A CASE OF PICA FOLLOWING A PARAMILITARY PRE-EMPLOYMENT ORIENTATION CAMP.

BACKGROUND: Pica is an unusual craving for and ingestion of either edible or inedible substances first observed in pregnant women but has been reported in all groups of people. Pica poses a significant health risk that often requires medical attention but the awareness of pica among physicians seems to be have reduced. METHOD: We report a case study of a young lady who presented with anaemia (pcv = 21%) and craving for sand. Laboratory investigations carried outwere in keepingwith iron deficiency anaemia. CONCLUSION: It is therefore postulated that pica may actually be a sign of iron deficiency anaemia.

Pattern of childhood leukaemia in University College Hospital, Ibadan.

BACKGROUND: Leukaemias are haematological malignancies characterized by unregulated clonal proliferation of haematopoietic cells. OBJECTIVE: To determine the pattern of childhood leukaemia in Ibadan. METHODOLOGY: This was a retrospective study of leukaemia cases diagnosed at the University College Hospital (UCH), Ibadan between January 1991 and December 2010 in children less than 15 years of age. Data obtained was subjected to statistical analysis using the Statistical Package for Social Sciences version 20. RESULTS: There were 64 cases of childhood leukaemia, accounting for 10.2% of childhood cancers seen during this study period. The male to female ratio was 2:1 and modal age group was between 10 and 14 years. Thirty (46.9%) cases were acute lymphoblastic leukaemia (ALL), 22 (34.4%) were acute myelogenous leukaemia (AML) and 12 (18.8%) were unspecified acute leukaemias. There was no case of chronic myeloid or lymphocytic leukaemia. CONCLUSION: There has been a relative increase in the frequency of leukaemia cases at UCH, Ibadan, which may be largely explained by increased awareness and referrals. There is a need for further collaborative multicentre studies of childhood leukaemias in Nigeria and other developing countries and focused research on childhood leukaemias in order to unravel the aetiology.

Detection of HIV antigen and cDNA among antibody-negative blood samples in Nigeria.

In developing countries as many as 50% of patients for whom a transfusion is indicated are at risk of dying immediately if transfusion is withheld. It is therefore important that blood transfusion is made as safe as possible. This study was designed to assess the safety of blood transfusion in two large blood banks in Ibadan, Nigeria. Aliquots of 250 samples already screened and passed as negative for HIV-1 and -2 were collected from each of the blood banks. Samples were tested for the presence of HIV-1 antigen (ELAVIA Ag I) and the antigen-positive samples tested for the presence of specific HIV-1 antibodies by Western blot (BioRad, France). All antigen-positive samples were also subjected to PCR. HIV-1 antigen was detected in 6 (1.2%) of the 500 samples, of which 4 (0.8%) and 3 (0.6%) were Western blot-indeterminate and PCR-positive, respectively. Transfusion of HIV-contaminated blood may be contributing significantly to the spread of the virus in Nigeria. There is therefore an urgent need for an organized blood-banking system with facilities for more sensitive assays for the detection of HIV in blood to prevent transmission through transfusion.

Benefit of modified plasmapheresis in the management of myasthenia gravis: a case report.

BACKGROUND: Myasthenia gravis is an autoimmune disease condition caused by the generation of antibodies against the acetylcholine receptor sites at the neuromuscular junction. The treatment modalities include anticholinesterase drugs, corticosteroids, immunotherapy, thymectomy and plasmapheresis. However, because of the poor financial state of our patients and the dearth of appropriate equipment in our centres modifications are made to standard treatment modalities including plasmapharesis. METHOD: We report a case of myasthenia gravis who was on various occasions on neostigmine, pyridostigmine and prednisolone. After about 18 months of treatment, he developed myasthenic crises on two occasions. He was admitted in the ICU for respiratory support where he also had modified plasmapheresis. RESULTS: The patient had remarkable improvement following the modified plasmapheresis with reversal of symptoms of the myasthenic crises. CONCLUSION: In the absence of facilities for standard plasmapheresis in this environment, the use of modified plasmapheresis is hereby recommended.

Orofacial lesions in 126 newly diagnosed HIV/AIDS patients seen at the University College Hospital, Ibadan.

Human immune deficiency virus (HIV) infection is one of the most devastating infection in modern times. Oral manifestations of HIV infection occur in approximately 30-80% of patients infected with this virus and the factors, which predispose to these lesions include: CD4 count less than 200 cells/mm, viral load, xerostomia, poor oral hygiene and smoking. These manifestations have subsequently become important entry criteria for: clinical trials of various therapeutic regimes, prophylaxis of HIV related opportunistic infections, anti-retroviral trials and vaccine studies. Over a six month period, all newly diagnosed HIV/AIDS patients attending the Special Treatment Clinic at the Haematology Department of the University College Hospital, Ibadan, Nigeria were recruited into this study before anti-retroviral therapy was commenced. As part of the general physical examination of these patients, a thorough orofacial evaluation was also carried out and the findings were documented. The most prevalent orofacial lesions were candidiasis, xerostomia, melanotic hyperpigmentation and herpetic ulcer among others. The aim of this study was to evaluate the pattern of oral lesions found in patients who were newly diagnosed as having HIV infection prior to commencement of anti-retroviral drugs and relate these lesions to the age, sex and occupation of the patients. These findings may suggest the likelihood that there is a pattern of oral manifestation of HIV infection.

Prevalence of venous thromboembolism at post-mortem in an African population: a cause for concern.

Venous thromboembolism (VTE) remains a fatal complication and a frequent cause of death among patients hospitalized for remediable and often minor conditions. Various prevalence and associated risk factors of VTE have been documented in different parts of the world. It has been reported that the prevalence of VTE in Africans and Asians is not as pronounced as it is in the Caucasians. However, there is still a relative paucity of information about the prevalence of VTE and its associated risk factors in Nigeria, which is an African population. Data was collected retrospectively from records of post-mortem reports at the University College Hospital, Ibadan, Nigeria between January 1991 and December 1998. Of the 989 autopsies documented within the 8-year period, 29 autopsies confirmed VTE. This indicates a prevalence of 2.9%. Sixty five percent of the subjects were older than 40 years and male to female ratio was 2.6:1. Hence the condition is more prevalent in males than females. Malignancy was the commonest predisposing risk factor for VTE (37.9%). Other predisposing factors included immobility for more than 4 days (27.6%), neuromuscular paralysis (24.1%), septicaemia (20.7%), multiple trauma involving the pelvis, abdomen and head (17.2%), major surgery (13.8%), congestive cardiac failure (3.4%) and obesity (3.4%). This study highlights the need to have a closer look at this grave but preventable and treatable health condition. VTE is a preventable and treatable condition, especially where haematological services, intensive care management and good pre-emptive physiotherapy are available. Thus, mortality from this condition should be considered as a cause for concern even in a poorly funded health care delivery system such as in Africa. It is therefore recommended that appropriate physical and pharmacological methods of prophylaxis should be prescribed according to the degree of risk of VTE in individual patients.

Guillain-Barre syndrome in a haemoglobin S patient.

A 43 year old female sickle cell anaemia patient who had a mild clinical course of the disease developed ascending paralysis, areflexia, sensory disturbance and bulbar affectation while on therapy with vitamin B12 for neurological complications of megalobalstic anaemia. She had initially presented with a history of paresthesia involving all extremities and moderate pain in both feet. Blood smear picture revealed macro-ovalocytosis and hyper-segmented neutrophils. Cerebrospinal fluid analysis revealed protein of >200mg %, WBC <5/mm3-predominatly lymphocytes and was negative for cytology and Gram stain. This is the first case report of Guillain- Barre syndrome in a sickle cell anaemia patient.

Hodgkin's disease after treatment for Burkitt's lymphoma: case report.

Hodgkin's disease and non-Hodgkin's lymphomas are interrelated disorders which have been reported to occur either simultaneously or sequentially in the same patient. We report here the development of nodular sclerosing type Hodgkin's disease in a patient two decades after successful treatment for Burkitt's lymphoma with cyclophosphomide and abdominal resection (AR). While the onset of symptoms after treatment for Burkitt's lymphoma was seven years definitive diagnosis of Hodgkin's disease was only made 22 years after the initial diagnosis of Burkitt's lymphoma. The recurrent and solitary nature ofthe lymphadenopathy and the fact that it was initially reported as reactive hyperplasia is typical of nodular lymphocyte predominant Hodgkin's disease. We believe that there was a transitory period of the malignancy as nodular lymphocyte predominant Hodgkin's disease.

Aplastic anaemia: a review of cases at the University College Hospital, Ibadan, Nigeria.

Thirty male and 27 female patients were treated at the University College Hospital, Ibadan, over a 20 year period (January, 1971 to December, 1990) for aplastic anaemia. Age range was three months to 52 years with a median of 19 years. In 26 patients the aplasia could not be linked with a particular cause. Most patients in this category were students in secondary and tertiary institutions, office workers and casual labourers. Nineteen patients were automobile and factory workers who are exposed to lead while two were dealers in petroleum products. In two patients aplasia was linked to chloramphenicol ingestion while in three, the aplasia linked to the use of hair dye. Another three linked the aplasia to a past history of viral hepatitis. One patient had congenital aplasia of the marrow and one was a radiographer. Treatment included oxymethalone 100 mg given three times daily (tds) or intramuscular (i.m.) Durabolin 500 mg weekly. When these drugs were unavailable prednisolone 60 mg daily was administered. No patient had the benefit of bone marrow transplantation (BMT) or the superior drugs, e.g. anti-thymocyte globulin and cyclosporin A. This might have contributed to the poor prognosis as revealed by the survival pattern in which 24 patients died within six months of diagnosis while 19 survived 12 months. Seven patients died within 18 months and four others died within three years. Three patients were alive five years after presentation. Death generally resulted from complications of the aplastic anaemia with gastro-intestinal bleeding, cerebro-vascular accidents and overwhelming infections.

The efficacy of chemotherapy and splenic irradiation in the management of chronic myelogenous leukaemia at Ibadan, Nigeria.

Chronic myelogenous leukaemia (CML) in Nigerians shows a male predominance over females as has been observed in other centres. Out of 25 patients treated between 1987 and 1990, 18 were male. The mean survival of CML patients on chemotherapy was 48.7 months with a median of 38 months, while the mean survival of patients who had chemotherapy plus splenic irradiation was 53.3 months with a median survival of 53 months. The difference between the two mean survival rates was non-significant. Splenic irradiation resulted in significant reduction in splenic size with total disappearance of gastrointestinal symptoms. The need for red cell and blood products transfusion diminished. Patients had a feeling of well being though short-lived. In a developing country, the added cost of irradiation must be weighted against the relatively brief improvement in well-being when deciding mode of management of the disease. Cause of death in all cases was septicaemia, complications of thrombocytopaenia and marrow failure.

Septicaemia in sickle cell anaemia patients: the Ibadan experience.

OBJECTIVE: To describe the pattern of septicaemia among sickle cell anaemia patients. DESIGN: Descriptive study. SETTING: Haematology Day Care Unit of the University College Hospital, Ibadan, Nigeria. SUBJECTS: 269 patients with sickle cell anaemia who presented with fever greater than 38 degrees C. RESULTS: The blood of 97 of the patients exhibited positive growth with isolation of bacteria thereby confirming the diagnosis of septicaemia in them. Fifty seven (59%) of the isolates were gram negative while 40 (41%) were gram positive pathogens. Klebsiella sp. was the predominant gram negative bacteria while Staphylococcus aureus was the predominant gram positive bacteria. The sensitivity tests on the isolates confirmed Ceftozidine (Fortum) was the most effective antibacterial agent for the gram negative and gram positive pathogens. The 172 patients, who had no bacteria pathogens isolated did well with prophylactic broad spectrum antibiotics. Thirty one patients with positive malarial parasites had full anti-malarial therapy. CONCLUSION: The incidence of gram negative septicaemia is high in patients with sickle cell anaemia. Klebsiella spp. is the predominant gram negative bacterium while Staphylococcus aureus is the predominant gram positive bacterium. Ceftozidine appears to be the most effective antibiotic against both the gram positive and gram negative bacterial infection.

Association between HIV/AIDS and malignancies in a Nigerian tertiary institution.

BACKGROUND: Following the outbreak of the Human Immunodeficiency Virus (HIV) infection in 1981, there has been a widespread increase in the incidence of many malignancies including non-Hodgkin's lymphoma, cervical carcinoma and Kaposi's sarcoma. The scarcity of reports linking HIV infection with malignancies in Nigeria necessitated this study. We prospectively screened one hundred patients with various forms of malignancies seen at the University College Hospital Ibadan, Nigeria between October 2001 and June 2002 for HIV infection by the Enzyme Linked Immunosorbent Assay (ELISA) method and confirmed with the Western Blot method. RESULTS: Six of the patients were found to be seropositive for HIV antibodies. There were 41 males (41%) and 59 females (59%) with age ranging from 7 months to 80 years and a median of 46 years. The HIV seropositive patients were between 29 and 35 years of age. Two patients with non-Hodgkin's lymphoma (NHL) and one patient each with carcinoma of the cervix, Kaposi's sarcoma. Hodgkin's lymphoma and carcinoma of the breast were HIV seropositive. All the p values were greater than 0.05. CONCLUSION: The seroprevalence of HIV infection in patients with malignancies in this study was 6%. Despite the HIV/AIDS epidemic, there is yet no significant statistical relationship between HIV infection and malignancies in this environment. Larger, preferably multicenter studies need to be carried out to ascertain the relationship between HIV infection and malignancies in Nigeria.

Outcome of twin pregnancies in patients with haemoglobinopathies--case reports.

Pregnancy in patients with haemoglobinopathy is associated with increased risk of maternal and perinatal morbidities and mortalities. Multiple pregnancy is potentially more hazardous than singleton pregnancy. There is a dearth of information concerning multiple pregnancies in patients with haemoglobinopathy. Four of such patients seen in the obstetric service of the University College Hospital, Ibadan are presented here and discussed. Increased surveillance and elective caesarean delivery are suggested in the management of these patients.

Bacterial causes of acute osteomyelitis in sickle cell anaemia: changing infection profile.

The bacterial causes of osteomyelitis were reviewed on 25 patients with sickle cell anaemia using blood culture and direct wound swab. Age range was 2 to 45 years with a median of 23 years. Klebsiella species were cultured in 45% of the blood samples. Staphylococcus aureus was responsible in 20%, Salmonella species in 8% and Streptococcus pyogenes was cultured in 4% of the samples. From direct wound swab culture, Klebsiella was responsible for 36%, Staphylococcus aureus 28% and coagulase Negative Staphylococcus 24%. Proteus species were responsible for 8% and Salmonella was cultured in 4%. The highest number of patients presenting with osteomyelitis occurred in the second decade. From (culture) sensitivity tests, ceftazidine and Ofloxacine were found to be the most effective antibacterial drugs. The preponderance of Klebsiella indicates a change in the previously accepted pattern of infection in which Salmonella species were considered to be the main causative organism.

Levels of malaria specific immunoglobulin G in Nigerian sickle cell disease patients with and without splenomegaly.

Fifty patients with sickle cell disease(SCD) reporting for routine clinical evaluation and fifty normal individuals at the University College Hospital (UCH) community were recruited into this study. They were matched for age and sex. Patients were aged 15 to 54 years. Forty-four (88.0%) of the patients were haemoglobin S while 6 (12.0%) were haemoglobin S + C. Blood samples were collected and examined for malaria parasite. Malaria specific Immunoglobulin G (pf-IgG) absorbance reading was estimated by Enzyme linked immunosorbent assay in all the patients. Of the forty-four patients with sickle cell anaemia, twenty-two had palpable spleen while the remainder (twenty-two) did not have palpable spleen, and four of the six with Haemoglobulin S + C had palpable enlarged spleens. Spleens were graded using the Hacketts grading system. Five (10%) had grade I splenic size, seventeen (34.0%) had splenic size grade II, one (2%) had grade III, two (4%) had grade IV splenic size and one (2%) had grade V splenic size. Malarial specific. Immunoglobulin G (pf-IgG) was estimated by the Enzyme linked immunosorbent assay. Thick blood films stained with Giemsa were examined microscopically for malaria parasite. The result revealed the mean plasmodium falciparum specific pf-Ig G absorbance reading in patients was 1.081 +/- 0.66 while that of the control was 1.037 +/- 0.38. The difference was not statistically significant (p > 0.05). The high mean pf-IgG indicated intensive malarial exposure and higher impact of malaria infection in patients with sickle cell disease in this environment.

Waldenstrom's macrogloblinaemia: modified plasmapheresis as treatment option in a Nigeria setting.

We describe a case of Waldenströms macroglobulinaemia in a 56 year old Negroid male, to whom modified plasmapheresis/plasma exchange was offered with good control of symptomatic hyperviscosity Amelioration of the clinical status and objective assessment of response was evident by dramatic reduction in monoclonal immunoglobulins M (IgM) from 100g/L to 14.7 g/L and a fall in erythrocyte sedimentation rate from 130 mm/hr to 80 mm/hr with this therapy. This highlights the need to adopt a modification of manual plasmapheresis in the treatment of the hyperviscosity syndrome complicating this B-cell disease in this environment.

Ferritin and serum iron levels in adult patients with sickle cell anaemia at Ibadan, Nigeria.

The ferritin and serum iron levels in 100 adult patients with sickle cell anaemia (SCA) and in ten pregnant (SCA) females were measured. All the adult sickle cell anaemia patients had serum ferritin levels ranging between 325 ng/dl and > 1500 ng/dl. These levels are within and above the normal range. The same trend was observed in the pregnant adult females with SCA. However, in the pregnant women, significantly lower ferritin levels than in the non-pregnant women were recorded. There is, therefore, a reduction in ferritin levels in pregnancy. This could be due to the increased iron requirements and demand by the developing foetus. Serum iron was below normal in 30% of the pregnant women, only 6% of all the adult patients had serum iron levels below the normal levels. Given the adequacy of ferritin levels in the patients studied and the very low incidence of below normal serum iron levels, it is concluded that the sickle cell anaemia patients in the area of study have adequate levels of iron and ferritin in their serum. Iron should therefore be given only in proven cases of iron deficiency anaemia.

Haematological profile of patients with pulmonary tuberculosis in Ibadan, Nigeria.

The haematological indices of sixty two pre-treatment, sputum-smear-AFB positive pulmonary tuberculosis patients were examined. Haematocrit, white cell count and differentials and erythrocyte sedimentation rates (ESR) were estimated by manual methods. The heamatological parameters were compared with age and sex matched control subjects. Statistically significant heamatologic abnormalities found include high erythrocyte sedimentation rate (ESR), anaemia occurred in 93.6%, leucocytosis in 22.3%, neutrophilia in 45.2% and lymphopaenia in 4.8% of the patients. Thrombocytosis occurred in 12.9%,while 8% had thrombocytopaenia. None of the patients had leucopaenia and only 8.4% had lymphocytosis.

Bone marrow findings in patients with pulmonary tuberculosis.

The cytology and culture of bone marrow aspirate in sixty-two newly diagnosed patients with pulmonary tuberculosis were studied. The findings were depressed erythroid activity in 69% of the patients, micronormoblastic changes in 18% and megaloblastic changes in 16.6%. Myeloid activity was increased in 65% of the patients. Normal looking plasma cells above 5% was found in 17.7% of the bone marrow aspirates while 12.9% had eosinophilic precursors above 5% in the marrow. None of the marrow smears showed granuloma formation or caseation necrosis. The bone marrow cultures yielded no growth of Mycobaterium tuberculosis while stainable iron in the marrow was found to be low or negative in 88.8% of the patients.

Neurological manifestations of chronic myelogenous leukaemia.

Neurological manifestations occur in about one-quarter of patients with chronic myelogenous leukaemia (CML), usually as a result of hyperleukocytosis, predisposing to intravascular thrombus formation. We report the clinical and pathological findings in a 16-year-old female with CML who presented with deafness, blindness and paraplegia, and discuss possible aetiopathogenetic mechanism.