Atypical tuberculous peritonitis presenting as a peritoneal pseudocyst in an immunocompetent adult: insights from a case and literature review.

BACKGROUND: Tuberculous peritonitis often presents with nonspecific symptoms that can lead to diagnostic challenges, particularly when manifesting as peritoneal pseudocysts. This study highlights the clinical complexity and diagnostic approach of tuberculous peritonitis presented as a pseudocyst in an immunocompetent adult, an atypical scenario that is rarely documented. CASE PRESENTATION: We report a detailed case of a 41-year-old man presenting with abdominal distension, pain, and significant weight loss over four months. Abdominal CT showed a peritoneal pseudocyst, initially misdiagnosed due to its resemblance to more common abdominal pathologies. The diagnosis of tuberculous peritonitis was confirmed through histopathological analysis. Additionally, a systematic literature review was conducted to identify and analyse similar cases, focusing on clinical presentations, diagnostic methods, and patient outcomes. Our patient exhibited classic symptoms of abdominal TB but was unique due to the absence of prior ventriculoperitoneal shunting, a common factor in similar cases. Our literature review found that such presentations typically result in diagnostic delays averaging five months, complicating patient management and outcomes. This review also underscores the importance of considering tuberculosis in the differential diagnosis of peritoneal pseudocysts, particularly in TB-endemic regions. CONCLUSION: This case and review emphasize the need for high clinical suspicion and prompt investigation of tuberculosis in patients presenting with atypical abdominal symptoms and pseudocysts. Improved diagnostic strategies, including early use of imaging and pathological evaluations, are essential for timely diagnosis and management, thereby improving patient outcomes in suspected cases of extrapulmonary tuberculosis.

Immunogenicity and reactogenicity of COVID-19 Pfizer-BioNTech (Bnt162b2) mRNA vaccination in immunocompromised adolescents and young adults: a systematic review and meta-analyses.

BACKGROUND: This study aimed to evaluate the safety and effectiveness of the BNT162b2 vaccine in immunocompromised adolescents and young adults. RESEARCH DESIGN AND METHODS: The study conducted a meta-analysis of post-marketing studies examining BNT162b2 vaccination efficacy and safety among immunocompromised adolescents and young adults worldwide. The review included nine studies and 513 individuals aged between 12 and 24.3 years. The study used a random effect model to estimate pooled proportions, log relative risk, and mean difference, and assessed heterogeneity using the I2 test. The study also examined publication bias using Egger's regression and Begg's rank correlation and assessed bias risk using ROBINS-I. RESULTS: The pooled proportions of combined local and systemic reactions after the first and second doses were 30% and 32%, respectively. Adverse events following immunization (AEFI) were most frequent in rheumatic diseases (40%) and least frequent in cystic fibrosis (27%), although hospitalizations for AEFIs were rare. The pooled estimations did not show a statistically significant difference between immunocompromised individuals and healthy controls for neutralizing antibodies, measured IgG, or vaccine effectiveness after the primary dose. However, the evidence quality is low to moderate due to a high risk of bias, and no study could rule out the risk of selection bias, ascertainment bias, or selective outcome reporting. CONCLUSIONS: This study provides preliminary evidence that the BNT162b2 vaccine is safe and effective in immunocompromised adolescents and young adults, but with low to moderate evidence quality due to bias risk. The study calls for improved methodological quality in studies involving specific populations.

Prevalence and Impact of HIV Infections in Patients with Rheumatic Heart Disease: A Systematic Review and Meta-Analysis.

Socioeconomic factors such as poor health and poor nutrition in low- and middle-income countries (LMICs) may favour inflammatory reactions, thus contributing to the recurrence of rheumatic fever (RF) and thereby modifying trends in rheumatic heart disease (RHD). Apart from epidemiological studies, studies of HIV infections in RHD patients are limited. This systematic review synthesises data on the prevalence and impact of HIV infections or AIDS on RHD from PubMed, Scopus, Web of Science databases up to April 2021. The outcomes were managed using PRISMA guidelines. Of a total of 15 studies found, 10 were eligible for meta-analyses. Meta-analysis found that 17% (95 % CI 8-33, I2 = 91%) of adults in cardiovascular disease (CVD) cohorts in Southern Africa are HIV positive. The proportion of RHD diagnosed among people living with HIV was 4% (95% CI 2-8, I2 = 79%) for adults but lower [2% (95% CI 1-4, I2 = 87%)] among perinatally infected children. Despite limited reporting, HIV-infected patients with RHD are prone to other infections that may enhance cardiac complications due to poor immunological control. PROSPERO registration number: CRD42021237046.

Effectiveness of COVID-19 Pfizer-BioNTech (BNT162b2) mRNA vaccination in adolescents aged 12-17 years: A systematic review and meta-analysis.

The rapid emergence of COVID-19 variants of concern (VOCs) has hindered vaccine uptake. To inform policy, we investigated the effectiveness of the BNT162b2 vaccination among adolescents against symptomatic and severe COVID-19 diseases using mostly real-world data (15 studies). We searched international databases until May 2022 and used Cochrane's risk of bias tools for critical appraisal. Random effects models were used to examine overall vaccine effectiveness (VE) across studies (general inverse-variance) and the effect of circulating VOCs on VE (log relative ratio and VE). Meta-regression assessed the effect of age and time on VE (restricted-maximum likelihood). BNT162b2 VE against PCR-confirmed SARS-CoV-2 was 82.7% (95%CI: 78.37-87.31%). VE was higher for severe (88%) than non-severe (35%) outcomes and declining over time improved following booster dose in omicron era [73%(95%CI:65-81%)]. Fully vaccinated adolescents are protected from COVID-19 circulating VOCs by BNT162b2 especially for the need of critical care or life support.

Mycobacterial-specific secretion of cytokines and chemokines in healthcare workers with apparent resistance to infection with Mycobacterium tuberculosis.

Background: Currently, diagnosis of latent TB infection (LTBI) is based on the secretion of IFN-γ in response to Mycobacterium tuberculosis (Mtb) antigens, the absence of which is regarded as no infection. Some individuals appear to resist Mtb infection despite sustained exposure (resisters). In this study, we aimed to assess cytokines, chemokines and antibodies that may be associated with resistance to Mtb infection. We hypothesized that there may be an alternative immune response to Mtb exposure in the absence of IFN-γ in resisters. Methods: We enrolled HIV-uninfected healthcare workers who had worked in high TB-exposure environments for 5 years or longer. We screened them for LTBI using the tuberculin skin test and the QuantiFERON-TB Gold Plus assay. We performed multiplex Luminex to measure concentrations of T cell-associated cytokines and chemokines as well as total antibodies in plasma collected from unstimulated fresh whole blood and supernatants from QuantiFERON-TB Gold Plus tubes following incubation of whole blood for 16-24 hours with ESAT6/CFP10 peptides. Results: Samples from 78 individuals were analyzed: 33 resisters (TST<10mm; IGRA<0.35 IU/mL), 33 with LTBI (TST≥10mm and IGRA≥0.35 IU/mL) and 12 discordant (TST=0mm; IGRA≥1.0 IU/mL). There were no differences in concentrations of cytokines and chemokines in plasma between the different groups. Resisters had significantly lower concentrations of IFN-γ, IL-2, TNF-α, MIP-1α, MIP-1ß, ITAC, IL-13 and GM-CSF in supernatants compared with LTBI group. There were no significant differences in the concentrations in supernatants of IL-10, IL-1ß, IL-17A, IL-21, IL-23, MIP-3α, IL-4, IL-5, IL-6, IL-7, IL-8, Fractalkine and IL-12p70 between the groups. We observed that resisters had similar concentrations of total antibodies (IgG1, IgG2, IgG3, IgG4, IgA, and IgM) in plasma and supernatants compared to the LTBI and discordant groups. Conclusion: Resistance to Mtb infection despite sustained exposure is associated with lower Mtb-specific secretion of Th1-associated cytokines and chemokines. However, resisters showed secreted concentrations after Mtb stimulation of total antibodies and cytokines/chemokines associated with innate and Th17 immune responses similar to those with Mtb infection. This suggests an ability to mount non-IFN-γ immune responses to Mtb in apparent resisters.

A case report of clinical implications of a delayed antiretroviral therapy switch in a patient with multiple treatment interruptions.

The Namibia national antiretroviral therapy guidelines recommend that patients living with HIV who interrupt antiretrovirals and in the process disengage from care be restarted on their usual antiretroviral therapy regimen upon return. We introduce a 39-year-old male patient on first-line antiretroviral therapy, namely, tenofovir disoproxil fumarate, lamivudine and efavirenz, from 2015 to 2019 (4 years), who returned to care after the fourth episode of interrupting his treatment, though his adherence to antiretroviral therapy was deemed poor. Thus, he presented with severe immunosuppression and an AIDS-defining condition. Hence, he was switched to second-line antiretroviral therapy, treated with fluconazole for oesophageal candidiasis and reinitiated on cotrimoxazole prophylaxis. The client is currently clinically stable with a suppressed viral load. Medical and drug history taking with an emphasis on the previous history of treatment failure in patients returning to care are paramount in guiding the choice of future prescriptions of antiretrovirals. The multiple antiretroviral therapy interruptions from the patient and the delay in decision-making on the side of the clinician to switch treatments contributed to the emergence of an AIDS-defining condition.

A case of undisclosed prior exposure to antiretroviral therapy (ART) and early virologic failure that improved on a pre-emptive third-line ART regimen.

Introduction: The test and treat strategy recommends starting ART on the same day of diagnosis; yet, in Namibia neither baseline viral load (VL) nor genotypic resistance testing (GRT) are recommended prior to ART initiation. However, some clients return to care having defaulted ART and undergo HIV testing as "new" clients without disclosing their previous exposure, which predisposes them to primary virologic failure. Case report: A 53-year-old man tested HIV positive in 2019 without disclosing his prior exposure to ART from 2010-2015 and who stopped medication from 2015-2019 due to religious advice. He was thus initiated of first-line ART on the same day of his new diagnosis with a nadir CD4 count of 102 cells/mm3. He had a negative cryptococcal serum antigen, a normal creatinine clearance but with hepatitis B coinfection. He presented later with a primary virologic failure (VL >1000 copies/mL) and severe immunosuppression. The in-depth discussion revealed previous exposure to ART. He consequently benefited from a presumptive third-line ART that suppressed his VL while a GRT was being processed which later confirmed ART resistance. Conclusions: In poor resource settings where GRT is not performed regularly, undisclosed exposure to ART might lead to subtherapeutic treatment and primary virologic failure. In such patients where primary virologic failure is suspected despite good adherence, presumptive third-line ART can be considered in severely immunocompromised patients while waiting for GRT.

Health trends, inequalities and opportunities in South Africa's provinces, 1990-2019: findings from the Global Burden of Disease 2019 Study.

BACKGROUND: Over the last 30 years, South Africa has experienced four 'colliding epidemics' of HIV and tuberculosis, chronic illness and mental health, injury and violence, and maternal, neonatal, and child mortality, which have had substantial effects on health and well-being. Using data from the 2019 Global Burden of Diseases, Injuries and Risk Factors Study (GBD 2019), we evaluated national and provincial health trends and progress towards important Sustainable Development Goal targets from 1990 to 2019. METHODS: We analysed GBD 2019 estimates of mortality, non-fatal health loss, summary health measures and risk factor burden, comparing trends over 1990-2007 and 2007-2019. Additionally, we decomposed changes in life expectancy by cause of death and assessed healthcare system performance. RESULTS: Across the nine provinces, inequalities in mortality and life expectancy increased over 1990-2007, largely due to differences in HIV/AIDS, then decreased over 2007-2019. Demographic change and increases in non-communicable diseases nearly doubled the number of years lived with disability between 1990 and 2019. From 1990 to 2019, risk factor burdens generally shifted from communicable and nutritional disease risks to non-communicable disease and injury risks; unsafe sex remained the top risk factor. Despite widespread improvements in healthcare system performance, the greatest gains were generally in economically advantaged provinces. CONCLUSIONS: Reductions in HIV/AIDS and related conditions have led to improved health since 2007, though most provinces still lag in key areas. To achieve health targets, provincial governments should enhance health investments and exchange of knowledge, resources and best practices alongside populations that have been left behind, especially following the COVID-19 pandemic.