Browsing by Author "Bateman, Kathleen"

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    Cognitive outcomes in adults with HIV-associated Tuberculous Meningitis
    (2017) Albertyn, Christine Herculine; Solms, Mark; Marais, Suzaan; Gouse, Theta; Bateman, Kathleen
    Tuberculous meningitis (TBM) is a common cause of meningitis in adults in South Africa (1-3), second only to cryptococcal meningitis in studies of microbiologically confirmed meningitis, and accounting for 28% of cases in one (1). Conventional diagnostic tests for TBM are, however, relatively insensitive, and the true incidence is likely to be underreported. When both microbiological and clinical diagnostic criteria (4) are used in the same setting, the incidence of TBM rose to 57% (3), emerging as the most common cause of meningitis in adults in a district level hospital in the Western Cape. In the setting of high human immunodeficiency virus (HIV) and tuberculosis (TB) prevalence, approximately 88% of patients with definite or probable TBM are co-infected with HIV (3, 5) and six-month mortality in this group approaches 50% (3). Survivors may be left with long-term disability secondary to hydrocephalus, cranial neuropathies, seizures and strokes (6).
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    Guillain Barre Syndrome (GBS) in Cape Town, South Africa: a descriptive outcomes cohort study
    (2019) Chetty, Sarvani; Bateman, Kathleen
    INTRODUCTION Guillain-Barré syndrome (GBS) or acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is an important cause of acute severe and life-threatening weakness. It occurs worldwide and may affect all age groups, but varies widely in clinical presentation, subtype, electrophysiology, course and outcome. There is sparse literature on GBS in low and middle income countries (LMIC), and the effect, if any, of HIV on GBS. This observational cohort study aims to describe the clinical presentation and outcome of acute GBS in Cape Town, South Africa, in participants recruited into the International Guillain-Barré Syndrome Outcome Study (IGOS). A secondary aim, given the high HIV prevalence in South Africa, is to describe and compare GBS participants with and without HIV infection. METHODS Between 1 June 2014 and 31 January 2017, we recruited participants 18 years or older presenting to Groote Schuur Hospital in Cape Town with acute GBS (< 2 weeks onset of symptoms) who were available for 1 year follow up. We recorded demographic, clinical, laboratory, electrophysiological and treatment data at entry. At follow-up at weeks 4, 26 and 52, GBS-related complications and GBS disability scale scores (GDSs) were evaluated. A good outcome was defined as the ability to walk unaided (GDSs 2) by 6 months. The clinical presentation and outcomes of HIV-uninfected and -infected participants were compared. RESULTS: Of 31 recruited participants, 1 participant was re-diagnosed as acute onset-CIDP and excluded from the study and 1 participant demised of an unrelated cause within the first week. 19 participants were male and the median age was 40 years. Reported antecedent infections (73%), co-morbid HIV infection (30%) and tuberculosis (15%) were frequently seen. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP; 67%) and acute motor axonal neuropathy (AMAN; 17%) were the most common phenotypes. Overall, GBS-related complications occurred in 46% of participants. The major complication was pneumonia which occurred in 23% of the total group, and all required intubation/ventilation. Other septic complications (drip site or systemic) were less common, 6% of the entire group. At entry, 83% had GDSs >4 indicating severe disability. The ability to walk unaided was regained by 37% at 4 weeks, 75% at 6 months and 79% at 1 year. Three participants remained severely affected at 1 year (GDSs of >3). There were no differences in antecedent infections, treatments given, or motor outcomes between HIV-infected and -uninfected GBS participants apart from a trend towards higher CSF protein in the HIV-infected group (p-value 0.05). AIDP was the most common GBS variant in both groups. AMAN was only seen in the HIV-uninfected group, whereas Miller Fisher 5 syndrome (MFS) was more common in the HIV-infected group. However, the numbers were too small to reach statistical significance. CONCLUSION Infections with HIV and tuberculosis frequently co-occurred with acute GBS, whether this reflects true disease association or merely high background disease prevalence cannot be confirmed by this study. AIDP is the most common phenotype unlike other LMIC regions such as Asia where AMAN predominates. In this cohort, 76% of participants showed good outcomes being able to walk unaided or having no/minor symptoms by 6 months. However, of the remainder only 1 showed significant recovery at 1 year. HIV participants had similar clinical presentations, complications and outcomes compared to the HIV-uninfected group. Mortality was low.
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    Outcomes of mechanical thrombectomy at a single-centre tertiary level public health care hospital in South Africa
    (2025) Kiriinya, Martin; Taylor, Allan; Bateman, Kathleen; Le Feuvre, David
    Introduction: Mechanical thrombectomy (MT) is standard of care for acute ischemic stroke from large vessel occlusion following randomized controlled trials performed largely in high-income countries. Limited data exists on its effectiveness in the real-world setting, particularly in low- and middle-income countries. We aimed to evaluate the safety and efficacy of MT in a public hospital in Cape Town, South Africa. Methods: We evaluated acute ischaemic stroke patients presenting consecutively to Groote Schuur Hospital between 01 January 2018 to 01 January 2022 with proximal intracranial occlusion in the anterior circulation treated with MT within 6 hours from onset using CT and CTA imaging-based protocols. Demographic, clinical, radiological and procedural data were obtained from the stroke unit database. Recanalization was evaluated post-procedure by modified Treatment in Cerebral Infarction score (mTICI). We assessed functional independence (modified Rankin scores (mRS) 0-2) and mortality at 90 days. Results: Thrombectomies were performed in 84 patients during the study period. The median age was 56 years and 51% of participants were female. Median National Institute of Health Stroke Score was 18 and median baseline Alberta Stroke Programme Early CT score was 8. Bridging thrombolysis was given to 65% of participants. Median time from symptom onset to reperfusion was 339 minutes. Successful recanalization (mTICI 2b/3) was obtained in 62%. At 90 days, 34 % of participants reached functional independence and mortality was 34% . Conclusions: We achieved similar rates of recanalization and functional independence to that seen in trials in high-income countries using basic imaging despite a higher mortality and longer median time to reperfusion. These data support the effectiveness of MT in a public hospital in south Africa despite the challenges of providing emergent stroke care in a resource-constrained setting.
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    A single-blinded trial of methotrexate versus azathioprine as steroid-sparing agents in generalized myasthenia gravis
    (BioMed Central Ltd, 2011) Heckmann, Jeannine; Rawoot, Amanullah; Bateman, Kathleen; Renison, Rudi; Badri, Motasim
    BACKGROUND:Long-term immunosuppression is often required in myasthenia gravis (MG). There are no published trials using methotrexate (MTX) in MG. The steroid-sparing efficacy of azathioprine (AZA) has been demonstrated after 18-months of starting therapy. However, AZA is considered expensive in Africa. We evaluated the steroid-sparing efficacy of MTX (17.5 mg weekly) compared with AZA (2.5 mg/kg daily) in subjects recently diagnosed with generalized MG by assessing their average monthly prednisone requirements. METHODS: The primary outcome was the average daily prednisone requirement by month between the two groups. Prednisone was given at the lowest dose to manage MG symptoms and adjusted as required according to protocol. Single-blinded assessments were performed 3-monthly for 2-years to determine the quantitative MG score and the MG activities of daily living score in order to determine those with minimal manifestations of MG. RESULTS: Thirty-one subjects (AZA n = 15; MTX n = 16) satisfied the inclusion criteria but only 24 were randomized. Baseline characteristics were similar. There was no difference between the AZA- and MTX-groups in respect of prednisone dosing (apart from months 10 and 12), in quantitative MG Score improvement, proportions in sustained remission, frequencies of MG relapses, or adverse reactions and/or withdrawals. The MTX-group received lower prednisone doses between month 10 (p = 0.047) and month 12 (p = 0.039). At month 12 the prednisone dose per kilogram bodyweight in the MTX-group (0.15 mg/kg) was half that of the AZA-group (0.31 mg/kg)(p = 0.019). CONCLUSIONS: This study provides evidence that in patients with generalized MG methotrexate is an effective steroid-sparing agent 10 months after treatment initiation. Our data suggests that in generalized MG methotrexate has similar efficacy and tolerability to azathioprine and may be the drug of choice in financially constrained health systems.TRIAL REGISTRATION:SANCTR:DOH-27-0411-2436
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    The viral protein R in HIV-associated acute ischaemic stroke: a case-control study
    (2021) McMullen, Kate; Bateman, Kathleen
    Background: HIV-1 viral proteins have been implicated in endothelial dysfunction, which is a major determinant of ischaemic stroke risk in HIV-infected individuals. Polymorphisms in HIV-1 viral protein R (Vpr) may alter its potential to promote endothelial dysfunction, by modifying its effects on viral replication, reactivation of latent cells, upregulation of proinflammatory cytokines and infection of macrophages. Methods: We analysed Vpr polymorphisms and their association with acute ischaemic stroke by comparing Vpr signature amino acids between 54 HIV-infected individuals with acute ischaemic stroke, and 80 age-matched HIV-infected non-stroke controls. Results: Isoleucine at position 22 and serine at position 41 were associated with ischaemic stroke in HIV. Individuals with stroke had lower CD4 counts and CD4 nadirs than controls. These polymorphisms are more common in individuals with stroke compared to South African subtype C and the control group consensus sequences. Conclusions: Signature Vpr polymorphisms have been identified that are more common in people with acute ischaemic stroke in HIV compared to HIV-infected individuals without acute ischaemic stroke. These may be involved in increased stroke risk by promoting endothelial dysfunction and susceptibility to opportunistic infections, as well as more advanced HIV disease. Therapeutic targeting of HIV-1 viral proteins may present an additional mechanism of decreasing stroke risk in HIV-infected individuals.
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    The utility of CSF PCR in central nervous system Varicella zoster infection in HIV
    (2015) Stanley, Alan Michael; Bryer, Alan; Bateman, Kathleen
    Aims: To assess the clinical and cerebrospinal fluid characteristics, and the role of tuberculous meningitis (TBM) as a confounder, in a cohort of HIV positive individuals with positive varicella zoster virus (VZV) positive cerebrospinal fluid PCR. Methods: Patients in the NHLS database at Groote Schuur Hospital with positive CSF VZV PCR who were also HIV co-infected and whose folders were available for clinical review were reviewed. Clinical and biochemical data were collected. Patients were divided into two groups based an accepted case definition for TBM. Differences between groups were assessed using Mann-Whitney U or Chi squared tests as appropriate. Results: There were 437 for VZV PCR over three years. Of these 98 were positive and, after exclusions, 31 HIV positive patients were included for further analysis. Median age was 31 and median CD4 count was 146 cells/mm³. 11 (35%) had meningitis and 8 (25%) had encephalitis. 13 (42%) met the case definition for TBM. Patients with CNS varicella were frequently confused whereas those with TBM presented sub-acutely. There were no differences in CSF characteristics. Additional organisms were detected 6 (19%) patients. 4 (13%) patients died in hospital. CSF TB culture was requested in 24 (77%) patients and extra CNS samples were sent in only 4 patients. Conclusion: The clinical and CSF presentation of CNS Varicella and TBM overlap and in this cohort patients were under investigated for TB. In settings of high TB prevalence the possibility of false positive PCR or incidental varicella reactivation should be considered.