Browsing by Author "Mosam, Anisa."

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Human T cell lymphotropic virus 1 associated infective dermatitis in KwaZulu-Natal, South Africa.
(2008) Hlela, Carol.; Mosam, Anisa.
Background Human T cell Lymphotropic Virus Type I (HTLV-I) associated infective dermatitis, first described by Sweet in Jamaican children, is a pattern of eczema characterized by exudation, crusting around the nostrils, ears and scalp with eventual appearance of a generalized fine papular rash. More recently LeGranade and co-workers have proposed major and minor criteria in establishing the diagnosis of HTLV-I associated infective dermatitis (HAID). HTLV-I has been aetiologically linked to Adult T cell leukaemia/lymphoma (ATLL) and tropical spastic paraparesis (TSP). HAID is not only a marker of childhood infection with HTLV-I but may be a harbinger of more serious HTLV-I associated diseases later on in life such as ATLL or TSP. The pathogenesis of HAID is poorly understood so are the histopathological features of this entity. The effects of co-infection with human immunodeficiency virus- 1 (HIV-1) are inconclusive. HAID is described in Sub Saharan Africa, Senegal but no data is published on this entity in Southern Africa, characterizing the clinical, laboratory features and the histopathology of this entity. Aims and Objectives 1) To describe the clinical and histological features of HTLV-I associated infective dermatitis in KZN, South Africa 2) To determine the virological characteristics of HTLV-I in KZN, South Africa 3) To assess for HTLV-I / HIV co-infection Methods This was a prospective study of all patients with HAID who presented to King Edward VIII hospital (KEH), outpatient department over a period of 42 months. These were patients who fulfilled the clinical criteria of HAID. Enrolled patients were subjected to a confirmatory HTLV-I serology testing. Demographic data was obtained from all HTLV-I seropositive patients. Their clinical examination included dermatological, neurological and pathological examination. A blood count, immunoglobulin levels, serum protein electrophoresis measuring albumin levels and globulin fractions were measured. For bacteriological assessment skin swabs were taken from the affected sites with stool samples examined for parasites, ova and cysts. The HIV-1 status together with HIV-1 viral load were determined on those enrolled. The CD4 count, CD8 counts and CD4/CD8 ratio were also calculated. Skin biopsies were taken for histological examination. PCR for HTLV subtyping was performed on a subset of the cohort. Results Demography Of the 60 patients recruited, 33 fulfilled criteria for HAID. The majority of patients fell between age categories of 6 to lOyears. The male to female ratio was 1:1. There were more females in the adult group than there were within the childhood group. All of the patients in our cohort were African. Clinical features The lesions were erythematous, scaly, exudative, and crusted in all cases. The distribution of lesions was as follows: scalp (77.4%), retroauricular areas (71%), the axilla (65%) and paranasal areas (58%) were the sites more commonly affected. Nasal crusting was not a significant feature in this series. Bacteriology Culture was positive for Staphylococcus aureus (S. aureus) in 90%, with streptococcal group of organisms found in 68% of the skin swabs taken from the lesional skin. Haematological Our patients were mildly anaemic as has been shown in previous studies. They had a mean Hb of 11.5g/dl. In 12 of the 14 patients tested, the erythrocyte sedimentation rate (ESR) was elevated. Serum protein electrophoresis and levels of Immunoglobulin A, G and M were raised. The mean CD4 count in the entire group was elevated at 1730 cells/fil, CD8 was 1299 cells/ul Histopathology The major histological findings were as follows: 38% demonstrated a superficial and deep perivascular inflammatory infiltrate, 28% had a superficial and deep perivascular inflammatory infiltrate together with a lichenoid dermatitis, 12.9% had features of superficial and deep inflammatory infiltrate with an interface dermatitis, 6.4% revealed features of seborrhoeic dermatitis. Genotyping Our patients were infected with the strains belonging to the Cosmopolitan, A Subtype (HTLV-Ia). Complications Complications were low in this series with the commonest being scabies in 6(18.1%), corneal opacities in 3(8.6%), 2(6 %) with HAM/TSP. No parasitic worm infestations were isolated. HIV/HTLV-I co-infection Of the 33 patients, 9 (30 %) were co-infected with HIV. The mean viral load in this group was 52 000 copies/ml. Their mean CD4 count was also elevated at 1505cells/^il with a CD8 of 1704 cells/Mi and a CD4/CD8 ratio of 1.15. Discussion Thirty three of the 60 patients enrolled met the diagnosis for HAID according to the established criteria. The mean age in this series was 17 years (range: 8 months-46 years)however; almost a third (30.3%) were children under 12 years, reinforcing the entity as a childhood infective condition. There was an equal male female distribution in the childhood group and a female predominance in the adult group. Clinically patients presented with infected erythematous, scaly lesions mainly on the scalp, neck and post- auricular area. The clinical features were in keeping with other series worldwide. The complication rate was low in our cohort. S. aureus was the predominant organism in both anterior nares and lesional skin. The most common histological pattern was superficial and deep perivascular inflammatory infiltrate. The subtype in our series was the Cosmopolitan Subtype A (HTLV-Ia) as opposed to subtype B in Japan. We share with Brazil a common subtype. A subset of our patients (30%) was co-infected with HIV. The CD4 cell count in this subgroup was lower than the entire group but this was not statistically significant. The histological patterns found in this subgroup infected with HIV were similar to the rest of the group except for a more intense eosinophilic infiltrate in these skin biopsy specimens. Conclusion HTLV-I associated infective dermatitis is distinct entity which affects the African population of KwaZulu Natal, South Africa. It is predominantly a disease of childhood with an equal female to male ratio in children. The clinical features are an exudative, erythematous scaly rash most commonly found involving the scalp, axillae, paranasal and retroauricular areas. HTLV-I positivity is essential for the diagnosis; the Cosmopolitan Subtype A is commonest in South Africa. The commonest histological pattern is a superficial and deep perivascular infiltrate in 38%. A subset, 30%, was co-infected with HIV.
An investigation into the use of complementary and alternative medicine for atopic eczema.
(2016) Thandar, Yasmeen.; Botha, Julia Hilary.; Mosam, Anisa.
Atopic eczema (AE) is one of the most common skin diseases that patients frequently present with to dermatological practices in South Africa (SA). It has shown to impact negatively on the quality of life of many patients suffering from it. Epidemiological studies have shown high rates of AE prevalence, ranging from 2-7% in adults and 7-20% in children. Over the last decade, the lifetime prevalence of physician-diagnosed AE has almost doubled in SA. This rise continues despite accessible effective treatments. Due to AE’s chronic and relapsing nature and the unattainability of complete clinical cure, patients are progressively exploring complementary and alternative medicines (CAM) in search of a solution. Although the global popularity of CAM for AE is on the rise, a review of the literature demonstrated contradictory evidence with regards to their efficacy with shortcomings in many of the published data thus making it difficult for clinicians to assess their role, if any, in the management of AE. Objective One To objectively evaluate the information on the efficacy and safety of CAM in light of the most recent findings, the study entitled “Complementary Therapy in Atopic Eczema: The Latest Systematic Reviews” in Chapter Two of this thesis collectively evaluated all published systematic reviews (SRs) to date on the most popular CAM modalities for AE. These SRs included those of Chinese herbal medicines(CHM), homeopathy, oral herbal remedies (including evening primrose oil and borage oil), probiotics and certain dietary supplements. The study concluded that none of the alternative therapies evaluated demonstrated obvious and indisputable evidence of efficacy due to many limitations in study design, poor methodologies, patient numbers etc. Further studies may be warranted with some therapies (CHM, different probiotic strains and fish oil), whereas homoeopathy failed to show any treatment effect and further studies with evening primrose oil and borage oil may be difficult to justify. This overview was able to provide objective information to enable dermatologists and general practitioners to advise and manage their patients holistically in the light of the most recent findings. Objective Two Topical corticosteroids remain the mainstay of treatment for AE. However, many patients are concerned about their long-term safety and thus seek evidence-based safer alternatives. Many published papers have made reference to the wide use of topical herbal creams for AE and many of these been tested, but few in controlled clinical trials. No SRs of these trials could be found, although SRs of topical herbal extracts have been published for other chronic skin conditions. The study entitled “Topical Herbal Medicines for Atopic Eczema: A Systematic Review of Randomised Controlled Trials” in Chapter Three of this thesis was the first SR to be conducted for topical herbal preparations for AE. Using Cochrane SR methodology, numerous databases were searched from inception until June 2014. All controlled clinical trials of topical herbal medicines for AE in humans of any age and published in English were included regardless of the control intervention or randomisation. Of eight studies that met the inclusion criteria, seven investigated extracts of single plants and one an extract from multiple plants. The study concluded that there is currently insufficient evidence of efficacy for any topical herbal extract in AE with many studies having methodological flaws. Even studiesthat did show efficacy over placebo were single trials with small patient cohorts. Together with providing clarity to both prescribers and patients, the study was able to identify opportunities for future research in better designed trials with topical extracts that showed a promising effect and had a low risk of bias across all domains. These were randomised controlled trials (RCTs) of licorice gel and Hypericum perforatum. Objective Three The literature has thus far reported on numerous international studies on the widespread use of CAM for AE. These studies not only investigated the prevalence of CAM use but also the modalities used, motivations for use and demographic variables that influence their use. All these factors potentially impact on the treatment of AE. No such studies conducted anywhere in Africa could be found. Given the lack of literature in SA, the study entitled “Complementary and Alternative Medicine Use amongst patients with Atopic Eczema - a South African Perspective” in Chapter Four of this thesis was a cross-sectional study that was conducted amongst AE patients in Durban, KwaZulu-Natal to bridge this gap in knowledge. This study found a 66% current or previous CAM use, which was moderately higher than those reported in other countries. Frequently used CAM were vitamins, aromatherapy oils, herbal creams, traditional African medicines and homeopathy. Non-disclosure to the dermatologist was high and almost half of the patients interviewed said they were not questioned about CAM use. More Indian patients used CAM and Muslims were the most frequent CAM users. Duration of AE was also a predictor of use. Although not statistically significant, the more educated and higher income bracket used CAM more. The study was able to provide detailed trends of CAM use by South Africans for AE which is an important addition to the literature. This information is able to highlight to dermatologists and healthcare professionals treating AE patients, the need to be more conversant with CAM that patients explore, as this could impact overall clinical outcome. Objective Four Although evident from the literature that patients have embraced CAM, it is uncertain whether mainstream healthcare professionals are as embracing. Their attitude and knowledge of CAM will influence their pro-activeness in enquiring about CAM and confidently discussing proven/unproven remedies with their patients, thereby influencing an overall positive clinical experience and disease course. Several international studies have explored the knowledge, attitudes and practices amongst general practitioners (GPs), physicians, pharmacists, paediatricians, academic doctors and other healthcare workers towards CAM, but none within the context of a specific disease. No published studies conducted in SA or elsewhere investigating HCPs’ knowledge, attitudes and norms of practice with regards to CAM for AE could be found. As a result, and given the extensive use among SA patients with AE as per the study’s previous findings, a cross-sectional study entitled “Knowledge, Attitude and Practices of South African Healthcare Professionals towards Complementary and Alternative Medicine Use for Atopic Eczema - A Descriptive Survey” was conducted. Results amongst GPs, dermatologists, paediatricians and pharmacists are reported in Chapter Five of this thesis. GPs and pharmacists were significantly more embracing of CAM compared to dermatologists and paediatricians. The study revealed poor CAM knowledge and communication between HCPs and patients, however there was a strong interest to learn more. It was also found that there is an urgent need for continuing education programmes on CAM and inclusion into undergraduate curriculums as most HCPs were interested in learning more about CAM. Conclusion Overall, this thesis was able to fill a gap in the knowledge of CAM use for AE both globally and within the context of SA. The study provided clarity and objective conclusions from the many SRs previously published for popular oral CAM therapies. Furthermore, the study conducted and published the first SR on topical herbal therapies for AE. This SR identified therapies that have demonstrated positive results for AE with low risk of bias and is thus able to provide direction for future research in this regard. Within the SA context, the study described the perspectives and practices of both patients and mainstream healthcare professionals on CAM use for AE, which was lacking in Africa. With this information we were able to ascertain the popular CAM that SA patients are using, the extent of their use as well as establish CAM education needs for local healthcare professionals.
Predictors of response of AIDS-associated Kaposi sarcoma to standard chemotherapy.
(2006) El-Koha, Omran Ali.; Mosam, Anisa.
Predictors of response of AIDS-associated Kaposi-Sarcoma to standard chemotherapy Overview: Kaposi Sarcoma is the most common HIV-associated cancer. Its etiology and pathogenesis is not fully understood. Little is known about what predicts prognosis, survival and therapeutic response in HIV-KS. In South Africa given the high seroprevalence rates of HIV-l and human herpes virus 8 (HHV 8), Kaposi's sarcoma is a significant problem. The majority of patients have been treated solely with palliation due to the poor outcome associated with a diagnosis of HIV-KS, more so in the absence of highly active antiretroviral therapy (HAART). Since the national ARV rollout programme and the availability and accessibility of HAART to all patients with a diagnosis of HIV-KS, a new strategy has to be established to enable adequate patient selection for chemotherapy. There have been a few published studies addressing the predictors of response to chemotherapy in the first world. However, this is the first study of these factors in HIV-l infected African patients with Kaposi's sarcoma. Aim: To identify and assess the potential value of several parameters predictive of outcome, survival and therapeutic response in HIV- infected patients with KS. Clinical, hematological, biochemical, immunological and virological variables were evaluated. Methods: We collected data from 25 patients with AIDS-KS who were enrolled in a phase III randomized controlled trial comparing HAART alone with the combination of HAART and chemotherapy. All patients were from the combination therapy arm. The following variables were evaluated as predictors of prognosis and therapeutic response: age, gender, ethnic origin, Haemoglobin (Hb), white blood cells (WBCs), lymphocytes, neutrophils, platelets, S.albumin, ALP, GGT, CD4 count, HIV viral load. These variables were assessed in patients at baseline and month 6 of therapy. Patients were staged into good risk and poor risk according to the AIDS clinical trial group (ACTG) criteria. The outcomes assessed were response to treatment and mortality. Results: A total of 25 patients participated to the study. Of these 16(64%) were males and 9(36%) were females, with male: female ratio of 2.7:1. Median age was 34 years (24-47); all patients were of Black African origin. Of the 21 patients, 15 (71.4%) were of good prognosis and 6(28.6%) were of poor prognosis. At baseline the median values of the different variables were as follows: Hb 10.9 g/dl, WBCs 5.95x109/L, lymphocytes 1.7 x109/L, neutrophils 3 x10 9 /L, platelets 272 x10 9 /L, S.albumin 30 gil, total protein 88 gil, ALP 64 U/L, and GTT 21 U/L, CD4 count was 255 cells/mm 3 , HIV-RNA viral load was 42000( 4.610gs). At month 6, 22 patients remained alive, their median values were: Hb 12.2 g/dl, WBCs 4.65 x109/L, lymphocytes 1.5 x109/L, neutrophils 3 x10 9 /L, platelets 301 x109/L, S.albumin 36.5 gil, total protein 84.5 gil, ALP 78.5 U/L, GTT 44.5 U/L, CD4 count 288 cells/mm3 , HIV-RNA viral load was 50500( 4.6910gs). The baseline median CD4 and HIV-RNA viral load counts for the 3 patients who died before month 6 were 47 cells/mm3 and 31000(4.610gs); respectively. Response to therapy was evaluated in 21(84%) patients as 4(16%) patients were missing, of the 21 patients 3 (14.3%) had complete response and 18(85.7%) had partial response. With respect to sex 2(14.3%) males had complete response and 12(85.7%) had partial response, 1(14.3%) female had complete response and 6 (85.7%) had partial response. Non-parametric statistics were used because of the small sample size and the skewness of the data. Variables were described using medians and ranges, and compared between two independent groups using Mann-Whitney tests. Baseline and month 6 comparisons were done using Wilcoxon signed ranks tests. Receiver Operating Characteristic (ROC) curves were used to analyze cut points to optimize sensitivity and specificity of a quantitative variable for a dichotomous outcome. Discussion In the univariate analysis age and sex didn't influence prognosis and therapeutic response, the influence of ethnic origin couldn't be assessed as all patients were of the same ethnic origin. Baseline WBCs (P= 0.004) and lymphocytes (P=0.026) were significantly associated with complete response. Higher values of GGT (p=O.OOl); ALP (P=0.006) were associated with more deaths. Baseline CD4 count and HIV viral load were not of predictive value, lthough change CD4 (P=002) and VL (p=.OOO) over time was significant and most likely attributed to response to therapy. 90.9 % of patients reached undetectable HIV-l Viral loads at month 6. CONCLUSION: Neither CD4 count nor HIV viral load at baseline predicted prognosis or survival; however there was a borderline significance of CD4 (P=0.058) towards a better survival.
A randomized controlled trial of HAART versus HAART and chemotherapy in therapy-naïve patients with HIV-associated Kaposi sarcoma in South Africa.
(Lippincott Williams & Wilkins., 2011) Mosam, Anisa.; Shaik, Fahmida.; Uldrick, Thomas S.; Esterhuizen, Tonya.; Friedland, Gerald H.; Scadden, David T.; Aboobaker, Jamila B.; Coovadia, Hoosen Mahomed.
Background: The optimal approach to HIV-associated Kaposi sarcoma (HIV-KS) in sub-Saharan Africa is unknown. With large-scale rollout of highly active antiretroviral therapy (HAART) in South Africa, we hypothesized that survival in HIV-KS would improve and administration of chemotherapy in addition to HAART would be feasible and improve KS-specific outcomes. Methods: We conducted a randomized, controlled, open-label trial with intention-to-treat analysis. Treatment-naive patients from King Edward VIII Hospital, Durban, South Africa, a public-sector tertiary referral center, with HIV-KS, but no symptomatic visceral disease or fungating lesions requiring urgent chemotherapy, were randomized to HAART alone or HAART and chemotherapy (CXT). HAART arm received stavudine, lamivudine, and nevirapine (Triomune; CXT arm received Triomune plus bleomycin, doxorubicin, and vincristine every 3 weeks. When bleomycin, doxorubicin, and vincristine were not available, oral etoposide (50–100 mg for 1–21 days of a 28-day cycle) was substituted. Primary outcome was overall KS response using AIDS Clinical Trial Group criteria 12 months after HAART initiation. Secondary comparisons included time to response, progression-free survival, overall survival, adverse events, HIV control, CD4 reconstitution, adherence, and quality of life. Results: Fifty-nine subjects were randomized to HAART and 53 to CXT; 12-month overall KS response was 39% in the HAART arm and 66% in the CXT arm (difference, 27%; 95% confidence interval, 9%–43%; P = 0.005). At 12 months, 77% were alive (no survival difference between arms; P = 0.49), 82% had HIV viral load <50 copies per milliliter without difference between the arms (P = 0.47); CD4 counts and quality-of-life measures improved in all patients. Conclusions: HAART with chemotherapy produced higher overall KS response over 12 months, whereas HAART alone provided similar improvement in survival and select measures of morbidity. In Africa, with high prevalence of HIV and human herpes virus-8 and limited resources, HAART alone provides important benefit in patients with HIV-KS.
Seroprevalence and viral quantification of Kaposi Sarcoma-associated Herpes Virus (KSHV) in a Human Immunodeficiency Virus (HIV) infected adult South African cohort.
(2017) Singh, Shoohana.; Mosam, Anisa.; Shaik, Fahmida.; Uldrick, Thomas S.; Naidoo, Kogieleum.
Background Kaposi sarcoma-associated herpes virus (KSHV), also known as human herpes virus 8 (HHV8), is aetiologically implicated in Kaposi’s sarcoma (KS). Although HIV associated KS has increased in incidence and is a public health problem in South Africa, serological studies of KSHV have not been extensively documented in this population. This cross-sectional study investigates the seroprevalence and viral load of KSHV in an adult South African cohort. Method Cross-sectional data of 140 participants attending an urban research HIV counseling and testing (HCT) clinic site in Durban, KwaZulu-Natal, between July and October 2013 was analyzed. Detection of antibodies against latent (Orf73) and lytic (K8.1) KSHV antigens was performed on 70 HIV-seropositive and 70 HIV-seronegative participants. Subjects reactive to either antigen were considered KSHV seropositive and analyzed for salivary KSHV DNA, which was quantified using primers for the K6 gene region. Results The demographic characteristics of the two groups were similar, with 36% males (median age, 35yrs.) and 64% females (med. age, 34yrs.) in the HIV-positive group, and 31% males (med. age, 36.5yrs.) and 69% females (med. age, 36.5yrs.) in the HIV-negative group. Of 70 HIV-positive participants, 100% were black Africans, as was 97% of the HIV-negative group, with the remaining 3% being Indian/Asian and Mixed race. Only 24% of HIV-positive patients were on Anti-retro viral treatment. Fifty-four percent of all participants tested positive for KSHV, with 33% reactive to lytic K8.1, 37% to latent Orf73 and 21% to both. Of those HIV-positive, 50% were seropositive for K8.1 and 46% for Orf73. In those HIV-negative, 16% were seropositive for K8.1 and 29% for Orf73. The HIV-positive group demonstrated a significantly higher percentage KSHV seropositivity (70% vs. 37%, p=0.0001). Amongst the KSHV seropositive participants, KSHV DNA was detected in 41 % HIV-positive and 23% HIV-negative participants. Conclusion KSHV seroprevalence was high in South African adults attending an urban HCT clinic. HIV positive status was associated with a higher KSHV seropositivity and a greater KSHV salivary shedding. HIV positive individuals should be tested for KSHV infection and those found infected, be monitored aggressively for development of KS.