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Figure 1 shows that the number of endoscopies with findings of duodenal ulcer and gastritis increased over time while those for esophageal cancer and gastric cancer were stable.

Figure 1. Trends in main upper segment diseases, 1990-94

Analysis of histological reports indicates that 90% of esophageal carcinoma are of the squamous-cell type. Gastric cancer was more often frankly invasive but did not show any evidence of predisposing intestinal metaplasia or atrophic gastritis. Further analysis of the data appearing in the reports could not be done as biopsy and histological evaluation were not done on a regular basis for gastritis so that the histological type of gastritis remained unclassified in most cases. The cause of bleeding in 93 patients related to erosive gastritis and/or Mallory-Weiss syndrome following alcohol abuse (80 patients) and to esophageal varices (13 patients).

Discussion

As upper gastro-intestinal endoscopy is performed only in Victoria Hospital in Seychelles, the indication of the investigation is open (‘open access’) and this service is free to the patients, Hospital records of the pathology of the esophagus, stomach and duodenum are likely to provide a good picture of the situation prevailing in the country as a whole.

The Seychelles population is made of 76,000 people who are mostly of African descent but also share Asiatic and Caucasian genetic admixture. Local food typically includes fish, rice and spices such as chili, ginger, curry, garlic and cinnamon. Consumption of alcohol and smoking are common among men (1). Cardiovascular diseases are frequent and account for almost 40% of total mortality. The population is experiencing rapid epidemiological transition with dramatic social, cultural and economic development. With rapid modernization, it may be considered that stress has become part of every day life which may result in increasing psychosomatic conditions.

In our series, 43,1% of patients had no macroscopic findings during endoscopy even though many qualified for non-ulcer dyspepsia (NUD) syndrome. NUD is defined as a functional gastric disorder with no evident pathology lasting more than 4 weeks. The fact that 66% of referred patients for gastro-intestinal endoscopy are men is consistent with the high alcohol intake and smoking habits in the male population. No test was available to screen Helicobacter pylori in this series but such a screening program is currently in progress. Helicobacter pylori is indeed known to strongly relate to several upper gastrointestinal diseases. Because no attempt was made to account for repeat endoscopy in same patients (analyses were made on the basis of endoscopy reports), a few patients with selected diseases may have undergone endoscopy several times (data presented in this study might therefore result in slight overestimate of the frequency of the related diseases).

The study confirms the very low frequency of gastric cancer in Seychelles. Our findings are consistent with the incidence of gastric cancer of 3.5 per 100,000 based on cases recorded in the pathology register between 1983 and 1995. Similarly, the frequency of esophageal cancer was low in our series and is consistent with an incidence of 3.7 per 100,000, based on cases recorded in the pathology register between 1983-1995. These figures suggest that both gastric cancer and esophageal cancer are far less common than in other countries of the same geographic area (2-4).

Endoscopic diagnosis is still often performed at a late stage of the disease as only few cancer cases were captured at an early stage during which surgery would be most effective. Among the 13 patients with stomach cancer, only 4 had an early stage disease so that surgical treatment could be radical. The other 9 cases were at an advanced stage and could only be offered palliative procedures. In the case of esophageal cancer, 11 patients out of 20 underwent radical resection. These findings indicate that further efforts must be done to detect cancer cases at an earlier stage where radical treatment can be administered.

Conclusion

The frequency of diseases observed in this retrospective analysis of 1039 endoscopy reports over 5 years is likely to be fairly reliable as there is little barrier to undergo endoscopy within a national health system with ‘open access’ to endoscopy (5,6). As most cancer cases were detected at a late stage, further effort must be done to improve early diagnosis. Among others, biopsies should be performed more systematically. The study also gives an interesting epidemiological picture of certain upper gastrointestinal conditions in the Seychellois population, particularly a low frequency of gastric and esophageal cancers. Further studies should be conducted in Seychelles to determine the role on gastric mucosa of Helicobacter pylori (7,8), genetic factors (9), and protective factors such as phospholipids (10) in bananas or alkaloids from chili (11).

Bovet P, Shamlaye C, Kitua A, Riesen WF, Paccaud F, Darioli R. High prevalence of cardiovascular risk factors in the Seychelles (Indian Ocean). Arterioscler Thromb 1991; 11: 1730-6.

Rubin P. Clinical Oncology. 7th edition, University of Rochester Cancer Center, WB Saunder Company, 1993.

Neugut A, Hayek M, Howe G. Epidemiology of gastric cancer. Semin-Oncol.1966 Jun; 23(3): 281-91.

Japanese Cancer Association. Cancer in Asia, opportunities for prevention, detection and treatment, 1976.

Numans ME, Van Der Graaf Y, de Wit NJ, Touw Otten F, de Melker RA. How much ulcer is ulcer-like? Diagnostic determinants of peptic ulcer in open access gastroscopy. Fam Pract 1994 Dec; 11(4): 382-8.Hungin AP, Bramble MG, O’Callaghan H. Reasons for variations in the use of open access gastroscopy by general practitioners. Gut 1995 Feb: 36(2): 180-2.

Marshall BJ, Warren RJ. Unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration. Lancet 1984;1:1311-5.

Marshall BJ. Helicobacter Pylori. Am J Gastroenterol 1994; 89(Suppl): S116-28.

Zhao l, Blot WJ, Liu-WD, Chang YS, Zhang Hu YR, You WC, Xu GW, Fraumenu JF L Jr. Familial predisposition to precancerous gastric lesions in a high risk area of China. Cancer Epidemiol Biomarkers Prev 1994 Sep; 3(6): 461-4.

DunjicB. Gastric mucosal protection. Bulletin No7, Department of Surgery, Lund University, Sweden, 1993.

Yeoh KG, Kang JY, Yap I, Guan R, Tan CC, Wee A, Teng CH. Chili protects against aspirin- induced gastroduodenal mucosal injury in humans. Dig Dis Sci 1995 Mar; 40(3): 580-3.

 

 

Tropical spastic paraparesis in Seychelles: a case report (Page 33)

Department of Internal Medicine, Victoria Hospital, Seychelles

Abstract

Ten years ago the Seychelles were identified as a new geographic isolate of endemic tropical spastic paraparesis (TSP). The prevalence of the disease was reported to be 35/100’000. Several studies have linked human T-lymphotrophic virus type-I (HTLV-I) with the endemic form of TSP. In the Seychelles the age and sex standardized seroprevalence of HTLV-I is almost 5%. Eight new cases of TSP were diagnosed in Victoria Hospital during the years 1993 to 1995. This paper reports a last case diagnosed in 1995, stressing characteristics of the history and the physical examination of the patient. Following other reports, it is suggested that systematic screening for antibodies to HTLV-I in blood donors has to be considered for countries with high endemicity for HTLV-I infection.

Introduction

Tropical myeloneuropathies are not rare in tropical countries [1]. The tropical spastic paraparesis (TSP) is one of them. An epidemic form of TSP of acute onset, related to nutritional toxic factors (malnutrition, vitamin deficiency, cyanide intoxication) [2] and an endemic form of slow evolution have been differentiated. Clinically both forms are very similar and include a pyramidal syndrome with sphincter disturbances and mild sensation changes. Clusters of the endemic forms have been noted in Senegal, Côte d’Ivoire [3], Seychelles Islands [4], Caribbean [5], and Colombia [6]. The etiology of endemic TSP is actually unclear. Diet, treponemal infections such as yaws and syphilis have been suggested to be related to endemic TSP although this has not been confirmed [7,8]. More recently, studies have linked human T-lymphotrophic virus type-I (HTLV-I) with endemic TSP [4,9]. In Japan a very similar clinical syndrome has been identified and referred to as HTLV-I-associated myelopathy (HAM) and may be a non-tropical version of the same disease [10].

Not long ago this disease was shown to occur in all ethnic groups and all socioeconomic statuses and in temperate, subtropical, and tropical climates [11]. Furthermore HTLV-1 is now associated not only with neuropathies but also with lymphocytic alveolitis, sicca syndrome and more rarely with uveitis, arthritis or vasculitis [12-15].

In 1985 twenty-one patients with TSP were identified in the Seychelles [4]. Based on this number of 21 patients, the prevalence of the disease was 35/100’000 and consequently the Seychelles was identified as a new geographic isolate of endemic TSP [4]. A register of all admissions on the 2 main hospitals of the main island, Mahé, was carried out from 1 January 1993 to 31 December 1995. One new case of TSP was diagnosed in 1993, none in 1994 and 7 in 1995. We report the last case of 1995.

Case report

A 38-year-old woman was admitted to Victoria hospital because of progressive weakness of the legs and numbness of both soles. She had been well until 9 months before, when uncontrolled jerking movements and cold sensation of whole body happened several times a day. She noticed also progressive constipation, passing stool once a-week only. Eight months before admission, weakness of the right leg and numbness of the right sole developed simultaneously. Four months before admission she noticed progressive loss of sensation of the vulva and vagina and became frigid. One month later, the left leg became weak and the left sole numb. She had difficulty to walk rapidly and to maintain her balance when changing direction, and her soles were painful when walking on a rough surface. Two months before admission, she noticed difficulty to pass urine but did not complain of odynuria. One day before admission, she saw a physician who noticed weakness in the legs and bilateral Babinsky sign and was referred to this hospital.

The patient was married, of mixed descent and had been working in a fish processing factory, preparing fish filets for several years. She had never smoked and was not drinking alcohol. She had a dog and a tortoise. She did not remember any particular disease. She had 6 pregnancies, the first one 20 years ago; one pregnancy ended with death in utero; one child died of pneumonia when he was 19 months old. She had a blood transfusion immediately after the last delivery. She underwent sterilization 9 years ago. The patient was unaware of any tick bites, arthralgia, or localized rash. There was no history of trauma, recent immunization, previous transient neurologic deficits, thoracic or abdominal pain, or risk factors for infection with the human immunodeficiency virus.

On general examination, her temperature was 36.6°C, her pulse 72 beats/min, regular, and her respiration 16/min. Her blood pressure was 120/80 mmHg. On examination the patient was looking healthy, moderately obese and was cooperative. Brownish itchy papules were present on the legs, the arms and the chest; no vesicles, pustules or furrows were seen. The oropharynx was normal. The neck was supple. Lhermitte’s sign was absent. The lungs and heart were normal. The abdomen was normal. The extremities appeared normal and the peripheral pulses were felt.

On neurological examination the patient was alert and oriented, with intact speech and intellectual function. She was able to walk without help but was very unsteady when going backwards. Cranial-nerve functions were preserved. Fundoscopy was normal. Motor power was 5/5 in the upper extremities with normal tone; in both legs strength was 3/5 in the proximal muscles and 4/5 in the dorsiflexors and plantar flexors of the feet; tone was slightly increased in both legs. Sensation was normal in the upper extremities; there was slight dysesthesia distally to the right knee and marked dysesthesia on both soles, on testing of pinprick and temperature sensation; vibratory sensation and sense of joint position were conserved. Coordination was normal. The deep tendon reflexes were very brisk in all extremities; bilateral Babinsky signs were noted; superficial abdominal reflexes were absent; no jaw jerk was found. During examination no fasciculation was noted.

An electrocardiogram and a radiographic examination of the chest and lumbar spine were normal. The patient declined a myelographic examination of the spine.

Hematological laboratory values. Erythrocyte sedimentation rate: 5mm/hr; hemoglobin 14.5 g/d; hematocrit:41%; white-cell count: 9,100 per mm³; neutrophils 62%; lymphocytes: 25%; monocytes: 3%; eosinophils: 10%; platelet count: normal.

Blood chemical values. Sodium: 138mmol /liter; potassium: 4.1 mmol/liter; urea nitrogen: 2.8 mmol/liter; creatinine: 87 m mol/liter; uric acid: 0.16 mmol/liter; total bilirubin: 15 m mol/liter; aspartate amino-transferase: 13 U/liter; alanine amino-transferase: 9 U/liter; alkaline phosphatase: 110 U/liter; g -glutamyl transferase: 16 U/liter; protein: 75 g/liter; albumin: 45 g/l.

Lumbar puncture. Appearance of fluid: clear, colorless; initial pressure: normal; cells/high-power field: 8; white cells: 3; red cells: 5; glucose: 2.5 mmol/liter; protein: 2.6 mg/dl; microscopical examination for micro-organisms: negative; culture: sterile.

Serologies. HBsAG, anti-HBc, anti-HCV, anti-HIV1, anti-HIV2: negative. HTLV-I/II was reported as positive in the serum and in the cerebro-spinal fluid.

Discussion

The clinical picture of TSP in the Seychelles was first described by Roman et al. in 1985 [4]. It resembles that observed by the same authors in Tumaco (Colombia) and by others in Martinique [16] and Jamaica. TSP is of slow onset and progression with gradual weakness and spasticity of the legs resulting in a slow and unstable gait that requires later support from crutches. Low back pain, dysesthesia in feet and legs, increased urinary frequency, and constipation are usual. After years of progressive evolution, the patient may become bedridden and incontinent. In one third of cases, the disease has a relatively acute onset and rapid progression and can incapacitate the patient in 1 or 2 years. Neurologic examination reveals signs of pyramidal tract involvement with paraparesis or paraplegia with hyperactive tendon reflexes, spasticity, clonus, and extensor plantar responses. Sensory findings are usually mild, although some patients have paresthesia, dysesthesia, or pain in the legs and a true sensory level is usually not found. Half of the patients have brisk reflexes in the arms. Rarely cranial nerve abnormalities (optic neuropathy, deafness, nystagmus, diplopia, facial paresis), and cerebellar signs (tremor, dysmetria) are observed [4].

In Seychelles HTLV-I antibodies were demonstrated in 85% of the patients with TSP and in only 12.5% of controls [4]. In the adult population of this country, the prevalence of anti-HTLV-I antibody was 4.2% in men and 7.9% in women; the crude prevalence increased with age from 1.9% and 4.8% at age 25-34 to 6.6% and 12.7% at age 55-64, in men and women respectively [17]. In Trinidad, Martinique, Ivory Coast and Jamaica, the seropositivity for HTLV-I among control groups studied was 1% [18], 2% [5], 4% [3] and 7% [5], respectively.

The role of retroviral infection in the pathogenesis of TSP is actually the object of research. If the mode of transmission of HTLV-I is similar to that known for other retroviruses, risk factors for TSP would include intravenous drug abuse (unknown in Seychelles), sexual contact [19], blood transfusion [20-23] and maternal transmission through uteroplacental hemorrhage and breastfeeding [24]. As already suggested in 1991 by Lavanchy et al. [17], screening for antibodies to HTLV-I in blood donors has to be taken into account for countries with high endemicity for HTLV-I infection. A screening program in preventing HTLV-I transmission through blood donors will soon be implemented in Seychelles.

Acknowledgments

The author wishes to thank Dr. Pascal Bovet for his pertinent advise; Professor Philippe Frey (Immunology and Allergy Division, University Hospital, Lausanne, Switzerland) for serological analyses; Mrs Anne Gédéon for careful review; and the Ministry of Health of Seychelles for its support.