Neurobrucellosis--a case report and review of literature.

Neurobrucellosis is a rare form of systemic brucellosis, a disease acquired through ingestion of unpasteurized dairy products, which may manifest as stroke, encephalitis, meningitis, or psychiatric disorders. Presently there is no known report ofneurobrucellosis in Nigeria, although consumption of unpasteurized dairy products is not uncommon in this country. In this report we present a 28 year old spinster with history of significant ingestion of unpasteurized cow milk and brucellosis of the brain diagnosed in our centre through brain magnetic resonance imagining (MRI) and brucella antigen agglutination test. Because of the indolent nature of brucellosis infection, it should be suspected in individuals with pyrexia of unknown origin so that early detection and treatment could prevent long-term sequelae such as focal neurologic deficits, hydrocephalus and psychiatric illness.

Echocardiographic findings in children with surgically correctable non-cardiac congenital anomalies.

BACKGROUND: Congenital cardiac anomalies may co-exist with non-cardiac congenital malformations and, for those requiring surgical correction, there can be an anaesthetic risk. AIM: To estimate the burden of congenital heart disease (CHD) in children with surgically correctable non-cardiac congenital malformations. PATIENTS/METHODS: Records of 120 children aged between 1 week and 11 years [mean (SD) 0.6 (1.5) years] undergoing corrective surgery for non-cardiac congenital malformations were examined. Results of clinical cardiac examination and surgical and echocardiographic findings were analysed. RESULTS: Cleft lip or palate was the commonest surgical anomaly (46, 38.3%), followed by ano-rectal malformation (32, 26.7%). Forty-two children (35.0%) had an abnormal echocardiographic scan. A cardiac abnormality was detected clinically and confirmed by echocardiography in ten patients (8.3%), which represents 24% of all the cardiac abnormalities. The commonest cardiac anomalies were atrial septal defect (ASD) (30 children, 25%), followed by ventricular septal defect (VSD) (seven children, 5.8%). The frequency of ASD was highest in children with a cleft lip or palate (14/46, 30.4%). CONCLUSIONS: Over one-third of patients undergoing surgical correction of congenital malformations have co-existing CHD. Echocardiography is important for pre-surgical evaluation. No association between type of CHD and specific non-cardiac congenital malformations was found.

Euthyroid Sick syndrome And Cardiac Failure In Zaria, Nigeria.

AIMS AND OBJECTIVES: The study was aimed at establishing the existence of sick euthyroid syndrome in our patients with cardiac failure and to find out whether the syndrome in the our patients has a peculiar pattern PATIENTS AND METHODS: Thirty subjects diagnosed with cardiac failure in NYHA class 3 and 4 were studied; they had clinical evaluation, electrocardiograph, chest radiograph and echocardiograph. The biochemical investigation included urea, electrolyte, and creatinine, thyroid function test (T3, T4 and TSH). Thirty individuals who served as control (age and sex matched) also had similar evaluation to the subjects. RESULTS: The subjects' ages ranging from 17 to 85 years and a mean of 51.0 +/- 15.8 years compared to controls with a mean age of 48.9 +/- 8.1 years (p < 0.1). Twenty-two and eight patients were in NYHA class3 and 4 respectively. The subjects had a lower mean T3 than controls of 1.42 +/- 0.07 ug/l and 2.3 +/- 1.0 ug/l respectively and p < 0.001. The mean T4 levels were higher in the subjects than controls (85.4 +/- 26 ug/l and 70.0 +/- 1.7 ug/l respectively and p < 0.001) but TSH levels were similar in the two groups. The subjects had higher mean values of LAD, aortic root diameter, IVSD, LVIDD, LVPW, EDV ESV, LVM and LVMI (p < 0.05). The LV ejection fraction and fractional shortening were lower in subjects than controls (p <0.01). Six, seventeen and seven subjects had diastolic, systolic and combined diastolic-systolic dysfunction on echocardiography respectively. There was a positive correlation between T3 with duration of cardiac failure and ejection fraction (p < 0.05). There was a negative correlation between T3 and LVM, LVMI, LVIDD, EDV, LAD and cardio-thoracic ratio. The levels of T4 showed a positive relationship with LAD and CTR. Partial correlation was statistically significant between T3 and duration of cardiac failure, duration of aetiology of cardiac failure and LVM. The various forms of cardiac failure (diastolic, systolic and combined diastolic-systolic dysfunction) showed no statistically significant difference in mean levels of T3, T4 and TSH. CONCLUSION: Euthyroid sick syndrome is also seen in Nigerians with cardiac failure as reported elsewhere and the levels of T3 seemed to be inversely proportional to LAD, CTR, LVIDD, LVM and LVMI. Serum T3 levels are also directly proportional to EF and FS. Low serum levels of T3 with normal T4 and TSH is associated with severe cardiac failure.

Normal values of echocardiographic parameters of apparently healthy adult Nigerians in Zaria.

The usefulness of echocardiography as a non invasive tool in the assessment of cardiac function is well established. Ninety two (54 males and 38 females) apparently healthy adult Nigerians were assessed echocardiographically to determine the normal values for the commonly measured parameters in our area of clinical practice. The mean age, body mass index (BMI), cardiothoracic ratio (CTR) and electrocardiographic left ventricular hypertrophy (ECG - LVH) were 51.4 +/- 11.15 years, 23.85 +/- 4.91 kg/m2, 0.49 +/- 0.05, and 27.3 +/- 7.46 mm respectively. The mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure ('MAP) were 125.0 +/- 9.94, 79.7 +/- 6.23 and 94.7 +/- 6.54, mmHg respectively. While the results of the echocardiographic measurements followed the same pattern as other published reports from outside Nigeria especially with relation to age, there were still some differences in terms of absolute values. This emphasizes the need to have our own normal reference values. A multicenter study across the country involving much larger number of subjects is required to establish normal reference values for Nigeria.

The outcome of peripartum cardiac failure in Zaria, Nigeria.

We have studied 227 women who had peripartum cardiac failure (PPCF) in Zaria, Nigeria, since 1969-72. This follow-up and review of survivors in 1993-95 depended chiefly on a Zaria woman (A. Abdullahi) and on her careful reporting. Overall, 31 (13.7%) were completely lost to follow-up, 17 (7.5%) were thought to be alive, and there were data on 179 others (78.8%). Of the 75 known deaths, 55 were cardiovascular--20 due to PPCF, 31 due to cardiac failure unrelated to pregnancy (CF), and four were due to a cerebrovascular accident. PPCF recurred in 13% of 551 subsequent pregnancies. Thirty-two women had a recurrence of PPCF only, and 27 an episode of CF only. Blood pressures rose steadily over the years. An enlarged left ventricle on discharge after the index admission predicted a poor prognosis. In 1993-5, we compared 100 survivors with 100 non-PPCF controls: 96 PPCF women but only 50 control women took extra salt (p = 0.0001). Significantly more PPCF women than controls had a diastolic pressure of 110 mm Hg (p = 0.011). The syndrome is probably provoked in potentially hypertensive women by the traditional practices of eating kanwa, which is rich in Na+, taking additional excess salt and heating the body after delivery. Evidence is presented that PPCF women are potentially hypertensive, and cannot handle the excess ingested sodium which therefore leads to hypervolaemia and thus PPCF.

Ischaemic heart disease and myocardial infarction in ABU Teaching Hospital, Zaria: a 10 year review (1985 to 1994); a short report.

Ten patients, eight males and two females with a mean age of 51.20 +/- 8.23 (SD) were seen in ABU Teaching Hospital, Zaria from 1985 to 1994 with either myocardial infarction or angina. Three patients were Asians and Lebanese. Seven had myocardial infarction and two had angina and one patient had ischaemic cardiomyopathy. There were four patients with anterior-lateral, two with inferior lateral and one anterior septal myocardial infarction. The diagnosis of acute myocardial infarction was based on symptoms and electrocardiograph. Five patients had angiogram with evidence of severe coronary disease. The risk factors identified were hypertension, hyperlipidaemia, smoking, Diabetes mellitus and male sex. Laboratory evidence was minimal because CK-MB is not a routine investigation in our centre, this might compromise the diagnosis.

Echocardiographic features of peripartum cardiac failure: the Zaria syndrome.

Zaria has the highest incidence of peripartum cardiac failure, a syndrome of unsettled aetiology. Over the years it has been noted that there has been a decrease in the period of treatment by traditional methods from an average of 90 days to 30 days and with a complete avoidance of hot bed treatment. Twenty-one subjects with the syndrome were studied: they exhibited the same clinical findings as evinced in previous reports from our centre. Echocardiography findings of dilated heart with depressed left ventricular function were noted. There was a statistically significant relationship between the duration of practice and ejection fraction (EF), r=0.36 and P<0.05, duration of practice and left ventricular internal diameter in diastole (LVIDd), r=0.28, P<0.05. Were these subjects suffering from a quiescent heart muscle disease from a previous viral myocarditis and did they require an expanded volume as a trigger? Or are they intolerant of salt requiring only a small increase from the traditional method of treatment to precipitate cardiac failure? Further investigation in the field of molecular biology is required.

Cardiovascular involvement in HIV/AIDS: report of 3 cases.

Three cases of dilated cardiomyopathy in patients with IIIV/AIDS are being reported. The three patients are of young age group and they presented with cardiac symptoms for the first time. They were all heterosexuals and not known was as intravenous drug abuser. There was no history of rheumatic fever or hypertension or diabetes mellitus and ischaemic heart disease. Examination confirmed cardiac failure and investigations including chest x-ray, echocardiograph and electrocardiograph confirmed dilated heart. All the patients tested positive to HIV-1 antibodies. They were managed with the usual anticardiac failure regimen. Two of the patients died on admission, one developed multi organ failure and the other had tonic-clonic seizure. In other parts of Africa reports have also emerged describing the cardiovascular involvement in HIV/AIDS.

A randomised trial to compare the efficacy and safety of Felodipine (Plendil) and Nifedipine (Adalat) retard in patients with mild-to-moderate hypertension.

The efficacy and tolerability of Felodipine extended-release was compared with Nifedipine retard in the management of patients with mild-to-moderate hypertension. A total of one hundred and thirty three patients were screened out of which one hundred and twenty-one patients were enrolled in a 9-week multicentre open, randomised rising-dose trial to receive either Felodipine 5-10 mg once daily or Nifedipine 10-20 mg twice daily. Blood pressure was measured at the end of the dosing interval that is 24 hours and 12 hours after Felodipine and Nifedipine respectively. Both drugs, Felodipine and Nifedipine were found to lower blood pressure significantly compared with baseline. After three weeks of treatment, seated blood pressure was reduced by 20/14 mmHg (systolic/diastolic) and by 24/16 mmHg after 6 weeks in the felodipine group. Corresponding values in the Nifedipine group were 16/09 mmHg and 24/13mmHg. Pulse rate was not significantly affected by either drugs. The percentage of patients who had satisfactory control after 3 weeks treatment was 57.6% for Felodipine and 33.3% for Nifedipine (significant). After dose titration (where necessary), at the end of the study the response rates were 76.3% (n=45) and 79.6% (n=43) for Felodipine and Nifedipine respectively (non significant). Both drugs were metabolically inert and did not derange the haematologic and biochemical profile of patients. They produced no significant weight changes. The pattern of side effects were similar in both groups but tended to be more severe with Nifedipine necessitating withdrawal of two patients in this group. In conclusion, Felodipine ER 5mg - 10mg once daily, and Nifedipine Retard, 20mg twice daily were equally effective medications for mild-to-moderate hypertension but Felodipine was better tolerated.

Fifteen years of upper gastrointestinal endoscopy in Zaria (1978 - 1993).

Seven hundred and ninety patients had upper gastrointestinal endoscope in a fifteen-year review in the Ahmadu Bello University Hospital, Zaria. Dyspepsia was the commonest indication for the procedure. The male female ratio was 1.5:1 The mean age of the patients was 37.8 years and most patients presented in the 4th and 5th decade of life. Epigastric tenderness was the commonest physical finding and chronic liver disease was seen in only 4.3%. Gastritis and doudenitis were the commonest endoscopic findings. The duodenal and gastric ulcer ratio was 10:1. Gastric and oesophgeal malignancies were seen in the 6th and 7th decade of life. Non-ulcer dyspepsia was seen in 39% of the patients.

Case report: dextrocardia with situs inversus; two cases presenting differently.

Two patients presented to our centre with dextrocardia and complete situs inversus. The first a 35-year-old presented for the first time with respiratory symptoms but no cardiac symptoms and the second patient (14-year-old) presented with cardiac symptoms. Dextrocardia and situs inversus were confirmed by the chest radiograph, electrocardiograph, and abdominal ultrasound and computerised axial tomography in the two patients. Echocardiography established atrio-ventricular great arteries ventricular concordance and bicuspid aortic valve in the second patient that presented with cardiac symptoms.

Tuberculosis myocarditis: a case report.

A 35-year old man presented with fever, weight loss, drenching night sweats and symptoms of cardiac failure for three months. Examination revealed wasting, peripheral oedema, bilateral pleural effusion and constrictive pericarditis. A diagnosis of constrictive pericarditis with bilateral pleural effusion probably due to tuberculosis was made. Human immunodeficiency virus antibodies and six sputum for acidfast bacilli were negative. Electrocardiograph revealed low voltages globally and echocardiography showed global myocardial hypokinesia. He had pericardiectomy, pericardial and pleural histology was non-specific inflammatory reaction but myocardial histology showed granulomatous changes of tuberculous myocarditis. We suggest that in experienced hands myocardial biopsy could be useful in making the diagnosis.

Left ventricular geometry in Nigerians with type II diabetes mellitus.

BACKGROUND: Left ventricular hypertrophy is independently associated with increased incidence of cardiovascular disease, cardiovascular and all cause mortality. In a relatively healthy hypertensive adult population, type II diabetes is associated with higher left ventricular mass, concentric left ventricular geometry and lower myocardial function independent of age, sex, body size, and arterial blood pressure. OBJECTIVE: The study is to investigate left ventricular geometry in Nigerians with Type II Diabetes mellitus. METHODS: The study design was cross-sectional and it comprised 75 consecutive patients with type II diabetes mellitus with or without hypertension. Using a structured pre-evaluated questionnaire, the demographic and clinical data were obtained. All subjects had two dimensional (2D) and 2D derived M-mode echocardiography using Sonoline G60s Ultrasound imaging system with 4.2 MHZ transducer equipped with simultaneous ECG tracing. RESULTS: A total of 75 consecutive type II diabetic patients with or without hypertension were recruited into the study. There were 18 (24.0%) hypertensive-diabetic and 12 (16.0%) normotensive-diabetic males and Thirty-four (45.3%) hypertensive-diabetic and 11 (14.0%) normotensive-diabetic were females. Hypertensive-diabetic males had significantly higher left ventricular mass compared to normotensive-diabetic counterpart 207.05 +/- 41.5g and 156.00 +/- 27.1g P = 0.001. Similarly, left ventricular mass index was found to be higher in hypertensive-diabetic males than their normotensive-diabetic counterpart 114.50 +/- 29.2g/m2 and 92.28 +/- 20.5g/m2 P = 0.014. Hypertensive-diabetic female significantly had higher LVM compared to the normotensive-diabetics 196.06 +/- 41.5g and 161.54 +/- 31.6g P = 0.016. Left ventricular mass index was also found to be higher in hypertensive-diabetic female than their normotensive counterpart 118.52 +/- 27.8g/m2 and 95.75 +/- 23.0g/m2 P = 0.019. Hypertensive-diabetics had predominantly concentric left ventricular hypertrophy compared to the normotensive-diabetics 36 (69.2. %) and 5 (21.7%) P = 0.001. CONCLUSION: The study reported that hypertensive-diabetics have predominantly concentric left ventricular hypertrophy, higher left ventricular mass and left ventricular mass index compared to normotensive-diabetic. Female hypertensive-diabetic had predominantly concentric left ventricular hypertrophy, while male hypertensive-diabetic and normotensive-diabetic had predominantly concentric left ventricular remodelling.

Technician run open access exercise electrocardiography.

OBJECTIVE: To evaluate the safety, efficacy, and feasibility of the technician run open access exercise electrocardiography service at Freeman Hospital. DESIGN: Questionnaire analysis of the responses of the general practitioners of randomly selected patients who used the service. SETTING: A tertiary care cardiac centre, providing an open access service to general practitioners in the community. PATIENTS: 269 patients randomly selected from 552 who underwent open access exercise electrocardiography over a 2.5 year period. OUTCOME MEASURES: Utilisation of service: the reasons for referral, whether the service was optimally used by the general practitioners, and its effect on their management practice; effect on number of cardiology referrals; benefit to the patients; safety, efficacy, and feasibility of a technician run service; general practitioners' assessment of the service. RESULTS: 147 of 178 general practitioners (82.6%) responded to the questionnaire, on 247 of 269 patients (91. 8%). General practitioners used the service for diagnosing ischaemic heart disease in 72.5% of cases, for prognostic purposes in 17.8%, or both in 5.3%. In 197 cases (79.8%), the general practitioners felt that the service had changed the way they managed their patients. The exercise test was positive in 90 patients (36.5%) and identified 38 as at high risk. The service was effective in optimising the cardiology service by reducing referrals by 47%. CONCLUSIONS: The service was used by general practitioners primarily for diagnosing ischaemic heart disease and not so often for prognosis. The utilisation of the service was optimal as assessed by the high positivity rate. The service meets its primary objective of assisting general practitioners in the management of patients with suspected ischaemic heart disease, and may have helped to optimise resources by reducing the number of referrals to cardiologists. It has helped prioritize patient management and may have benefited high risk patients by facilitating rapid identification and referral. It can be run safely and effectively by trained technicians.