Accepted Manuscript Neck Mass in Rural Africa Antonio Grimaldi, MD Barbara Kakande, MD Kumar Narayanan, MD Elias Sebatta, MD Giorgio Trucco, MD Mariana Mirabel, MD Roxane Ducloux, MD Emmy Okello, MD Eloi Marijon, MD, PhD PII:
S0002-9343(14)00919-X
DOI:
10.1016/j.amjmed.2014.10.018
Reference:
AJM 12730
To appear in:
The American Journal of Medicine
Received Date: 25 September 2014 Revised Date:
15 October 2014
Accepted Date: 15 October 2014
Please cite this article as: Grimaldi A, Kakande B, Narayanan K, Sebatta E, Trucco G, Mirabel M, Ducloux R, Okello E, Marijon E, Neck Mass in Rural Africa, The American Journal of Medicine (2014), doi: 10.1016/j.amjmed.2014.10.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Neck Mass in Rural Africa Antonio Grimaldi, 1,4 MD, Barbara Kakande,1 MD, Kumar Narayanan,2,3 MD, Elias Sebatta,1 MD, Giorgio Trucco,1 MD, Mariana Mirabel,1,3 MD, Roxane Ducloux,3 MD, Emmy Okello,1,5 MD, Eloi Marijon,1,3 MD, PhD 1
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Corresponding authors: Dr Antonio Grimaldi San Raffaele Hospital and Università Vita-Salute Via Olgettina, 60 Milano, Italy Phone: +39 02 26434524 Emails: [email protected]
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RI PT
Uganda Heart Institute, Mulago Hospital, Kampala, Uganda 2 Cedars Sinai Medical Center, Los Angeles, CA 3 Paris Descartes University and European Georges Pompidou Hospital, Paris, France 4 San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy 5 Department of Medicine, Makerere University/Uganda Heart Institute, Kampala, Uganda
Clinical Communication to the Editor– The American Journal of Medicine
EP
Running head: neck mass in rural Africa
Funding source: none
AC C
Conflict of interest for all authors: none We confirm that all authors had access to the data and have read and approved the manuscript
Word count: 653 3 References
Key Words: Thyroid Goitre, Developing Nations; Global Health; Iodine; World Health Organization
ACCEPTED MANUSCRIPT A 59 year-old woman farmer from Luweero District in Central Uganda presented with progressive difficulty in breathing and swallowing and several episodes of dizziness related to sudden positional changes. On clinical examination, a massive neck mass was noted, with severe engorgement of the superficial veins of the upper chest
compression. The patient was scheduled for thyroidectomy.
RI PT
[Figure]. Chest radiograph was suggestive of intra-thoracic goitre with tracheal
In Africa, thyroid goitre is most often related to iodine-deficiency. According to
SC
the World Health Organization, iodine deficiency (defined as a median urinary iodine concentration of less than 50 µg/L) affects more than one billion people worldwide,
M AN U
resulting in 3.5 million DALYs (Disability Adjusted Life Years) [1]. In addition to a high prevalence of thyroid goitre (30–70%), iodine-deficiency results in hypothyroidism, which affects several organs including the central nervous system (causing cretinism among newborns) and causes congenital abnormalities [1]. Recent UNICEF data
TE D
estimate that 8% of newborns are still unprotected overall [2]. Iodine deficiency is also thought to play a role in follicular thyroid cancers which are often associated with low socioeconomic status.
EP
In Africa, patients affected by thyroid goitre generally come to medical attention at a late stage of the disease, mainly due to the lack of medical services.
AC C
The enlargement usually takes many years to compress the laryngeal nerves and displace the trachea and oesophagus, resulting in coughing, sensation of food stuck in throat, and dyspnea (especially while lying on the back). Thyroid hormone pills may be given to treat small goitres, preventing further increase in size of the gland, whereas larger goitres may need surgery or radioiodine therapy, which are available only in developed countries.
ACCEPTED MANUSCRIPT Aetiologies of thyroid goitres in developing areas vary and chronic malnutrition plays a major role as well as certain substances that interfere with iodine uptake, called “goitrogens”. Examples of goitrogens include thiocyanates from poorly detoxified cassava, apigenin and luteolin from millet (Table). In more industrialized African
RI PT
settings, different patterns of goitres may be observed, such as Graves’ disease, hypothyroidism due to autoimmune Hashimoto's disease, inflammatory goitre related to hyperactive states such pregnancy or puberty, lithium intake, radiation exposure
SC
and thyroid cancer.
Elimination of iodine-deficiency is part of the Millennium Development Goals
M AN U
agreed upon by the United Nations Member States [2]. In 1994, the World Health Organization endorsed Universal Salt Iodization program to prevent iodine-deficiency disorders, by far the most important population-based intervention and a remarkably cost-effective public-health strategy [3]. Approximately 70% of the world’s population
TE D
is estimated to use iodized salt in a total of 130 countries [3]. Although salt iodization increases costs by only 3-5 cents per person per year—a price quite affordable even for consumers of the poorest emerging nations— the coverage of iodized salt is still
EP
incomplete in many countries. Nigeria and South Africa (where mandatory iodized table salt was introduced in 1995) have been among the first African nations to
AC C
successfully eliminate iodine-deficiency. In those countries there is now some concern regarding potential adverse effects of excessive salt intake on blood pressure (leading to research on alternative iodized foods). Several other countries have absent or weak legislation and iodised-salt programmes have been derailed by poverty and political instability. Greater emphasis is needed on the education of government leaders and generation of country-specific information on iodinedeficiency status.
ACCEPTED MANUSCRIPT In conclusion, in Africa, thyroid gland disease is still predominantly related to iodine-deficiency and promoted by other environmental factors. The lack of medical services as well as public education/awareness are major obstacles to be overcome
RI PT
and constitute a public health challenge for this century.
References
Lancet 2008; 372: 1251–62.
SC
1. Zimmermann MB, Jooste PL, Pandav CS. Iodine-deficiency disorders.
M AN U
2. Sustainable elimination of iodine deficiency: progress since the 1990 World Summit for Children. New York, NY: United Nations Children’s Fund, 2008. http://www.childinfo.org/files/idd_sustainable_elimination.pdf (last access: April 2014)
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3. Pearce EN, Andersson M, Zimmermann MB. Global iodine nutrition: Where
EP
do we stand in 2013? Thyroid 2013; 23: 523–8.
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Figure Legend.
Ugandan woman with massive thyroid goitre and severe engorgement of the superficial veins of the upper chest. The intrathoracic mass extends from hypopharynx and thyroid cartilage superiorly to beyond the suprasternal notch inferiorly and along both sternomastoids laterally.
ACCEPTED MANUSCRIPT Table – Main Causes of Thyroid Goitre in Africa
Emerging Areas
– Overactive thyroid gland (Graves’ disease, pregnancy, menopause and puberty) – Underactive thyroid gland (Hashimoto's disease) – Smoking – Lithium – Radiation exposure – Thyroid nodules – Thyroid cancer
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EP
TE D
Urban Settings Under Epidemiological Transition
M AN U
SC
RI PT
– Alimentation (iodine, vitamin A, iron, selenium deficiencies) – Environment (chemicals, pollution, fertilizers) – Other “Goitrogens”: Thiocyanates (from detoxified cassava, sweet potatoes, linseed, smoking and fertilizers) Flavonoids (apigenin and luteolin from millet) – Ion concentrations in soil and drinking water
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0002-9343(14)00919-X
DOI:
10.1016/j.amjmed.2014.10.018
Reference:
AJM 12730
To appear in:
The American Journal of Medicine
Received Date: 25 September 2014 Revised Date:
15 October 2014
Accepted Date: 15 October 2014
Please cite this article as: Grimaldi A, Kakande B, Narayanan K, Sebatta E, Trucco G, Mirabel M, Ducloux R, Okello E, Marijon E, Neck Mass in Rural Africa, The American Journal of Medicine (2014), doi: 10.1016/j.amjmed.2014.10.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Neck Mass in Rural Africa Antonio Grimaldi, 1,4 MD, Barbara Kakande,1 MD, Kumar Narayanan,2,3 MD, Elias Sebatta,1 MD, Giorgio Trucco,1 MD, Mariana Mirabel,1,3 MD, Roxane Ducloux,3 MD, Emmy Okello,1,5 MD, Eloi Marijon,1,3 MD, PhD 1
TE D
M AN U
Corresponding authors: Dr Antonio Grimaldi San Raffaele Hospital and Università Vita-Salute Via Olgettina, 60 Milano, Italy Phone: +39 02 26434524 Emails: [email protected]
SC
RI PT
Uganda Heart Institute, Mulago Hospital, Kampala, Uganda 2 Cedars Sinai Medical Center, Los Angeles, CA 3 Paris Descartes University and European Georges Pompidou Hospital, Paris, France 4 San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy 5 Department of Medicine, Makerere University/Uganda Heart Institute, Kampala, Uganda
Clinical Communication to the Editor– The American Journal of Medicine
EP
Running head: neck mass in rural Africa
Funding source: none
AC C
Conflict of interest for all authors: none We confirm that all authors had access to the data and have read and approved the manuscript
Word count: 653 3 References
Key Words: Thyroid Goitre, Developing Nations; Global Health; Iodine; World Health Organization
ACCEPTED MANUSCRIPT A 59 year-old woman farmer from Luweero District in Central Uganda presented with progressive difficulty in breathing and swallowing and several episodes of dizziness related to sudden positional changes. On clinical examination, a massive neck mass was noted, with severe engorgement of the superficial veins of the upper chest
compression. The patient was scheduled for thyroidectomy.
RI PT
[Figure]. Chest radiograph was suggestive of intra-thoracic goitre with tracheal
In Africa, thyroid goitre is most often related to iodine-deficiency. According to
SC
the World Health Organization, iodine deficiency (defined as a median urinary iodine concentration of less than 50 µg/L) affects more than one billion people worldwide,
M AN U
resulting in 3.5 million DALYs (Disability Adjusted Life Years) [1]. In addition to a high prevalence of thyroid goitre (30–70%), iodine-deficiency results in hypothyroidism, which affects several organs including the central nervous system (causing cretinism among newborns) and causes congenital abnormalities [1]. Recent UNICEF data
TE D
estimate that 8% of newborns are still unprotected overall [2]. Iodine deficiency is also thought to play a role in follicular thyroid cancers which are often associated with low socioeconomic status.
EP
In Africa, patients affected by thyroid goitre generally come to medical attention at a late stage of the disease, mainly due to the lack of medical services.
AC C
The enlargement usually takes many years to compress the laryngeal nerves and displace the trachea and oesophagus, resulting in coughing, sensation of food stuck in throat, and dyspnea (especially while lying on the back). Thyroid hormone pills may be given to treat small goitres, preventing further increase in size of the gland, whereas larger goitres may need surgery or radioiodine therapy, which are available only in developed countries.
ACCEPTED MANUSCRIPT Aetiologies of thyroid goitres in developing areas vary and chronic malnutrition plays a major role as well as certain substances that interfere with iodine uptake, called “goitrogens”. Examples of goitrogens include thiocyanates from poorly detoxified cassava, apigenin and luteolin from millet (Table). In more industrialized African
RI PT
settings, different patterns of goitres may be observed, such as Graves’ disease, hypothyroidism due to autoimmune Hashimoto's disease, inflammatory goitre related to hyperactive states such pregnancy or puberty, lithium intake, radiation exposure
SC
and thyroid cancer.
Elimination of iodine-deficiency is part of the Millennium Development Goals
M AN U
agreed upon by the United Nations Member States [2]. In 1994, the World Health Organization endorsed Universal Salt Iodization program to prevent iodine-deficiency disorders, by far the most important population-based intervention and a remarkably cost-effective public-health strategy [3]. Approximately 70% of the world’s population
TE D
is estimated to use iodized salt in a total of 130 countries [3]. Although salt iodization increases costs by only 3-5 cents per person per year—a price quite affordable even for consumers of the poorest emerging nations— the coverage of iodized salt is still
EP
incomplete in many countries. Nigeria and South Africa (where mandatory iodized table salt was introduced in 1995) have been among the first African nations to
AC C
successfully eliminate iodine-deficiency. In those countries there is now some concern regarding potential adverse effects of excessive salt intake on blood pressure (leading to research on alternative iodized foods). Several other countries have absent or weak legislation and iodised-salt programmes have been derailed by poverty and political instability. Greater emphasis is needed on the education of government leaders and generation of country-specific information on iodinedeficiency status.
ACCEPTED MANUSCRIPT In conclusion, in Africa, thyroid gland disease is still predominantly related to iodine-deficiency and promoted by other environmental factors. The lack of medical services as well as public education/awareness are major obstacles to be overcome
RI PT
and constitute a public health challenge for this century.
References
Lancet 2008; 372: 1251–62.
SC
1. Zimmermann MB, Jooste PL, Pandav CS. Iodine-deficiency disorders.
M AN U
2. Sustainable elimination of iodine deficiency: progress since the 1990 World Summit for Children. New York, NY: United Nations Children’s Fund, 2008. http://www.childinfo.org/files/idd_sustainable_elimination.pdf (last access: April 2014)
TE D
3. Pearce EN, Andersson M, Zimmermann MB. Global iodine nutrition: Where
EP
do we stand in 2013? Thyroid 2013; 23: 523–8.
AC C
Figure Legend.
Ugandan woman with massive thyroid goitre and severe engorgement of the superficial veins of the upper chest. The intrathoracic mass extends from hypopharynx and thyroid cartilage superiorly to beyond the suprasternal notch inferiorly and along both sternomastoids laterally.
ACCEPTED MANUSCRIPT Table – Main Causes of Thyroid Goitre in Africa
Emerging Areas
– Overactive thyroid gland (Graves’ disease, pregnancy, menopause and puberty) – Underactive thyroid gland (Hashimoto's disease) – Smoking – Lithium – Radiation exposure – Thyroid nodules – Thyroid cancer
AC C
EP
TE D
Urban Settings Under Epidemiological Transition
M AN U
SC
RI PT
– Alimentation (iodine, vitamin A, iron, selenium deficiencies) – Environment (chemicals, pollution, fertilizers) – Other “Goitrogens”: Thiocyanates (from detoxified cassava, sweet potatoes, linseed, smoking and fertilizers) Flavonoids (apigenin and luteolin from millet) – Ion concentrations in soil and drinking water
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
