Atypical lipomatous tumour of the oesophagus.

Atypical lipomatous tumours (ALT) of the oesophagus are rare malignant tumours that are found most commonly in the cervical oesophagus. They are commonly misdiagnosed as giant fibrovascular polyps of the oesophagus (GFP). The differentiation between these clinical entities is important as ALTs are malignant tumours with the potential for local recurrence and metastases. We present a case of an ALT which was misdiagnosed as a GFP. The correct diagnosis was made on histological examination of the resected specimen, and confirmed by immunohistochemistry. The tumour cells extended to involve the resection margins, highlighting the need to consider this diagnosis when dealing with all oesophageal polyps, and ensure complete resection of these tumours.

Prevention and treatment of leptospirosis.

Leptospirosis is a common zoonosis acquired by exposure to body fluids, to tissues of infected animals, or to contaminated soil or fresh water. Large outbreaks of leptospirosis have occurred following excess rainfall or in tourists following exposure to fresh water during adventure activities. Prevention may be achieved through the use of protective clothing or by changes in animal husbandry. Immunization is not widely used in human populations but has a role in agriculture. Oral administration of doxycycline (Periostat , CollaGenex) once-weekly can give short-term protection in high-risk environments. The disease in humans has a broad range of symptoms. Treatment may be symptomatic or may require administration of antibiotics, such as doxycycline or penicillin.

Direct detection of leptospiral material in human postmortem samples.

Leptospiral culture, direct immunofluorescence, and the polymerase chain reaction (PCR) were used to detect leptospiral material in postmortem specimens collected from eight patients who died of leptospirosis. Diagnosis of leptospiral infection was based on clinical summary (premortem) and confirmed by serological analysis and/or culture of leptospires. Leptospiral culture was the least sensitive technique, yielding two isolates (3%) from 65 samples. Both isolates were from the aqueous humour and cerebrospinal fluid of the same patient. Direct immunofluorescence was of intermediate sensitivity for detection of leptospires, confirming the presence of leptospires in 11% (2 of 18) of tissue samples from three patients. PCR analysis was the most sensitive technique for detection of leptospiral material in tissue samples, being positive in 20% (11 of 56) of samples from eight patients. Both samples (cerebellum and liver) positive by immunofluorescence were also positive by PCR. The sensitivity of the PCR assay was 1-10 leptospires ml(-1) sample, and the assay was specific for Leptospira pathogenic species. Multi-system involvement was indicated based on successful amplification of leptospiral DNA from more than one tissue sample, which corroborated with the clinical and pathologic findings. The results suggest that in acute and/or fatal leptospirosis, the pathogenesis of the pathologic features are related to the presence of the organisms in the tissues. In conclusion, PCR combined with serology appears to be a useful tool for diagnosis of leptospirosis and may be invaluable in epidemiological studies.

Helicobacter pylori infection in the Caribbean: update in management

Helicobacter pylori infection of the stomach is one of the commonest chronic infections world wide and in the Caribbean, over 50 of the population are affected. H pylori is probably transmitted from person to person by oro-fecal and oro-oral means. H pylori is directly associated wirh peptic ulcer disease, chronic antral gastritis, gastric carcinoma and B-cell lymphoma of the stomach. In patients with peptic ulcer and H pylori infection, eradication of infection with antibiotics significantly decreases recurrence of ulcers. All patients with H pylori related disease should be tested and treated if positive. The treatment of H pylori infection has evolved over the years but at present triple therapy which includes two antibiotics is recomended.(AU)

Antimicrobial resistance in Helicobacter pylori in Barbados

OBJECTIVE: Helicobacter pylori eradication is essential in patients with peptic ulcer who are infected with the organism. The rate of eradication is related to the level of antimicrobial resistance to metronidazole, clarithromycin, amoxycillin and tetracycline in H pylori in this community. DESIGN AND METHODS: Gastric biopsies from all patients undergoing upper gastrointestinal endoscopy were cultured. Isolation was done on Thayer-Martin medium under microaerophilic conditions and isolates were sub-cultured on chocolate agar. MICs were determined using the E-test. RESULTS: 64 isolates were available for testing. Metronidazole resistance (MIC > 8mg/l) was observed in 39 percent (25/64), clarithromycin resistance (MIC > 2mg/l) in 4.7 percent (3/64), amoxycillin resistance (MIC > 8mg/l) in 4.7 percent (3/64) and tetracycline resistance (MIC > 4mg/l) in 3.1 percent (2/64). CONCLUSIONS: The high level of metronidazole resistance precludes the use of this antibiotic as first line therapy for H pylori in Barbados. It is recommended that a proton pump inhibitor, amoxycillin and clarithromycin be the combination of choice for eradication of H pylori in patients in Barbados.(Au)

Evaluation of two methods for rapid serological diagnosis of acute leptospirosis

OBJECTIVE: To evaluate two rapid assays for serological diagnosis of acute leptospirosis in diagnostic laboratories. DESIGN AND METHODS: 209 specimens were examined from 104 patients admitted to hospital for investigation in a leptospirosis diagnostic protocol. Specimens for serology were taken on days 1 and 4 of the hospital admission. Antibodies were detected using IgM-ELISA, microscopic agglutination (MAT), an IgM-dipstick assay and indirect haemagglutination assay. RESULTS: 51 patients were found to have leptospirosis. The sensitivity of the IgM-dipstick was 98 percent, specificity was 90.6 percent, positive predictive value was 90.9 percent and the negative predictive value was 98 percent. The sensitivity of IHA was 92. percent, specificity was 94.4 percent, positive predictive value was 95.9 percent and negative predictive value was 92.7 percent. The IgM-dipstick assay was positive in 71 percent of the cases in the first sample tested. CONCLUSIONS: Both assays are highly sensitive and specific. Neither requires specialized equipment, and both are suitable for use in diagnostic laboratories.(Au)

Detection of dengue infection in patients investigated for leptospirosis in Barbados

The annual incidence of leptospirosis in Barbados is approximately 13 severe cases/100,000. The peak incidence occurs in October to December of each year, coinciding with the months of heaviest rainfall. During the second half of 1995, the epidemic of dengue type 1 infection produced almost 1.000 laboratory-confirmed cases. During the same period, leptospirosis mortality was twice the average, suggesting that some cases of leptospirosis were being misdiagnosed and treated inappropriately. Sera from patients investigated for dengue or leptospirosis were analyzed retrospectively to determine the extent of misdiagnosis. During 1995 and 1996, 31 of 139 and 29 of 93 patients, respectively, were confirmed as having leptospirosis. Sera from the remaining leptospirosis-negative patients were tested for IgM antibodies to dengue virus. During 1995 and 1996, 48 of 108 patients and 21 of 64 patients, respectively, were found to have dengue. In 1997, sera from all patients investigated for leptospirosis were treated prospectively for IgM antibodies to dengue: 38 of 92 leptospirosis-negative patients (41 percent) were dengue IgM-positive, while 2 of 25 leptospirosis cases also had serologic evidence suggesting acute dengue infection. A second large outbreak of dengue caused by serotype 2 occurred in 1997 dengue epidemics in Barbados, dengue cases outnumbered leptospirosis cases investigated in the leptospirosis diagnostic protocol. During, 1997, patients investigated but negative for dengue were also tested for anti-leptospiral IgM: 7.3 percent (19 of 262) were IgM-positive. Substantial misdiagnosis of both dengue and leptospirosis can occur and greater public awareness and clinical suspicion of the similar presentations of these two diseases are necessary. (AU)

Detection of dengue infection in patients being investigated for leptospirosis in Barbados

Leptospirosis in endemic in Barbados, with an annual incidence of approximately 13 cases per 100,000 of the population admitted to hospital. The peak incidence occurs in October to December of each year, coinciding with the months of heaviest rainfall. During the second half of 1995 there was an epidemic of dengue type I infection, with almost 1000 laboratory-confirmed cases. During the same period, the mortality rate due to leptospirosis was twice the average. It is postulated that some cases of leptospirosis were being mis-diagnosed as dengue during the early stages of infection. A retrospective analysis of sera from patients investigated for leptospirosis was done to determine whether dengue was being mis-diagnosed as leptospirosis. Patients entered into a protocol for diagnosis of leptospirosis were studied if the first sample was collected during the months of July to December in the years 1995 to 1996. During 1995 and 1996, respectively, 27/106 and 22/65 patients were confirmed as having leptospirosis. The remaining sera from 79 and 43 leptospirosis-negative patients were tested for IgM antibodies to dengue virus, using a monoclonal antibody capture ELISA (MRL Diagnostics, CA). The results concluded that dengue fever may be under-diagnosed during non-epidemic periods. (AU)

Severe primary HIV-1 infection among black persons in Barbados

Descriptions of primary HTV-1 infection have so far been based on Caucasians living in industrialized nations. Due to studies of leptospirosis in predominantly black population of Barbados, serum was available for patients admitted with acute febrile illnesses to the Queen Elizabeth Hospital (QEH). By searching the medical records of 510 adult patients with known HIV-1 infection we identified 10 patients who had stored serum from an admission for an acute febrile illness that predated or coincided with their first HIV-1-positive test. Serological testing confirmed primary HIV-1 infection in 9 and was suggestive in the 10th patient. The clinical features of these 10 patients were in keeping with previous descriptions of primary HIV-1 infection but differed from leptospirosis cases seen at the QEH. One patient died during the seroconversion illness and another died 3 months after seroconversion. The findings suggest that severe primary HIV-1 infection could be a relatively uncommon occurence, that the condition may be misdiagnosed, and that cases may not occur until the AIDS epidemic is established.(AU)

Epidemiology of Helicobacter pylori infection in Barbados

The epidemiology of Helicobacter pylori infection in Barbadian patients and controls was studied. H. pylori was isolated from biopsies from 50/100 (50 percent) adult patients undergoing endoscopy for investigation of upper gastrointestinal tract symptoms. Urease was detected in biopsies from 54 patients and gastritis was detected by histology in 71 patients. Serology was performed using a commercial ELISA method. Using an IgG concentration of 10 U/ml as a threshold, antibodies were detected in 78 percent of 100 patients undergoing endoscopy, 72 percent of 230 blood donors and 22 percent of 50 children. The mean antibody concentration was significantly higher in patients (92 U/ml) than in blood donors (49 U/ml) or in children (9.5 U/ml). Culture-positive patients (120 U/ml) had higher IgG concentration than culture-negative patients (64 U/ml). Using isolation of H. pylori or a positive biopsy urease test as a measure of true prevalence of infection, the sensitivity of serology was 96 percent, the specificity 42 percent positive predictive value 67 percent and negative predictive value 90 percent. Seroprevalence increased with age, to a peak of more than 90 percent in blood donors aged 50 - 59 years and in patients aged over 60 years. The epidemiology of H. pylori in Barbados is similar to that in developed countries, where few children was infected, but resembles other developing countries in the high seroprevalence observed in middle-aged adults. (AU)

Epidemiology of Helicobacter pylori infection in Barbados

The epidemiology of Helicobacter pylori infection in Barbadian patients and controls was studied. H. pylori was isolated from biopsies from 50/100 (50 percent) adult patients undergoing endoscopy for investigation of upper gastrointestinal tract symptoms. Urease was detected in biopsies from 54 patients and gastritis was detected by histology in 71 patients. Serology was performed using a commercial ELISA method. Using an IgG concentration of 10 U/ml as a threshold, antibodies were detected in 78 percent of 100 patients undergoing endoscopy, 72 percent of 230 blood donors and 22 percent of 50 children. The mean antibody concentration was significantly higher in patients (92 U/ml) than in blood donors (49 U/ml) or in children (9.5 U/ml). Culture-positive patients (120 U/ml) had higher IgG concentration than culture-negative patients (64 U/ml). Using isolation of H. pylori or a positive biopsy urease test as a measure of true prevalence of infection, the sensitivity of serology was 96 percent, the specificity 42 percent positive predictive value 67 percent and negative predictive value 90 percent. Seroprevalence increased with age, to a peak of more than 90 percent in blood donors aged 50 - 59 years and in patients aged over 60 years. The epidemiology of H. pylori in Barbados is similar to that in developed countries, where few children was infected, but resembles other developing countries in the high seroprevalence observed in middle-aged adults.

Inflammatory bowel disease in Barbados, West Indies - abstract

The incidence and prevalence of inflammatory bowel disease (IBD) in the West Indies is unknown. Barbados is a small West Indian island with a 1990 population of 260,491 persons; 92 percent of these are black (African or mixed African in origin). A prospective study of all patients diagnosed with ulcerative colitis (UC) or Crohn's disease (CD) between January, 1984 and December, 1993 was used to calculate the incidence and point prevalence of IBD. At December 1993, there were 60 patients with UC, 43 were diagnosed in the period under study. The point prevalence was 23/100,000 population and average incidence 1.65/100,000/year. At December 1993, there were 29 patients with CD, 25 having been diagnosed during the period of study. The point prevalence for CD at December 1993 was 11.1/100,000 population and the average incidence 0.96/100,000/year. The age specific incidence for ages 20 years and over was 2.24/100,000/year for UC and 1.26/100,000/year for CD (AU)

Seroepidemiology of helicobacter pylori infection in Barbados - abstract

Helicobacter pylori is now recognised as the cause of chronic (type B) gastritis. We have previously reported on the detection of H.pylori in biopsies obtained by endoscopy of patients with upper gastrointestinal symptoms. An ELISA method was used to study the seroepidemiology of H.pylori infection in Barbadian patients and controls. Using an IgG concentration of 10 U/ml as a threshold, antibodies were detected in 78 percent of 100 patients undergoing endoscopy, 72 percent of 230 blood donors and 22 percent of 50 children. The mean antibody concentration was significantly higher in patients (91.9 U/ml) than in blood donors (48.56 U/ml) or in children (9.5 U/ml). Similarly, culture-positive patients (120 U/ml) had significantly higher IgG concentrations than in culture-negative patients (63.88 U/ml). Using isolation of H.pylori or a positive biopsy urease test as a measure of true prevalence of infection, the sensitivity of serology was 96 percent the specificity 42 percent, its positive predictive value was 67 percent and the negative predictive value was 90 percent. Seroprevalence increased with age, to a peak of more thatn 90 percent in blood donors aged 50-59 years and in patients aged over 60 years. The epidemiology of H.pylori in Barbados is similar to that in developed countries, in that few children are infected, but resembles other developing countries in the high seroprevalence observed in middle-aged adults. Our results confirm the utlitiy of serology for detecting H.pylori by a non-invasive technique (AU)

Use of the polymerase chain reaction for rapid diagnosis of leptospirosis - abstract

Leptospirosis is endemic in Barbados with 97 percent of severe cases caused by three serovars of leptospira interrogans. Early diagnosis is important since the disease can run a fulminant course and patients may die before the appearance of characteristic clinical manifestations of Leptospirosis and/or leptospiral antibodies are detected, and therefore the disease may go unrecognized. In this study, the potential of the polymerase chain reaction (PCR) was explored for the early diagnosis of leptospirosis, with a view to detecting leptospirosis within the first ten days of the onset of the disease. Blood and urine samples from 83 patients with leptospirosis admitted to the Queen Elizabeth Hospital, Barbados, between January 1990 and December 1992, were examined serologically, by culture and by PCR. The mortality rate during the study period was 8.4 percent. PCR was more often positive than culture for the detection of leptospires in proven cases by antibody titre and detected the presence of leptospires in sera before the development of antibodies. As culture can take up to 13 weeks, it does not contribute to an early diagnosis. Seroconversion usually occurs on about the seventh day of the disease, thus diagnosis by serology can take a week or more to be decisive. PCR, on the day of admission, and the characterization of PCR products by Southern hybridization can be completed within one or two subsequent days. PCR is potentially a valuable addition to the diagnostic process in leptospirosis (AU)

Risk of transfusion-related hepatitis and HTLV-1 in Barbados - abstract

The study was designed to determine the prevalence of hepatitis B, hepatitis C, and human T-cell lymphotropic virus type 1 (HTLV-1) among blood donors in Barbados, with a view to reviewing the blood bank screening practices currently in place. Blood samples from 1,022 consecutive blood donors were collected and stored. Samples were then tested for hepatitis B surface antigen (HBsAg), antibodies to surface and core antigens of hepatitis B (anti-HBs) and anti-HBc, respectively, hepatitis C (HCV), and HTLV-1. HBsAg was found in 0.98 per cent, anti-HBs in 7.24 per cent, anti-HBc in 8.4 per cent (n=619), anti-HCV in 2.57 per cent (n=894) and anti-HTLV-1 in 1.4 per cent (n=708). It is recommended that while screening of blood donors is adequate for hepatitis B infection, urgent consideration should be given to additional screening for hepatitis C and HTLV-1 (AU)

Neuroleptic malignant syndrome among acute psychiatric admissions in Barbados

The main features of the neuroleptic malignant syndrome (NMS), a complication of neuroleptic therapy, are fever, muscle rigidity, autonomic dysfunction, and an alteration in consciousness level. We describe five cases of NMS comprising 0.6 per cent of acute neuroleptically-treated admissions to a psychiatric hospital over a one-year period. All patients, four females aged 26 to 63 years, and one male, aged 65 years, were of African origin and received multiple neuroleptic drugs, at least one of which was a depot preparation. Four were being treated for functional psychiatric disorders while one had dementia. All patients had fever and depressed consciousness level while four had rigidity and autonomic dysfunction. Serum creatine phosphokinase was elevated in 4 cases, and there was indirect evidence of myoglobinuria in 3 cases suggested by a positive urine dipstick test for blood despite the absence of red cells on microscopy. Rhabdomyolysis was associated with renal failure in one case. Both bromocriptine mesylate and dantrolene sodium were given in two cases. Three patients died in hospital, one with persistent rigidity and progressive decubitus ulceration, one from peritonitis following dialysis, and another suddenly. Early recognition of NMS is important; it should be considered in any patient on neuroleptic therapy who develops fever, rigidity or alteration in consciousness level. (AU)

An investigation of some risk factors for severe leptospirosis on Barbados

Between November 1979 and the end of December 1986 (7.17 years), 248 cases of leptospirosis were confirmed among hospital patients on Barbados (mean 35 per year; range 25-57). Considering the 235 who were greater than or equal to 15 years of age, the annual incidence of leptospirosis was 19.2/100,000 population (14.0 for all age groups). There were 173 males and 62 females, and for cases aged 15-34 leptospirosis was 9.6 times more common in men than women. Among men, incidence increased fairly steadily with age, and an even steadier increase was apparent in women up to age 64, with some decline in later years. The incidence of disease was much higher among agricultural than other workers and the un-employed. Highest case numbers were recorded in the parishes of St Michael (65 or 28 percent) and Christ Church (36 or 15 percent), though the incidence was lowest in these two parishes (13.1/100,000 and 17.4/100,000, respectively). The highest incidence rates were in St Andrew and St Joseph ((50.2 and 36.1/100,000, respectively). The incidence in areas with rainfall greater than or equal to 1600 mm (32.6/100,000) was nearly twice that in areas with rainfall less than 1600 mm (17.3/100,000). There is a clear link between cases of severe disease and recent rainfall. Using 134 patients greater than or equal to 15 years of age with fever due to other illnesses as controls, a higher proportion of cases than controls came from rural areas. The risk of contracting leptospirosis was increased for all categories of manual workers relative to the group at lowest risk (non-manual indoor workers). Sugar-cane workers were five times more likely to contract leptospirosis than were non-manual indoor workers, while those with rodents in their garden/yard were 1.8 times more likely to do so. Other risk factors examined did not show significant associations with the disease. Despite increasing mechanization and the use of more protective clothing, agricultural workers are still at high risk from leptospirosis. The annual range of cases is likely to stay much as it is in the foreseeable future. (AU)

Preventing gut dysfunction

Gastrointestinal dysfunction can be prevented by modifying our diet, drug use, lifestyle and environment. Diet modification significantly affects the symptoms of gastrointestinal tract in some individuals. Many foods will cause upset stomach and each individual has to learn this by trial and error. In the oesophagus, reflux symptoms are aggravated by a wide variety of substances including, alcohol, red wine, nicotine. The lack of fibre in our diet is thought to be responsible for the high incidence of constipation, diverticular disease and haemorrhoids seen in the western world. The availability of numerous drugs over the counter leads to a large intake of drugs by the population. The lifestyle of a patient may be important in some gastrointestinal conditions, and the environment in which our patients live may have considerable significance to their gut symptoms. Clean water and good sanitation are necessary to prevent the transmission of food-borne diseases which have a major impact on the gastrointestinal tract