Queen Elizabeth Central Hospital Research Articles

Children With Retinopathy-negative Cerebral Malaria

Cerebral malaria, defined as otherwise unexplained coma in a patient with circulating parasitemia, is a common disease in the developing world. The clinical diagnosis lacks specificity and children with other underlying causes of coma might be misdiagnosed as having cerebral malaria. The presence of malarial retinopathy can be used to differentiate children whose comas are caused by Plasmodium falciparum and its attendant pathophysiologies from those with other reasons for their abnormal mental status. Children with cerebral malaria who lack malarial retinopathy have not previously been described. All patients admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi, during a 12-month period with a clinical diagnosis of cerebral malaria were evaluated for the presence of malarial retinopathy. Thirty-two patients lacked retinopathy findings. Clinical, laboratory, and radiologic information data were collected. Thirty-two cases of retinopathy-negative cerebral malaria are presented. Children with retinopathy-negative cerebral malaria share a common clinical phenotype with lower rates of mortality compared with those who have malarial retinopathy. There are at least 4 possible pathophysiologic explanations for this common condition.

Case Report-The 46 year old man with a 5 month history of vomiting

On the 23rd of January 2011, we admitted a 46-year-old man to Queen Elizabeth Central Hospital (QECH) with a 5-month history of recurrent vomiting. This was associated with nausea. He would vomit at least 5 times per day. The vomitus was non-projectile, would usually take the colour of the food eaten and was never bilious. There was no history of abdominal pain, dysphagia, fever or headache. The colour of stools was normal but he had complained of constipation for 6 days prior to admission. He also admitted to weight loss, which could not be quantified.

Group B Streptococcus and HIV Infection in Pregnant Women, Malawi, 2008–2010

To determine whether an association exists between group B streptococcus carriage and HIV infection, we recruited 1,857 pregnant women (21.7% HIV positive) from Queen Elizabeth Central Hospital, Blantyre, Malawi. Overall, group B streptococcus carriage was 21.2% and did not differ by HIV status. However, carriage was increased among HIV-positive women with higher CD4 counts.

Hospital based palliative care in sub-Saharan Africa; a six month review from Malawi

BackgroundThe World Health Organisation recognises the importance of palliative care in an African setting. Despite this services are often patchy and inconsistent, and many operate at health centre and/or community level. Few reports from hospital based palliative care services in sub-Saharan Africa exist in the current literature. As part of its activities Tiyanjane Clinic has been providing hospital based palliative care to patients at Queen Elizabeth Central Hospital, a large government tertiary referral institution, in the Southern region of Malawi since 2003, caring for patients with HIV, cancer and other non-malignant palliative diagnoses.MethodsA retrospective review of case notes for all in-patients seen by Tiyanjane Clinic over a six month period (April-Sept 2009) was undertaken.ResultsA total of 177 patients were seen, for whom 137 case notes were available (77%). 58% of patients were male, 42% female. The average age of patients was 39.1 years (range 15-92 years). 54% of patients were HIV positive, with 34% on ARV drugs at the time of care. 42% of patients had HIV related diagnoses, including AIDS defining malignancies, 48% had (non AIDS related) cancers and 9% had other palliative diagnoses. The mean age of patients with HIV related diagnoses was 34 years, for cancer patients it was 48 years. Pain was the most commonly reported symptom (74%), with 56% of patients requiring oral morphine. The mean daily dose of morphine was 30 mg/day (range 9-100 mg). 65% of patients were discharged home, 26% of patients died during admission.ConclusionsThe palliative care population in this setting is relatively young, especially among patients with HIV related diagnoses. HIV and cancer are the main diagnostic groups. Pain is the most commonly reported symptom, with oral morphine frequently required. Health workers require access to and knowledge of oral morphine in order to provide appropriate assistance to patients under their care.

Teaching Corner: A new method of measuring mid upper arm circumference at Queen Elizabeth Central hospital, Blantyre, Malawi

Pediatric anesthesia faces many challenges in Africa. Lack of personnel, equipment and late presentation are some of them. In Malawi malnutrition is another challenge. One in five children is underweight in Malawi. It is therefore necessary for the anaesthetist practising in the Malawian setting to be aware of the effects of malnutrition on their practice.

Ward Round – A patient with multi-organ failure

A 33 year old woman was admitted to the gynaecology ward in Queen Elizabeth Central Hospital with a four day history of abdominal pain and jaundice. She was 16 weeks pregnant in her third pregnancy. Both her previous pregnancies resulted in live, healthy children. Her health passport showed that she had been diagnosed HIV positive in 2008 during antenatal testing, although neither the patient nor her relatives were aware of her status and she was not taking anti-retroviral treatment. Three weeks before admission she had received treatment for malaria with quinine and had made a full recovery. She had no other past medical history.

Applying lessons learnt from the ‘DOTS’ Tuberculosis Model to monitoring and evaluating persons with diabetes mellitus in Blantyre, Malawi

The global burden of diabetes mellitus (DM) is immense and predicted to reach 438 million by 2030, with 80% of the cases being in the developing world. The management of chronic non-communicable diseases like DM is poor in most resource-limited settings, and the 'directly observed therapy, short course' (DOTS) framework for tuberculosis control has been proposed as a feasible way to improve this situation. In late 2009, aspects of the DOTS model were applied to the management of persons with DM in the diabetes clinic in Queen Elizabeth Central Hospital, Blantyre, Malawi, and a point-of-care electronic medical record system was set up to support and monitor patients in care. This is the first quarterly and cumulative report of persons with DM registered for care stratified by treatment outcomes, complications and medication history up to 31 December 2010. There were 170 new patients registered between October and December 2010, with 1864 ever registered by 31 December 2010. Most patients were alive and in care; 3 died, 53 defaulted and 3 transferred out. Of those on oral hypoglycaemic agents, metformin was most commonly used. Complications were common. The monitoring and evaluation will be further refined, and at the same time, the systems developed in Blantyre will be expanded to other parts of the country.

High transfusion failure rates in Malawian children with severe anaemia following a standard blood transfusion regimen

High transfusion failure rates in Malawian children with severe anaemia following a standard blood transfusion regimen

Ten Years of Surveillance for Invasive Streptococcus pneumoniae during the Era of Antiretroviral Scale-Up and Cotrimoxazole Prophylaxis in Malawi

ObjectiveTo document trends in invasive pneumococcal disease (IPD) in a central hospital in Malawi during the period of national scale-up of antiretroviral therapy (ART) and cotrimoxazole prophylaxis.MethodsBetween 1 January 2000 and 31 December 2009 almost 100,000 blood cultures and 40,000 cerebrospinal fluid (CSF) cultures were obtained from adults and children admitted to the Queen Elizabeth Central Hospital, Blantyre, Malawi with suspected severe bacterial infection.Results4,445 pneumococcal isolates were obtained over the 10 year period. 1,837 were from children: 885 (19.9%) from blood and 952 (21.4%) from CSF. 2,608 were from adults: 1,813 (40.8%) from blood and 795 (17.9%) from CSF. At the start of the surveillance period cotrimoxazole resistance was 73.8% and at the end was 92.6%. Multidrug resistance (MDR) was present in almost one third of isolates and was constant over time. Free ART was introduced in Malawi in 2004. From 2005 onwards there was a decline in invasive pneumococcal infections with a negative correlation between ART scale-up and the decline in IPD (Pearson's correlation r = −0.91; p<0.001).ConclusionDuring 2004–2009, national ART scale-up in Malawi was associated with a downward trend in IPD at QECH. The introduction of cotrimoxazole prophylaxis in HIV-infected groups has not coincided with a further increase in pneumococcal cotrimoxazole or multidrug resistance. These data highlight the importance of surveillance for high disease burden infections such as IPD in the region, which will be vital for monitoring pneumococcal conjugate vaccine introduction into national immunisation programmes.

Case Report: Locally advanced skin cancer in an albino, a treatment dilemma

We report on a 27 year old albino woman, who was admitted on the 20th May 2010 to our facility at Queen Elizabeth Central Hospital with a left-sided pre-auricular ulcerating mass suspected to be originating from the skin.The mass developed three weeks prior to admission and was progressively growing in size.

Characterising B cell numbers and memory B cells in HIV infected and uninfected Malawian adults

BackgroundUntreated human immunodeficiency virus (HIV) disease disrupts B cell populations causing reduced memory and reduced naïve resting B cells leading to increases in specific co-infections and impaired responses to vaccines. To what extent antiretroviral treatment reverses these changes in an African population is uncertain.MethodsA cross-sectional study was performed. We recruited HIV-uninfected and HIV-infected Malawian adults both on and off antiretroviral therapy attending the Queen Elizabeth Central hospital in Malawi. Using flow cytometry, we enumerated B cells and characterized memory B cells and compared these measurements by the different recruitment groups.ResultsOverall 64 participants were recruited - 20 HIV uninfected (HIV-), 30 HIV infected ART naïve (HIV+N) and 14 HIV-infected ART treated (HIV+T). ART treatment had been taken for a median of 33 months (Range 12-60 months). Compared to HIV- the HIV+N adults had low absolute number of naïve resting B cells (111 vs. 180 cells/μl p = 0.008); reduced memory B cells (27 vs. 51 cells/μl p = 0.0008). The HIV+T adults had B-cell numbers similar to HIV- except for memory B cells that remained significantly lower (30 vs. 51 cells/μl p = 0.02). In the HIV+N group we did not find an association between CD4 count and B cell numbers.ConclusionsHIV infected Malawian adults have abnormal B-cell numbers. Individuals treated with ART show a return to normal in B-cell numbers but a persistent deficit in the memory subset is noted. This has important implications for long term susceptibility to co-infections and should be evaluated further in a larger cohort study.

Epidemiology of Rotavirus Infection in Children in Blantyre, Malawi, 1997–2007

Acute gastroenteritis caused by rotavirus infection is an important cause of morbidity and mortality among infants and young children in Africa. From 1997 through 2007, we enrolled 3740 children <5 years of age with acute gastroenteritis who received hospital care at the Queen Elizabeth Central Hospital in Blantyre, Malawi. Group A rotavirus was detected in fecal specimens by enzyme immunoassay. Rotavirus strains were characterized for VP7 (G) and VP4 (P) types with use of reverse-transcription polymerase chain reaction. Overall, rotavirus was detected in one-third of children. The median age of children with rotavirus gastroenteritis was 7.8 months, compared with 10.9 months for those without rotavirus in stool specimens (P > .001). Rotavirus circulated throughout the year, with the detection proportion greatest during the dry season (from May through October). A total of 15 single rotavirus strain types were detected during the study period, with genotypes P[8]G1, P[6]G8, P[4]G8, P[6]G1, P[8]G3, and P[6]G9 comprising 83% of all strains characterized. Serotype G12 was detected for the first time in Blantyre during the final 2 years of study. Zoonotic transmission and viral reassortment contributed to the rich diversity of strains identified. Current rotavirus vaccines have the potential to greatly reduce the rotavirus disease burden in Malawi, but they will be required to protect against a broad range of rotavirus serotypes in a young population with year-round rotavirus exposure.

Case Report-Right iliac fossa mass in an HIV-positive woman

A 35 year old woman was admitted to Queen Elizabeth Central Hospital (QECH) with fever, abdominal pain and vomiting for 3 days. A week earlier she had started antiretroviral therapy (ART) in a clinical trial in Blantyre, Malawi, after meeting all the requirements of the study. At the time of enrolment, her CD4 count was 19/µl, and viral load >400,000 copies/ml. She was started on a combination of amtricitabine (FTC), tenofivir (TDF) and atazanavir (ATV). At the present admission, she looked ill. Her axillary temperature was 38°C, blood pressure 110/70 mmHg, pulse rate 100/minute, weight 56Kg. The abdomen was tender to touch without any palpable enlarged organs. A full blood count showed a haemoglobin concentration of 9.8g/dl, other parameters being within normal limits. Blood biochemistry and liver function tests were normal. A blood sample for culture was taken which remained sterile after 7 days of incubation. The patient was started on empirical intravenous broad spectrum antibiotic (ceftriaxone 2g once a day) for possible sepsis. Two days later the patient remained ill and examination now revealed a right iliac fossa mass which was tender to touch. A bimanual pelvic examination suggested that the mass was arising from the pelvis. A gynecological review confirmed the findings. An ultrasound of the abdomen and pelvis identified a mass arising from the pelvis but was unable to define the organ of origin. Intravenous metronidazole was added to ceftriaxone. After ten days of antibiotic treatment, there was no clinical response. The gynecologists decided to take the patient for surgical exploration. During the procedure a mass was found affecting the ileocaecal junction and the whole of the ascending colon. The visual findings were suggestive of a carcinoma of the ascending colon with areas of perforation. A hemi-colectomy was done (see figure 1-gross specimen of the colon) Figure 1 Part of the resected tumor The patient remained unwell and died two weeks later in hospital after repeated breakdown of the anastomosis site. A histology report came out two days after the patient died. What is the diagnosis?

Perspectives of patients towards medical students at the Queen Elizabeth Central Hospital, Blantyre, Malawi

Medical students gaining experience in outpatient's clinics and admission wards are exposed to clinical clerkship as this is an important part of their training. There is paucity of reported patients' experiences and perceptions of medical students in low-income settings. The present study was conducted at the Queen Elizabeth Central Hospital (QECH), Malawi to describe patients' and perceptions of, and experience with medical students being present when patients are seen by a medical doctor or students' individual clerking. Participants mostly felt that medical students were compassionate, enthusiastic and helpful to them. The participants' who had been ever clerked by students felt motivated to be present for student learning for altruistic reasons as well as for mutual benefit between student and patient. Patients attending the QECH in Blantyre, Malawi are generally satisfied with the attention and support they obtain from students. Balancing the need for appropriate supervision of students, and facilitating the retention of this patient-cantered approach to care should be maintained.

The Platelet Count in Cerebral Malaria, Is It Useful to the Clinician?

We conducted this study to determine the prognostic significance of the platelet count in children with cerebral malaria. We studied children with cerebral malaria admitted to the pediatric research ward at Queen Elizabeth Central Hospital, Malawi. We analyzed 1,811 children with cerebral malaria and compared them with 521 children with bacterial meningitis. There was a significant difference in platelet counts between children with cerebral malaria and those with meningitis. Among children with cerebral malaria, there was no relationship between the platelet count and either the admission coma score or the eventual outcome. Those with malarial retinopathy were more thrombocytopenic than those without. Our results suggest that the platelet count is not prognostic in Malawian children with cerebral malaria.

Post exposure prophylaxis of HIV transmission after occupational injuries in Queen Elizabeth Central Hospital, Blantyre, Malawi, 2003 – 2008

Health care worker (HCW) in Malawi may acquire HIV infection through occupational injuries, in particular since HIV prevalence among inpatients and incidence of occupational injuries are high. A post exposure prophylaxis (PEP) programme for occupational injuries at Queen Elizabeth Central Hospital (QECH) commenced in 2003. We performed an audit of this programme from 2003 through 2008. 203 Occupational injuries were reported. The majority were needle stick injuries (76.3%). Half of the clients were in a training position. A dual ART regimen was most frequently prescribed. Triple therapy use increased over time and was more frequent in expatriate students. Many nurses and clinical officers were not fully vaccinated for HBV. Based on previous incidence data, occupational injuries were likely to be underreported. Data on side effects were incomplete, however PEP discontinuation due to side effects occurred only twice. Follow up visits were poorly attended, therefore the efficacy of PEP could not be evaluated. Prevention efforts for occupational injuries should be increased and specifically target HCWs in training positions. Measures to improve quality of the PEP programme include effective publicity campaigns, compulsory Hepatitis B vaccination and active tracing of HCWs who default follow up after PEP.

Patients' satisfaction with reproductive health services at Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi.

Patient satisfaction is an individual's state of being content with the care provided in the health system. It is important for reproductive health care providers to get feedback from women regarding satisfaction with reproductive health services. There is a dearth of knowledge about patient satisfaction in Malawi. The specific objective of the study was to determine the extent to which women are satisfied with the care they receive when they come to deliver at the Queen Elizabeth Central Hospital maternity unit. A cross sectional study of postpartum women using interviewer administered semi-structured questionnaires was conducted between November 2008 and May 2009. The questionnaires captured mainly quantitative data. 1562 women were interviewed. Most women were housewives (79%) who were referred from Health Centres within the city. Ninety five percent delivered a live baby. The majority of women (97.3%) were satisfied with the care they received from admission through labour and delivery and the immediate postpartum period. Most women cited doctors' and nurses' reviews (65%) as what they liked most about the care they received during their stay in the unit. Most women expected to receive efficient and definitive care. The women's knowledge on patient's rights was extremely low (16%) and equally very few women were offered an opportunity to give an opinion regarding their care by the doctors and nurses in the maternity unit. Most women who deliver at the hospital are satisfied with the care offered. This satisfaction is mainly due to the frequent reviews of patients by nurses and doctors in the unit. There is a great need to educate both the population of women served and the health workers that serve them on patient's rights.

Ward Round – Cough, painful throat and progressive hoarseness of voice for 1 year

Clinical presentation A 30 year old fisherman was admitted to the medical ward at Queen Elizabeth Central Hospital, Blantyre as a referral from Chikwawa District Hospital with a one year history of cough, painful throat, hoarse voice and difficulty swallowing. The cough was productive of cream colored sputum with no blood staining. There were no relieving or exacerbating factors and there was no diurnal variation in the intensity of coughing. He also had a sore throat and chest pains which were burning in nature. Five months after the onset of the cough he developed hoarseness of voice which became progressively worse. He experienced a “burning sensation” when speaking. Within this period, he also developed pain and difficulties in swallowing both solid foods and water. Dysphagia for fluids started at the same time as dysphagia for solids. Three months prior to admission, the patient noted that there was slight protrusion of his throat which was tender on touch. He also had a sensation of a rough mass in his throat and hence could often clear his throat. He had a history of intermittent night sweats, fevers and weight loss, which he was not able to quantify. He also described dyspnoea on exertion. However, he had normal appetite, no abdominal pains and normal bowel habits. There was no history of ear pain or TB contact. The cough had not responded to Amoxycillin and Erythromycin which had been prescribed by a local health centre in his area. He never smoked nor took any form of alcohol. However, for many years he had worked as a fish smoker. On examination, he was, alert with a fair nutritional status and not in obvious respiratory distress. The conjunctivae were pink and there was no jaundice. There was no finger clubbing. He was afebrile with a temperature of 36.8 °C , pulse rate 80/ min, respiratory rate of 20 breaths/min and a blood pressure of 110/70 mmHg. He had a hoarse voice and was often clearing his throat and coughing. The cough had a “bovine” quality. The uvula was not deviated and there was normal movement of the pharynx, normal sensation in the oropharynx, an intact gag reflex and no stridor was heard. He had bilateral cervical lymphadenopathy in the posterior triangle of the neck. The lymph nodes were mobile, not matted, with sizes ranging from 0.5-2cm in diameter. Bilateral crepitations were heard on chest examination. The cardiovascular and abdominal examinations were unremarkable. Questions 1. Based on the history and examination described above what are the important differential diagnoses to consider? 2. What investigations should be done? The important diagnoses to consider are either; • Malignant process • Infectious process Theresa Allain1, Kondwani Katundu1, Wakisa Mulwafu2 1.Dept of Medicine College of Medicine, University of Malawi 2.Dept of Surgery College of Medicine, University of Malawi

Stroke in Malawi – What do we know about it and how should we manage it?

AB is a 63-year-old tobacco farmer. He lives with his wife together with one of his daughter's family and 4 orphans from his deceased son. He occasionally smokes tobacco leaves. He does not have any regular medication. He was once given propranolol for 2 months owing to his high blood pressure, but it made him very tired. He did not go to get more medication after that. One August morning, he could not get up from his bed, his speech was incomprehensible and he could not move the right side of his body. He was brought to Queen Elizabeth Central Hospital. CD is a 35-year-old mother of 4 living children, 2 other children having passed away. She is a business lady selling vegetables on Chileka road. A month before admission she had had shingles on her chest, however she was an otherwise healthy woman who did not consume alcohol or tobacco products. One afternoon, on the way home she suddenly collapsed. Her daughter accompanied her to Queen Elizabeth Central Hospital.

Diagnosis of cryptococcal and tuberculous meningitis in a resource-limited African setting

Cryptococcal meningitis (CM) and tuberculous meningitis (TBM) are common in HIV-infected adults in Africa and difficult to diagnose. Inaccurate diagnosis results in adverse outcomes. We describe patterns of meningitis in a Malawian hospital, focusing on features which differentiate CM and TBM with the aim to derive an algorithm using only clinical and basic laboratory data available in this resource-poor setting. Consecutive patients admitted with meningitis were prospectively recruited, clinical features were recorded and cerebrospinal fluid (CSF) was examined. A total of 573 patients were recruited, and 263 (46%) had CSF consistent with meningitis. One hundred and twelve (43%) had CM and 46 (18%) had TBM. CM was associated with high CSF opening pressure and low CSF leukocyte count. Fever, neck stiffness and reduced conscious level were associated with TBM. A diagnostic index was constructed demonstrating sensitivity 83%and specificity 79% for the differentiation of CM and TBM. An algorithm was derived with 92% sensitivity for the diagnosis of CM, but only 58% specificity. Although we demonstrate features associated with CM and TBM, a sufficiently sensitive and specific diagnostic algorithm could not be derived, suggesting that the diagnosis of CM and TBM in resource-limited settings still requires better access to laboratory tools.