Clinical challenges in the co-management of diabetes mellitus and tuberculosis in Southern Africa

Over the past 20 years; tuberculosis incidence in southern Africa has increased at an alarming rate; fuelled primarily by the human immunodeficiency virus epidemic. The emerging prevalence of diabetes mellitus in the region represents a new threat to tuberculosis control. The intersecting double burden is a cause for concern since diabetes mellitus increases the risk of tuberculosis and results in poor treatment outcomes. This review article discusses the evidence of a causal association between these two conditions; and examines the numerous clinical challenges that relate to tuberculosis and diabetes mellitus co-management. Diabetes is associated with a more advanced age and body weight in patients with tuberculosis; although not with a specific clinical presentation of tuberculosis. Rifampicin adversely alters glycaemic control by lowering the concentrations of most oral antidiabetic drugs. Poor glycaemic control; possibly exacerbated by tuberculosis and anti-tuberculous therapy; is an important contributing factor to tuberculosis case fatality and relapse. Clinicians need to be aware of these clinical and pharmacological challenges when co-managing these complex diseases

Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum.

PURPOSE: The role of abdominoperineal resection for rectal cancer has changed because of advances in sphincter-preserving surgery. Our aim was to evaluate the results of this operation in the five-year period following introduction of the concept of total mesorectal excision METHODS: Data on all patients undergoing abdominoperineal resection for very low rectal cancer between 1992 and 1997 were collected prospectively. All patients had had total mesorectal excision. Curative resection was defined as absence of macroscopic disease after resection and local recurrence as any infiltration or tumor identified in the pelvis, alone or combined with distant disease. Survival and local recurrence rates were calculated using the Kaplan-Meier method and log-rank analysis. RESULTS: Of 165 abdominoperineal resections performed, 106 were for primary adenocarcinoma of the rectum. The male:female ratio was 50:56, with a median age of 65 (range, 33-85) years. There was one postoperative death. Twenty-seven patients received short-course preoperative radiotherapy (25 Gy over 1 week), whereas 22 had a longer course, with concomitant chemotherapy in 2. Postoperative chemotherapy was administered in 29, postoperative radiotherapy in 4, and combined therapy in 8. After curative resection (n = 91), survival at five years was 76 percent and differed significantly by stage. Recurrence at any site was 7 percent (3/34) for Stage I, 27 percent (6/26) for Stage II, and 53 percent (16/31) for Stage III. Nine patients presented with local recurrence, with an overall rate at five years of 10 percent. Isolated locale recurrence was observed in only 5 percent of patients CONCLUSIONS: After abdominoperineal resection and total mesorectal excision, good rates of local control may be achieved provided surgical technique is meticulous.

Successful case of extracorporeal life support in a patient with postcardiotomy cardiogenic shock.

Over the past five years, the use of extracorporeal life support in the adult population has gained acceptance. Indications have ranged from respiratory failure secondary to trauma, and adult respiratory distress syndrome, to cardiac failure secondary to a number of causes. The results of extracorporeal life support, when applied to postcardiotomy patients, have been variable. In this article, we present the successful utilization of extracorporeal life support for 28 hours in a patient with postcardiotomy cardiogenic shock following mitral valve replacement.

Instability of lymphocyte chromosomes in a girl with Rothmund-Thomson syndrome.

Rothmund-Thomson syndrome is a rare autosomal recessive syndrome characterised by poikiloderma of the face and extremities, alopecia, short stature, and skeletal defects. We report a patient with the characteristic features of Rothmund-Thomson syndrome who also had lymphocyte chromosome abnormalities. She has a small flat face with short palpebral fissures and micrognathia together with severe skeletal abnormalities of the upper extremities with absence of both radii, short dysmorphic ulnae, a rudimentary right thumb, and aplasia of the left thumb. She also has anal atresia with a rectovaginal fistula. From the age of 3 months she developed poikiloderma skin changes on the face and extensor surfaces of the extremities. Mental development seems to be normal. Lymphocyte chromosomes in the neonatal period showed an unidentified marker chromosome in eight of a total of 32 cells. A repeat analysis at the age of 10 months showed three abnormal cells out of 100 analysed: 47,XX,-7,+i(7q),+7p, 46,XX,t(3;18)(p14.2;q22), and 49,XX,+del(3)(p11.2),+mar,+mar. A skin biopsy from an affected area showed poor growth and five of 48 cells analysed had structural abnormalities. The father had one of 48 cells with an additional marker chromosome and two cells with different 7;14 translocations. The abnormal chromosome complements in lymphocytes indicate that there may be in vivo chromosome instability in Rothmund-Thomson syndrome.

Effect of a new narrow-band UVB lamp on photocarcinogenesis in mice.

Thirty lightly pigmented hairless (Hr/Hr) mice were irradiated 5 days per week for 30 weeks to assess the photocarcinogenicity of a new Philips TL 01 narrow-band (311 nm +/- 2) UVB lamp. All mice were found to be tumour-bearing after 16 weeks and histologically, 83% of these had definite squamous cell carcinomas. Compared with our previous study where conventional broad-band Philips TL 12 UVB irradiation was used, tumours appeared earlier with the TL 01 lamp. The total irradiation dose was, however, several times greater in the TL 01 assay while the total MED dose was considerably less.

Aluminum-induced granulomas in a tattoo.

A patient who developed localized, granulomatous reactions in a tattoo is described. With the use of scanning electron microscopy and energy dispersive x-ray microanalysis, both aluminum and titanium particles were found in the involved skin sections. Intradermal provocation testing with separate suspensions of aluminum and titanium induced a positive response only in the case of aluminum. Examination by scanning electron microscopy and energy dispersive x-ray microanalysis of the provoked response established aluminum as the only nonorganic element present in the test site tissue. This is the first report of confirmed aluminum-induced, delayed-hypersensitivity granulomas in a tattoo.

[A study of new patients at a dermatologic outpatient clinic]. / En studie av nye pasienter ved en hudpoliklinikk.

Data on all new dermatology outpatients seen during the period 1 January to 30 June 1987 were analyzed in order to obtain information on the types of patients attending the clinic and on the skin diseases presented. We also recorded the source of referral, the frequency of the need for surgery, and patient compliance. There was a general predominance of female patients (60%), particularly in the 21-30 years age group. The leading diagnoses were atopic dermatitis (18%) and psoriasis (11%), and 2/3 of the atopic dermatitis patients were female. A skin biopsy was performed in 12% of the new patients and the clinical pre-biopsy diagnosis was correct in 72% of the cases. Surgery was necessary in 16% of all new patients. 54% of the patients required a follow-up appointment. 11% of these (108 patients) failed to appear. Patients with atopic dermatitis were the chief offenders in this latter group. The results of the study suggest that out-patient costs and waiting lists could be reduced by revising the indications for biopsy and follow-up appointments.

A survey of elderly new patients at a dermatology outpatient clinic.

A study of all new dermatitic out patients greater than 70 years of age, referred in the period January-June 1987 (257 patients), was undertaken to obtain information on the types of skin diseases and the dermatological outpatient services required in the case of the elderly. The group accounted for 14% of all new patients. The leading diagnoses were seborrheic keratosis (15.6%), basal cell carcinoma (13.6%), solar keratosis (13.2%), psoriasis (9.7%) and leg ulcer (9.3%). A skin biopsy was required in 27%, and surgical treatment in 31% of the group, compared with 12% and 16%, respectively, of all new patients during the same period. Consequently, the elderly group were more likely to require a follow-up appointment and tended to be more time-consuming outpatients.

The Scandinavian multicenter photopatch study 1980-1985: final report.

At 16 different dermatology clinics in Scandinavia from 1980-1985, photopatch testing was performed on 1993 patients with suspected photodermatosis. The collective results are presented in this article. The most common cause of sun-related dermatosis was polymorphic light eruption (PLE) (38%), while secondary aggravation of pre-existing skin diseases was established in 16% of the patient group. Photocontact dermatitis (11%) and contact dermatitis (10%) were responsible for 274 and 369 positive test reactions (respectively) on photopatch testing using the SPDRG standard series. Musk ambrette and para-aminobenzoic acid were the leading photosensitizers, while perfume mixture, balsam of Peru and lichen mixture were the most frequent causes of contact sensitivity. The principal photoallergens and contact allergens in the PLE, persistent light reaction and actinic reticuloid groups are discussed, together with the problems, risks and possible mechanisms of induction of photosensitization in these patients. The incidence, causes and diagnostic and therapeutic implications of secondary sunscreen sensitivity in these groups are also addressed.

Scleredema adultorum associated with a monoclonal gammopathy and generalized hyperpigmentation.

Scleredema associated with a monoclonal gammopathy and generalized skin pigmentation is described in a 56-year-old man with hyperlipoproteinemia and cardiovascular disease. The patient had IgG-lambda paraproteinemia, without any evidence of multiple myeloma or immunoglobulin deposition in affected skin. Ultrastructural studies of pigmented lesional skin showed increased transfer of melanosomes to basal keratinocytes and dermal melanophages containing complex melanosomes. In addition, cytoplasmic, electron-opaque lipid droplets were seen in approximately every third keratinocyte or melanocyte, while only an occasional dermal cell contained lipid droplets. The hyperpigmentation appeared to be directly related to the scleredema, while the lipid deposition in skin was a likely consequence of the hyperlipoproteinemia. The findings further support the contention that paraproteinemia and hyperpigmentation may, in some patients, be associated features of scleredema adultorum.

Erythrokeratodermia variabilis: immunohistochemical and ultrastructural studies of the epidermis.

Immunohistochemical and ultrastructural study of the epidermis was performed in a 53-year-old female with erythrokeratodermia variabilis (EKV) before and after treatment with the aromatic retinoid Etretinate (RO 10-9359). Aberrant expression of cytokeratin PKK2 (Labsystems, Helsinki, Finland) in lesional EKV stratum corneum was observed; this feature disappeared after Etretinate therapy. A normal distribution of DR-positive dendritic Langerhans' cells was seen in diseased, control and post-treatment skin specimens. The striking finding of this study was thus the shift to a basal cell-type keratin reactivity in stratum corneum in lesional skin, perhaps a reflection of cytoskeleton features related to cell adhesion. Increased adhesion between the cells in stratum corneum might account for the retention type of hyperkeratosis characteristic of EKV.

Histopathologic evaluation of lupus patients with transient renal failure.

Patients with lupus nephritis and severe renal failure progress to end-stage renal disease despite aggressive therapy to suppress immunologic function. Within this group is a small subset presenting with rapid progression of renal failure and requiring dialytic support. We reviewed the clinicopathologic data of four such patients who were able to terminate dialysis after acute renal failure due to lupus nephritis. Three of these patients have remained independent of dialysis up to 4 years, and one patient returned to dialysis 1 month following discontinuation. Although glomerular pathology was variable in the four patients, a lesion common to all at presentation was acute tubular necrosis. It is suggested that tubular necrosis may cause reversible renal failure when part of the nephropathy of disseminated lupus treated with corticosteroids.

Polymorphous light eruption: the properties of a UVA-induced PLME patient group.

Experimental induction of PLME lesions in 22 patients, using a pure, high-intensity UVA light source is reported. Fourteen patients had a reduced MED value for either UVB (11 patients) and/or UVA (7 patients). The UVA-SUN 2000 dose required to provoke a positive PLME reaction varied from 26 to 104 J/cm2. The small papular PMLE-type patients were shown to be more photosensitive and the UVA provocation doses required exceeded 50 J/cm2 in 20/22 patients. Lesional immunoglobulin deposition along the BMZ was seen in 3 patients while lesional BMZ complement deposits occurred in 9/15 patients, 2 of whom had similar findings in the dermal capillaries. Complement deposition occurred in non-irradiated control sites in 4 patients. The immunohistologic findings, for reasons given, fail to support the hypothesis of an immune cell-mediated response as the primary event in the pathogenesis of PMLE.

Infantile acropustulosis.

We report two patients with infantile acropustulosis; one patient with a history of atopic dermatitis and the second with an abnormally high IgE serum value. Atopy has not been reported previously in patients with infantile acropustulosis. Immunofluorescent studies of involved skin gave negative results.

UVA sensitivity and topical photoprotection in polymorphous light eruption.

The efficacy of a non-PABA, non-benzophenone broad-spectrum sunscreen was investigated experimentally in 8 patients with polymorphous light eruption (PMLE). A UVA-SUN 2000 lamp, emitting high intensity UVA radiation was used to irradiate unprotected and sunscreen protected skin sites of the upper back of each patient. Morphological and histological skin changes were noted in non-protected test-sites, while no clinical or microscopic changes were observed in the sunscreen-treated test-sites. Low minimal erythema dose (MED) values for both UVA and UVB light were noted in several PMLE patients.