University of Zambia Medical Library

AIDS-Related Complexes -- ARCs (AIDS in Zambia Bibliography #53-67)

(#53) "Aggressive Kaposi's Sarcoma in Zambia, 1983"
Bayley, A.C. (1984) The Lancet, June 16th, pp 1318-1320
Geographical area: Lusaka; Key words: Kaposi's sarcoma, chemotherapy; Location: UNZA Medical Library

From 1975 to 1982 between 8 and 12 new cases of Kaposi's sarcoma (KS) were seen each year in Lusaka, Zambia, and the clinical presentation and rumour behaviour conformed to descriptions of endemic KS from Uganda and Kenya. 23 patients presented with KS in 1983, 10 men, mean age 41, presented with typical symptoms and signs (modules or plagues on oedematous limbs, with florid tumours or woody infiltration) and all 10 patients responded promptly to actinomycin D and vincristine. 13 patients (10 men and 3 women), mean age 27, presented with unusual symptoms and signs, including generalised symmetrical lymphadenopathy, oral or gastrointestinal lesions, respiratory distress, gross weight loss, and absence of nodules or plagues on the limbs. 8 of 13 patients with atypical KS failed to maintain an initial response to chemotherapy and died before the end of 1983, but there were no deaths amongst patients with endemic disease.

(#54) African Kaposi's Sarcoma and AIDS
Downing, R.G., Eglin, R.P., Bayley, A.C. (1984) The Lancet, March 3rd, pp 478-480.
Geographical area: Lusaka; Key words: Kaposi's sarcoma, cytomegalovirus; Location: UNZA Medical Library

16 Zambian patients with Kaposi's sarcoma (KS) were studied to determine whether they had evidence of lymphopenia with decreased T helper/T suppressor ratios or previous infection with opportunistic infections. Serological tests for viruses commonly associated with AIDS were also carried out. 12 patients had a decreased TH/Ts and 2 of these were also lymphopenic. Serological evidence for infection with Toxoplasma and with Pneumocystis was present but this was not significantly more common in KS patients than in controls. All 16 patients had antibodies to cytomegalovirus (CMV), 15 had antibodies to Epstein-Barr virus and 13 to human T lymphotropic virus (HTLV) infected cells. Five patients had evidence of previous infection with hepatitis B virus. African patients with KS seem to have an immunological and virological profile similar to that seen in American patients with AIDS.

(#55) HTLV-III serology distinguishes atypical and endemic Kaposi's Sarcoma in Africa
Bayley, A.C., Cheingsong-Popov, R., Dalgleish, A.G., Downing, R.G., Tedders, R.S. et al., (1985) The Lancet, 16 Feb, p132.
Geographical area: NA; Key words: Kaposi's sarcoma; Location: UNZA Medical Library

Serum samples from African patients with Kaposi's sarcoma and AIDS-related disorders and from normal subjects in Uganda and Zambia were tested for antibodies to the human T-lymphotropic retroviruses (HTLV) types I, II, and III. Nearly 90 per cent of patients with AIDS-related disorders or with atypical, aggressive Kaposi's sarcoma were seropositive. Among the controls 20 per cent were seropositive for HTLV-III in both countries, whereas only 17 per cent of patients with classic endemic Kaposi's sarcoma were seropositive. Among the controls 20 per cent were seropositive for HTLV-III in Uganda but only 2 per cent in Zambia. None of the subjects tested had antibodies to HTLV-I or HTLV-II. These results are further evidence of the emergence of a clinically atypical form of Kaposi's sarcoma in Africans, which resembles that seen in American patients with AIDS, and which is associated with HTLV-III infection. The low frequency of antibodies to HTLV-III in the normal Zambian population together with the first appearance of HTLV-III-associated diseases during the past 2 years suggests that this virus is new to Zambia, although it may have been present in Uganda for longer.

(#56) HTLV-III antibody positivity in Zambian Copperbelt
Buchanan, D.J., Downing, R.G., Tedder, R.S. (1986) The Lancet, Jan 18, p 155.
Geographical area: Copperbelt; Key words: Kaposi's sarcoma, surveillance; Location: UNZA Medical Library

Studies in Lusaka have shown that an aggressive form of Kaposi's sarcoma (KS) in Zambia is linked to an infection by the AIDS virus (HTLV-III/LAV). We have looked at the HTLV-III status in the normal population living in the Copperbelt. Sera were collected over a period of three months and tested using ELISA. HTLV-III appears to be endemic in the Copperbelt. Both the students (3/28, 11 per cent) and the ZCCM staff (6/29, 21 per cent) regarded themselves as healthy. The sample taken at random at the Konkola Mine Hospital (6/44, 14 per cent) were from patients presenting with a variety of diseases and complaints not obviously associated with AIDS. The virus does not seem to have infected a population of prisoners (0/24), who are physically separated from the natural community: however, only 24 such sera have been tested. The results of this small survey contradict earlier studies in Zambia. This may be due to a rapid increase in the background prevalence of the AIDS virus in the normal population or, more likely, to sampling error associated with patchy distribution of the virus in a recently infected community.

(#57) Evidence for the heterosexual transmission and clinical manifestations of human immuno-deficiency virus infection and related conditions in Lusaka, Zambia
Melbye, M., Bayley, A.C., Manuwele, J.K., Claydon, S.A., Blattner, R. et al., (1986) The Lancet, 15 Nov p?
Geographical area: Lusaka; Key words: Surveillance; Location: UNZA Medical Library

In a hospital-based survey in Lusaka, Zambia, 189 (17.5 per cent) of 1078 subjects had HIV. The prevalence of antibodies was low in subjects aged <20 or >60 years; in men the peak prevalence (32.9 per cent) occurred in those aged 30-35 years, and in women (24.4 per cent) it occurred in the 20-25 year age-group. There was no significant difference in prevalence by sex after adjusting for age. High educational level was independently associated with HIV seropositivity; HIV antibodies were found in 18.4 per cent of blood donors and in 19.0 per cent of hospital workers. Among patients the antibody prevalence ranged from 8.7 per cent in antenatal women and 9.3 per cent in orthopaedic patients to 29.2 per cent in those attending sexually transmitted disease (STD) clinics (the prevalence being 37.3 per cent in previous attenders and 22.8 per cent in first-time attenders). Seropositivity rates were higher in patients with an infectious problem (23.4 per cent) than in those without (11.4 per cent, p=0.0002). Herpes zoster, oral thrush, diarrhoea, tuberculosis, and weight loss were independently correlated with seropositivity. The data strongly suggest that HIV infection is prevalent in Africa and is transmitted heterosexually. The restricted distribution of seropositivity to the sexually active age-groups indicates that the epidemic, at least in this part of Africa, is newly introduced; this has substantial implications for prevention.

(#58) HIV seroprevalence in clinically ill patients in Zambia
Watters D.et al. (1988), AIDS, Vol. 2, No. 2, 1988, (letter).
Geographical area: Lusaka; Key words: Surveillance, blood transfusion; Location: UNZA Medical Library

The following is a report of HIV seroprevalence rates in clinically ill patients in Zambia and the influence of HIV positivity on outcome. Three hundred and ninety-six patients admitted to the intensive care unit between 21 January 1986 to 20 January 1987 were tested for HIV positivity using a competitive immunoassay (Wellcozyme) for the detection of antibodies to HIV. The intensive care unit caters for adult patients and paediatric trauma. Only one patient who was known to have AIDS and two with upper airway obstruction (later shown to have tonsillar KS) were admitted. All blood transfusions were screened from 28 April 1986. The introduction of screening did not alter the seropositivity rates. Forty-three out of 240 males were seropositive (17.9 per cent) and 38 out 156 females (24.3 per cent). There was no significant difference between males and females. The highest seropositive rates were in the 21-30 (28 per cent) and 30-40 (25 per cent) age groups. There was a significant difference between septic (46.1 per cent) and non-septic (17.9 per cent) obstetric and gynaecology patients (x =6.03; p < 0.01). Forty-one out of 81 seropositive patients died in hospital (50.5 per cent) compared with 138 of the 315 seronegative patients (43.8 per cent). This was not statistically significant. There was a significant correlation between HIV seropositivity and the need for blood transfusion during the management of the critical illness (x2 =8.37; p < 0.001). Twenty-eight out of 69 seropositive patients (40.5 per cent) required transfusion, compared to 45 out of the 208 seronegative patients (21.8 per cent). Conclusion: Suppressor T-cell ratios might, in the future define a group of acutely ill patients who do badly. At present, however, all acutely ill patients should be treated in the same way, regardless of HIV status. There is no justification for withholding treatment for previously healthy patients who happen to be HIV-positive. Further follow-up of the patients over a 2-3 year period would provide evidence as to whether the acute illness might adversely affect the balance between the patients and their retrovirus infection, such as occur in pregnancy. The positive correlation between HIV infection and gynaecological sepsis is alarming. This may occur as a result of lifestyle which affords more opportunity to contract infection, or because acquired immunodeficiency may predispose patients to overwhelming sepsis.

(#59) Cutaneous Manifestations of Human Immunodeficiency Virus in Lusaka, Zambia
Hira, S.K. (1988) Journal of American Academic Dermatology; Vol l9(3); 1988 pp 451-7
Geographical area: Lusaka; Keywords: Tuberculosis, AIDS-related complexes; Location: UNZA Medical Library

Of the 1124 human immunodeficiency virus (HIV)-infected patients studied, one or more cutaneous lesions were found in 113 (8.3 per cent) of the 115 patients with acquired immunodeficiency syndrome (AIDS) and in 541 (53.6 per cent) of 1009 patients with AIDS-related complex (ARC). Kaposi's sarcoma, multidermatomal, necrotic herpes zoster, and pruritic maculopapular rashes are common cutaneous manifestation of AIDS and its related complexes (ARC) in Zambia. The maculopapular rash results from a lymphoplasmacytic antiitis in the dermis, possibly in response to the presence of HIV in the dermis. Candidiasis, severe genital herpes, extensive molluscum contagiosum, and tinea corporis were less frequent and usually refractory to treatment. Drug reactions are also frequent in Zambians with AIDS. In seven patients given streptomycin, thiacetazone, and rifampicin for treatment of pulmonary tuberculosis, Stevens-Johnson syndrome occurred shortly after therapy was begun, and two died despite high-dose prednisone and discontinuance of tuberculosis therapy. Extensive seborrhoeic dermatitis refractory to tropical fluorinated corticosteroids is also an association condition in AIDS patients who have pulmonary tuberculosis.

(#60) AIDS and AIDS-related complexes (ARC) in twenty Zambians with Sickle-cell anaemia
Fleming, A.F. (1988) The Central African Journal of Medicine, Vol 34, pp 70-72
Geographical area: NA; Keywords: AIDS-related Complex, Sickle-cell anaemia, blood transfusion; Location: UNZA Medical Library

Twenty Zambians with Sickle-cell anaemia (SCA) presented with generalised lymphadenopathy and other signs suggestive of AIDS. All had previously received transfusions of blood untested for antibodies against HIV. All were found to have antibodies. Three are known to have died within 10 months of diagnosis. Patients with CSA form a major group at risk for HIV infection through transfusion. The first step in prevention is to maintain the health of the patients, so avoiding the need to transfuse blood, and a call is made for the development of Sickle-cell Clinics. Secondly, blood transfusion should be confined to only those patients in danger of dying of anaemic heart failure. These two steps should be taken, even when blood donors are screened for HIV.

(#61) Relation between falciparum malaria and HIV seropositivity in Ndola, Zambia
Simooya, O.O., Mwendapole, R.M., Siziya, S., Fleming, A.F. (1988) British Medical Journal, 297, pp 30-31.
Geographical Area: Ndola; Keywords: Malaria; Location: UNZA Medical Library

Objective:
To determine whether infection with HIV increases the risk or severity of infection with falciparum malaria in patients aged 12 and above.

Method:
The study was conducted at the Ndola Central hospital in January 1987. Patients aged 12 and above with symptoms suggestive of malaria were included. Symptoms included fever, chills, rigors, headaches, vomiting, joint pains, myalgia, and acute diarrhoea. None had manifestations of AIDS. Each patient was screened for malaria parasitaemia (determined by examining blood films with Giemsa under a light microscope and titres of antibody to Plasmodium falciparum by an indirect fluorescent antibody technique), specific malaria antibodies, and HIV antibody (determined with the Wellcozyme immunoassay). All serum samples that gave positive results were retested, and if positive results were found again the samples were tested in ELISA that used a bacterially synthesised polypeptide homologous with a hybrid of p24 and gp41 as antigen. Altogether 172 patients were studied. Two infected with P malariae were excluded from the analysis.

Results:
Of the 170 patients analysed (107 males, 63 females), 67 (39 per cent, 95 per cent confidence interval 32.06 to 46.75) had falciparum malaria. 28 (18 males, 10 females) (17 per cent, 95 per cent confidence interval 10.80 to 22.04) were positive for HIV antibody. Parasitaemia was less common among those with HIV antibodies than among those without (8 out of 28 [29 per cent] v 59 out of 142 [42 per cent], respectively), but the difference was not significant.
The loge mean parasite density in blood slides showing parasitaemia was higher in patients who were negative for HIV antibody than for those who were positive for HIV antibody, but the difference was not significant. 3. Sixty three of the 67 (94 per cent) patients with parasitaemia and 74 of the 103 (72 per cent) without had considerable antibody titres to P falciparum. No significant differences existed in antibody titres to P falciparum in patients who were positive for HIV antibody and in those who were negative whether or not they had parasitaemia.

Conclusions:
There is no cross-reaction between the antibody to P falciparum by the indirect fluorescent antibody technique and the HIV antibody by the Wellcozyme immunoassay associated with malarial parasitaemia. Many patients with HIV infection may be presenting with an illness similar clinically to malaria before AIDS-related complex or AIDS is recognisable.

(#62) Pneumocystis Carinii is not a major cause of pneumonia in HIV infected patients in Lusaka, Zambia
Elvin, K.M., Lumbwe, C.M., Luo, N.P., Bjorkman, A., Kallenius, G., et al. (1989) Transactions of the Royal Society of Tropical Medicine and Hygiene Vol.83(4);1989; pp 553-5
Geographical area: Lusaka; Keywords: Pneumonia, pneumocystis carinii, TB; Location: UNZA Medical Library

The clinical occurrence of Pneumocystis carinii and Mycobacterium tuberculosis was investigated in patients infected with human immunodeficiency virus (HIV) who had clinical pneumonia of unknown aetiology in Lusaka, Zambia. The results were compared with a similar group of patients in Stockholm, Sweden. Induced sputum samples were stained for Pneumocystis by indirect immunofluorescence using monoclonal antibody 3F6 and toluidine blue O. Mycobacterial culture and acid fast stain were performed on the specimens from Lusaka. P. carinii cysts were detected in none of 27 Lusaka patients, compared to 10 of 33 Stockholm patients. M. tuberculosis was identified in 11 of 22 Lusaka patients tested. In conclusion, P. carinii could not be incriminated as the aetiological agent of HIV-associated pneumonia in Zambia in contrast to the situation in Sweden, where pneumocystis is the dominating aetiological agent.

(#63) Management of Empyema Thoracis at Lusaka, Zambia
Desai, G.A., Mugala, D.D. (l989) British Journal of Surgery; Vol.79();; Pg: 537-538
Geographical area: Lusaka; Key words: Empyema thoracis; Location: UNZA Medical Library

Of the 39 consecutive patients with empyema thoracis managed by one of the five general surgical units at Lusaka, Zambia, 26 suffered from human immunodeficiency virus (HIV) infection and 19 were diagnosed as suffering from pulmonary tuberculosis within 3 years of developing empyema thoracis. Thirty patients were between 10 and 16 years of age. Of these, 22 suffered from acquired immune deficiency syndrome (AIDS) and all 19 patients with pulmonary tuberculosis belonged to this age group. Of the four patients with empyema thoracis in the age group of 0-5 years, two were suffering from AIDS. The majority of cases of empyema thoracis associated with AIDS present insidiously and, because of late presentation, rib resection is necessary. After surgery these patients were managed at home with the help of a home care team, thus reducing the burden on hospital resources. The morbidity and mortality rates in these patients are higher than in those in whom empyema thoracis is not associated with AIDS. Mortality rates in these patients are higher than in those in whom empyema thoracis is not associated with AIDS.

(#64) Faecal mycobacteria and their relationship to HIV-related enteritis in Lusaka, Zambia
Conlon, C.P., Banda, H., Luo, N.P., Namaambo, M.K.M., Perera, C.U., et al. (1989) AIDS; Vol.3(8); 1989; pp 539-41
Geographical area: Lusaka; Key words: Mycobacteria, diarrhoea, enteropathy; Location: UNZA Medical Library

The prevalence of infection with mycobacteria, both typical and atypical, is increasing along with prevalence of infection with HIV. Patients with pulmonary tuberculosis (PTB) and patients with chronic diarrhoea are forming a growing proportion of the patient population in hospital in central Africa. To investigate the possibility that mycobacteria may be responsible for some of the HIV-related enteropathy seen in Lusaka, 89 patients in four different diagnostic groups were clinically studied by Mantoux test and by microscopy and culture of stool specimens for mycobacteria. In the HIV-positive group with chronic diarrhoea (n = 3l), two patients were found to have mycobacteria on faecal smear and three were culture positive. Of the 15 patients with proven PTB, three had positive faecal smears but none were culture positive. In the fourth group of 24 patients with suspected PTB, seven were smear positive and five, culture positive. Only in this last group was there some correlation between smear results and culture results. Although this last finding is difficult to explain, it appears that there is no correlation between the symptom of chronic diarrhoea and the presence of mycobacteria in the stool. The conclusion is that mycobacteria do not play a significant role in the pathogenesis of HIV-related enteropathy in Lusaka.

(#65) Prevalence of HIV infection among patients with leprosy and tuberculosis in rural Zambia
Meeran, K., (1989) British Medical Journal, 298, pp. 364-365.
Geographical area: Chikankata, Southern Province; Key words: Leprosy, tuberculosis; Location: UNZA Medical Library

Objectives:
To find out whether an association between leprosy and HIV infection exists similar to that shown for tuberculosis. Methods: The study comprised subjects presenting with leprosy and tuberculosis to a rural hospital in Zambia in December 1987. Blood donors and surgical patients were also included in the study. A full history was taken from the patients about the onset of symptoms and progression of the disease. Personal details such as age, sex and area of residence were also recorded. Venous blood samples were allowed to clot and the serum separated by centrifugation. Antibodies to HIV were detected with Wellcozyme VK competitive ELISA. All tests that did not give an obvious negative result were repeated on another sample of blood taken from the patient at least one week later. Thus all positive results were confirmed. In addition, many samples were retested with both the Fujirebio HIV agglutination assay (in which agglutination indicated a positive result) and Elavia (non-competitive ELISA) kit.

Results:
Of the 18 new patients with leprosy, 6 (33 per cent) were positive for HIV antibody. Of 54 with suspected tuberculosis, 27 (50 per cent) were positive for HIV antibody. 18 of the 54 had active pulmonary tuberculosis, with results of smears of sputum positive for acid fast bacilli, and 8 of these (44 per cent) were also positive for HIV antibody. By comparison, only 7 out of 63 blood donors (11 per cent) and 2 out of 42 surgical patients (5 per cent) were positive for HIV antibody.
The prevalence of HIV infection was significantly higher for patients with leprosy than among blood donors (p<0.05) or for surgical patients (p<0.01). Some patients came from Lusaka, which may have a higher prevalence of HIV infection than rural Zambia. When the analysis was restricted to rural residence, patients with leprosy still had a higher prevalence of HIV infection than surgical patients or blood donors (p<0.001). Conclusions: As with tuberculosis, there may be an association between leprosy and HIV infection, which would have serious implications for programmes to control leprosy.

(#66) HIV infection presenting as Guillain-Barre syndrome in Lusaka, Zambia
Conlon, C. (1989) Transactions of the Royal Society of Tropical Medicine and Hygiene, 83, p109.
Geographical area: National; Keywords: Guillain-Barre Syndrome; Location: UNZA Medical Library

Objective:
To report of 3 cases of ascending polyneuritis (Gullain-Barre syndrome) presenting to the University Teaching Hospital in Lusaka, Zambia, for whom the common aetiological cause appears to be infection with HIV.

Methods:
Detailed case studies of 3 patients admitted to the UTH.

Results:

• Case 1: A 28-year-old female presented with a 2 day history of weakness starting in the lower limbs and moving to the upper limbs. There was a vague history of diarrhoea 2 weeks before admission but otherwise she had been previously well. On admission she had no lymphadenopathy and had no sign of opportunistic infection. There was a left facial nerve palsy and she had lower motor neurone weakness of both legs (grade 3 on the left and grade 4 on the right) and similar weakness of both upper limbs (grade 3/4 on the left and grade 4 on the right). Reflexes were absent and sensation was intact. Routine biochemistry and haematology were normal. Cerebrospinal fluid (CSF) showed no cells and no organisms. CSF protein was 0.39 g/litre and CSF sugar was 4.5 mmol/litre (blood sugar 7.2 mmol/litre). Both serum and CSF were positive for HIV antibody with Wellcozyme ELISA. The Venereal Disease Research Laboratory (VDRL) test was negative. Her weakness progressed and required assisted ventilation the day after admission for 5 weeks but she died from an overwhelming bronchopneumonia. A postmortem examination was not done.
• Case 2: A 19-year-old female was admitted with a week's history of gradually increasing weakness starting in the lower limbs and ascending to the upper limbs. She had been previously been well. On examination there no signs suggesting immunosuppression and there was no lymphadenopathy. She had a left facial nerve palsy and severe lower motor neurone weakness of the upper and lower limbs (grade 0 in both lower limbs and grade 1 in the upper limbs). Routine blood tests were normal. Examination of the CSF showed no cells and no organisms. The CSF protein was 1.1 g/litre and the sugar was 3.4 mmol/litre (blood sugar 6.4 mmol/litre). The serum and CSF were positive for HIV antibody. The VDRL test was negative. Her condition slowly improved but after several weeks she was taken home prematurely by relatives and lost to follow-up.
• Case 3: A 29-year-old female admitted with a week's history of weakness beginning in the lower limbs and rising to the upper limbs. She had previously been healthy. On examination she had a right facial nerve palsy and a partial left third nerve palsy. There was lower motor neurone weakness in the upper and the lower limbs (grade 3/4 in the upper and grade 2/3 in the lower limbs). Routine blood test were normal. CSF examination revealed no cells or organisms and the CSF protein was 0.1 g/litre with a sugar of 3.8 mmol/litre (blood 6.1 mmol/litre). Serum and CSF were both positive for HIV antibody but the VDRL test was negative. Her weakness gradually improved so that after one month she was able to walk with the support of one person and was discharged.

Conclusions:

• These 3 patients all presented with clinical features suggestive of Guillain-Barre syndrome and only one had a brief prodromal diarrhoeal illness.
• All 3 patients had antibody to HIV detectable in both serum and CSF but had no clinical feature of immunosuppression.
• Since there is evidence of the formation of HIV antibody within the central nervous system, it is likely that HIV was directly responsible for the neurological disease in these patients.

(#67) The Aetiology of Severe Anaemia in Pregnancy in Ndola, Zambia
Fleming, A.F. (1989) Annals of Tropical Medicine and Parasitology: Vol.83(1); pp 37-49.
Geographical area: Ndola ; Key words: Pregnancy, malaria; Location: UNZA Medical Library

The aetiology of severe anaemia (haemoglobin, 7.Og dl-l) has been studied in 37 pregnant Zambians. Aetiology was usually multiple; 31 (84 per cent) had plasmodium falciparum malaria, 23 (62 per cent) were folate deficient, 13 (35 per cent) were iron deficient, one had sickle-cell anaemia and one had the acquired immunodeficiency syndrome (AIDS). Folate deficiency was most often secondary to malarial while atmolysis iron deficiency was nutritional. Hookworm was a contributory in about one-third of patients. Anaemia due to malaria and folate deficiency was both more common and more severe than anaemia due to iron deficiency. Vigorous antimalarial treatment and prophylaxis are essential in the management and prevention of anaemia in pregnancy.

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