AJTCCM VOL. 29 NO. 2 2023 83
ABSTRACTS
ADULT PULMONOLOGY
A tale of two waves: Characteristics
and outcomes of COVID-19 admissions
during the Omicron-driven fourth
wave in Cape Town, South Africa, and
implications for the future
M S Moolla, T G Maponga, H Moolla, E Kollenberg, S Anie,
A Moolla, D Moodley, U Lalla, B W Allwood, N Schrueder,
W Preiser, C F N Koegelenberg, A Parker
Division of Pulmonology, Department of Medicine, Faculty of
Medicine and Health Sciences, Stellenbosch University and Tygerberg
Hospital, Cape Town, South Africa
Corresponding author: M S Moolla (saadiq.moolla@gmail.com)
Objectives. To describe the pattern of admissions during the fourth
wave of COVID-19 in order to inform future public health policies.
Methods. is was a retrospective descriptive study of an early cohort
of all adult patients with SARS-CoV-2 infection admitted to a tertiary
hospital in Cape Town, South Africa, at the start of the country’s fourth
wave. e cohort was compared with an early cohort from the rst wave
at the same institution.
Results. In total, 121 SARS-CoV-2-positive admissions from the fourth
wave were included. Thirty-one patients (25.6%) had COVID-19
pneumonia, while 90 (74.4%) had incidental SARS-CoV-2 infection.
(In the rst wave all 116 patients had COVID-19 pneumonia.) irty-
two patients (26.4%) self-reported complete or partial COVID-19
vaccination, of whom 12 (37.5%) were admitted with COVID-19
pneumonia. Twenty-nine patients (24.0%), including 20 (64.5%) with
COVID-19 pneumonia, received oral or intravenous steroids, which
were not routinely prescribed in the rst-wave cohort. Compared with
the rst wave, there were fewer intensive- or high-care admissions
(n=18/121 (14.9%) v. 42/116 (36.2%); p<0.001), and mortality was lower
(n=12/121 (9.9%) v. n=31/116 (26.7%); p=0.001).
Conclusion. Admissions to the COVID-19 wards during the fourth wave
primarily comprised patients with incidental SARS-CoV-2 infection.
ere was a reduction in the need for critical care and in-hospital
mortality. is changing epidemiology of COVID-19 admissions may
be attributed to a combination of natural and/or vaccination-acquired
immunity.
Comparison of patients with severe
COVID-19 admitted to an intensive care
unit in South Africa during the rst and
second waves of the COVID-19 pandemic
U Lalla, B W Allwood, C F N Koegelenberg, L N Sigwadhi, E Irusen,
A E Zemlin, T E Masha, R T Erasmus,
Z C Chapanduka, H Prozesky,
J Taljaard, A Parker, E H Decloedt, F Retief, T P Jalavu, V D Ngah,
A Yal e w,
J L Tamuzi,
N Baines, M McAllister, A Zumla, P S Nyasulu;
for the COVID-19 Rapid Research Response Collaboration
Division of Pulmonology, Department of Medicine, Faculty of Medicine
and Health Sciences, Stellenbosch University and Tygerberg Hospital,
Cape Town, South Africa
Corresponding author: U Lalla (us[email protected]c.za)
Background. The second wave of COVID-19, dominated by the
SARS‑CoV‑2 Beta variant, was reported to be associated with increased
severity in South Africa (SA).
Objectives. To describe and compare the clinical characteristics,
management and outcomes of COVID‑19 patients admitted to an
intensive care unit (ICU) in SA during the rst and second waves.
Methods. In a prospective single-centre descriptive study, we compared
all patients with severe COVID-19 admitted to the ICU during the rst
and second waves. e primary outcomes assessed were ICU mortality
and ICU length of stay (LOS).
Results. In 490 patients with comparable age, comorbidities and degree
of hypoxaemia, no dierence in mortality was demonstrated during
the second compared with the rst wave (65.9% v. 62.5%, respectively;
p=0.57). ICU LOS was longer in the second wave (10 v. 6 days; p<0.001).
More female than male admissions (67.1% v. 44.6%; p<0.001) and
a greater proportion of patients managed with invasive mechanical
ventilation compared with non-invasive respiratory support (39.0%
v. 14.0%; p<0.001) were noted in the second wave. No dierence in
the administration of corticosteroids (85.8% v. 81.5%; p=0.32) or
anticoagulants (92.2% v. 86.4%; p=0.092) was noted between the two
waves. Less empirical antibiotic and antiviral therapy was administered in
the second wave (18.5% v. 72.1%; p<0.001 and 2.5% v. 21.4%; p<0.001). No
vitamin C was administered in the second wave (0% v. 58.9%; p<0.001),
and less thiamine was prescribed (6.1% v. 80.1%; p<0.001).
Conclusion. While clinical characteristics were comparable between
the two waves, a higher proportion of patients were invasively ventilated
and ICU stay was longer in the second wave. ICU mortality was
unchanged. Drugs that lacked evidence of ecacy in the management
of severe COVID-19 were used less frequently in the second wave.
An autologous human dendritic cell
vaccine from extensively drug-resistant
tuberculosis patients polarises antigen-
specific polyfunctional and cytotoxic
T-cell responses that are bactericidal to
Mycobacterium tuberculosis
R Londt, L Semple, A Esmail, A Pooran, R Meldau, M Davids,
K Dheda,* M Tomasicchio*
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
South African oracic Society Congress 2023
A SATS C
D I C C
- A
84 AJTCCM VOL. 29 NO. 2 2023
ABSTRACTS
* Co-senior authors
Corresponding author: K Dheda (keertan.dheda@uct.ac.za)
Background. Extensively drug-resistant tuberculosis (XDR-TB) is an
increasing public health concern, as drug resistance is outpacing the
drug development pipeline. Alternative immunotherapeutic approaches
are needed.
Methods. Dendritic cells (DCs) were cultured from XDR-TB patient-
derived peripheral blood monocytes (N=30) by maturation with
Mycobacterium tuberculosis (MTB)-specic antigens, with/without a
maturation cocktail (interferon-γ, interferon-α, CD40L, interleukin
(IL)-1β, and TLR3, TLR7 and TLR8 agonists). Two peptide pools
were evaluated: (i) an ECAT peptide pool (ESAT6, CFP10, Ag85B
and TB10.4 peptides); and (ii) a PE/PPE peptide pool (PE and PPE
peptides). A sonicated lysate of HN878 served as an antigen control.
DCs were assessed for the expression of key maturation markers and
the secretion of 1-polarising cytokines. e ability of the DC-primed
peripheral blood mononuclear cells to restrict the growth of MTB-
infected monocyte-derived macrophages was evaluated using an in vitro
mycobacterial containment assay.
Results. In patients with XDR-TB, DCs matured with MTB antigen +
cocktail, compared with DCs matured with MTB antigen only, showed
significantly higher upregulation of key co-stimulatory molecules,
CD80, CD83, CD86, and CCR7 (p<0.001 for all comparisons), and
higher secreted levels of the IL-12p70 (0.67 v. 0.01 ng/mL/106 cells;
p<0.001). e matured DCs enhanced antigen-specic CD8+ T-cell
responses to ESAT6 (p=0.05) and Ag85B (p=0.03). Furthermore,
containment was signicantly higher with MTB antigen + cocktail v.
antigen alone (p=0.0002 for PE/PPE). PE/PPE + cocktail-matured DCs
achieved a higher magnitude of containment compared with ECAT +
cocktail-matured DCs (50% (interquartile range 39 - 75) v. 46% (15 -
62); p=0.02).
Conclusion. In patients with XDR-TB, an eector response primed
by the PE/PPE peptide pool and cocktail-matured DCs was capable of
restricting the growth of MTB in vitro. ese data support the generation
of a DC-based immunotherapeutic intervention for therapeutically
destitute patients with drug-resistant TB. Further mechanistic studies
and future phase 1 human clinical studies are warranted.
Cough aerosol sampling of tuberculosis
patients indicates that highly infectious
‘super-spreader’ individuals can be
accurately identied through predictive
modelling of GeneXpert cycle thresholds
S Meier, S Jaumdally, S Oelofse, A Esmail, D Willemse, A Pooran,
K Dheda
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Department of Medicine, Faculty
of Health Sciences, University of Cape Town, South Africa
Corresponding author: S Meier (smeier@sun.ac.za)
Background. To control the spread of tuberculosis, particularly at
community level, it is critical to identify highly infectious individuals,
who should be isolated and their contacts traced. Given the current
resource limitations, it would be desirable to target the most infectious
individuals, especially in the context of screening (active case nding)
programmes. In a previous study, we used a cough aerosol sampling
system (CASS) to identify individuals who exhaled culturable and
presumably contagious Mycobacterium tuberculosis (MTB) in their
cough aerosols (particles <10 µM).
Objectives. To rapidly identify highly infectious super-spreader
individuals.
Methods. In the previous study, of 452 tuberculosis patients, 310 did
not emit any culturable cough aerosols (CASS negative), while 142 had
culturable MTB (CASS positive) in their respirable cough droplets.
Here, we performed a more granular analysis by dividing the CASS-
positive patients into two groups, those who emitted 1 - 9 (n=100) and
those who emitted ≥10 (the ‘super-spreaders’, n=42) colony-forming
units in their cough aerosols. We compared various demographic,
clinical, physiological and diagnostic characteristics between the three
groups and performed predictive linear modelling (with bootstrapping)
to evaluate whether super-spreaders could be accurately identied.
Results. Compared with CASS-negative patients, super-spreaders were
signicantly more likely (p<0.05 for all comparisons) to be male (79%
v. 55%; relative risk (RR) 2.6 (1.3 - 5.3)), to be HIV negative (79% v.
54%; RR 2.8 (1.4 - 5.6)), to be smokers (76% v. 60%; RR 1.97 (1 - 3.9)),
to have a persistent cough (86% v. 69%; RR 2.5 (1.1 - 5.7)), and to have
better lung function. In addition, super-spreaders had a signicantly
(p<0.0001 for all comparisons) shorter time to sputum culture positivity
(6.1 (0.5) v. 21.2 (1.1) days), a lower GeneXpert cycle threshold (CT)
average (CT 16.1 (0.5) v. 22.4 (0.3)), and higher average smear grade
(3.6 (0.2) v. 1.4 (0.1)). Predictive modelling using the Xpert CT alone
(preferred for its fast turnaround time) revealed that super-spreaders
could be distinguished from CASS-negative patients with a sensitivity
of 0.83 (0.78 - 0.86) and specicity of 0.73 (0.63 - 0.78).
Conclusion. Tuberculosis super-spreaders can be accurately identied
using readily available demographic, clinical and GeneXpert results,
showing great potential to inform isolation and contact tracing
protocols that could considerably limit the transmission of tuberculosis.
SARS-CoV-2 viral replication persists
in the human lung for several weeks
after symptom onset in mechanically
ventilated patients with severe COVID-19:
A prospective tissue-sampling study
M Tomasicchio, S Jaumdally, A Pooran, A Esmail, L Wilson,
A Kotze, L Semple, S Meier, K Pillay, R Roberts, R Kriel,
R Meldau, S Oelofse, C Mandviwala, J Burns, R Londt, M Davids,
C van der Merwe, A Roomaney, L Kühn, T Perumal, A J Scott, M J
Hale, V Baillie, S Mahtab, C Williamson, R Joseph, A Sigal,
I Joubert, J Piercy, D omson, D L Fredericks, M G A Miller,
M C Nunes, S A Madhi, K Dheda
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
Corresponding author: K Dheda (keertan.dheda@uct.ac.za)
Background. The immunopathogenesis of severe COVID-19 is
incompletely understood. Remdesivir is not recommended in
mechanically ventilated (MV) patients. In the upper respiratory tract
(URT), replicating (culturable) SARS-CoV-2 is recoverable for ~ 4
AJTCCM VOL. 29 NO. 2 2023 85
ABSTRACTS
- 8 days aer symptom onset; however, there is a paucity of data on
the frequency or duration of replicating virus in the lower respiratory
tract (i.e. the human lung).
Methods. We undertook lung tissue sampling (needle biopsy), shortly
aer death, in 42 MV decedents during the Beta and Delta COVID-19
waves. An independent group of 18 ambulatory patients served as a
comparative control. Lung biopsy cores from decedents underwent
viral culture, histopathological analysis, electron microscopy,
transcriptomic proling, immunohistochemistry and cell-based ow
cytometry of deconstructed tissue.
Results. Of MV decedents, 38% (n=16/42) had culturable virus in the
lung for a median of 15 days (persisting for up to 4 weeks) aer symptom
onset, compared with <~5 days in the URT of ambulatory patients.
Lung viral culture positivity was not associated with comorbidities
or steroid use. Delta but not Beta variant lung culture positivity was
associated with accelerated death and secondary bacterial infection
(p<0.05). NP culture was negative in 23.1% (n=6/26) of decedents
despite lung culture positivity. This hitherto undescribed bio-
phenotype of lung-specic persisting viral replication was associated
with an enhanced transcriptomic pulmonary pro-inflammatory
response, but concurrent with viral culture positivity.
Conclusion. In a sizeable subset of patients with acute COVID-19,
concurrent rather than sequential active viral replication continues
to drive a heightened pro-inammatory response in the human lung
beyond the 2nd week of illness (despite lack of viral replication in the
URT), and was associated with variant-specic increased mortality
and morbidity. ese ndings have potential implications for the
design of interventional strategies and clinical management of patients
with severe COVID-19 disease.
Funding. South African Medical Research Council.
Frequency, kinetics and determinants of
viable SARS-CoV-2 in bioaerosols from
ambulatory COVID-19 patients infected
with the Beta, Delta or Omicron variants
S Jaumdally, M Tomassichio, A Pooran, A Esmail,
A Kotze, S Meier, L Wilson, S Oelofse, C van der Merwe,
A Roomaney, M Davids, T Suliman, R Joseph, T Perumal,
A Scott, M Shaw, W Preiser, C Williamson, A Goga, E Mayne,
G Gray, P Moore, A Sigal, J Limberis, J Metcalfe, K Dheda
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
of the Witwatersrand, Johannesburg, South Africa
Corresponding author: M Tomassichio (Michele.Tomasicchio@uct.
ac.za)
Background. Airborne transmission of SARS-CoV-2 aerosol remains
contentious. Importantly, whether cough- or breath-generated bioaerosols
can harbour viable and replicating virus remains largely unclaried.
Methods. We performed size-fractionated aerosol sampling
(Andersen cascade impactor) and evaluated viral culturability in
human cell lines (infectiousness), viral genetics, and host immunity
in ambulatory participants with COVID-19.
Results. Sixty-one percent (n=27/44) and 50% (n=22/44) of
participants emitted variant-specic culture-positive aerosols <10 μm
and <5 μm, respectively, for up to 9 days aer symptom onset. Aerosol
culturability was significantly associated with lower neutralising
antibody titres, and suppression of transcriptomic pathways related
to innate immunity and the humoral response. A nasopharyngeal Ct
<17 ruled in ~40% of aerosol culture positives and identied those
that were probably highly infectious. A parsimonious three transcript
blood-based biosignature was highly predictive of infectious aerosol
generation (positive predictive value >95%). Only 29% of participants
produced culture-positive aerosols <5 μm at ~6 days aer symptom
onset, therefore supporting the super-spreader hypothesis.
Conclusion. ese data, the rst to comprehensively conrm variant-
specic culturable SARS-CoV-2 in aerosol, inform the targeting of
transmission-related interventions and public health containment
strategies emphasising improved ventilation.
Comparison of the eects of electronic
cigarette vapours and tobacco smoke
extracts on human neutrophils in vitro
G A Richards, A J eron, I van den Bout, R Anderson,
C Feldman, R van Zyl Smit, J-W Chang, G R Tintinger
Corresponding author: G A Richards (guy.richar[email protected])
Background. Electronic cigarettes (ECs) are aerosol delivery
systems composed of nicotine and various chemicals, widely used
to facilitate smoking cessation. Although ECs are considered safer
than cigarettes, their vapours contain chemical toxicants that
may interact with cells of the host’s innate immune system such
as neutrophils, adversely aecting the innate immune system and
potentially predisposing EC users to respiratory infections.
Objectives. To compare effects of aqueous EC aerosol extracts
(ECEs, with or without nicotine) with cigarette smoke extract (CSE)
on neutrophil and platelet reactivity in vitro.
Methods. Neutrophil reactivity is characterised by generation of
reactive oxygen species (ROS), degranulation (elastase release)
and release of extracellular DNA (neutrophil extracellular
trap (NET) formation: NETosis), which were measured using
chemiluminescence, spectrophotometric and microscopic
procedures, respectively. Platelet reactivity was measured according
to the magnitude of upregulated expression of the adhesion molecule
CD62P using ow cytometry.
Results. Exposure of neutrophils to ECEs or CSE significantly
inhibited ROS generation and elastase release by N-formyl-L-
methionyl-L-leucyl-L-phenylalanine (1 μM)-activated neutrophils.
Pretreatment of neutrophils with CSE also resulted in a marked
attenuation of phorbol 12-myristate 13-acetate (6.25 nM)-mediated
release of extracellular DNA, which was unaected by the ECEs.
Similarly, CSE, but not the ECEs, inhibited the expression of CD62P
by platelets activated with ADP (100 μM).
Conclusion. These observations suggest that EC aerosols may
inhibit some immunoprotective activities of neutrophils such as ROS
production and elastase release by activated cells, the eect of which
was not enhanced by nicotine. e inhibitory eects of CSE were
signicantly more pronounced than those of ECEs, especially for
suppression of NET formation and platelet activation. If operative
in vivo, this may compromise intrinsic pulmonary antimicrobial
defence mechanisms, albeit less so than cigarette smoke.
86 AJTCCM VOL. 29 NO. 2 2023
ABSTRACTS
Early experience and outcomes of novel
generic cystic brosis transmembrane
conductance regulator protein
modulator drugs in South Africans with
cystic fibrosis: A real-world study to
challenge Big Pharma patent monopoly
in low- and middle-income countries
C Baird
Corresponding author: C Baird (cathy@drcathybaird.com)
Background. Cystic brosis (CF) transmembrane conductance regulator
protein modulator drugs (CFTRm) have transformed the prognosis of
people with CF (pwCF), but they are not available in South Africa (SA).
Some pwCF in SA are personally obtaining a cheaper generic elexacaor/
tezacaor/ivacaor (ETI).
Objectives. To describe and compare patient outcomes aer initiating
standard (daily) generic ETI dosing or o-label ‘modulator-sparing’
dosing (twice weekly), in combination with a strong CYP3A-inhibitor.
Methods. is was a multicentre descriptive study from December 2021
to March 2023, using SA CF registry data. Uni- and multivariable repeated
measures analyses were conducted to describe changes in sweat test,
forced vital capacity in 1 second (FEV1pp) and body mass index (BMI)
over the 12-month follow-up period, for dierent dosing schedules.
Results. Forty-three pwCF (median age 25 years; 41 with ³1 copy
F508del) initiated ETI with standard (n=31) or modulator-sparing
doses (n=12). One patient died during the study period. Mean
(standard deviation) pretreatment sweat chloride, BMI and FEV1pp
were 92 (21) mmol/L, 19.1 (2.4) kg/m2 and 58 (29.4), respectively. e
overall mean reduction in sweat chloride over the rst month of ETI
treatment was 52 mmol/L (p<0.01), with improvements in FEV1pp
and BMI of 15.1 (p<0.01) and 0.98 kg/m2 (p<0.001), respectively.
Improvements in FEV1pp and BMI were sustained or improved
further throughout follow-up, with no dierence between dosing
groups (p>0.1).
Conclusion. e treatment eect of generic ETI appears similar to
real-world data reported using the original product. ere was no
signicant dierence in response between modulator-sparing and
standard dosing; reduced dosing may therefore be considered as an
interim measure to reduce cost and increase access to CFTRm in SA.
Management and outcomes of
community-acquired sepsis in patients
admitted to medical wards at a
tertiary academic hospital: A 6-month
prospective study
V Mcebula, M B Kgole
Department of Medicine, Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, South Africa
Corresponding author: V Mcebula (vmcebula@gmail.com)
Background. Sepsis is a life-threatening organ dysfunction secondary
to the dysregulated body’s immune response to infection, and it is a
signicant cause of morbidity and mortality worldwide.
Objectives. To describe the management and outcomes of community-
acquired sepsis among medical admissions at Dr George Mukhari
Academic Hospital (DGMAH), Pretoria, South Africa.
Methods. A prospective cross-sectional review of medical records of
consecutive adult patients with community-acquired sepsis admitted to
the internal medicine wards at DGMAH between 1 August 2022 and
31 March 2023 was performed. Clinical outcomes were measured by
mortality, length of hospital stay and intensive care unit (ICU) transfer.
Results. A total of 169 patients fullled the study inclusion criteria,
representing 7.3% of the total admissions. Their mean (standard
deviation) age was 43.4 (16.5) years (range 18 - 91), and more than half
(52.7%) were <40 years of age. Most of the patients (63.3%) were male.
e most prevalent diagnoses were community-acquired pneumonia,
infective endocarditis and tuberculosis. More than eighty percent (86.4%)
had at least one comorbid condition. Retroviral disease (HIV), diabetes
mellitus, acute kidney injury and hypertension were the most frequent
comorbidities. e most common samples submitted for investigation
were blood cultures (72.8%), and 74 of 123 samples (60.2%) were found to
be positive for one or more microbial pathogens. e two most common
bacteria isolated from blood cultures were Staphylococcus aureus
and coagulase-negative staphylococci. e most common antibiotics
prescribed were augmentin and azithromycin. Of the study cohort, 15.4%
of patients died, over half (55.0%) stayed in the hospital for over a week,
and 16.6% were transferred to the ICU for escalation of care.
Conclusion. e study suggests that overall mortality due to community-
acquired sepsis was high, particularly in patients admitted with infective
endocarditis and community-acquired pneumonia who were co-infected
with HIV. Bacteraemia, especially from S. aureus, was associated with
increased hospital mortality.
The diagnostic performance of
unstimulated IFN-γ (IRISA-TB) for pleural
tuberculosis: A prospective study in
South Africa and India
A J Scott, L Wilson, P Randall, K Radia, B angakunam, D
Shankar, E Shanmugasundaram, S Rajasekar, C Sondararajan, A
Esmail, K Dheda, D J Christopher
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
Corresponding author: A J Scott (al[email protected])
Background. Tuberculous pleural eusion (TPE) is the most common
form of extrapulmonary tuberculosis in many settings. e diagnostic
performance of frontline rapid nucleic acid amplication tests, such
as GeneXpert MTB/RIF, remains suboptimal (sensitivity ~30%).
However, a more sensitive version (GeneXpert MTB/RIF Ultra), and
alternative newer assays, are now available.
Objectives. To evaluate the diagnostic performance of Xpert Ultra and
the newer interferon-gamma rapid immunosuspension assay (IRISA-
TB), a rapid (same-day) diagnostic test, in patients with presumed
TPE (the pleural uid sample remains unprocessed and there is no
overnight stimulation step, and this is therefore not an IGRA).
Methods. In this multicentre, observational study, a total of 218
participants with suspected TPE were recruited (110 and 108 from
South Africa and India, respectively). Participants underwent routine
diagnostic testing and pleural biopsy. IRISA-TB testing was performed
concurrently. Performance was compared with other available same-
day diagnostic tests (adenosine deaminase (ADA) and Xpert Ultra).
AJTCCM VOL. 29 NO. 2 2023 87
ABSTRACTS
e reference standard for tuberculosis (TB) was microbiological and/
or histopathological conrmation of TB using the uid and/or pleural
biopsy sample.
Results. Results for this preliminary analysis were available for
133/218 participants (61.0%). e sensitivity of IRISA-TB (cut point
20.5 pg/mL) was signicantly better than that of Xpert Ultra (81.9%
v. 34.6% (25.2 - 45.5), respectively; p<0.001). e specicity of IRISA-
TB was signicantly higher than that of ADA (97.5% v. 84.7% (76.5
- 90.4); p=0.029), but was similar to Xpert Ultra (97.5% v. 99.1% (94.9
- 99.9)). e negative predictive value (NPV) of IRISA-TB (88.4%
(80.0 - 93.7)) was higher than that of ADA (86.3% (78.3 - 91.7)) and
Xpert Ultra (66.7% (59.1 - 73.6)) (p=0.036). e positive predictive
value (PPV) of IRISA-TB was 88.4% (80.0 - 93.6).
Conclusion. Xpert Ultra has poor sensitivity for the diagnosis of
pleural TB. In contrast, IRISA-TB demonstrated high sensitivity,
specicity, NPV and PPV for the diagnosis of TPE in TB-endemic
settings.
High rates of cavitary disease, detected
during community-based active case
nding, in individuals with subclinical
v. symptomatic active tuberculosis
A J Scott, T Perumal, P Gina, S Jaumdally, S Oelofse, L Kühn,
J Swanepoel, A Esmail, K Dheda
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
Corresponding author: A J Scott (al[email protected])
Background. Subclinical tuberculosis (TB; asymptomatic individuals
with microbiologically proven TB) represents a large proportion of the
global TB burden. Whether these individuals contribute to disease
transmission is unclear. Lung cavitation is associated with infectiousness
and disease transmission.
Objectives. To compare radiological findings, including cavitary
disease, in individuals with subclinical v. symptomatic active TB during
community-based active case nding.
Methods. Participants with microbiologically conrmed TB (GeneXpert
and/or culture positivity; N=77), recruited from two ongoing, prospective
community-based active case-nding studies in South Africa, underwent
a chest x-ray (CXR) and fluorodeoxyglucose positron emission
tomography computed tomography (18F FDG PET-CT).
Results. A total of 1 013 participants were enrolled, of whom
77 (7.6%) had microbiologically confirmed TB (43 (55.8%) had
subclinical TB and 34 (44.2%) had symptomatic active TB). CXRs
and PET-CTs were available for 72/77 participants (93.5%), of whom
61.1% (n=44/72) had cavitary disease on CXR (signicantly higher
in those with symptomatic active TB than in those with subclinical
TB (78.8% v. 46.2%, respectively; p=0.005)) and 75.0% (n=54/72) had
cavitary disease on PET-CT (similarly higher in symptomatic active
TB v. subclinical TB (84.8% v. 66.7%)). Compared with PET-CT, CXR
correctly identied 74.1% (n=40/72) with cavitary disease (~25% of
cavitary disease was therefore missed on CXR). Of participants with
TB, 27.3% (n=21/77) were smear positive (44.1% of symptomatic
active TB v. 14.0% of subclinical TB; p=0.005). Of smear-positive
participants, 17/21 (81.0%) had cavitary disease on PET-CT. is
pattern of ndings remained largely unchanged when individuals with
a history of previous TB were excluded from the analysis.
Conclusion. Among community-based individuals who did not
self-report to healthcare facilities, the rates of cavitary disease were
substantial (even in those with subclinical TB). To our knowledge,
these data are the rst to compare community-based CXR and PET-
CT ndings, thus informing future active case-nding strategies that
seek to detect almost all probably infectious persons with TB.
Feasibility of concurrent COVID-19
screening during community-based
active case finding for tuberculosis in
symptomatic individuals in South Africa
A J Scott, T Perumal, S Jaumdally, A Pooran, C van der Merwe, A
Kotze, S Oelofse, L Kühn, J Swanepoel, A Esmail, K Dheda
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
Corresponding author: A J Scott (al[email protected])
Background. Tuberculosis (TB) is a global public health threat. e
COVID-19 pandemic resulted in extensive resource reallocation,
disrupting healthcare services and reversing years of TB control eorts.
Objectives. To evaluate the feasibility of concurrent COVID-19
screening during community-based active case nding (ACF) for TB
in symptomatic individuals in South Africa (SA).
Methods. In this cross-sectional study, we recruited participants
with clinical symptoms suggestive of TB and/or COVID-19 from the
SA site of an ongoing, European and Developing Countries Clinical
Trials Partnership-funded, community-based ACF study (XACT-
19 (RIA2020S-3295)). Participants underwent simultaneous point-
of-care (POC) testing; for TB, we tested sputum using GeneXpert
MTB/RIF Ultra, and for COVID-19, we tested nasopharyngeal swabs
using Xpert SARS-CoV-2. Diagnostic accuracy was compared with
sputum culture and reverse transcription polymerase chain reaction
at a central laboratory (reference standards for TB and COVID-19,
respectively). To assess feasibility and usability of POC Xpert testing,
minimally trained study personnel completed the System Usability
Scale (SUS, a Likert-based questionnaire with a score ranging from 0
(negative) to 100 (positive)).
Results. Between February 2022 and March 2023, a total of 490
participants were enrolled, of whom 123 (25.1%) were symptomatic
and included in this analysis; n=16/123 (13.0%) participants tested
positive for TB, n=9/123 (7.3%) tested positive for COVID-19, and
n=2/123 (1.6%) had concurrent TB and COVID-19. Sensitivity and
specicity of POC Xpert Ultra was 75.0% (42.8 - 94.5) and 96.4%
(91.0 - 99.0), respectively, whereas those of POC Xpert SARS-CoV-2
were 66.7% (22.3 - 95.7) and 97.4% (92.6 - 99.5), respectively. Five
study personnel completed the SUS with a mean (standard deviation)
score of 77.5 (17.2), indicating POC Xpert to be acceptable and to
have ‘good’ usability.
Conclusion. When performing ACF for TB, concurrent screening
for COVID-19 using POC molecular tools is feasible and has a
moderate diagnostic yield. Further research may establish the optimal
distribution of resources for potential future COVID-19 waves or
pandemics.
88 AJTCCM VOL. 29 NO. 2 2023
ABSTRACTS
Evaluating the impact of computer-
assisted X-ray diagnosis and other triage
tools to optimise GeneXpert-orientated
community-based active case nding for
tuberculosis and COVID-19 (XACT-19)
A J Scott, M Limbada, T Perumal, S Jaumdally, A Pooran, A
Kotze, C van der Merwe, M Cheeba, D Milimo, S Oelofse, A
Esmail, H Ayles, K Dheda
Centre for Lung Infection and Immunity, Division of Pulmonology,
Department of Medicine, Faculty of Health Sciences, University of
Cape Town and UCT Lung Institute, Cape Town, South Africa
Corresponding author: A J Scott (al[email protected])
Background. Almost 40% of persons newly diagnosed with
tuberculosis (TB) are unreported. Detecting cases in TB/HIV-
endemic communities has been restricted by a lack of sensitive
and user-friendly point-of-care (POC) diagnostic tools. Computer-
aided detection (CAD) has been recommended by the World Health
Organization for screening for TB; however, implementation of CAD
in community-based active case nding (ACF) is unclear.
Objectives. To determine the adjunctive role of CAD in GeneXpert-
orientated community-based ACF for TB.
Methods. In this ongoing, European and Developing Countries
Clinical Trials Partnership-funded (RIA2020S-3295), open-label
randomised controlled trial, high-risk persons (symptomatic and/
or HIV-infected) with presumed TB were recruited from TB/HIV-
endemic communities in South Africa (SA) and Zambia (Zimbabwe
is an additional site). Using a low-cost mobile van staed by three
healthcare workers and equipped with an ultra-portable X-ray and
GeneXpert system, participants were randomised into either ‘CAD
+ POC Xpert’ (arm 1: CAD followed by Xpert MTB/RIF Ultra in
CAD-positive participants using a CAD4TB v7 threshold of 10
(South Africa) and 50 (Zambia) based on prior population-specic
calibration), or ‘POC Xpert alone’ (arm 2: POC Xpert MTB/RIF Ultra
only). e primary outcome was time to detection of microbiologically
proven TB (Xpert and/or culture positivity). We present an interim
trial progress report.
Results. From February 2022, a total of 505 participants have been
enrolled (256 (50.7%) from SA and 249 (49.3%) from Zambia). Of the
505 participants, 26.9% (n=136) were HIV infected (median CD4 count
609 cells/µL) and 33 (6.5%) tested positive for TB (n=25/256 (9.8%)
in SA and 8/249 (3.2%) in Zambia). Fieen participants underwent
screening to detect 1 case of TB. Of TB-positive participants, 7/33
(21.2%) were smear positive.
Conclusion. Community-based ACF detected a high burden of TB,
of which a signicant minority (~20%) was probably infectious. ese
data have implications for ACF strategies in high-burden settings.
The clinical profile of teenagers with
asthma attending the respiratory
outpatient clinic of an academic hospital
B Garrach, M J Mpe.
Division of Pulmonology, Department of Medicine, Faculty of Health
Sciences, Sefako Makgatho Health Sciences University, Pretoria, South
Africa
Corresponding author: M J Mpe (oupamp[email protected]m)
Background. Asthma is a heterogeneous disease characterised by
chronic airway inammation. e chronic inammation is associated
with airway hyper-responsiveness. e burden of asthma is particularly
high in adolescents, with an increased prevalence and mortality
compared with younger children. Studies have shown that asthma
management creates a particular set of challenges among adolescents,
who are seeking greater autonomy, developing socially and emotionally,
and experiencing changes in their relationships with friends and family.
Adolescence is a time of testing limits, and oen risk-taking behaviour
such as experimentation with smoking.
Objectives. To describe the clinical prole of teenage asthmatics in a
tertiary care centre.
Methods. A cross-sectional study of teenage asthmatics attending a
respiratory clinic was performed. e study consisted of face-to-face
interviews and review of clinical and laboratory records.
Results. Eighty-seven teenagers were studied. e mean (standard
deviation) age was 15.5 (1.52) years. e majority (59%) were male.
Forty-seven percent had been diagnosed with asthma between the
ages of 3 and 5 years. Ten (11.5%) were current smokers. e mean
CAT score of the group was 19.2 (2.29). Fieen (26.7%) had had an
attack requiring hospitalisation in the past 12 months, and 5.8% had
had a previous intensive care unit (ICU) admission. Eighteen patients
(20.7%) had access to a home nebuliser. ere were no statistically
signicant dierences in CAT scores or smoking status between males
and females. Knowledge of asthma medication and appropriateness
of inhaler technique did not independently aect the risk of ICU
admission.
Conclusion. e majority of the participants had satisfactory asthma
control as determined by the CAT score, even though inhaler technique
was largely unsatisfactory. e prevalence of tobacco use in this cohort
is a cause for concern.
A benign endobronchial polyp with
breath-taking consequences
G Zollmann, AGraham
Department of Pulmonology, Helen Joseph Hospital and Department
of Medicine and Pulmonology, Faculty of Health Sciences, University
of the Witwatersrand, Johannesburg, South Africa
Corresponding author: G Zollmann (gabi.zollman[email protected]m)
Case presentation. A 30-year-old man was referred to our hospital with
a 4-month history of progressively worsening dyspnoea, signicant
loss of weight, and night sweats. He also reported a chronic dry cough
which was now productive of yellow-coloured sputum. He denied
experiencing haemoptysis.
His background medical history was signicant for radiation-induced
hypothyroidism and previous childhood lymphoma, which was
successfully cured aer treatment with chemotherapy and radiation
at age 12. He also reported having completed 6 months of anti-
tuberculosis (TB) treatment for pulmonary TB 17 years prior to this
admission. He was HIV negative. He reported a 5 pack-year cigarette
smoking history.
On clinical examination, the patient was found to be in respiratory
distress with generalised muscle wasting. His room air oxygen
saturation was 85% with a sinus tachycardia of 144 bpm. ere was
nger and toe digital clubbing. ere was evidence of volume loss of
AJTCCM VOL. 29 NO. 2 2023 89
ABSTRACTS
the le hemithorax with a deviated trachea to the le, decreased chest
expansion and decreased breath sounds. e right side of the chest
was normal to examination. Cardiovascular examination was normal
without features of pulmonary hypertension.
A chest X-ray conrmed le hemithorax volume loss and a dense le-
sided opacication without air bronchograms. ere was compensatory
hyperination of the right lung.
A contrast-enhanced computed tomography scan of the chest
revealed collapse-consolidation of the entire le lung. An endobronchial
mass was noted within the le main bronchus with almost complete
endobronchial obstruction. No calcification or enhancement was
visualised, and there was no erosion through the tracheal walls. e
right lung was normal. No signicant mediastinal lymphadenopathy
was noted.
Sputum cultured a Proteus mirabilis sensitive to amoxicillin, and
GeneXpert Ultra was positive for rifampicin-sensitive TB. e patient
was commenced on co-amoxiclav and anti-TB treatment.
Flexible bronchoscopy revealed a well-circumscribed multilobulated
endobronchial polypoid mass, originating from the proximal le main
bronchus. ere was complete occlusion of the le main bronchus.
Histological examination showed a benign broepithelial polyp.
The patient was referred for cardiothoracic surgery. A left
pneumonectomy was performed with complete excision of the polyp
and successful stump closure. e patient was discharged home 4 days
postoperatively.
At follow-up 6 months later, the patient reported being well, with
resolution of all respiratory symptoms. He reported a return to baseline
weight and return to normal activities.
Discussion. Benign broepithelial polyps of the bronchial tree are
rarely reported in the literature, and this is the rst case report described
in South Africa (SA).
e aetiology of broepithelial polyps is unclear, and the pathogenesis
has not been well established. ere are case reports which suggest
that these lesions arise from chronic inammatory processes.
[1]
is
patient had multiple risk factors for chronic inammation: he was a
smoker with a 5 pack-year history, he had received radiation therapy for
lymphoma as a child, he had had previous pulmonary TB, and he also
had newly diagnosed pulmonary TB and bacterial co-infection of the
post-obstructed lung.
Radiological findings typically show a well-defined nodule
growing into the bronchus, with lobulated margins, resembling a
blackberry.
[2]
During bronchoscopy, the lesions appear as a well-
dened round, whitish pedunculated mass with a smooth surface
and rm consistency.
[3]
e histological ndings of these lesions
have been reported as dense brovascular stroma, lacking epithelial
overgrowth, covered by normal respiratory epithelium.
[2]
SA has a high prevalence of pulmonary TB, and not infrequently
patients are reinfected with TB. Our case highlights the importance of
investigating for endobronchial obstruction in patients with persistent
pulmonary infection, particularly when isolated to one anatomical area
of the thorax.
is case posed a challenge when deciding on a therapeutic strategy
for relieving the endobronchial obstruction, preventing polyp growth
and curing the TB. e commonest treatment modality is endobronchial
excision with biopsy forceps.
[2]
Endoscopic resection offers the
therapeutic potential of lung re-expansion, allowing for improved
clearance of mucus and secretions from the airways, and therefore better
pulmonary hygiene and an improved chance of TB treatment success.
However, the risk of contaminating the right lung was a major concern.
Furthermore, re-expansion of the le lung seemed unlikely given the
radiographic features of chronicity.
Although broepithelial polyps are slow-growing lesions with no
malignant potential, and no evidence of increased mortality, our case
shows that this benign lesion can result in signicant endobronchial
obstruction with resultant chronic pulmonary infection and structural
changes, therefore posing a signicant risk of morbidity and mortality
if le unaddressed. Surgical treatment, including pneumonectomy for
cure of infection, should be considered in order to prevent complications
related to persistent pulmonary mycobacterial infection.
Conclusion. Fibroepithelial polyps are most commonly found in the
skin and genitourinary tract, and benign endobronchial broepithelial
polyps are rare.[4] While the aetiology of these lesions remains
unclear, an inammatory pathogenesis is likely. ese lesions may be
identied by their typical radiological ndings, and by their appearance
macroscopically during bronchoscopy. e diagnosis can be conrmed
with a biopsy. ere is no consensus on the treatment of these lesions,
but as our case demonstrates, surgery may be required to provide cure
of endobronchial obstruction and treatment of infection.
1. Schnader J, Harrell J, Mathur P, Carmel J, Koduri J, Kvale P. Clinical conference
on management dilemmas: Bronchiectasis and endobronchial polyps. Chest
2002;121(2):637-643.https://doi.org/10.1378/chest.121.2.637
2. Labarca G, Caviedes I, Vial MR, et al. Airway broepithelial polyposis. Respir Med
Case Rep 2017;22:154-157. https://doi.org/10.1016/j.rmcr.2017.08.005
3. Casalini E, Cavazza A, Andreani A, et al. Bronchial broepithelial polyp: A clinico-
radiologic, bronchoscopic, histopathological and in-situ hybridisation study of
15 cases of a poorly recognised lesion. Clin Respir J 2017;11(1):43-48. https://doi.
org/10.1111/crj.12300
4. Melo RC, Ribeiro C, Sanches A, Oliveira A. A rare benign tumor of tracheobronchial
tree: Endobronchial broepithelial polyp. Rev Port Pneumol 2015;21(4):221-222.
https://doi.org/10.1016/j.rppnen.2015.03.001
Bilateral catamenial pneumothoraces
with a left-sided diaphragmatic defect
and omental herniation: A case report
G Titus, R omas, V Naidoo
Division of Pulmonology, Department of Medicine, Faculty of Health
Sciences, University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: G J Titus (drgjtit[email protected])
Background. Catamenial pneumothorax is the most common
presentation of thoracic endometriosis syndrome. oracic endometriosis
syndrome is dened as recurring spontaneous pneumothorax occurring
within 72 hours before or aer the start of menstruation, and occurs
primarily in women aged 30 - 40 years. ere is no denitive aetiology,
though there are currently three popular theories – the metastatic,
hormonal, and diaphragmatic air passage (anatomical) theories.
Case presentation. A 35-year-old woman presented with sudden-
onset shortness of breath, and a chest radiograph revealed bilateral
pneumothoraces. Intercostal chest drains were inserted and the
pneumothoraces resolved. Two months later she re-presented with
shortness of breath, and a chest radiograph again showed bilateral
pneumothoraces. Further history revealed that the rst episode had
90 AJTCCM VOL. 29 NO. 2 2023
ABSTRACTS
occurred at the start of her menstrual cycle, and the current cycle was
also concurrent with her menstrual cycle. High-resolution computed
tomography showed no underlying parenchymal lung disease.
Left-sided video-assisted thoracoscopic surgery was done, and two
diaphragmatic defects were noted, with omentum herniating into the
chest. e omentum was resected, the defect was closed, and the hernia
was repaired. Biopsy conrmed endometriosis. While right-sided video-
assisted thoracoscopic surgery was planned for 6 weeks later, the patient
started menstruating in postoperative recovery and developed a right-
sided pneumothorax. A right-sided pleurectomy was performed and
gonadotropin-releasing hormone (GnRH)-analogue therapy was started.
Conclusion. e current literature reports only cases of right-sided
hernias, so this case with a le-sided defect and omental herniation is a
novel presentation of thoracic endometriosis syndrome. Additionally, the
presence of diaphragmatic fenestrations contributes evidence that may
support the diaphragmatic air passage theory for the aetiology of thoracic
endometriosis syndrome.
Clinical audit of connective tissue
disease-associated interstitial
lung disease at Charlotte Maxeke
Johannesburg Academic Hospital over
30 years
S Marais
Corresponding author: S Marais (sheldonkmara[email protected]m)
Background. Connective tissue diseases (CTDs) are a heterogeneous
group of diseases, with variable clinical manifestations. e individual
CTDs vary in their prevalence. CTDs are among the more common
causes of non-idiopathic interstitial lung disease. Almost all connective
tissue diseases may be associated with interstitial lung disease (CTD-
ILD).
Objectives. To review and compare the prevalence, clinical features,
laboratory results, high-resolution computed tomography (HRCT)
imaging patterns and treatment of patients with CTD-ILD with
those in other centres.
Methods. is was a retrospective study of 1 614 CTD patients conducted
between 1993 and 2022 at the Charlotte Maxeke Johannesburg Academic
Hospital rheumatology clinic. CTD-ILDs were noted in patients with
systemic lupus erythematosus, systemic sclerosis, dermatomyositis,
polymyositis, Sjögren’s syndrome and mixed connective tissue disease.
Results. Of 1 614 CTD patients, 117 (7.2%) were diagnosed with
CTD-ILD during this period. There was a female predominance of
91.5% (n=107). e median age was 54 years and the majority (83.3%;
n=98) of the patients were of black ethnicity. Most of the patients were
diagnosed with systemic sclerosis (40.2%; n=47), followed by systemic
lupus erythematosus (34.2%; n=30), these two conditions constituting
the bulk (74.4%) of disease burden. More than two-thirds of the patients
were antinuclear antibody positive (72.6%). Cough and dyspnoea were
reported in 42.7% and 38.5%, respectively, and 61.5% of the patients had
audible crackles. e most frequent comorbidities were hypertension
(22.2%), diabetes mellitus (18.8%) and gastro-oesophageal reflux
disease (18.8%). e predominant HRCT pattern was usual interstitial
pneumonia (49.6%; n=58) followed by nonspecic interstitial pneumonia
(46.2%; n=54). Approximately half of the patients had a restrictive defect
on pulmonary function testing and 90.6% had low carbon monoxide
diusing capacity. Most patients were treated with corticosteroids and
an additional immunosuppressive agent; <10% received only one agent
throughout the course of their disease.
Conclusion. CTD-ILD has a varied incidence and prevalence across
the spectrum of connective tissue disease. e clinical manifestations,
serological markers, radiological patterns and histopathology vary
between the dierent connective tissue diseases. e current study reects
similar ndings compared with other national and international studies.
Evaluation and determinants of asthma
control among adult asthmatic patients
attending Johannesburg academic
respiratory clinics: A cross sectional study
G J Titus, J Clark-Buchner J Coetzee, Y Mbule, S Moodley,
V Nephalama, T Seroka, T Stransky, L Wagener, A Graham, M L
Wong, E J Shaddock
School of Clinical Medicine, Faculty of Health Sciences, University of
the Witwatersrand, Johannesburg, South Africa
Corresponding author: G J Titus (drgjtit[email protected])
Background. e prevalence of asthma in South Africa (SA) is among
the highest in Africa, and case mortality is h highest in the world.
Little research has been done regarding levels of asthma control and
associated determinants in SA.
Objectives. To explore the level of asthma control and the perceived risk
factors associated with poor control in adult asthma patients attending
three hospitals in Johannesburg.
Methods. is was a quantitative, descriptive, cross-sectional study of
adult patients presenting to asthma clinics in selected hospitals over
a period of 6 months. Participants were given a three-section self-
reporting survey, consisting of a demographic section, the Asthma
Control Test (ACT), and the 8-item Morisky Medication Adherence
Scale (MMAS-8) questionnaire.
Results. e prevalence of poor asthma control based on participants’
ACT scores in this study was 48.6%. A signicant linear regression (r=–
0.41; p<0.001) was identied between the ACT and the MMAS-8 score
in the uncontrolled asthma group. No signicant associations between
uncontrolled asthma and sociodemographic factors, including age
(p=0.12), gender (p=0.60), body mass index (p=0.15) and participants’
education (p=0.15), were identied. Similar clustering and increases
in prevalence of certain comorbidities, such as sinusitis and gastro-
oesophageal reux disease, occurred. Of the patients, 89% used short-
acting beta-agonists and 93.3% inhaled corticosteroids (ICSs), of whom
58.7% were on combined long-acting beta-agonist and ICS treatment.
Conclusion. Asthma control in this setting is poor. ere is also an
interesting inverse relationship between control and therapy adherence.
Further research needs to be done to better understand the issues
surrounding asthma control and to lay the groundwork for policies to
benet asthma patients in the future.
Interventions to reduce outdoor air
pollution and its impact on asthma
outcome: A systematic review
S T Hlophe, R Mphahlele, K Mortimer,* R Masekela*
Department of Paediatrics and Child Health, Nelson Mandela School
of Medicine, College of Health Sciences, University of KwaZulu Natal,
AJTCCM VOL. 29 NO. 2 2023 91
ABSTRACTS
Durban, South Africa
* Joint senior authors
Corresponding author: S T Hlophe (sbehlophe@gmail.com)
Background. Exposure to air pollutants can lead to asthma symptoms,
exacerbations and hospitalisations.
Objectives. To collate data on studies of outdoor air pollution
exposure reduction and asthma outcomes.
Methods. In this systematic review, we identified studies from 6
databases, articles written in English published in the 10 years up
to 31 March 2022. We included randomised and non-randomised
studies. Asthma outcomes included symptom control (asthma control
test (ACT), childhood ACT (c-ACT)), asthma exacerbations, forced
expiratory volume in 1 second (FEV1), and ratio of FEV1 to forced
vital capacity (FVC).
Results. Seven studies met the inclusion criteria. Participants’ ages
ranged from 0 to ≥65 years. In one study, 50% of patients reported
improved symptoms, ACT ≥20 improving post intervention from
41.1% to 60.7%, whereas in another mean (SD) ACT increased from
20.0 (2.4) at baseline to 21.5 (2.3) aer intervention. For the children,
there was signicant improvement and a mean dierence of 3 and
4 points for c-ACT and ACT. ere was a reduction in the number
of asthma admissions, mean 2.8 v. 4.0 (p<0.001). Asthma-related
emergency department visits decreased by 25%. Lung function test
changes varied from none to greater changes in FVC and FEV1. Owing
to the diversity of study designs, we could not perform meta-analyses.
Conclusion. We found few studies of outdoor air pollution reduction
interventions on asthma outcomes, despite the importance of this
topic. is eld would benet from further high-quality randomised
clinical trial evidence to inform policy and decision-making.
Rituximab therapy in connective tissue
disease associated interstitial lung
disease: A retrospective single-centre
observational study
U F Seedat, B Christian, G K Schleicher
Wits Donald Gordon Medical Centre, University of the
Witwatersrand, Johannesburg, South Africa
Corresponding author: U F Seedat (ubaidseeda[email protected]m)
Background. Connective tissue disease-associated interstitial lung
disease (CTD-ILD) is a challenging clinical entity. Rituximab (RTX) is
a chimeric monoclonal antibody targeted to CD20+ B cells, resulting
in B-cell depletion, and has been suggested as a potential therapeutic
modality in progressive disease.
Objectives. To investigate the therapeutic eects and safety of rituximab
in patients with progressive CTD-ILD.
Methods. A retrospective observational analysis was performed at Wits
Donald Gordon Medical Centre between January 2010 and December
2020. A total of 19 patients with CTD-ILD were treated with RTX and
various combinations of immunomodulatory therapy. e eects of
RTX were investigated with serial pulmonary function testing, high-
resolution computed tomography (HRCT) of the chest, and the World
Health Organization functional class assessment (FC).
Results. At an average of 24 months’ follow-up from baseline, the mean
change in forced vital capacity (FVC) was not signicantly dierent
from baseline (0.01 L; 95% condence interval –0.13 - 0.14) (p=0.91).
At an average of 24 months’ follow-up, 17 follow-up HRCT scans were
available, of which 13 showed disease stability, 3 indicated progression,
and 1 indicated improvement. At an average of 24 months’ follow-up,
FC remained stable compared with baseline (p=0.083). No serious
adverse drug reactions or mortalities occurred.
Conclusion. Rituximab is a potential therapeutic option in patients
with progressive CTD-ILD and appears to result in stability in FVC,
HRCT ndings and FC over a 24 month period.
PAEDIATRIC PULMONOLOGY
The development of a multilingual
health-related quality of life tool for
children with bronchiectasis in South
Africa
L Nkosi, J Abbott, T Havermans, R Masekela
Department of Psychology, Steve Biko Academic Hospital, Pretoria,
South Africa
Corresponding author: L Nkosi (lilliannkos[email protected]m)
Background. ere is currently no validated health-related quality of life
(HRQoL) tool for children with bronchiectasis with varying cultural and
language needs in low- to middle-income settings.
Objectives. To develop a multilingual HRQoL tool and to assess the
evolution of QoL measured with the developed tool over a 1-year period.
Methods. Children with bronchiectasis aged 8 - 17 years at Steve Biko
Academic Hospital, Pretoria, were included. A mixed-methods approach
was used, with the study in two phases. In phase 1, development of the
tool involved item generation and reduction for questionnaire content,
generated from semi-structured interviews, and translation into three
ocial South African languages. In phase 2, the tool was administered
to children at baseline and at 1 year.
Results. In phase 1, 49 participants were included. Aer item reduction
(37 items) and 4 Likert scales, a nal tool with 31 items (17 physical and
14 emotional) was developed. In phase 2, 78 participants were included.
We found that HRQoL in physical activities was stable with light physical
activity and progressively declined with higher-impact activities. Despite
this, coping skills such as the ability of the children to laugh at themselves
increased by 8%, and anxiety and sleep disturbance decreased.
Conclusion. Language is critical in the development of HRQoL
questionnaires that are culturally appropriate in a multilingual
setting. e tool showed improvements in the emotional domain and
some minor decline in the physical domain. is tool still requires
psychometric evaluation as a future step.
Pulmonary interstitial glycogenosis in
an infant: Case report
R Nchabeleng
Corresponding author: R Nchabaleng (nchabelengr@yahoo.com)
Background. Childhood interstitial lung diseases (ChILDs) are rare
group of heterogeneous diseases affecting the lung parenchyma.
Pulmonary interstitial glycogenosis (PIG) is a type of ChILD that is
rare and poorly understood.
92 AJTCCM VOL. 29 NO. 2 2023
ABSTRACTS
Case presentation. We present the case of a female neonate, referred
from a local regional hospital, who presented with persistent
tachypnoea and hypoxaemia. A chest radiograph demonstrated
diuse reticular-nodular inltrates. ChILD was suspected, particularly
in view of the ndings on the chest radiograph of diuse bilateral
multiple cystic lesions and ground-glass opacities, and this diagnosis
was conrmed by a high-resolution chest computed tomography scan
demonstrating multiple interlobular septal thickening and diuse
areas of ground-glass opacities. e denitive diagnosis of PIG was
made by a lung biopsy demonstrating expansion of the alveolar septae
on reticulin stain and the presence of glycogen-laden mesenchymal
cells on periodic acid-Schi stain/D stain.
Aer conrmation of the diagnosis of PIG, the baby was treated with
monthly cycles of high-dose intravenous pulses of methylprednisone.
She was discharged home on home oxygen in a stable condition and
subsequently weaned o oxygen, but unfortunately died suddenly and
unexpectedly at the age of 9 months.
Conclusion. More research is still required to determine the aetiology
of PIG and a quicker non-invasive method for diagnosing it. It is of
paramount importance to improve understanding and knowledge in
the paediatric fraternity that will in turn assist with early recognition
and diagnosis of ChILD. is will contribute to improved management
and prognosis.
Paediatric pulmonary Langerhans cell
histiocytosis complicated by recurrent
haemothoraces
S M Wordui, S Makate, J Eze, S Chaya, H de Quintal,
A Mbonisweni, D von Del, M Zampoli, D Gray, A Vanker
Division of Paediatric Pulmonology, Department of Paediatrics and
Child Health, Red Cross War Memorial Children’s Hospital and
Faculty of Health Sciences, University of Cape Town, South Africa
Corresponding author: S M Wordui (swordui@gmail.com)
Background. Langerhans cell histiocytosis (LCH) is a rare disease in
which clonal proliferation and deposition of immature dendritic cells
in various tissues, including the lungs, causes inammation and organ
destruction. We report the case of a 4-year-old girl with refractory
multisystem LCH complicated by recurrent bilateral haemothoraces,
in a paediatric tertiary hospital in Cape Town, South Africa.
Case presentation. An HIV-negative girl aged 4 years and 11 months
presented with a 4-day history of cough, runny nose and fever. She
had a recurrent wheeze and night sweats and had had poor weight
gain for 2 years. An initial chest radiograph showed multiple lytic rib
lesions and a right pneumothorax, treated with an intercostal drain
(ICD). Notable ndings on presentation were decreased air entry of
the right hemithorax, bilateral expiratory wheezes, and a non-tender
2 cm hepatomegaly.
Urine homovanillic acid, tuberculosis work-up, and bone marrow
aspirate and biopsy were negative. Computed tomography and bone
scans showed multiple lytic skeletal lesions. A diagnosis of LCH was
conrmed on clavicular biopsy, classied as multifocal multisystemic
disease (liver, lung and bone involvement). Treatment response was
poor despite maximal chemotherapy, with a course characterised
by recurrent right pneumothoraces requiring ICD insertions. She
subsequently developed bilateral haemothoraces requiring fluid
resuscitation and ICD drainage. e eusions were paucicellular,
predominantly blood with scanty reactive lymphocytes, and no
organisms were cultured.
To manage the recurrent haemopneumothoraces, a right video-
assisted thoracoscopic biopsy and pleurodesis was performed, nding
a small lower lobe bleb, inammation of the parietal pleura, and upper
and middle lobes adherent to the chest wall. e ndings on lung
biopsy were normal, but the pleura showed chronic inammation and
brosis. e child has continued to have pneumothoraces and pleural
eusions and is currently awaiting a stem cell transplant.
Conclusion. Paediatric LCH can present as a prolonged debilitating
disease with recurrent pneumothoraces. Haemothorax, a rare
complication, can result from inammation of the pleura. Management
involves a multidisciplinary approach. oracoscopy may be useful to
conrm the site of bleeding, biopsies and/or pleurodesis.
Persistent hydropneumothorax
secondary to hydatid disease
A Masu, J Eze, S Wordui, S Makate, A Brooks, A Rajkumar, M
Zampoli, A Vanker, D Gray
Faculty of Health Sciences, University of Cape Town, South Africa
Corresponding author: A Masu (adelaidemasu@rocketmail.com)
Background. Hydatid cyst is an important parasitic zoonosis caused by
echinococcus granularis that aects the lungs and can result in rupture
of cysts into the pleural space, causing hydrothorax, pyopneumothorax
or pneumothorax.
Case presentation. A 10-year-old boy who had previously been well
presented to a referral hospital with a persistent hydropneumothorax
on chest radiology that failed to drain aer multiple intercoastal drain
(ICD) insertions.
On arrival at our hospital, a repeat chest radiograph revealed the
presence of a le-sided hydropneumothorax with a le ICD in situ.
Aer re-insertion of an ICD at our institution, the hydropneumothorax
persisted. Pleural uid analysis revealed an exudate and was negative
for tuberculosis (TB) (GeneXpert). Bronchoscopy revealed normal
anatomy of the airways. A bronchoalveolar lavage specimen was sent
o for further analysis. A computed tomography scan did not provide
a further diagnosis.
e large air leak persisted despite initial treatment with broad-spectrum
antibiotics and empirical TB treatment. The patient proceeded to
thoracotomy for pleural clear-out and surgical treatment of a presumed
bronchopleural stula. Surgery revealed a large, complicated hydatid
cyst in the le pleural space which was safely removed, with subsequent
good recovery.
At follow-up at 3 months the child was well, a chest radiograph showed
a fully re-expanded le lung, and lung function was normal. A liver
cyst identied at diagnosis was successfully treated and the child made
a full recovery.
Conclusion. is case reports an unusual presentation and cause of
persistent hydropneumothorax in the paediatric population and the
value of surgical intervention for both management and diagnosis.
AJTCCM VOL. 29 NO. 2 2023 93
ABSTRACTS
The role of objective testing in urban
adolescents with asthma symptoms in
Durban, South Africa
R E M Mphahlele, V Oyenuga, G Mosler, J Grigg, R Masekela
Department of Paediatrics and Child Health, Nelson Mandela School
of Medicine, College of Health Sciences, University of KwaZulu Natal,
Durban, South Africa
Corresponding author: R E M Mphahlele (mphahlel[email protected])
Background. Urban African adolescents suer from undiagnosed
and uncontrolled asthma symptoms.
Objectives. In this pilot study, to evaluate the role of objective testing
and whether the European Respiratory Society Task Force (ERS-TF)
diagnostic algorithm for children assisted with asthma diagnosis in
urban adolescents with asthma symptoms in Durban, South Africa.
Methods. Between July 2019 and November 2021, we conducted
a cross-sectional cohort study of urban schoolgoing adolescents
aged 12 - 14 years as part of the Achieving Control of Asthma in
Children in Africa (ACACIA) project. e study comprised two
stages: (i) screening for asthma symptoms and diagnosis; and (ii)
the Asthma Control Test, pre- and post-bronchodilator spirometry,
and fractional exhaled nitric oxide (FeNO) measurements in those
who screened positive for asthma symptoms.
Results. Of 2 093 adolescents screened, 180 were included, of whom
56% were female. Most participants had severe (n=128; 71%) and
uncontrolled (n=157; 87%) asthma, while less than half (n=74;
41,1%) had eosinophilic asthma (EA), as shown by FeNO >25 ppb.
Half (n=90) had a previous asthma diagnosis, but were more likely to
have uncontrolled asthma (p=0.04). Of the 109 included spirometry
measurements, the median ratio of forced expiratory volume in 1
second (FEV1) to forced vital capacity (FVC) (FEV1/FVC ratio), LLN
and z-score were 88.96, 78.80 and –0.12, respectively. Spirometry
measures were no different across asthma control and severity
groups. Spirometry sensitivity for diagnosing asthma was 37.5%
(95% condence interval 15.2 - 64.6), and specicity was 95.7% (89.4
- 98.8). ose with EA had signicantly lower FEV1 % predicted
(94.9 v. 102.0) and FEV1/FVC ratio (86.6 v. 89.9) (all p-values
<0.05). e prevalences of abnormal spirometry and bronchodilator
responsiveness (BDR) were 9% and 12%, respectively. By performing
the BDR test in those with normal spirometry, the diagnostic yield
of the ERS-TF algorithm increased by 62.5%.
Conclusion. ere was a high prevalence of severe and uncontrolled
asthma in this cohort. FeNO may assist in phenotyping asthma where
no discriminatory dierences are found using spirometry. e ERS-
TF diagnostic algorithm may miss adolescents with asthma if BDR
testing is not performed in those with normal baseline spirometry.
THORACIC SURGERY
Surgical treatment of bronchiectasis
in children: An 11-year experience at a
central health facility in KwaZulu-Natal,
South Africa
M Hbish
Inkosi Albert Luthuli Central Hospital, Durban, South Africa
Corresponding author: M Hbish (m-ihbesh@hotmail.com)
Background. e surgical management of children with bronchiectasis
has seldom been reported.
Objectives. To describe the presentation, surgical management and
outcomes in children with bronchiectasis presenting for surgery.
Methods. We retrospectively reviewed the electronic records of
0 - 13-year-old children who underwent pulmonary resection for
bronchiectasis at Inkosi Albert Luthuli Central Hospital, Durban,
South Africa, between January 2004 and December 2014. Clinical,
radiological and preoperative bronchoscopic findings, as well as
surgical and histological outcomes, were analysed.
Results. Eighty-eight patients underwent surgical resection. e female/
male ratio was 3:2, with a mean age at surgery of 8.2 (range 2 - 13) years;
39 patients were HIV infected and 39 were HIV uninfected. Tuberculosis
(TB) (n=68; 77.2%) was the most common cause of bronchiectasis, and
recurrent chest infection (n=45; 51.1%) was the most common clinical
nding. Radiological examination conrmed isolated le-sided disease
in 40 children (45.4%), isolated right-sided disease in 28 (31.8%) and
bilateral disease in 20 (22.7%). Saccular disease with brocavitation
(n=35; 39.7%) was the most common morphological disease type.
Preoperative bronchoalveolar lavage samples conrmed a bacterial
cause in 27 patients (30.6%). e most common operative procedures
were primary pneumonectomy in 33 patients (37.0%), lobectomy in
30 (34.0%) and bilobectomy in 13 (14.7%). Seventy-ve patients were
asymptomatic aer the operation, and complications occurred in 13.
Two children (2.2%), one with sepsis and the other with intraoperative
hypoxia, died. Seventy patients underwent complete resection. At 1
month aer surgery, 89.2% of patients were asymptomatic, while 77.7%
of symptomatic patients were HIV positive.
Conclusion. Complete pulmonary resection in children with advanced-
stage bronchiectasis is safe, with a low morbidity and mortality. Surgery
in HIV-positive patients was not associated with worse outcomes and
is not contraindicated.
1. HIV- and TB-preventive measures could reduce the burden of childhood
bronchiectasis. S Afr J Child Health 2022;16(3):152-157. https://doi.org/10.7196/
SAJCH.2022.v16i3.1842
