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Background: The occurrence of endocrine diseases in people who are infected with HIV is traditionally thought to occur in the setting of AIDS with opportunistic infections and malignancies. However, recent studies find the correlation between hypocortisolism and stage of HIV (CD4 count and WHO clinical stage) inconsistent. Methods: This descriptive cross-sectional study included three hundred and fifty (350) consecutive patients with HIV infection. They were interviewed, and subsequently underwent laboratory evaluation for the detection of hypocortisolism. Blood samples for serum cortisol estimation were taken at baseline and at 30 minutes following the administration of 1μg of tetracosactrin (Synacthen). In addition, the patients had blood samples taken at 0 minutes (baseline) for CD4+ lymphocyte cell counts. Results: At baseline, 108 (30.9%) participants had serum cortisol levels below 100 μg/L with a median value of 55.48 μg/L (11.36-99.96 μg/L), but only 57 (16.3%) study participants had stimulated serum cortisol levels below 180 μg/L with median of 118 μg/L (19.43-179.62). There was no significant difference in the occurrence of clinical features between participants with low and normal serum cortisol, nor WHO clinical stage, CD4 count and ART regimen. The occurrence of hypocortisolism was higher among participants who had been on ART for a longer period of time. Conclusion: There is a high prevalence of hypocortisolism among HIV patients by biochemical testing, especially those who have been on ARVs for a longer duration. Hypocortisolism cannot be predicted based on the participants’ WHO clinical stage of disease, CD4 cell count, or the treatment regimen. Funding: Personal Funds Keywords: HIV, Adrenocortical insufficiency, CD4 cell count, Tetracosactrin

Background Snakebite though neglected, affects 5 million people yearly. More neglected is the psychological effect of envenomation. We determined prevalence and pattern of depression among patients admitted into snakebite wards of Kaltungo General Hospital Nigeria, and percentage recognized by clinicians. We also assessed for factors associated with depression. Methods In a descriptive hospital based study, we used Patient Health questionnaire (PHQ-9) to make diagnosis of depression among the patients. We reviewed patients’ clinical records to determine clinicians’ recognition of depression. Results Of 187 interviews analyzed, 47 (25%) had depression with none recognized by attending clinicians. Patients with snakebite complications (odd ratio [OR] 3.1, 95% CI 1.1–8.5), and previous history of snakebites (OR 2.7, 95% CI 1.1–6.1) were associated with mild depression. Worrying about family welfare (OR 31.5, 95% CI 6.5–152.9), financial loss (OR 14.6, 95% CI 1.8–121.5) and time loss (OR 14.6, 95% CI 1.8–121.5), past history of snakebites (OR 8.3, 95% CI 1.9–36.5) and lower income (Mean difference −25,069 [84 USD], 95% CI 35,509 [118 USD]–14,630 [49 USD]) were associated with severe depression. Conclusion A quarter of in-patients of snakebite wards of the general hospital had comorbid depression that went unrecognized. Independent predictors of depression such as past history of snakebite, worrying about relations and having snakebite complications could help clinicians anticipate depression among patients. We recommend training of clinicians in the hospital on recognition of common psychological disorders like depression.

BACKGROUND There are conflicting reports of sex differences in HIV treatment outcomes in Africa. We investigated sex disparities in treatment outcomes for adults on first line antiretroviral treatment (ART) in Nigeria. METHODS We compared clinical and immunologic responses to ART between HIV-infected men (n=205) and women (n=140) enrolled in an ART program between June 2004 and December 2007, with follow-up through June 2014. We employed Kaplan-Meier estimates to examine differences in time to immunologic failure and loss to follow-up (LTFU), and generalized estimating equations to assess changes in CD4+ count by sex. RESULTS Men had lower baseline mean CD4+ count compared to women (327.6 cells/µL vs 413.4, respectively, p

Summary Objective To estimate the burden of HIV neurocognitive impairment (NCI) among adult patients on and off antiretroviral therapy (ART) in Sub-Saharan Africa. Methods Estimates were derived from a random effects meta-analysis of prospective studies reporting HIV status, utilization of ART, and the presence of NCI determined using the International HIV Dementia Scale. Results Sixteen studies with quality data from seven countries in Sub-Saharan Africa up to June 2012 were included. Among HIV patients, the frequency of NCI pre-ART was 42.37% (95% confidence interval (CI) 32.18–52.56%), and among those on ART for ≥6 months was 30.39% (95% CI 13.17–47.61%). Respective NCI estimates in studies from Uganda were 46.49% (95% CI 30.62–62.37%) and 28.50% (95% CI −1.31–58.30%). NCI was more common among patients with a concomitant psychiatric ailment. HIV-positive patients compared to HIV-negative controls were predisposed to NCI (odds ratio (OR) 6.49, 95% CI 1.68–25.08); the estimated unadjusted attributable risk of HIV infection leading to NCI was 85%. Meta-regression showed no associations between age, gender, CD4 cell counts, or years of education with NCI. Patients on ART were less likely to have NCI compared to HIV-infected pre-ART patients, with OR 0.36 (95% CI 0.19–0.69). In longitudinal studies with the same patients followed before and at ≥6 months after ART, the OR of NCI after ART compared to pre-ART was 0.23 (95% CI 0.14–0.37). The combined burden of NCI among pre-ART and on-ART patients in Sub-Saharan Africa was estimated at 8 121 910 (95% CI 5 772 140–10 471 680). No publication bias was observed, although residual confounding from differing environmental factors, stages of HIV infection, and viral clades might be a limitation. Conclusions HIV strongly predisposes to NCI leading to a huge burden in Sub-Saharan Africa, and scale-up of ART can substantially reduce it.

Background Neisseria meningitidis constitutes a major public health problem among countries in the African meningitis belt. Following regional vaccination campaigns for serogroup A and subsequent increases in protection against this serogroup, non-A serogroups such as C and W now pose significant epidemic threats, particularly in young children. Objective To evaluate the cost-effectiveness of broadening coverage from conjugate serogroup A to quadrivalent ACWY vaccination. Methods We developed a 40-year Markov state transition model with annual cycles to simulate costs and clinical outcomes in children aged 1 to 10 in the 26 countries of the African meningitis belt. The incidence of CWY meningitis cases among an unvaccinated population was held constant at inter-epidemic rates of 50 per 100,000/year and 150 per 100,000/year. The country-specific cost and probability of access to meningitis care, vaccine efficacy, the mortality risk among treated and untreated meningitis cases, the risk of clinical sequelae and their respective disability weights were based on published sources. Vaccination cost was based on international prices lists, presented in 2014 US$. Results At an incidence rate of 50 per 100,000/year, routine conjugate vaccination is highly cost-effective in 14 out of 26 countries with a cost/DALY averted ranging from US$555-US$787. At the higher incidence rate of 150 per 100,000/year, quadrivalent vaccination is cost-effective in all 26 countries with a cost/DALY averted ranging from US$105-US$250. The annual incidence rate at which routine conjugate quadrivalent vaccination is expected to be economically justifiable ranges from 13 per 100,000/year in Nigeria to 142 per 100,000/year in Burundi. Conclusion Routine quadrivalent conjugate vaccination against Neisseria meningitidis is cost-effective at incidence rates well below the epidemic threshold among children living in the African meningitis belt.

Background: Pityriasis rosea (PR) is an acute self-limiting papulo-squamous skin disorder commonly observed in otherwise healthy children and young adults. Objective: To describe the clinical pattern of PR in Kano, Northwest Nigeria. Materials and Methods: This was a descriptive cross-sectional study that was carried out between June 2010 and May 2011 among out-patients attending three dermatology clinics in Kano, Nigeria. Patients with rashes that met the clinical diagnostic criteria of PR were recruited and followed up until there was resolution of lesions. The demographic characteristics of the patients were recorded along with the clinical manifestations of the lesions. All the data obtained were analysed using SPSS for Windows. Results: Out of 1,528 patients seen over the 12 months study period, 56 patients had PR out of which 23 (41.1%) were males and 33 (58.9%) were females, giving a male:female ratio of 1:1.4. PR, therefore, accounted for 3.6% of all dermatology out-patient visits in Kano. The patients' ages ranged from 6 years to 55 years with most of them in the age range of 11–20 years. The peak month of incidence was January in which about a quarter (21%) of the patients were seen. Only 5 (8.9%) patients had prodromal symptoms preceding the onset of the rash. Herald patch, which was mainly located on the trunk, was present in 45 (80%) of the studied patients. Secondary eruptions appeared within 7 days after the herald patch in 69% and had a typical Christmas tree pattern of distribution along the line of skin cleavage in 70% of the patients. Approximately three-quarter (73 %) of the patients had complete resolution of the rash by the 4th week. Recurrence was not reported 24 weeks after the last patient was seen. Conclusion: The pattern of presentation of PR was not different from that observed by other researchers. However, contrary to earlier reports from south Nigeria, our study shows that PR occurs more frequently during the cold dry season.

Snake Bite Envenoming (SBE) is a major under-appreciated medical and public health problem causing significant mortality and morbidity, particularly among rural dwellers throughout the tropics. Occasionally, snakebite may lead to important complications such as amputation, blindness resulting from spitting cobra (Naja nigricollis) induced venom ophthalmia, foetal loss, wound infection, tetanus and scarring with potential for malignant transformation. Here, we report a case of a 13 year old student bitten by a snake whose bite site became infected with multidrug resistant Methicillin Resistant Staphylococcus aureus (MRSA). He was bitten on the neck, in the night while sleeping on his bed. The bite site suppurated, the skin underwent necrosis and began to discharge thick brownish pus necessitating surgical exploration to drain deep-seated abscesses. The patient survived the acute phase after receiving intravenous polyvalent anti-snake venom (EchiTab-Plus(R)) and intravenous Levofloxacin in addition to wound care. The case stresses the need for comprehensive care of victims of snakebite. This care should be multidisciplinary, and health care workers should be educated on snakebite wound care and management.

Snakebites disproportionately affect the lower socioeconomic segments of the society, people with poorly constructed houses, and those with limited access to education and health care. Cases of snakebite are rare in urban areas. Therefore, health centers located in urban areas are sometimes unprepared for managing cases of snakebite. Potent snake antivenoms are not available, and most healthcare workers lack basic training needed for the management of snakebite. Here, we report a case of 28-year-old cleric who was rushed to the accident and emergency unit of an urban tertiary hospital on account of snakebite injury involving the left forearm. At presentation, there was history of persistent vomiting and hypersalivation. However, there was no history of bleeding from the site of bite, hematemesis, hematuria, or bleeding from any orifice. He later became confused with altered level of consciousness, developed bilateral ptosis, and broken neck sign. The patient survived after receiving intravenous polyvalent snake antivenom (EchiTab-plus; Instituto Clodomiro Picado, Costa Rica), which was incidentally purchased for laboratory experiment and not for patient care. The case highlights the challenges frequently encountered in the management of snakebite victims, especially in nonendemic areas; it also stresses the need for urban health centers to stock snake antivenom in their pharmacy and train healthcare workers in the management and care of snakebite victims.

Presentation of tuberculosis (TB) in pregnancy may be atypical with diagnostic challenges. Two patients with complicated pregnancy outcomes, foetal loss and live premature delivery at 5 and 7 months of gestation, respectively, and maternal loss, were diagnosed with pulmonary TB. Chest radiography and computed tomography showed widespread reticuloalveolar infiltrates and consolidation with cavitations, respectively. Both patients were Human Immunodeficiency Virus (HIV) seronegative and sputum smear negative for TB. Sputum GeneXpert MTB/Rif (Xpert MTB/RIF) was positive forMycobacterium tuberculosis. To strengthen maternal and childhood TB control, screening with same-day point-of-care Xpert MTB/RIF is advocated among both HIV positive pregnant women and symptomatic HIV negative pregnant women during antenatal care in pregnancy and at puerperium.

This article presents the clinical manifestation of Norcardial infection in the setting of iatrogenic immunosuppression. The patient suffered from myasthenia gravis for which he received a prolonged course of high dose steroid. At the time of presentation he had lesions in the brain, lungs, and soft tissue consistent with Norcardial infection. He developed disseminated intravascular coagulopathy (DIC) and acute kidney injury (AKI) and died on the 12 th day in intensive care unit (ICU).