Highlights We report findings from a point prevalence survey across 14 Kenyan public hospitals. About half of the hospitalised patients received appropriate antibiotic therapy. Laboratory investigations supported less than 1% of the antibiotic prescriptions. Physical availability of treatment guidelines influenced treatment appropriateness. There is need for context-specific, up-to-date, and accessible treatment guidelines.

Objective: Patients with adrenal insufficiency require life-long glucocorticoid replacement therapy. Hydrocortisone (15–30 mg/day) and prednisolone (3–7.5 mg/day) are the preferred agents used although there is a lack of consensus among endocrinologists regarding the impact of different steroid regimens on quality of life, bone metabolism, cardiometabolic outcomes, adrenal crisis and infections. We carried out a retrospective systematic review of the literature to compare the efficacy and side effects of various glucocorticoid replacement regimens in patients with chronic adrenal insufficiency. Methods: We searched PubMed, Cochrane Reviews and Google Scholar databases up to March 14, 2019, for studies evaluating various clinical outcomes with glucocorticoid replacement therapy. The abstracts and full studies were appraised and data extracted from the eligible studies. The quality of evidence was evaluated and risk of bias carried out. Results: A total of 47 studies including 9 randomised controlled trials (RCTs) and 38 observational studies were evaluated in this systematic review. Prednisolone therapy was observed to be safe as well as efficacious as hydrocortisone although a higher dose was associated with an increased risk of cardiovascular (CV) disease. A lower hydrocortisone dose (15–20 mg/day) was associated with a reduction of blood pressure and improved clinical outcomes although this observation was based on a solitary RCT. Modified release hydrocortisone was observed to reduce the risk of CV disease based upon results from 2 of the RCTs. However, there was no conclusive evidence of benefit of modified release hydrocortisone and continuous subcutaneous hydrocortisone infusion in improving subjective health status. Conclusion: Prednisolone therapy remains a safe and efficacious alternative to hydrocortisone although there are concerns of dyslipidaemia and CV disease with higher doses. There is limited level I evidence suggestive of a positive effect of modified release hydrocortisone on CV and metabolic outcomes, particularly weight reduction.

Rationale: Polyserositis describes contemporaneous inflammation of multiple serous membranes accompanied by effusions in serous cavities. It has been associated with different aetiologies, including autoimmune diseases, endocrine diseases, neoplasia, drug-associated cases, and infectious diseases, such as tuberculosis. Patient concerns: We report the case of a 34-year-old woman who presented with abdominal swelling for 8 months, fatigability, and shortness of breath for 2 months. She denied a history of lower-limb swelling, orthopnea, paroxysmal nocturnal dyspnoea, or right upper quadrant pain. She had no history of cigarette smoking, prior treatment for tuberculosis, malignancy, or contact with someone known to have tuberculosis (TB). On examination, she had a weak pulse, muffled heart sounds, and ascites. Diagnosis: Polyserositis was suspected following visualization of fluid in the peritoneal, pleural, and pericardial cavities on imaging. Interventions: The patient underwent pericardiocentesis and ascitic taps. The patient also received spironolactone, prednisolone, and paracetamol. Despite repeated ascitic tapping and use of diuretics, fluid continued to accumulate until the initiation of empiric anti-TB drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol), as noted from the elevated levels of adenosine deaminase (pleural fluid-46.30U/L) and living in an endemic area for tuberculosis (Kenya). Outcomes: Three weeks after the initiation of anti-TB drugs, the ascites and pericardial and pleural effusions resolved. Two months after discharge, the patient showed marked improvement, with no residual fluid noted in the serous cavities on imaging. Lessons learnt: We report a case of extrapulmonary TB presenting with polyserositis (pericardial, pleural, and ascitic fluid) with elevated adenosine deaminase levels when the traditional Ziehl Neelsen staining yielded negative results. Good clinical judgment and more novel diagnostic tools are necessary to avoid unnecessary delays in initiating definitive management.