Journal of Kenya Assocation of Physicians

Establishing Rheumatoid Arthritis care in Zanzibar: a year of clinical outcomes and challenges

Sanaa S. Said — 2025-03-14

Background: Chronic Inflammatory Joint Diseases (CIJD) are systematic conditions that primarily affect the joints. If untreated they cause permanent deformity, increased morbidity and mortality. Although treatment options are available in Zanzibar, many patients have delayed presentation.
Objective: This study aims to describe a Rheumatoid Arthritis (RA) patient cohort’s presentation and outcomes after implementation of treat-to-target (T2T) strategy.
Methods: A total of 132 patients with RA were recruited across three hospitals in Zanzibar and followed up for one year. Sociodemographic, clinical, radiological, laboratory, medication adherence and expenditure on health data were collected. Descriptive statistics were used for patient characteristics and clinical parameters. Summary statistics were used to describe demographic variables. Paired-sample t-test was used to determine significance of changes from baseline to one year. A p value of <0.05 was considered significant.
Results: The majority were female (86%) with a mean age of 45±13 years and a mean disease duration of six years. At baseline, mean disease activity based on the Clinical Disease Activity Index (CDAI) was moderate but improved at one year to low disease activity (p <0.001). Rheumatoid factor positivity was 60% and 64% had evidence of radiological damage at enrollment. Prior steroid and non-steroidal anti-inflammatory drug use was common.
Conclusion: RA can be adequately managed in resource limited settings in the absence of biologic disease-modifying antirheumatic drugs using the T2T approach with good outcomes. Educational measures are needed to increase awareness among communities and health care providers to reduce delays in diagnosis and treatment.

Mortality and associated factors in End-Stage Renal Disease patients admitted at the Kenyatta National Hospital from 2017 to 2021

Allan Were Omollo — 2025-03-14

Background: End Stage Renal Disease (ESRD) presents a challenge to global healthcare systems. While there have been improvements in treatment modalities available, the mortality associated with ESRD is still high.
Objective: To determine the mortality and associated factors among ESRD patients admitted at the Kenyatta National Hospital (KNH) between 2017 and 2021.
Methodology: A retrospective study design using medical records of 252 patients obtained through simple random sampling. Data of in-patients with ESRD at KNH from 2017-2021 was extracted from records. Data on socio-demographic and disease-related factors was also extracted from the records. Stata 17 software was used for data analysis. The main study outcomes were death or survival at discharge.
Results: Sixty percent of the patients were males and the median age was 52 years. Over the 5 years, 33% of the patients died during admission. Older age (>50 years), male gender, rural residence, lack of medical insurance, hypertension as an aetiology and comorbidity, unknown cause of ESRD, using a catheter for dialysis access, eGFR at admission, and hyperkalemia were associated with higher mortality with p values ≤ 0.05.
Conclusion: Mortality among ESRD patients on haemodialysis admitted at KNH is high. The focus should be on prevention and improving access to kidney transplantation services. For patients on haemodialysis, modifiable risk factors associated with mortality such as catheter access as a route for dialysis and hyperkalemia at admission should be identified early.

Spectrum and patterns of EEG Abnormalities in a peripheral outpatient centre in Kenya

Paul Bundi Karau — 2025-03-14

Background: Electroencephalography (EEG), which records electrical activity in the brain, is a valuable tool for assessing epilepsy and other paroxysmal events. However, despite the high prevalence of epilepsy in Africa, EEG remains underutilised.
Objective: This study aimed to evaluate the indications for and patterns of EEG abnormalities in a busy outpatient neurophysiology laboratory in Kenya.
Methods: This was a retrospective observational, non-interventional study. We abstracted and analysed EEG reports and recordings from 1st June 2021 to 31st December 2023. The sociodemographic data, handedness, reasons for referral, clinical diagnoses, EEG abnormalities, types of epileptiform and non- epileptiform patterns, and EEG diagnoses were encoded and entered into IBM SPSS version 27.
Results: A total of 445 EEGs were carried out during the study period, with males constituting 53.9% of the cases. The majority of patients (40.4%) fell within the 10-19-year age group. Additionally, 59.6% of patients were already receiving anticonvulsant medications. The most common reason for referral was suspected seizure in 34.6% of cases, followed by loss of consciousness without abnormal movement in 32.8% of cases. Among males, abnormal movement suspected to be a seizure was the most frequent presentation, while unconsciousness was the predominant presentation among females. The EEG revealed epileptiform abnormalities in 68.3% of cases, with generalised seizure observed in 48.0% of cases. Furthermore, 40.6% of subjects in the 10 - 19 year age group showed no abnormalities on the EEG.
Conclusions: The current study underscores the high prevalence of seizure abnormalities in this rural setting, the common reasons for referral, and the demographic features of patients who present for EEG. It highlights the importance of EEG in distinguishing seizure and non-seizure episodes, especially in paediatric and adolescent age groups.

Case Series on prosthetic valve thromboses treated with intravenous thrombolysis at a Tertiary Teaching Hospital in Nairobi – Kenya

John Otieno Odhiambo — 2025-03-14

Valvular heart disease is a significant global health issue, particularly in developing countries where Rheumatic Heart Disease (RHD) is the leading cause. Valve replacement surgeries have increased, with mechanical prostheses favored for their durability. However, thromboembolism remains a critical complication post-surgery, with prosthetic valve thrombosis rates of 0.03% for bioprosthetic valves and between 0.5% to 8% for mechanical valves in the aortic and mitral position. This report details two cases of heart failure following valve replacement due to rheumatic heart disease. The first case involves a 42-year-old female who developed prosthetic valve thrombosis after discontinuing warfarin for menorrhagia postmechanical mitral valve replacement. The second case features a 37-year-old male who experienced valve thrombosis after undergoing mechanical aortic valve replacement and subsequently became dehydrated from acute gastroenteritis while on warfarin. Both patients were managed with anticoagulation and fibrinolysis, highlighting the importance of careful monitoring and management in post-operative care to prevent thromboembolic complications.

The dancing disabling tongue: tongue tremor as a presentation for Parkinson’s disease

Henry Owuor — 2025-03-14

Even though Parkinson’s disease may rarely present with tremors of the mandible, the chin and the head, hardly does it present with disabling tongue tremors. We have only come across two cases in published literature. This is a case of a 63-year-old lady who presented with disabling tongue tremors and other unnoticed PD features who responded spectacularly to levodopa/carbidopa. Clinicians should be aware that PD may present with disabling tongue tremors. However, other PD features must be assessed for as PD remains a clinical diagnosis especially in rural third world. A history of neuroleptic use has to be elicited.

Stroke secondary to hypertension as initial presentation in pheochromocytoma: a case report

Charles Masese — 2025-03-14

Pheochromocytoma presenting with stroke as the initial presentation is rare and carries a high mortality rate. Early detection is essential to prevent the attendant life-threatening effects. There is no algorithmic approach in diagnosing and managing this condition due to a lack of evidence-based guidelines and randomized control studies. The objective of this study was to analyze the prevalence of pheochromocytoma among patients presenting with secondary hypertension and stroke and to identify the diagnostic challenges and the outcome of a patient with pheochromocytoma-associated secondary hypertension presenting with stroke. This is a retrospective study of a 54-year-old male presenting with stroke and hypertensive crisis diagnosed with pheochromocytoma. He had complaints of sudden left- sided weakness, facial drooping, slurred speech, and severe global headache with no history of chronic illnesses. Non-contrast computed tomography of the brain revealed a hyperdense intracerebral haemorrhage, confirming stroke. An electrocardiogram revealed left ventricular and atrial enlargement, confirming cardiovascular manifestation. A transthoracic echocardiogram showed left ventricular hypertrophy and grade 1 diastolic dysfunction with an ejection fraction of 79%, suggestive of hypertensive heart disease. The persistently high blood pressure raised suspicion, and a 24-hour urine monitor for catecholamine and metanephrines was normal. Abdominal pelvic ultrasound showed a left adrenal mass. Adrenalectomy and biopsy were done, which confirmed pheochromocytoma. There was an improvement in the patient’s clinical status post-adrenalectomy. There are significant diagnostic challenges, including symptom overlap with other conditions, low clinical awareness, and the need for specific biochemical and imaging tests, which delay diagnosis and appropriate treatment. Early detection is essential to prevent life-threatening cardiovascular effects.

Non-Ketotic Hyperglycemic Hemichorea as an initial manifestation of Type 2 diabetes mellitus: case report and review of the literature

Paul Bundi Karau — 2025-03-14

Non-Ketotic Hyperglycemic Hemichorea (NKHCB) is a rare movement disorder associated with uncontrolled diabetes mellitus. It has been reported in type 2 diabetes, and much rarer in type 1 diabetes mellitus. It is characterized by hemichorea-hemiballism that resolves with glycemic control, though some cases may be unremitting. It has hardly been reported as the presenting complaint in a new diagnosis of diabetes mellitus. We hereby discuss a case of NKHCB as a first complaint in a 52-year-old lady not previously known to have diabetes. The CT scan did not reveal any abnormality. The disorder resolved within a month of the diagnosis after proper glycemic control and use of neuroleptic agents. NKHCB is an important differential diagnosis to consider in patients presenting with hemichorea-hemiballism, even if not previously known to be diabetic.

Enhancing clinical competence: transitioning from long case examinations to OSCEs in medical education

George Omondi Oyoo — 2025-03-14

No abstract