vulva in the female were the third most affected sites. The scalp and the lip were more affected in females than males. Chronic trauma, chronic ulcers, and scars were the main predisposing risk factors to the lower limb and the scalp, while ultra violet radiation to the head and neck, and smegma of the uncircumcised penis were thought to be predisposing risk factors.