Browsing by Author "Gounden, Strinivasen."

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Extrapulmonary tuberculosis at King Edward hospital : a descriptive retrospective study.
(2016) Gounden, Strinivasen.; Magula, Nombulelo Princess.
Background Globally, South Africa remains one of the top twenty high tuberculosis(TB) burden countries. In addition, South Africa has the highest burden of tuberculosis/Human Immunodeficiency virus (TB/HIV) coinfection in the world, with the province of KwaZulu-Natal representing the global epicenter of TB/HIV. With the scaling up of one of the world’s largest antiretroviral therapy programs, it was envisioned that the burden of tuberculosis would be reduced. While significant progress has been made to improve the diagnosis of pulmonary tuberculosis, the diagnosis of extrapulmonary TB(EPTB) remains a significant challenge in resource constrained settings. This study describes the profile of patients with EPTB at a tertiary hospital in a TB/HIV hyperendemic setting in Durban, South Africa. Methods A retrospective chart review was conducted, and included all adult patients diagnosed with EPTB at a tertiary hospital in Durban, South Africa, between 1 January 2016 and 31 March 2016. Data was extracted from the facility TB register, as well as patient clinical records. All data was analysed using SPSS software (SPSS 23.0, Armonk NY: IBM Corp). For all statistical comparisons, a 5% level of significance was used; correspondingly 95% confidence intervals were used to describe effect size. All data was assessed for normality, and non-parametric tests were used where necessary. Medians and interquartile ranges were used for data not amenable to parametric description. Pearson’s Chi-square test was utilised for comparison between subgroups. All p values were 2-tailed and considered significant below 0.05. Significant findings were analysed for association using Phi and Kramers V test for symmetric measures. Results There were 188 new cases of TB during the study period, with 80 patients diagnosed with EPTB. The mean age of patients was 34.73 years (SD ±9.44). Forty two (52.5%) patients were female, while 76(96%) were black African. The most common risk factor for EPTB was HIV co-infection (88.8%). The median CD4 cell count was 68 (IQR 32-165) cells/mm3. Pleural (36.3%), lymph node (28.7%) and abdominal(27.5%) involvement were the most common sites of extrapulmonary disease Eleven of the 80 patients (13.8%) presented with EPTB involving more than one anatomical system. Weight loss, fever, night sweats and cough were amongst the most common symptoms reported. Signs varied according to the site of infection. Non-specific symptoms were common. In the majority of cases, more than one diagnostic method was used to confirm the presence of TB in distant organs. Conclusion A high index of suspicion is required when assessing a patient with known risk factors for EPTB. Immunosuppression remains the most significant risk factor for the development of EPTB. In our setting, HIV co-infection remains the most common risk factor. Advancements in Xpert MTB/Rif and computer tomography have greatly assisted in rapidly diagnosing EPTB. Despite improved access to antiretroviral therapy over the past years, advanced HIV disease remains a significant challenge to eradicating TB.
Outpatient treatment of drug-resistant tuberculosis in a hyperendemic setting.
(2021) Pillay, Jashen.; Gounden, Strinivasen.; Sadhabiriss, Dhiren.; Magula, Nombulelo Princess.
Background: The existence of multidrug-resistant tuberculosis (MDR-TB) represents a failure of effective infection control. There are over half a million new cases diagnosed annually with treatment success rates of only 57% reported in 2019. These numbers are highest in hyperendemic regions of the world, including South Africa, which has a high burden of tuberculosis and HIV co-infection. Treatment of MDR-TB is challenging and is usually managed at specialised centres. There is currently a transition into the decentralised treatment of MDR-TB for outpatients. Describing the features of DR-TB may influence improved treatment strategies for the future. Objectives: To determine the prevalence of DR-TB at a single, central outpatient site in a hyperendemic area of South Africa, and to evaluate known risk factors and their relationship with outcomes, including time between diagnosis and treatment initiation. Methods: A retrospective chart review of all new cases of DR-TB referred to a central hospital in Durban for outpatient care for the period 01/01/2017 to 31/03/2017 was conducted. Data included demographics, co-morbidities, time-to-treatment, treatment adverse effects and outcomes and were collected and collated from physical charts and the computerised registry. The data was then analysed using SPSS software. Results: The period prevalence of MDR-TB at the site was 44 cases/100 000 population. Of these cases, one hundred and eleven new cases of DR-TB were included in the analysis which comprised 57 (51.35%) males. Most patients were of African ethnicity (n = 107, 96.4%). Thirty-one (27.9%) patients did not have HIV co-infection. More than one-half of patients (n = 56, 51.5%) had a history of TB and was significantly higher in males than in females (n = 34, 59.6%) and n = 22, 40.7%) respectively; p= 0.020). Five (4.5%) patients had co-morbidities of hypertension, diabetes mellitus, or renal impairment. Most patients (n = 98, 88.3%) were treated within three months of diagnosis. The mean time-to-treatment was significantly longer in patients with extrapulmonary DR-TB (150.14 (±175.90) days compared to 53.21 (±66.01) days; p-value=0.002). Significantly more patients were treated within 6 weeks if they had a positive GeneXpert test (n = 35, 89.7% compared to n = 11, 17.5%, p=0.013). Fifty-one different treatment regimens were used, and 139 side-effects were reported, the most common being ototoxicity, hypothyroidism and peripheral neuropathy. Eighty-two (73.87%) patients completed follow-up until cure. Conclusion: The high burden of TB and HIV co-infection as well as a history of TB are associated with the elevated prevalence of MDR-TB in this setting. Side-effects are common and may impact toward poorer treatment adherence in addition to co-morbidities. Outcomes are favourable in specialised outpatient settings. A decentralised approach reduces the time-to-treatment in other studies, but large-scale implementation is recommended for further evaluation.