Podoconiosis

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Podoconiosis
Other namesNonfilarial elephantiasis
Ethiopian Farmer affected by Podoconiosis - NIH - March 2011.jpg
Bilateral lower extremity swelling and "mossy" hyperkeratotic papillomata characteristic of podoconiosis
Specialty Toxicology

Podoconiosis, also known as nonfilarial elephantiasis, [1] is a disease of the lymphatic vessels of the lower extremities that is caused by chronic exposure to irritant soils. It is the second most common cause of tropical lymphedema after lymphatic filariasis, [2] and it is characterized by prominent swelling of the lower extremities, which leads to disfigurement and disability. Methods of prevention include wearing shoes and using floor coverings. Mainstays of treatment include daily foot hygiene, compression bandaging, and when warranted, surgery of overlying nodules.

Contents

Signs and symptoms

Podoconiosis causes bilateral yet asymmetrical leg swelling with overlying firm nodules. Early on, symptoms may include itching, tingling, widening of the forefoot, and swelling which then progress to soft edema, skin fibrosis, papillomatosis, and nodule formation resembling moss, giving rise to the disease's alternate name of "mossy foot" in some regions of the world. [3] As with other forms of tropical lymphedema, chronic disease can lead to rigid toes, ulceration, and bacterial superinfection. During acute episodes of adenolymphangitis, patients may develops fevers, extremity warmth, redness, and pain. These episodes are extremely debilitating and account for many days of activity and productivity loss each year. [4]

Psychological consequences

As a result of its appearance, podoconiosis can cause social stigmatization and discrimination. [5] People with podoconiosis also report a lower quality of life than people in similar neighborhood circumstances except without podoconiosis [6] and also higher levels of mental distress [7] and depression. [8]

Pathophysiology

According to the World Health Organization "Evidence suggests that podoconiosis is the result of a genetically determined abnormal inflammatory reaction to mineral particles in irritant red clay soils derived from volcanic deposits". [9]

The pathophysiology of podoconiosis is a combination of genetic susceptibility, possibly through associations with HLA-DQA1, HLA-DQB1, and HLA-DRB1 variants, and a cumulative exposure to irritant soil. [10] [11] In susceptible individuals, irritant soil particles penetrate the feet and collect in lymphatic vessels. [12] Over time, chronic inflammation within the lymphatic vessels leads to fibrosis and occlusion. [13]

Diagnosis

Differential diagnosis

The differential diagnosis for podoconiosis includes other causes of tropical lymphedema, such as filariasis or leprosy, and mycetoma pedis. [3] [12]

While filariasis is generally unilateral, podoconiosis affects the legs bilaterally albeit asymmetrically and in an ascending manner. Podoconiosis very rarely affects the groin while filariasis frequently involves the groin: a high ratio of lymphoedema/hydrocele cases in an area suggests podoconiosis as the dominant cause of lymphedema. In some cases, the history and clinical presentation alone are unable to differentiate between the two causes of tropical lymphedema. Local epidemiology can also be a clue to diagnosis, as podoconiosis is typically found in higher altitude areas with volcanic soils while filariasis is common in low-lying areas where mosquitos are prevalent. Blood smears for identification of microfilariae and antigen detection techniques can be helpful in the diagnosis of lymphatic filariasis.[ citation needed ]

Lepromatous lymphedema can also mimic podoconiosis clinically, but the former will have loss of sensation in the toes and feet, thickened nerves, and trophic ulcers. Other causes of lymphedema include Kaposi sarcoma, mycetoma, and elephantiasis nostras verrucosa. [14]

Prevention

Elimination of podoconiosis relies on prevention with widespread shoe implementation, stringent foot hygiene, and floor coverings. Community-based initiatives are crucial to achieving elimination of this disease. In Ethiopia, The Mossy Foot Treatment and Prevention Association (now Mossy Foot International) works to transform patients into community podoconiosis agents who in turn visit patients, teach basic treatment techniques such as foot hygiene, and educate families about the disease. [15] This model has been adapted by several other non-government groups as they have started programs in other regions of Ethiopia. [16] [17]

In 2011, podoconiosis was added to the World Health Organization's neglected tropical diseases list, which was an important milestone in raising global awareness of the condition. [18] The efforts of the Global Programme to Eliminate LF are estimated to have prevented 6.6 million new filariasis cases from developing in children between 2000 and 2007, and to have stopped the progression of the disease in another 9.5 million people who had already contracted it. [19] Dr. Mwele Malecela, who chairs the programme, said: "We are on track to accomplish our goal of elimination by 2020." [20] In 2010, the WHO published a detailed progress report on the elimination campaign in which they assert that of the 81 countries with endemic LF, 53 have implemented mass drug administration, and 37 have completed five or more rounds in some areas, though urban areas remain problematic. [21]

Treatment

This patient is receiving compression bandages as treatment for podoconiosis. Podoconiosis -- compression treatment.JPG
This patient is receiving compression bandages as treatment for podoconiosis.

The cornerstone of prevention and treatment of podoconiosis is avoidance of exposure to irritant soils. Wearing shoes in the presence of irritant soils is the primary method of exposure reduction. In Rwanda, a country of high disease prevalence, the government has banned walking barefoot in public, [22] in order to prevent podoconiosis and other soil-borne diseases. Increasing the availability of footwear must be coupled with education on the benefits of wearing shoes as cultural influences, such as barefoot traditions, can hinder widespread use of footwear. [23]

Once the disease has developed, rigorous foot hygiene including daily washing with soap and water, application of an emollient, and nightly elevation of the affected extremity has been shown to reduce frequency of acute attacks. [16] Nodules will not resolve with these conservative measures, although surgical removal of the nodules can be performed. [24]

Epidemiology

Podoconiosis is most frequently seen in the highland areas of Africa, India, and Central America. The highest prevalence is seen in Uganda, Tanzania, Kenya, Rwanda, Burundi, Sudan, and Ethiopia. [12] A recent review has summarized the global distribution of podoconiosis. [25] In some areas of Ethiopia, the prevalence is as high as 4%. [26] The incidence of podoconiosis increases with age, likely due to cumulative exposure to irritant soil. It is very rare to see podoconiosis in the 0–5 year old age group, and the incidence rapidly rises from 6 to 20 years of age, with the highest prevalence after 45 years of age. Podoconiosis is most commonly seen in higher altitude areas with volcanic soil, [12] and it is estimated to affect 4 million people worldwide. [2] Productivity losses associated with the disease are significant. In Ethiopia (where 1.6 million people are estimated to be affected), [27] the condition is thought to have caused US $200 million in lost productivity per year in 2004. [28]

History

After parasitic filariae were discovered to be an important cause of tropical lymphedema in the 19th century, early investigators assumed that filariae were the sole cause of lymphedema in the tropics. It was later discovered that the distribution of tropical lymphedema and filariasis did not perfectly overlap, and researchers began to recognize that some forms of tropical lymphedema were not associated with filariasis. [12] Ernest W Price, a British surgeon living in Ethiopia, discovered the true etiology of podoconiosis in the 1970s and 1980s by studying the lymph nodes and vessels of those afflicted with the disease. [29] Using light microscopy, he observed macrophage cells laden with micro-particles in lymph nodes of the affected extremity. After examining the same tissue using electron microscopy, he was able to identify the presence of silicon, aluminum, and other soil metals both in the phagosomes of macrophages and adhered to the surface of lymphocytes. [30] Price demonstrated that the lymphatic vessels of these patients experienced subendothelial edema and eventual collagenization of the lumen leading to complete blockage. [13] He wrote a monograph on podoconiosis which was published after his death in 1990. [31]

Current situation

Podoconiosis is now recognised as one of the WHO Neglected Tropical Diseases, [32] its importance as a public health problem is well recognised in Ethiopia. [33] Footwork [34] is a charity which bring together public and private partners to support prevention and treatment of podoconiosis. There is an active research group led by Gail Davey [35] at the Wellcome Trust Brighton and Sussex Centre for Global Health Research [36] which co-ordinates research worldwide. A recent article in The Lancet includes some excellent illustrations. [37]

Related Research Articles

<span class="mw-page-title-main">Lymphedema</span> Medical condition

Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized swelling caused by a compromised lymphatic system. The lymphatic system functions as a critical portion of the body's immune system and returns interstitial fluid to the bloodstream. Lymphedema is most frequently a complication of cancer treatment or parasitic infections, but it can also be seen in a number of genetic disorders. Though incurable and progressive, a number of treatments may improve symptoms. Tissues with lymphedema are at high risk of infection because the lymphatic system has been compromised.

<span class="mw-page-title-main">Elephantiasis</span> Medical condition

Elephantiasis, often incorrectly called elephantitis, is the enlargement and hardening of limbs or body parts due to tissue swelling. It is characterised by edema, hypertrophy, and fibrosis of skin and subcutaneous tissues, due to obstruction of lymphatic vessels. It may affect the genitalia. The term elephantiasis is often used in reference to parasitic worm infections, but may refer to a variety of diseases that swell parts of the subject's body to exceptionally massive proportions.

<span class="mw-page-title-main">Onchocerciasis</span> Human helminthiasis (infection by parasite)

Onchocerciasis, also known as river blindness, is a disease caused by infection with the parasitic worm Onchocerca volvulus. Symptoms include severe itching, bumps under the skin, and blindness. It is the second-most common cause of blindness due to infection, after trachoma.

<span class="mw-page-title-main">Filariasis</span> Parasitic disease caused by a family of nematode worms

Filariasis is a parasitic disease caused by an infection with roundworms of the Filarioidea type. These are spread by blood-feeding insects such as black flies and mosquitoes. They belong to the group of diseases called helminthiases.

<i>Wuchereria bancrofti</i> Species of parasitic worm

Wuchereria bancrofti is a filarial (arthropod-borne) nematode (roundworm) that is the major cause of lymphatic filariasis. It is one of the three parasitic worms, together with Brugia malayi and B. timori, that infect the lymphatic system to cause lymphatic filariasis. These filarial worms are spread by a variety of mosquito vector species. W. bancrofti is the most prevalent of the three and affects over 120 million people, primarily in Central Africa and the Nile delta, South and Central America, the tropical regions of Asia including southern China, and the Pacific islands. If left untreated, the infection can develop into lymphatic filariasis. In rare conditions, it also causes tropical pulmonary eosinophilia. No vaccine is commercially available, but high rates of cure have been achieved with various antifilarial regimens, and lymphatic filariasis is the target of the World Health Organization Global Program to Eliminate Lymphatic Filariasis with the aim to eradicate the disease as a public-health problem by 2020. However, this goal was not met by 2020.

<span class="mw-page-title-main">Helminthiasis</span> Any macroparasitic disease caused by helminths

Helminthiasis, also known as worm infection, is any macroparasitic disease of humans and other animals in which a part of the body is infected with parasitic worms, known as helminths. There are numerous species of these parasites, which are broadly classified into tapeworms, flukes, and roundworms. They often live in the gastrointestinal tract of their hosts, but they may also burrow into other organs, where they induce physiological damage.

<span class="mw-page-title-main">Tropical medicine</span> Interdisciplinary branch of medicine

Tropical medicine is an interdisciplinary branch of medicine that deals with health issues that occur uniquely, are more widespread, or are more difficult to control in tropical and subtropical regions.

<i>Brugia malayi</i> Medical condition

Brugia malayi is a filarial (arthropod-borne) nematode (roundworm), one of the three causative agents of lymphatic filariasis in humans. Lymphatic filariasis, also known as elephantiasis, is a condition characterized by swelling of the lower limbs. The two other filarial causes of lymphatic filariasis are Wuchereria bancrofti and Brugia timori, which both differ from B. malayi morphologically, symptomatically, and in geographical extent.

<span class="mw-page-title-main">Chromoblastomycosis</span> Medical condition

Chromoblastomycosis is a long-term fungal infection of the skin and subcutaneous tissue.

<span class="mw-page-title-main">Lymphatic filariasis</span> Medical condition

Lymphatic filariasis is a human disease caused by parasitic worms known as filarial worms. Usually acquired in childhood, it is a leading cause of permanent disability worldwide. While most cases have no symptoms, some people develop a syndrome called elephantiasis, which is marked by severe swelling in the arms, legs, breasts, or genitals. The skin may become thicker as well, and the condition may become painful. Affected people are often unable to work and are often shunned or rejected by others because of their disfigurement and disability.

<span class="mw-page-title-main">Neglected tropical diseases</span> Diverse group of tropical infectious diseases which are common in developing countries

Neglected tropical diseases (NTDs) are a diverse group of tropical infections that are common in low-income populations in developing regions of Africa, Asia, and the Americas. They are caused by a variety of pathogens, such as viruses, bacteria, protozoa, and parasitic worms (helminths). These diseases are contrasted with the "big three" infectious diseases, which generally receive greater treatment and research funding. In sub-Saharan Africa, the effect of neglected tropical diseases as a group is comparable to that of malaria and tuberculosis. NTD co-infection can also make HIV/AIDS and tuberculosis more deadly.

<span class="mw-page-title-main">Eradication of infectious diseases</span> Complete extermination of disease-causing agent to reduce its incidence to zero

The eradication of infectious diseases is the reduction of an infectious disease's prevalence in the global host population to zero.

Mycetoma is a chronic infection in the skin caused by either bacteria (actinomycetoma) or fungi (eumycetoma), typically resulting in a triad of painless firm skin lumps, the formation of weeping sinuses, and a discharge that contains grains. 80% occur in feet.

The London Declaration on Neglected Tropical Diseases was a collaborative disease eradication programme launched on 30 January 2012 in London. It was inspired by the World Health Organization roadmap to eradicate or prevent transmission for neglected tropical diseases by the year 2020. Officials from WHO, the World Bank, the Bill & Melinda Gates Foundation, the world's 13 leading pharmaceutical companies, and government representatives from US, UK, United Arab Emirates, Bangladesh, Brazil, Mozambique and Tanzania participated in a joint meeting at the Royal College of Physicians to launch this project. The meeting was spearheaded by Margaret Chan, Director-General of WHO, and Bill Gates, Co-Chair of the Bill & Melinda Gates Foundation.

Neglected tropical diseases in India are a group of bacterial, parasitic, viral, and fungal infections that are common in low income countries but receive little funding to address them. Neglected tropical diseases are common in India.

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) is a World Health Organization project to eradicate the Filarioidea worms which cause the disease lymphatic filariasis and also treat the people who already have the infection.

The eradication of lymphatic filariasis is the ongoing attempt to eradicate the Filarioidea worms which cause the disease lymphatic filariasis and also treat the people who already have the infection.

Lymphatic filariasis in India refers to the presence of the disease lymphatic filariasis in India and the social response to the disease. In India, 99% of infections come from a type of mosquito spreading a type of worm through a mosquito bite. The treatment plan provides 400 million people in India with medication to eliminate the parasite. About 50 million people in India were carrying the worm as of the early 2010s, which is 40% of all the cases in the world. In collaboration with other countries around the world, India is participating in a global effort to eradicate lymphatic filariasis. If the worm is eliminated from India then the disease could be permanently eradicated. In October 2019 the Union health minister Harsh Vardhan said that India's current plan is on schedule to eradicate filariasis by 2021.

Gail Davey OBE is a professor of epidemiology at Brighton and Sussex Medical School, University of Sussex, UK. Her work focuses on Neglected Tropical Diseases, particular podoconiosis.

The Kigali Declaration on Neglected Tropical Diseases is a global health project that aims to mobilise political and financial resources for the control and eradication of infectious diseases, the so-called neglected tropical diseases due to different parasitic infections. Launched by the Uniting to Combat Neglected Tropical Diseases on 27 January 2022, it was the culmination and join commitment declared at the Kigali Summit on Malaria and Neglected Tropical Diseases (NTDs) hosted by the Government of Rwanda at its capital city Kigali on 23 June 2022.

References

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  37. ↑ Alexander Kumar Kebede Deribe Nebiyu Negussu Gail Davey (2019). "Picturing health: podoconiosis—stepping out of neglect". The Lancet. 394 (10208): 1499–1512. doi:10.1016/S0140-6736(19)32129-4. PMID   32534625. S2CID   202583049 . Retrieved 18 December 2019.
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