New MRI grading system for the diagnosis and management of mycetoma.

The management of patients with mycetoma depends on accurate identification of the causative organisms and of the extent of disease involvement along the different tissue planes. Disease involvement cannot accurately be assessed with the available diagnostic tools, so in this study we set out to evaluate the effectiveness of MRI in the diagnosis and management of mycetoma. Forty-two patients with confirmed mycetoma had MRI examination of the affected parts. A grading system, The Mycetoma Skin, Muscle, Bone Grading System (MSMBS), was used to describe and grade disease severity on the basis of MRI findings. The logistic regression test was used to correlate the clinical and MRI findings. The study showed that MRI can help in the diagnosis and management of mycetoma patients. The dot-in-circle sign, conglomerated foci with low signal intensity and macro- and micro-abscesses on a background of a hypointense matrix are all diagnostic of mycetoma. In patients with mycetoma, the MSMBS can grade disease severity, compare patients and help to manage them. Further studies are needed to determine to what extent the grading system can be used to determine a patient's prognosis.

Quinine therapy in severe Plasmodium falciparum malaria during pregnancy in Sudan.

A prospective study was carried out in an area of unstable malaria transmission in central Sudan to determine the efficacy and toxicity of quinine in pregnancy. Thirty-three pregnant women with severe Plasmodium falciparum malaria at mean 28.8 weeks gestational age were treated with quinine for 7 days. The mean body temperature on presentation for 3 patients who delivered prematurely was significantly higher than for those who delivered at term (39.2 +/- 0.7 degrees C versus 38.7 +/- 1.3 degrees C). There were no significant difference between the 2 groups in other clinical or biochemical parameters. There were no clinically detectable congenital malformations and no auditory, visual or other neurological deficits in the babies at birth or 6 months later. Quinine may be safe in the treatment of severe falciparum malaria during pregnancy.

Quinine therapy in severe Plasmodium falciparum malaria during pregnancy in Sudan

A prospective study was carried out in an area of unstable malaria transmission in central Sudan to determine the efficacy and toxicity of quinine in pregnancy. Thirty-three pregnant women with severe Plasmodium falciparum malaria at mean 28.8 weeks gestational age were treated with quinine for 7 days. The mean body temperature on presentation for 3 patients who delivered prematurely was significantly higher than for those who delivered at term [39.2 +/- 0.7 degrees C versus 38.7 +/- 1.3 degrees C]. There were no significant difference between the 2 groups in other clinical or biochemical parameters. There were no clinically detectable congenital malformations and no auditory, visual or other neurological deficits in the babies at birth or 6 months later. Quinine may be safe in the treatment of severe falciparum malaria during pregnancy

Mortality due to schistosomiasis mansoni: a field study in Sudan.

Although schistosomiasis affects 200 million persons, 20 million of whom have advanced disease, little is known about the mortality pattern in areas of endemic schistosomiasis mansoni. In an attempt to assess the mortality rates in an endemic area in Sudan, we conducted two demographic surveys in a village in the Gezira area. Clinical, sonographic, and parasitologic examinations were performed in a randomly selected sample of 25% of the population in 1987 and 1994. One of us asked each head of household about the names, sex, and age of family members. Particularly, we asked about death in the family if any, history of schistosomiasis, abdominal swelling, and hematemesis. Possible causes of death were ascertained by reviewing medical records in the village dispensary and the district hospital. There were 42 deaths in the village. Four males died of hematemesis secondary to portal fibrosis. The crude mortality rate of schistosomiasis was is 51/100,000/year. The overall schistosomiasis fatality rate per year was 1/1,000 infected persons, but was as high as 11/100/infected patients with bleeding varices. These findings showed the impact of schistosomiasis on public health in this economically important region of Sudan.

The burden of Onchocerca volvulus in Sudan.

Onchocerciasis has been reported in Sudan since 1908 and now prevails in three endemic regions known as the southern, northern and eastern foci. The southern focus is the largest, with nodule and blindness rates exceeding 80% and 12%, respectively, in certain villages. Onchocercal infection in this region causes only a mild skin reaction although microfilarial loads in the skin are high. In contrast, those with onchocerciasis in the northern focus, located between the fourth and fifth Nile cataracts, present with limited but severe skin reactions, low nodule rates (16%), low microfilarial loads in the skin and no ocular involvement. The characteristics of patients from the eastern focus, close to the border with Ethiopian border are similar to those in the north, although most onchocercal skin disease in this area comprises the severe localized pruritus known as sowda.

Apoc impact assessment study Onchocerciasis: baseline ophthalmological Survey in southwestern Sudan

A cross-sectional survey of eye disease supported by the African Programme for Onchocerciasis Conffol (APOC) was carried out in October 1998, in Raja, Sudan, a Savanna ecological zone to determine the prevalence and distribution of onchocercal eye disease. Detailed eye examination including measurement of visual field using the Wu-Jones computerized Motion Sensitivity Screening Test (MSST) were carried out. A total of 481 individuals were examined, of which 379 underwent detailed eye examination. A high prevalence of blindness (8.1%) from all causes was recorded. Onchocerciasis-induced eye disease was responsible for blindness in 56.40/o of all blind persons. Of the 38 persons who had visual impairment, 13 (2.7%) were severely affected. As many as 91 (24.0%) persons had microfilariae (mfs) in the anterior chamber (AC) and /or cornea with the highest prevalence of 29.3Yo and 28.8% respectively, recorded among the young and active individuals. This age group (15-24yeus) also had the highest prevalence (15.3%) of flufff corneal opacities. Sclerosing keratitis was present in 46 (12.1%) subjects while iridocyclitis was diagnosed in 9.0% with the highest prevalenc e of 25 .0o/o noted in the 45 - 54 age group. Prevalence of blinding cataract was 54.1% while that of glaucoma was12.2%. Presumed optic nerye disease, a known pathway to onchocercal blindness was observed in 19.6% with one third of this percentage already at the advanced stage. Another common pathway to blindness, chorioretinitis, affected 15.2% of the subjects of which 7.2% had reached advanced stages.Prevalence of abnormal visual fields was 6.6Yo. Posterior segment oncho disease was found to be the main ocular pathology in 15.6% subjects followed closely by 13.5% whose main cause was anterior segment oncho lesion. Both sexes were almost equally affected. Ocular findings in this area particularly among the young conform to high intensity levels of onchocerciasis infection and therefore require urgent effective intervention to forestall further devastating oncho-induced blindness and alleviate the socio-economic burden imposed on this population.

Ultrasonographic imaging of mycetoma.

INTRODUCTION: The ultrasonographic appearance of mycetoma is described in this prospective study. METHODS: One hundred patients with foot swellings had sonographic evaluation of the swelling and surgical excision within 2 weeks of ultrasonography. The histopathological findings were compared with the preoperative images. Some of the excised swellings and grains were also imaged and compared with the in vivo findings. RESULTS: The mycetoma grains, their capsules and the accompanying inflammatory granulomas have characteristic ultrasonographic appearances. In eumycetoma lesions, the grains produce numerous, sharp hyper-reflective echoes and there are single or multiple thick-walled cavities with no acoustic enhancement. In actinomycetoma, the findings are similar but the hyper-reflective echoes are fine, closely aggregated and commonly settle at the bottom of the cavities. None of the non-mycetoma foot swellings (which included lipoma, ganglion, foreign body granuloma and others) studied had these features. CONCLUSION: Ultrasonography is simple, non-invasive, quick, reproducible and acceptable to patients. Mycetoma has characteristic ultrasonographic features. Furthermore, ultrasonography delineates the extent of mycetoma more accurately than clinical examination alone.

Clinical, parasitological and immunological features of canal cleaners hyper-exposed to Schistosoma mansoni in the Sudan.

The present work was a longitudinal study on Schistosoma mansoni infection in occupationally hyperexposed canal cleaners in the Sudan and the influence of therapy on the parasitological and humoral immune parameters. Chronically infected canal cleaners (n = 28) were more resistant to reinfection (Fisher's exact test, P < 0.05) than newly recruited canal cleaners (n=17). Chronically infected canal cleaners had a significantly higher degree of Symmers' fibrosis (chi2 = 19.1, P < 0.0001), significantly larger portal vein diameter (P < 0.05) and enlarged spleen (chi2 = 4.2, P < 0.05) than recently infected, newly recruited canal cleaners. ELISA was used to detect IgG, IgA and IgM in response to whole worm homogenate (WWH) and cercarial homogenate (CH). Chronically infected canal cleaners had significantly higher IgG to WWH antigen than newly recruited canal cleaners and normally exposed individuals (P < 0.05), while both chronically infected and newly recruited canal cleaners had higher IgG levels to CH antigen than normally exposed individuals (P < 0.05). The newly recruited canal cleaners had a significantly higher IgM level to CH antigen than chronically infected canal cleaners (P < 0.05). The IgG level to WWH antigen increased significantly after treatment in newly recruited canal cleaners and normally exposed individuals (P < 0.05). The IgA level to CH antigen increased significantly after treatment in the chronically infected group (P < 0.05). Comparison of the serological parameters between the different study groups with regards to infection and treatment is discussed.

The effectiveness of annual versus biennial mass chemotherapy in reducing morbidity due to schistosomiasis: a prospective study in Gezira-Managil, Sudan.

The most serious complication of schistosomiasis is periportal fibrosis, which affects a large number of subjects in endemic areas. Population-based chemotherapy remains the most effective way of controlling this disease. In an attempt to find the best way to deliver chemotherapy to the endemic population, we compared the impact of repeated annual versus biennial mass chemotherapy on morbidity due to schistosomiasis in two villages in Gezira, Sudan. One village was given five rounds of mass chemotherapy annually in the years 1990-1994 while the other village was given three rounds of mass chemotherapy biennially from 1988 to 1994. Before treatment, these villages had similar intensity of infection and prevalence. One round of either annual or biennial treatment reduced the intensity of infection, but not prevalence or morbidity. After two rounds of annual chemotherapy, infection rates, bloody diarrhea, and fibrosis in those 20 years of age and less were significantly reduced. Two rounds of biennial chemotherapy had a similar effect on rates and bloody diarrhea; however, fibrosis was reduced only after the third round of biennial chemotherapy. Prevalence of hepatosplenomegaly increased after both treatment regimens. Reinfection was most prominent in those 5-14 years of age. These findings support the general notion that repeated chemotherapy may be needed in areas of high transmission of schistosomiasis. We recommend two rounds of annual mass chemotherapy to significantly reduce infection and morbidity.

Ivermectin distribution in the plasma and tissues of patients infected with Onchocerca volvulus.

OBJECTIVE: To determine the distribution of ivermectin in plasma and tissues of onchocerciasis patients following a single oral dose of 150 micrograms kg-1. SETTING: Medical Department at Soba University Hospital, Khartoum. PATIENTS: Twenty five patients and fourteen healthy volunteers. METHODS: Serial blood samples were obtained from both groups. Tissue samples were removed from various patients as full thickness skin punch biopsies or during nodulectomy. Ivermectin concentration was determined by radioimmunoassay. RESULTS: The plasma pharmacokinetic variables for patients were; maximum plasma concentration 52.0 ng ml-1; time to achieve maximum concentration, 5.2 h.; elimination half life, 35.0 h; and the area under the plasma concentration curve versus time, 2852 ng.h.ml-1. In healthy volunteers, the plasma ivermectin distribution was similar to that in patients, and both groups showed a tendency for a second rise in plasma concentration of the drug suggestive of enterohepatic recirculation. Ivermectin was detected in tissues obtained from patients. Fat showed the highest and most persistent levels, whilst values for skin, nodular tissues, and worms were comparable. Subcutaneous fascia contained the lowest concentrations. CONCLUSIONS: Infection with O. volvulus does not affect the pharmacokinetics of ivermectin, and filarial infected tissues and parasites themselves do take up the drug. There may be prolonged retention of ivermectin because of depot formation in fat tissue.

Community based distribution of ivermectin in eastern Sudan: acceptability and early post-treatment reactions.

A study to monitor ivermectin acceptability and post-treatment reactions during mass community distribution was carried out in eastern Sudan, where severe reactive onchodermatitis is prevalent. Of 1081 individuals eligible for treatment, 1076 (99.5%) accepted the ivermectin. Post-treatment reactions were monitored by self reporting, 5 d after a single dose of about 150 micrograms/kg (range 103-200 micrograms/kg); 230 persons reported adverse events (21.4%). No reaction was rated as severe. The most common problem was itching with cutaneous papular eruptions (16.2%). Local oedematous swelling was the second most common and the most slowly resolving complaint (5.4%), followed by musculoskeletal pain. There was a high acceptance rate of the treatment and remarkable tolerance of the post-treatment effects, probably due to efforts made to prepare the community to expect reactions to ivermectin, widespread awareness of the beneficial effects of treatment by villagers who had participated in clinical trials previously, and the encouragement we gave to the population to become involved in improvement of their health care services. Single doses of ivermectin resulted in good clinical responses and created much goodwill among villagers. Improvements in physical fitness, ability to work, and freedom from musculoskeletal pain were reported at the 3 months' follow-up. We recommend that, during mass distribution of ivermectin, community involvement in planning overall health improvement should be included, since the treatment initiates the process well. In areas where sowda syndrome is prevalent, medical surveillance for 3 d or more should be considered.

Ivermectin treatment in severe asymmetric reactive onchodermatitis (sowda) in Sudan.

Ivermectin efficacy and post-treatment reactions in asymmetric severe reactive ochodermatitis (sowda) were studied in 8 patients with sowda syndrome and 6 with mild generalized onchodermatitis in Sudan. Initial skin snips from 12 patients contained microfilariae (1-9 per mg skin). Patients were treated in hospital with a single oral dose of c. 150 micrograms/kg ivermectin (103-200 micrograms/kg) and monitored for frequency and severity of post-treatment reactions for 4 weeks. Serial samples of heparinized blood were collected over the first 24 h after treatment for determination of ivermectin pharmacokinetics. Skin snips from all patients on days 3 and 28 revealed no microfilariae. Post-treatment reactions were more common and severe in individuals with sowda; they consisted mainly of musculoskeletal pain, local swellings with pitting oedema, and lymph gland tenderness and enlargement. No relation was established between these reactions, the microfilarial infection intensity, or the plasma pharmacokinetic profiles. A single oral dose of ivermectin cleared the skin of microfilariae and led to improvement of symptoms and dermatological signs of sowda, but resulted in more marked reactions than in cases of generalized onchodermatitis.

Predictors of upper gastrointestinal bleeding in patients with schistosomal periportal fibrosis.

A case-control study was conducted between 1985 and 1987 in the Gezira-Managil area of central Sudan to assess the major predictors of haematemesis. Eighty-four patients who had suffered at least one attack of oesophageal bleeding and had schistosomal periportal fibrosis demonstrated by ultrasonography were compared with 173 subjects without bleeding but with ultrasonographic evidence of periportal fibrosis. A splenic longitudinal dimension of more than 11 cm, periportal fibrosis worse than grade I and varices more than grade I were independently associated with a significant risk of variceal bleeding. Age, sex, presence of a palpable liver and portal vein diameter were not associated with a significant risk of bleeding after adjustment for potential confounding variables. Factors identified in this study could be helpful in the prophylactic management of patients with complicated schistosomiasis.

Significant reduction in chloroquine bioavailability following coadministration with the Sudanese beverages Aradaib, Karkadi and Lemon.

Chloroquine bioavailability in healthy males was examined following oral coadministration of 600 mg with three common Sudanese beverages, Aradaib (Tamarindus indica), Karkadi (Hibiscus sabdarifa) and Lemon (Citrus limetta) and drinking water. The tablets and beverages were taken on an empty stomach after an overnight fast. The plasma chloroquine concentrations were measured by HPLC. The extent and rate of chloroquine bioavailability were described by the area under the plasma concentrations versus time curve (AUC), the peak plasma concentration (Cmax) and with the time to reach Cmax (Tmax), respectively. The mean (+/- S.E.) AUC values after administration with water (control) and Aradaib, Karkadi and Lemon, respectively, were 7.52 +/- 0.87, 2.60 +/- 0.24, 2.16 +/- 0.30 and 2.41 +/- 0.29 mg.h/L. The corresponding mean Cmax values were 553 +/- 17.8, 184 +/- 21.3, 148 +/- 14.1 and 210 +/- 17.4 mg/L and the corresponding Tmax values were 3.0 +/- 1.0, 3.2 +/- 1.2, 2.6 +/- 0.8 and 2.5 +/- 1.0 h. The results indicate a statistically significant reduction in the AUC and Cmax of chloroquine as a result of a coadministration with each of the three beverages. A parallel reduction in the drugs antimalarial efficacy might be expected.

Demonstration of urinary eosinophils in Schistosoma haematobium: a comparative study among three different stains.

Three stains, Hansel's stain, alkaline erythrocin B (AEB) and naphthalene black (NB), were used to demonstrate eosinophils in the urine of patients infected with Schistosoma haematobium. Hansel's stain was superior to the other two stains; it stained eosinophils bright red and their nuclei faint blue, and they were easily differentiated from neutrophils, lymphocytes, macrophages and epithelial cells. The method using AEB took longer than Hansel's stain and 10% of the specimens were lost during staining with this method. Like eosinophils, the neutrophils took up NB stain and their nuclei stained poorly with the counterstain.

Infection with Schistosoma mansoni in two different endemic areas: a comparative population-based study in Elziedab and Gezira-Managil irrigation schemes, Sudan.

A cross-sectional survey of schistosomiasis was carried out in five villages around the Elziedab irrigation scheme, in the north, and three villages in the Gezira-Managil area in central Sudan. Stools and urine from 53% (2832 individuals) and 72% (3684 individuals) of the population of these villages, respectively, were examined using the modified Kato thick smear for stools and sedimentation for urine. Clinical history and examination were done on 2832 subjects (53%) in Elziedab and on 893 (18%) randomly selected samples in Gezira-Managil. Prevalence of Schistosoma mansoni was 36% in Elziedab and the mean egg count was 150 eggs per gram of faeces (e.p.g.). Prevalence of bloody diarrhoea was 6%, hepatomegaly 6% and splenomegaly 10%. There was a significant association between these parameters and infection in the age group 10-24 years. Prevalence and intensity in Gezira-Managil area were significantly higher than in Elziedab, 52% and 234 e.p.g. Prevalences of bloody stool 29%, hepatomegaly 17% and splenomegaly 15% were also significantly higher than in Elziedab. These parameters were unrelated to the presence of eggs in the stool. Advanced hepatosplenic schistosomiasis is less than 1% in both areas. While S. haematobium was not found in Elziedab, its prevalence varied from 10 to 15% in Gezira-Managil area. In conclusion, S. mansoni is much less prevalent in Elziedab than Gezira, signs and symptoms are much less prominent in Elziedab, and most of the symptoms are unrelated to the presence of eggs in the stool.

Duodenal ulcer in the Sudan. Clinical features and treatment with H2 blockers.

In a prospective study, 168 Sudanese patients with endoscopically proven duodenal ulcer were studied. The mean age was 36 (SD 3) years and the male:female ratio was 3:1. Most of the patients belonged to the lower social class (class 3) and the chief presenting features were long standing epigastric pain (72.6%), heartburn (66.4%) and upper gastrointestinal bleeding (45.5%). The endoscopic appearance of the ulcers was severe in 40% of patients; this, together with the genetic and distinct dietary factors, may have contributed to the low healing rates following treatment with H2 receptor blockers.

Evaluation of eosinophiluria in the diagnosis of schistosomiasis hematobium: a field-based study.

Using Hansel's stain, eosinophiluria greater than 5% of total urinary white blood cells was found in 59% of a randomly selected population sample in an area endemic for schistosomiasis hematobium. The prevalence and mean level of eosinophiluria were significantly higher in infected subjects than in noninfected subjects (P less than 0.05). The sensitivity (80%), specificity (86%), and positive predictive value (82%) of eosinophiluria as a diagnostic index for schistosomiasis hematobium were significantly higher (Youdin index 0.66; P less than 0.05) than those of proteinuria, hematuria, and leukocyturia taken singly or in combination. However, unlike the latter three measurements, this method involves microscopy. There is a great need for a chemical method for measuring eosinophiluria.