Browsing by Author "Burton, Rosie"

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    Cryptococcal immune reconstitution inflammatory syndrome presenting with erosive bone lesions, arthritis and subcutaneous abscesses
    (2009) Burton, Rosie; Gogela, Neliswa; Rebe, Kevin; McNally, Matt; Meintjes, Graeme
    A 35-year-old South African man was diagnosed with pulmonary tuberculosis (TB) in August 2007 and started on a 6-month course of treatment (intensive phase of rifampicin, isoniazid, ethambutol and pyrazinamide for 2 months, followed by continuation phase of rifampicin and isoniazid for 4 months). His TB symptoms responded rapidly. At the time of TB diagnosis, he tested HIV positive. His CD4 cell count was 12 cells/µl with a viral load of more than 500 000 copies/ml. He commenced antiretroviral therapy (ART) 6 weeks later (stavudine, lamivudine and efavirenz). After 16 weeks on ART, his CD4 cell count was 62 cells/µl with an HIV viral load of less than 50 copies/ml. Five months after starting ART and having recently completed his TB treatment, he presented to his local clinic with pain and swelling of the left hypothenar eminence. He was referred to the specialist Hand Clinic, and incision and drainage was performed. Ten days later, this was repeated due to recurrence of symptoms. He experienced no further problems, and remained compliant on ART. Six months later, he presented to our hospital for the first time with tender red subcutaneous abscesses over his sternal notch (Fig. 1a) and in his left flank. His left elbow was swollen, red and extremely painful, with a severely restricted range of movement. A radiograph of the left elbow showed a lytic lesion in the posterior periarticular aspect of the humerus and erosion of the proximal end of the radius with loss of joint space (Fig. 1b). A chest radiograph showed a pulmonary infiltrate in the base of the left lung and erosive lesions in the left 5th and 6th ribs on the lateral film (Fig. 1c). Six weeks prior to this presentation, his CD4 cell count had been 81 cells/µl, and viral load less than 50 copies/ml.
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    Rapid microbiological screening for tuberculosis in HIV-positive patients on the first day of acute hospital admission by systematic testing of urine samples using Xpert MTB/RIF: a prospective cohort in South Africa
    (2015-08-14) Lawn, Stephen D; Kerkhoff, Andrew D; Burton, Rosie; Schutz, Charlotte; van Wyk, Gavin; Vogt, Monica; Pahlana, Pearl; Nicol, Mark P; Meintjes, Graeme
    Abstract Background Autopsy studies of HIV/AIDS-related hospital deaths in sub-Saharan Africa reveal frequent failure of pre-mortem diagnosis of tuberculosis (TB), which is found in 34–64 % of adult cadavers. We determined the overall prevalence and predictors of TB among consecutive unselected HIV-positive adults requiring acute hospital admission and the comparative diagnostic yield obtained by screening urine and sputum samples obtained on day 1 of admission with Xpert MTB/RIF (Xpert). Methods To determine overall TB prevalence accurately, comprehensive clinical sampling (sputum, urine, blood plus other relevant samples) was done and TB was defined by detection of Mycobacterium tuberculosis in any sample using Xpert and/or mycobacterial liquid culture. To evaluate a rapid screening strategy, we compared the diagnostic yield of Xpert testing sputum samples and urine samples obtained with assistance from a respiratory study nurse in the first 24 h of admission. Results Unselected HIV-positive acute adult new medical admissions (n = 427) who were not receiving TB treatment were enrolled irrespective of clinical presentation or symptom profile. From 2,391 cultures and Xpert tests done (mean, 5.6 tests/patient) on 1,745 samples (mean, 4.1 samples/patient), TB was diagnosed in 139 patients (median CD4 cell count, 80 cells/μL). TB prevalence was very high (32.6 %; 95 % CI, 28.1–37.2 %; 139/427). However, patient symptoms and risk factors were poorly predictive for TB. Overall, ≥1 non-respiratory sample(s) tested positive in 115/139 (83 %) of all TB cases, including positive blood cultures in 41/139 (29.5 %) of TB cases. In the first 24 h of admission, sputum (spot and/or induced samples) and urine were obtainable from 37.0 % and 99.5 % of patients, respectively (P <0.001). From these, the proportions of total TB cases (n = 139) that were diagnosed by Xpert testing sputum, urine or both sputum and urine combined within the first 24 h were 39/139 (28.1 %), 89/139 (64.0 %) and 108/139 (77.7 %) cases, respectively (P <0.001). Conclusions The very high prevalence of active TB and its non-specific presentation strongly suggest the need for routine microbiological screening for TB in all HIV-positive medical admissions in high-burden settings. The incremental diagnostic yield from Xpert testing urine was very high and this strategy might be used to rapidly screen new admissions, especially if sputum is difficult to obtain.