Peter J Flegg,
Blackpool, UK, FY3 8NR
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At least the topic under discussion seems to have returned to the theme of South Africa.
How presumptuous of Alexander Russell to claim he knows better than Nelson Mandela what factors contributed to the death of his son, Makgatho. The fact that various sources initially stated different possible causes (gall bladder complications, pancreatic cancer) is not unusual in a society where many euphemisms have arisen to disguise the diagnosis of HIV and avoid the stigmatisation associated with it.
Why does Mr Russell think that antiretroviral drug “poisoning” is implicated in his death? It appears that he has gullibly swallowed the uninformed opinion of David Rasnick (SA Sunday Times, 16th January). However Rasnick, in his unseemly haste to exonerate HIV infection and implicate antiretroviral drugs as the cause of Makgatho Mandela’s gall bladder problems, seems to have forgotten some basic anatomy and physiology.
The fact that some HIV drugs (and not “all”, as Rasnick erroneously claims) can cause hepatotoxicity is quite irrelevant to the gall bladder. Where is the evidence that antiretroviral drugs cause gall bladder problems that need surgical intervention?
HIV infection itself is well documented as contributing to problems within the biliary tree which may require surgery.[2-7] These include cholangitis and cholecystitis from a wide range of “standard” microbial pathogens as well as opportunistic infections including Cryptosporidium, Microsporidium, Cytomegalovirus, Mycobacterium avium and Giardia. Additionally, tumour involvement of the gall bladder is described with Kaposi sarcoma and non-Hodgkin lymphoma.
I haven’t the faintest idea whether any of these conditions contributed to Makgatho Mandela’s death, and am not about to speculate, even if they are more plausible than the imaginary entity of drug-induced gallbladder disease.
 Keaveny AP, Karasik MS. Hepatobiliary and pancreatic infections in AIDS: Part One. AIDS Pat Care STDS. 1998;12(5):347-57.
 Keaveny AP, Karasik MS. Hepatobiliary and pancreatic infections in AIDS: Part Two. AIDS Pat Care STDS 1998; 12:451–6.
 Wilcox CM, Monkemuller KE. Hepatobiliary diseases in patients with AIDS: focus on AIDS cholangiopathy and gallbladder disease. Dig Dis. 1998;16(4):205-13.
 Leiva JI, et al. Surgical therapy for 101 patients with acquired immunodeficiency syndrome and symptomatic cholecystitis. Am J Surg. 1997;174(4):414-6.
 Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroenterol Clin North Am. 1997;26(2):323-35.
 Flum DR, et al. The role of cholecystectomy in acquired immunodeficiency syndrome. J Am Coll Surg. 1997; 184(3):233-9.
Competing interests: None declared