Graduation - 2022 - December (Open Access)

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    Clinical determinants distinguishing communicating and non-communicating hydrocephalus in childhood tuberculous meningitis at presentation
    (2022-12) Bovula, Siyabulela; Solomons, Regan; Van Toorn, Ronald
    ABSTRACT Introduction: Hydrocephalus occurs in up to 80% of children with tuberculous meningitis (TBM), of which the majority (70-80%) is of a communicating nature. Communicating hydrocephalus develops when cerebrospinal fluid (CSF) obstruction occurs at the level of the tentorium, whilst non-communicating hydrocephalus emanates from basal exudates that obstruct the outflow foramina of the fourth ventricle. Identifying the type of hydrocephalus is of critical importance since communicating hydrocephalus can be medically treated with diuretics whilst non-communicating hydrocephalus requires surgical CSF diversion. Conventional neuroimaging does not allow differentiation of the type of hydrocephalus. In resource-limited settings, air-encephalography is the only investigative modality that allows differentiation.
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    Clinical and laboratory characteristics of ocular syphilis and neurosyphilis among individuals with and without HIV infection
    (2022) Mathew, Dony Korah; Smit, Derrick
    Summary BACKGROUND/AIMS: In the era of increasing incidence of syphilis globally, ocular syphilis is re-emerging as an important cause of uveitis. The aim of this study was to determine the clinical and laboratory characteristics of ocular- and neurosyphilis among individuals with and without HIV infection. METHODS: Retrospective analysis of patients diagnosed with ocular syphilis presenting to Tygerberg Hospital, South Africa, over a 5-year period ending December 2018. RESULTS: Two-hundred-and-fifteen eyes of 146 patients were included. HIV co-infection was present in 52.1% of the patients, with 23.7% of these patients being newly diagnosed on presentation. The median age was 36.5 + 9.8 years. Bilateral involvement occurred in 47.3%; with 68.1% of these patients being HIV positive. The most frequent form of intraocular inflammation was posterior uveitis (40.9%), followed by panuveitis (38.1%); both of which were more predominant in HIV-positive eyes. Seventy-four percent of all eyes had a visual acuity < 20/50 and 40% < 20/200 at presentation. A lumbar puncture was performed in 113 patients (77.4%). Sixteen patients had confirmed neurosyphilis and 27 probable neurosyphilis according to the UpToDate algorithms. CONCLUSION: This study included the largest number of ocular syphilis cases with the largest proportion of HIV infection to date. Forty-three of 146 patients (29.5%) had neurosyphilis. HIV status must be determined in all patients with ocular syphilis since almost ¼ of patients were newly diagnosed with HIV infection by doing so.
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    CXCL13, CXCL10 and CXCL8 as indicators of ocular and neurological involvement in patients with ocular syphilis: An observational descriptive study
    (2022) Van der Merwe, Laurie Wiid; Smit, Derrick
    ABSTRACT Aim To investigate the role of the chemokines CXCL13, CXCL10 and CXCL8 in the diagnosis of ocular‐ and neurosyphilis by examining the serum, aqueous humour (AH) and cerebrospinal fluid (CSF) of patients with ocular syphilis. Methods An observational descriptive study was performed prospectively at Tygerberg Academic Hospital in Cape Town, South Africa from 1 February 2018 till 31 January 2021 which enrolled 23 participants. Upon diagnosis of ocular syphilis, the HIV status of each patient was determined, and 3 samples (AH, serum and CSF) were collected to measure the levels of CXCL13, CXCL10 and CXCL8 in each. Results The mean concentrations of all 3 biomarkers were higher in the AH and CSF than in the serum. The mean concentrations of the 3 measured biomarkers were markedly different when comparing both AH and CSF levels to serum levels. The level of CXCL13 measured in the AH correlated well with the concentrations found in the CSF of patients with neurosyphilis. In patients with neurosyphilis, mean AH levels of CXCL13 and CXCL10 were markedly higher than in serum while mean CSF levels of CXCL10 were also markedly higher than in serum. Also, the AH/serum ratio of CXCL13 and CXCL10, as well as the CSF/serum ratio of CXCL10, was much higher in patients with neurosyphilis than without. In patients with HIV infection, mean AH CXCL13 levels were much higher than in patients without HIV infection. Conclusion The levels of CXCL13, CXCL10 and CXCL8 in the AH of patients with neurosyphilis are similar to previously reported levels in the CSF of patients with neurosyphilis and can potentially be an adjunct in the diagnosis of ocular syphilis. Patients with ocular syphilis who tested negative for neurosyphilis with conventional CSF testing showed features of neurosyphilis when analysing the CSF chemokines.
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    Prevalence of Pathological Neck of Femur Fractures in Patients undergoing Arthroplasty at a Tertiary Referral Hospital
    (2022) Khan, Suhayl Amed; Jordaan, Daniel Jacobus; Burger, Marilize Cornelle
    Abstract Background: This study aimed to determine the prevalence of pathological neck of femur (NOF) fractures at a tertiary referral hospital through histological examination of specimens in all NOF fracture patients undergoing hip arthroplasty. A secondary aim was to determine whether the current practice of sending all femoral heads for histological evaluation, to avoid missing unsuspected malignancies, is financially warranted. Methods: A retrospective folder review of patients who underwent arthroplasty for NOF fractures was conducted. Patients with suspected pathological fractures were managed by the divisional Bone Tumour Unit whilst fragility traumatic fractures were managed by the Arthroplasty Unit. All femoral heads were sent for histological analysis regardless of suspicion of pathological fracture. Quotes from the public and private sector were sought to determine cost implications of sending femoral head specimens for histology Results: A total of 311 patients were included. Of these, 11 patients (3,5%) had suspected pathological fractures, with fragility/traumatic fractures being diagnosed in the remaining 300 patients (96.5%). Histology results were available for 195 patients (62.7%) including all of the patients with suspected pathological fractures. No unexpected malignant histological results were observed whilst 9 of the suspected pathological fracture group had pathological fractures, confirmed with histology. Conclusion: Pathological lesions were identified in 2.9% of patients undergoing arthroplasty for NOF fractures in our population, which is higher than other reports in the literature. Routine histological screening of femoral heads to exclude pathological fracture might not be necessary and cost effective, as pathological lesions can accurately be identified by clinical and radiographic evaluation.
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    Irrigation as Dead Space Management for Fracture Related Type I Intramedullary Chronic Osteomyelitis
    (2022) Grey, Jan-Petrus; Ferreira, Nando; Burger, Marilize Cornelle
    ABSTRACT Introduction: Dead space management following intramedullary debridement and reaming can be challenging and several alternatives have been described. The main objective of this study was to investigate the clinical outcome and resolution rate in patients treated for fracture related Cierny and Mader anatomical type 1 intramedullary chronic osteomyelitis by means of continuous irrigation (modified Lautenbach system) as dead space management following intramedullary reaming. Material and Method: A consecutive series of thirty patients with Cierny and Mader type 1 chronic osteomyelitis, treated between May 2016 and September 2019, were evaluated retrospectively. Patient history and clinical information, including imaging and laboratory results, were reviewed. Treatment procedures and antibiotic profiles were also recorded. Results: The initial cohort included 30 cases with 18 tibias, 11 femurs and one humerus. Seven patients were excluded; three patients did not return for follow up and four patients had less than six months follow up. Of the remaining 23 patients, 91% (21/23) achieved resolution of infection over a median follow up period of 16 months (Interquartile range, IQR 7-21 months). Infecting organisms where isolated in 65% (15/23). The median duration of hospital stay was 6 days (IQR 4-7 days). Post-operative complications were noted in two cases and involved a tibial and femoral refracture, respectively. Both patients however achieved union without recurrence of infection following surgical intervention. Conclusion: Continuous irrigation is a cost-effective single-stage surgical option for dead space management during the treatment of intramedullary chronic osteomyelitis. It provides the advantage of instilling high dose intramedullary antibiotics and negates the need for a second surgical procedure while achieving similar outcomes than other dead space management techniques.