Diagnostic delay in ankle and foot tuberculosis resulting in tuberculoma and tuberculous meningitis in a middle-aged female: A case report.

A middle-aged woman presents with chronic foot arthritis which progressed to a non-healing ulcer, which was unresponsive to conventional antibiotics and debridement. She then developed cerebral manifestations and was empirically treated with antitubercular medications which led to healing of the ulcer. Unfortunately, delays in initiating treatment resulted in development of other extrapulmonary tuberculosis complications such as cerebral tuberculoma with tuberculous meningitis. She was subsequently diagnosed with neurocysticercosis which continued to worsen during her hospital stay. She eventually succumbed to her illness due to the complications and a possible nosocomial infection. This case highlights the challenges with diagnosis of uncommon presentations of common diseases in an endemic area, leading to diagnostic delays and development of serious complications.

Chronic cough and noisy breathing: An 11-year journey to diagnosis and successful treatment.

Foreign body aspiration in an uncommon entity in adults which often leads to delays in diagnosis. Adults with long-standing foreign bodies in the airway can result in various complications including bronchiectasis, atelectasis and lung fibrosis. We describe the case of a primary school teacher who was diagnosed with foreign body aspiration 11 years after the aspiration event. Delays in diagnosis led to her receiving multiple doses of antibiotics including a course of antituberculous therapy.

Bronchoscopic view of post-tuberculosis lung cavity: A case report.

An elderly male, a former smoker, was evaluated at the pulmonary medicine clinic for recurrent episodes of streaky hemoptysis for the last 3 years. He had a history of being successfully treated for microbiologically confirmed pulmonary tuberculosis in the past. He presented in this consultation with two episodes of large volume hemoptysis, and the laboratory results suggested an ongoing active infection. Sputum smear was negative for an infectious etiology. Contrast-enhanced CT of the thorax revealed a lung cavity in the right upper lobe. He underwent flexible bronchoscopy with bronchoalveolar lavage which revealed Klebsiella pneumoniae infection. Small-diameter bronchoscope was used to navigate into the affected lung segment which revealed a cave-like appearance. This was an interesting finding and physicians should be familiar with such bronchoscopic findings and techniques in the management of their patients, particularly in tuberculosis endemic areas.

Magnitude and associated factors of anti-retroviral therapy adherence among children attending HIV care and treatment clinics in Dar es Salaam, Tanzania.

INTRODUCTION: The HIV pandemic continues to contribute significantly towards childhood mortality and morbidity. The up-scaling of the Anti-retroviral therapy (ART) access has seen more children surviving and sanctions great effort be made on ensuring adherence. Adherence is a dynamic process that changes over time and is determined by variable factors. This necessitates the urgency to conduct studies to determine the potential factors affecting adherence in our setting and therefore achieve the 90-90-90 goal of sustainable viral suppression. OBJECTIVES: To assess the magnitude and associated factors of ART adherence among children (1-14 years) attending HIV care and treatment clinics during the months of July to November 2018 in Dar es Salaam. METHODS: A cross-sectional clinic-based study, conducted in three selected HIV care and treatment clinics in urban Dar es Salaam; Muhimbili National Hospital (MNH), Temeke Regional Referral Hospital (TRRH), Infectious Disease Centre- DarDar Paediatric Program (IDC-DPP) HIV clinics during the months of July to November 2018. HIV-infected children aged 1-14 years who had been on treatment for at least six months were consecutively enrolled until the sample size was achieved. A structured questionnaire was used for data collection. Four-day self-report, one-month self-recall report and missed clinic appointments were used to assess adherence. Frequencies and percentages were used to describe categorical data. The odds ratio was used to analyse the possible factors affecting ART adherence Logistic regression models were used to determine the factors associated with ART adherence. Analysis was conducted using SPSS version 20.0 and p-value <0.05 were considered statistically significant. RESULTS: 333 participants were recruited. The overall good adherence (≥95%) was approximated to be 60% (CI-54.3-65.1) when subjected to all three measures. On multivariable logistic regression, factors associated with higher odds of poor adherence were found to be caregivers aged 17-25 years [AOR = 3.5, 95%CI-(1.5-8.4)], children having an inter-current illness [AOR = 10.8, 95%CI-(2.3-50.4)], disbelief in ART effectiveness [AOR = 5.495; 95%CI-(1.669-18.182)] and advanced clinical stage [AOR = 1.972; 95% CI-(1.119-3.484)]. The major reasons reported by caregivers for missing medications included forgetfulness (41%), high pill burden (21%), busy schedule (11%) and long waiting hours at the clinic (9%). CONCLUSION AND RECOMMENDATIONS: In the urban setting of Dar es Salaam, ART adherence among children was found to be relatively low when combined adherence measures were used. Factors associated with poor ART adherence found were younger aged caregivers, and child intercurrent illness, while factors conferring good adherence were belief in ART effectiveness and lower HIV clinical stage. More attention and support should be given to younger aged caregivers, children with concomitant illness and advanced HIV clinical stages. Educating caregivers on ART effectiveness may also aid in improving adherence.

Internal Iliac Aneurysm Causing Hydroureteronephrosis.

A 63-year-old presented with right lumbar pain and increased frequency of urination. Imaging revealed right internal iliac artery aneurysm causing hydroureteronephrosis and compressing the urinary bladder.

Adequacy of Hemodialysis and Its Associated Factors among Patients Undergoing Chronic Hemodialysis in Dar es Salaam, Tanzania.

The worldwide prevalence of maintenance hemodialysis continues to rise. An adequate delivery of hemodialysis dose as measured by Kt/V or urea reduction ratio is a crucial determinant of clinical outcome for chronic hemodialysis patients. The aim of this study was to assess the adequacy of hemodialysis and its associated factors among patients undergoing chronic hemodialysis in Dar es Salaam. This was a cross-sectional study done on patients undergoing chronic hemodialysis in four dialysis centers in Dar es Salaam. Sociodemographic information and treatment characteristics were collected. Urea reduction rate and single-pool Kt/V were calculated to determine the adequacy of hemodialysis. The data were analyzed and any associated factors for inadequate hemodialysis were determined using a chi-square test and a logistic regression analysis. A total of 143 patients participated in the study. Males represented 65.7% of the study population. The mean age (±SD) was 51.7 ± 1.2 years. Only 34.3% (based on urea reduction ratio (URR)) and 40.6% (based on Kt/V) of patients received adequate hemodialysis. The univariate analysis showed that males were more likely to have inadequate dialysis (65.6% versus 48.0%, p=0.048 based on Kt/V). Patients using hemodialyzers with dialyzer surface area less than 1.4 m2 received significantly less hemodialysis dose than those with more than 1.4 m2 (69.0% versus 41.2%, p=0.02, by URR) (62.7% versus 35.3%, p=0.03, by Kt/V criteria). Patients who had hemoglobin <10 g/dl received significantly inadequate hemodialysis dose as compared to patients with hemoglobin ≥10 g/dl by Kt/V criteria (69.8% versus 51.3%, p=0.03). None of the factors acquired significance in the multivariate analysis. The proportion of patients receiving an adequate hemodialysis dose is low (34.3% based on URR and 40.6% based on Kt/V). Male gender, dialyzer surface area of <1.4 m2, and hemoglobin level of <10 g/dl were associated with an inadequate delivered dose of hemodialysis in the univariate analysis but not in the multivariate analysis. This study can increase awareness about the importance of measuring hemodialysis adequacy and giving the correct hemodialysis dose to achieve the intended benefit.

Prevalence of Depression and Associated Factors among Diabetic Patients in an Outpatient Diabetes Clinic.

Despite adequate treatment for diabetes, it is estimated that 15%- 20% of people with diabetes are struggling with a moderate to severe form of depression daily. Little is known about depression in diabetes in East Africa, particularly in Tanzania. The study is aimed at determining the prevalence of depression and associated factors among patients with diabetes. A descriptive cross-sectional study was carried out at the diabetes clinic of Muhimbili National Hospital. The 9-item Patient Health Questionnaire (PHQ 9) scale was used to assess presence of depressive symptoms among diabetes patients at the clinic. In addition, patient's sociodemographic and clinical characteristics were obtained and analysed for their association with depression. A total of 353 participants were recruited, of whom 229 (64.9%) patients were female and 156 (44.2%) were aged between 41 and 60 years. The overall prevalence of depression among diabetes patients at the diabetes clinic was 87%. Most (56.7%) had minimal depression, 22.1% had mild depression, and 8.2% had moderate depression. None had severe depression. Factors independently associated with a diagnosis of mild to moderate depression were being on insulin therapy and being a current smoker. There was a high prevalence of depression in this diabetic population. Majority of patients had minimal depression but about 30% had either mild or moderate depression. A holistic approach that focuses on the identification and management of depression among patients with diabetes is recommended.

Prevalence and Associated Factors of Depression in an Asian Community in Dar es Salaam, Tanzania.

Depression is a common condition in developed countries and is a growing problem in developing countries like Tanzania. Various risk factors have been identified through different studies. This study aimed at finding the prevalence of depression in a predominantly migrant Asian community and the behavioral, familial, social, and medical factors influencing it. A cross-sectional study among adults in a closed Asian community was done. Interviews and self-administered questionnaires were used to obtain details of symptoms and factors related to depression. DSM-IV criteria were used to diagnose depression in the individuals. Factors were assessed for significance using Chi square test. A total 384 participants were interviewed. Depression was found in 6.5% of the population. Risk factors included psychological stress (p < 0.001, OR = 6.37, 95% CI = 2.42-16.69) and a family history of depression (p = 0.023, OR = 2.57, 95% CI = 1.02-6.42). A sufficient family income was associated with a lower risk of depression (p = 0.013, OR = 0.21, 95% CI = 0.06-0.77). The prevalence of depression is within the range of the worldwide prevalence. Past psychological trauma and a family history of depression were significant risk factors, while a sufficient income was protective.

Risk factors for mortality among patients admitted with upper gastrointestinal bleeding at a tertiary hospital: a prospective cohort study.

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency, which is potentially fatal. Proper management of UGIB requires risk-stratification of patients which can guide the type and aggressiveness of management. The aim of this was study was identify the causes of UGIB and factors that increase the risk of mortality in these patients. METHODS: This was a prospective cohort study conducted over a period of seven months at a tertiary hospital. Adults admitted with UGIB were included in the study. Demographic data, laboratory parameters and endoscopic findings were recorded. Patients were then followed up for 60 days to identify the occurrence of mortality. Chi-square tests and cox-regression was used to determine association between risk factors and mortality in the bivariate and multivariate analysis, respectively. RESULTS: A total of 170 patients with UGIB were included. Males accounted for the majority (71.2%). Median age of the study population was 40.0 years. Chronic liver disease was present in 30.6% of study patients. The most common cause of UGIB among the 86 patients who underwent endoscopy was oesophageal varices (57%), followed by peptic ulcer disease (18%) and gastritis (10%). Mortality occurred in 57 patients (33.5%) and was significantly higher in patients with high white blood cell count (HR 2.45, p 0.011), raised serum alanine aminotransferase (HR 4.22, p 0.016), raised serum total bilirubin (HR 5.79, p 0.008) and lack of an endoscopic procedure done (HR 4.40, p <0.001). Rebleeding was reported in 12 patients (7.1%) and readmission due to UGIB in 4 patients (2.4%) CONCLUSIONS: Oesophageal varices was the most common cause of UGIB. One-third of patients admitted with upper gastrointestinal bleeding died within 60 days of admission, signifying a high burden. Rebleeding and readmission rates were low. A high WBC count, raised serum ALT, raised serum total bilirubin and a lack of endoscopy were independent predictors of mortality. These findings can be used to risk-stratify patients who may benefit from early and more aggressive management.