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Rheumatology Advance Access originally published online on April 9, 2009
Rheumatology 2009 48(6):599-601; doi:10.1093/rheumatology/kep063
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© The Author 2009. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

EDITORIALS

Tropical rheumatology—a global issue

Ade Adebajo1,2, Paul McGill3 and Mohammed Tikly4,5

1Academic Rheumatology Group, Barnsley Hospital, Barnsley, 2Academic Rheumatology Group, University of Sheffield Medical School, Sheffield, 3Department of Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK, 4Chris Hani Baragwanath Hospital and 5University of the Witwatersrand, Johannesburg, South Africa

Correspondence to: Ade Adebajo, Academic Rheumatology Group, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, UK. E-mail: a.o.adebajo{at}sheffield.ac.uk

Rheumatic diseases, as they pertain to the tropics, are much neglected in both the developing and developed world alike. We believe that there is a need for these conditions to be recognized and addressed by all involved in healthcare in the developing world. With increasing travel and migration, we also believe that it is essential for rheumatologists in the West to be aware of these conditions and to avoid misdiagnosis and mismanagement of patients from the tropics who have rheumatological problems.

Nowadays, in the developed nations of the world, the main thrust of rheumatology research and increasingly daily practice is directed towards the control and management of inflammatory arthritis using the tools of modern molecular biology. This stands in stark contrast with what is available to the very large populations in the tropical regions of Africa, South America and Asia, who have little or no access to the particular skills and benefits which a rheumatologist brings including the diagnosis and management of a wide range of painful and disabling locomotor conditions. Often there is there is a lack of individuals to establish a basic service, teach the skills of locomotor examination, lobby for resources, educate the public and provide ancillary rehabilitation services. Consequently, it is not surprising that in many tropical countries where there is fierce competition for scarce resources, rheumatology remains very much a ‘Cinderella’ discipline. And yet our specialty is relatively ‘low tech’ in which clinical skills and experience remain paramount. Elements of rheumatology may be taught at all levels of medical and paramedical practice with some expectation of benefit to patients, and initiatives that help to bridge the gap between such a wealth of clinical need and dearth of rheumatological experience are to be encouraged.

Falling into this category is the WHO-ILAR COPCORD programme [1]. Designed to explore the feasibility of ‘rheumatic disease prevention and control in the community’, this was initially targeted at communities in the developing world, many sited in tropical regions. The programme consists of community data collection on rheumatic complaints and disability (Stage 1) and using this information to construct educational (Stage 2) and preventative (Stage 3) elements. So far Stage 1 data have been reported from over 17 countries, mainly in the Asia-Pacific region and a few Stage 2 and 3 programmes from India and Indonesia. The prevalence of musculoskeletal pain varies from 12 to 45% with the average ~25%. The commonest sites were low back, knee, neck and shoulder. The commonest rheumatic disorders were knee pain, mechanical low-back pain and soft tissue rheumatism, whereas inflammatory rheumatic disorders were rare in most surveys. Overall comparison of the prevalence of musculoskeletal pain in COPCORD and Western studies shows a remarkable similarity, highlighting the global nature of rheumatic complaints and disability. Most surveys find a paucity of health care resources as well as medical and paramedical staff who are very inadequately trained to manage musculoskeletal disorders. As a result, much remains to be done to progress much needed educational activities and preventative programmes in the tropics. It is also important to emphasize the remarkable range and variety of rheumatic disorders encountered these days in the tropical developing setting, which adds to the overall burden of disability and also mortality.

For example, the broad spectrum of infection-related rheumatic syndromes, which include rheumatic fever [2,3], brucellosis [4] and leprosy [5,6]. Osteoarticular tuberculosis, either affecting the spine or peripheral joints, continues to be a major diagnostic and therapeutic challenge even in the absence of underlying HIV infection [7,8]. Musculoskeletal disorders caused by fungi are uncommon and difficult to diagnose, particularly in the early stages [9]. In the immunocompromised patient from endemic parts of southern Africa, histoplasmosis and sporotrichosis can cause a destructive arthritis. Rare but well defined rheumatic syndromes occur in a variety of parasitic infections like filariasis, schistosomiasis and amoebiasis [10]. The so-called ‘tropical polyarthritis’ has been shown to be most commonly either a gonoccocal arthritis or reactive arthritis [11]. All of the above may afflict residents in endemic areas and sometimes appear far from the source of origin in travellers or migrants, frequently causing diagnostic confusion. Where rickets is found in sunny tropical regions of Africa and Asia, studies point to a low dietary intake of calcium as a major additional factor in its causation with calcium supplements alone healing bone lesions [12].

Exposure to excessive fluoride in water supplies drawn from boreholes in the Rift Valley provinces of Ethiopia, Kenya and Tanzania and in many regions in the Indian subcontinent is associated with osteopetrosis and significant musculoskeletal morbidity [13]. The sickle cell gene, which confers partial immunity to malaria in the tropics, in its homozygous state predisposes to infection and infarction of bone and other joint disorders [14].

Unfortunately, HIV/AIDS has become the major scourge in the tropics over the last two decades and the impact on the spectrum, diagnosis and management of rheumatological and orthopaedical conditions has been profound. Perhaps expected is the increase in musculoskeletal sepsis, especially in patients with advanced disease [15]. Pyomyositis and long bone osteomyelitis, traditionally seen in children in the tropics, are now common locomotor manifestations of advanced HIV disease in adults [16]. Less evident is the impact of HIV infection, as in the case of osteoarticular tuberculosis, on the prevalence of septic arthritis in the tropics [17]. Unexpected and largely unexplained has been the huge increase in the prevalence of reactive arthritis and undifferentiated SpA, initially observed in adults [18,19] and more lately in children [20], in sub-Saharan Africa, whose native populations seemed previously relatively immune to these disorders by virtue of a very low population frequency of HLA B27.

Major challenges for the rheumatologist practicing in an HIV endemic area include not only recognizing HIV infection-associated rheumatic syndromes but also distinguishing them from classic rheumatic diseases like RA, SLE, SS, SpA and the primary vasculitides. Similarly important is the impact of HIV on disease activity and severity of classic rheumatic diseases, and their assessment. A case in point is the invariably elevated erythrocyte sedimentation rate with HIV infection, even in the absence of active disease or infection [21]. Finally, the safety of DMARDs and immunosuppressive agents in the patient with underlying HIV infection poses a major therapeutic challenge.

In the tropics in general, therefore, not only are there different diseases to contend with, but also varying expressions of the more universal diseases. Lack of expertise in the diagnosis and treatment of rheumatic disorders is a problem and resources for investigation and treatment are usually severely restricted. Not only is the prevalence of conditions such as RA, SLE and gout increasing, but there is growing evidence that these conditions are also becoming more severe in the tropics [22,23]. In many tropical areas, gout is the foremost cause of acute arthritis and because of lack of access to appropriate care, many patients with gout develop severe joint deformities and physical disability [24,25].

In order to reduce morbidity and mortality from these various conditions, urgent measures are required. An aggressive multidisciplinary approach to early diagnosis and appropriate management is very much needed but is sorely lacking in many parts of the tropics. Regardless of the underlying reasons for the increase in the prevalence of virtually all rheumatological conditions, there is now a greater realization of the significant and increasing socio-economic burden from the rheumatic diseases across the tropics. This means that governments and health policy makers have to develop strategies to tackle this emerging musculoskeletal health problem alongside their strategies for tackling the traditionally important public health problems in the tropics, such as malaria and HIV/AIDS. In order to achieve this, manpower needs require addressing. Most parts of the tropics are under doctored, and the availability of doctors in the tropics with expertise in managing musculoskeletal problems remains extremely low, with only a few exceptions. For example there are currently less than 20 rheumatologists in sub-Saharan Africa, excluding South Africa, serving about 800 million people. One strategy to counter this is the increasing recognition of the need to involve Allied Health Professionals and even community health workers in preventative, diagnostic and management strategies for musculoskeletal disorders in the tropics [26]. In the longer term, more rheumatologists need to be trained and supported in the tropics. The availability and use of drugs for treating musculoskeletal disorders in the tropics remains a major challenge. Unsurprisingly, for example, the tropics are lagging behind in the use of the various biologic agents for RA. Drug costs and the required infrastructure support make the use of these drugs extremely difficult [27].

With increasing travel for migration and other purposes, many of the rheumatological conditions previously confined predominantly to the tropics and described above are now also being seen in the West. The most recent and dramatic have occurred in the wake of the huge new outbreaks of Chikungunya viral (Chick V) infection reported recently from the Indian Ocean islands of Mauritius, Seychelles, Mayotte, Reunion Island and Madagascar [28]. More than 1000 visitors to the affected region have returned to Europe and the USA, and then developed clinical disease. This indicates that there is an important need for physicians worldwide to be prepared to encounter this and other arboviral infections (e.g. Ross River Fever). Moreover, infected people can disseminate the virus and initiate new epidemics in countries where competent vectors reside, thus explaining the first recorded outbreak of Chick V disease in a non-tropical area (Northern Italy) in the summer of 2007, when 205 cases of infection were identified with one death [29]. The index case was an Asian man who had travelled from India to Italy in the viraemic stage and set up a man–mosquito–man cycle. Aedes albopictus (Asian tiger mosquito) is the vector in Italy, Reunion and Mauritius. In the past 50 years this mosquito has spread to all continents and adapted to most climates. The strain of Chick V in Italy was similar to that in the Indian Ocean. The occurrence of an outbreak of Chick V infection in a country with a temperate climate is a stark reminder that the globalization of human beings and vectors has become a reality. In this case it involved an African virus and an Asian mosquito and started in the Indian Ocean and came to Europe.

In recognition of this now global problem, the European League of Associations for Rheumatology (EULAR) has recently included the topic of tropical arthritis, as a module as part of its online postgraduate rheumatology course. This is just a start. Greater collaborative effort is required world wide to improve both public and health professional education of these predominantly tropical, impoverished conditions. It is therefore highly encouraging that ILAR, EULAR and the ACR among other international bodies are committed to support research targeted at solving some of these issues. ‘Tropical Rheumatology’ is now truly a global issue.

Disclosure statement: The authors have declared no conflicts of interest.

References

  1. Muirden KD. Community Oriented Program for the Control of Rheumatic Diseases: studies of rheumatic diseases in the developing world. Curr Opin Rheumatol (2005) 17:153–6.[CrossRef][Web of Science][Medline]
  2. Carapetis JR. Rheumatic heart disease in developing countries. N Engl J Med (2007) 357:439–41.[Free Full Text]
  3. Marijon E, Ou P, Celermajer DS, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med (2007) 357:470–6.[Abstract/Free Full Text]
  4. Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med (2005) 352:2325–36.[Free Full Text]
  5. Gibson T, Ahsan Q, Hussein K. Arthritis of leprosy. Br J Rheumatol (1994) 33:963–6.[Abstract/Free Full Text]
  6. Haroon N, Agarwal V, Aggarwal A, Kumari N, Krishnani N, Misra R. Arthritis as presenting manifestation of pure neuritic leprosy - a rheumatologist's dilemma. Rheumatology (2007) 46:653–6.[Abstract/Free Full Text]
  7. Lertsrisatit P, Nantiruj K, Totemchokchyakarn K, Janwityanujit S. Extraspinal tuberculous arthritis in HIV era. Clin Rheumatol (2007) 26:319–21.[CrossRef][Web of Science][Medline]
  8. Wiwatworapan T, Anantasetagoon T. Extra-pulmonary tuberculosis at a regional hospital in Thailand. Southeast Asian J Trop Med Public Health (2008) 39:521–5.[Medline]
  9. Maiti PK, Ray A, Bandyopadhyay S. Epidemiological aspects of mycetoma from a retrospective study of 264 cases in West Bengal. Trop Med Int Health (2002) 7:788–92.[CrossRef][Web of Science][Medline]
  10. McGill PE. Geographically specific infections and arthritis, including rheumatic syndromes associated with certain fungi and parasites, Brucella species and Mycobacterium leprae. Best Pract Res Clin Rheumatol (2003) 17:289–307.[CrossRef][Medline]
  11. Pile KD, Richens JE, Laurent RM, et al. Arthritis in the highlands of Papua New Guinea. Ann Rheum Dis (1993) 52:49–53.[Abstract/Free Full Text]
  12. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr (2004) 80(Suppl):1725–9S.
  13. McGill PE. Endemic fluorosis. Baillieres Clin Rheumatol (1995) 9:75–81.[CrossRef][Web of Science][Medline]
  14. Ejindu VC, Hine AL, Mashayekhi M, Shorvon PJ, Misra RR. Musculoskeletal manifestations of sickle cell disease. Radiographics (2007) 27:1005–21.[Abstract/Free Full Text]
  15. Mody GM, Parke FA, Reveille JD. Articular manifestations of human immunodeficiency virus infection. Best Pract Res Clin Rheumatol (2003) 17:265–87.[CrossRef][Medline]
  16. Jellis JE. Viral infections: musculoskeletal infection in the human immunodeficiency virus (HIV) infected patient. Baillieres Clin Rheumatol (1995) 9:121–32.[CrossRef][Web of Science][Medline]
  17. Ntsiba H, Makosso E, Ngandeu-Singwe M, Yala F. Septic arthritis in tropical environment. 176 cases report in Brazzaville. Le Mali medical (2006) 21:49–53.[Medline]
  18. Njobvu P, McGill P. Human immunodeficiency virus related reactive arthritis in Zambia. J Rheumatol (2005) 32:1299–304.[Abstract/Free Full Text]
  19. Njobvu P, McGill P, Kerr H, Jellis J, Pobee J. Spondyloarthropathy and human immunodeficiency virus infection in Zambia. J Rheumatol (1998) 25:1553–9.[Web of Science][Medline]
  20. Chinniah K, Mody GM, Bhimma R, Adhikari M. Arthritis in association with human immunodeficiency virus infection in Black African children: causal or coincidental? Rheumatology (2005) 44:915–20.[Abstract/Free Full Text]
  21. Arango CA, Midani S, Alvarez A, Kubilis PS, Rathore MH. Usefulness of acute phase reactants in the diagnosis of acute infections in HIV-infected children. South Med J (1999) 92:209–13.[CrossRef][Web of Science][Medline]
  22. Tikly M, Navarra S. Lupus in the developing world – is it any different? Best Pract Res Clin Rheumatol (2008) 22:643–55.[CrossRef][Medline]
  23. Kalla AA, Tikly M. Rheumatoid arthritis in the developing world. Best Pract Res Clin Rheumatol (2003) 17:863–75.[CrossRef][Medline]
  24. Darmawan J, Rasker JJ, Nuralim H. The effect of control and self-medication of chronic gout in a developing country. Outcome after 10 years. J Rheumatol (2003) 30:2437–43.[Abstract/Free Full Text]
  25. Singwe-Ngandeu M, Meli J, Ntsiba H, et al. Rheumatic diseases in patients attending a clinic at a referral hospital in Yaounde, Cameroon. East Afr Med J (2007) 84:404–9.[Medline]
  26. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet (2007) 370:2158–63.[CrossRef][Web of Science][Medline]
  27. Adebajo A, Fursts DE. Biologic agents and their use in resource-poor countries. J Rheumatol (2005) 32:1182–3.[Free Full Text]
  28. Charrel RN, de Lamballerie X, Raoult D. Chikungunya outbreaks–the globalization of vectorborne diseases. N Engl J Med (2007) 356:769–71.[Free Full Text]
  29. Rezza G, Nicoletti L, Angelini R, et al. Infection with chikungunya virus in Italy: an outbreak in a temperate region. Lancet (2007) 370:1840–6.[CrossRef][Web of Science][Medline]
Accepted 26 February 2009


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