Tropical Doctor, July 1990 by doctors had a positive finding, 32.8070 having peptic ulcer disease. The price of cimetidine 800 mg in Cameroon during the period of the study was us $3.50. The wage for manual labour is about 70 cents an hour. Much of the population depends principally on subsistence farming, with the sale of a cash crop such as coffee giving a family a few hundred dollars a year. There has been a tendency, even in Africa, to prescribe cimetidine indiscriminately for dyspeptic complaints. We found that gastroscopy could be quickly and easily performed and taught, that it assisted the prescription of appropriate medication, and avoided the unnecessary prescription of expensive medication. The high incidence of peptic ulcer disease in this part of Africa seems to be at variance with Pakistan-, New Guinea and some other parts of Africa. The local people consume large quantities of palm wine, corn (maize) beer and proprietary beers. They also have the habit of chewing the bitter kola nut and add a strong pepper spice to their meals. The people themselves believe these habits contribute to their gastric complaints, although cause and effect have not been properly studied. It is also interesting to speculate on the role of H. pylori which appears to be present in the stomach in many of the people of Cameroon. The results of continuing studies are awaited with interest.
121 7 Stahel et al. Gastroduodenitis and peptic ulcer in a rural Liberian community. An endoscopic prospective study. Trop Geogr Med 1981;33:155-60 8 Arigbabi AO, Adenkunle A. The value of early endoscopic diagnosis of bleeding from the upper gastrointestinal tract: experience at Ire. East Afr Med J 1985;62:716-19
Pancreatic calcification in diabetes mellitus at Ilorin, Nigeria D A Nzeh MBBS FMCR I R T Erasmus MBBS FMCPath2 Departments of 'Radiology and "Chemlcot Pathology, University of Ilorin Teaching Hospital, florin, Nigeria TROPICAL DOCTOR,
1990,20, 121-123
SUMMARY
Plain abdominal radiograph showed pancreatic calcification in four cases (5.2%) in a total of 77 cases of diabetes mellitus. All patients with calcified pancreas were insulin-dependent male diabetics. No direct relationship was observed between duration of illness and presence of calcification in the pancreas. Low incidence of pancreatic calcification among diabetics in recent reports from Nigeria probably suggests a changing pattern of the disease in the tropics.
ACKNOWLEDGMENTS
I thank Srs Xavieria, Rosa, Felicitas, and Emma, Mr John Fai, Mr Kevin Veranso, Mr Chrysanthus and all other staff of Shisong and Njinikom Catholic Mission Hospitals; also Dr John Dawson and Mr John Hall for help in the preparation of the paper; the Stamford and Rutland Hospital who made the gastroscope available; and the pathology staffs at Peterborough and Plymouth Hospitals who examined biopsies free of charge. REFERENCES
I 2 3 4 5 6
Wierman JA, Snyder CA. The feasibility of using the fibreoptic gastroscope in a small hospital in a developing country. Trop Doct 1978;8:110-11 Currie MA. Upper gastrointestinal endoscopy in a rural hospital: a facility assessed. Trop Doct 1984;14:77-9 Atoba MA. Endoscopy service in a developing country: problems and suggestedsolutions. Trop Doct 1984;14:79-81 Tsega E. Analysis of fibre-optic gastroduodenoscopy in 1084 Ethiopians. Trop Geogr Med 1981;33:149-54 Arabi MAM, Ibrahim S, Hamid MA. Fibre-optic panendoscopy of the upper gastrointestinal tract in a tropical hospital. East Afr Med J 1984;61:456-9 Capdeville P. Vingtmois d'endoscopie digestive a Tananarive. Med Trop (Mars) 1979;39:643-9
INTRODUCTION
Fibrocalculous pancreatic diabetes (FCPD) is a recognized disease in the tropics that is associated with high cassava intake and malnutrition I. In a recent report the WH02 made two distinct subclassifications of malnutrition-related diabetes mellitus which is peculiar to the tropics namely: malnutrition diabetes (MD), characterized by absence of radiographic evidence of calcification, absence of ketosis and early age of onset; and FCPD, in which features of MD are associated with attacks of abdominal pain and pancreatic calcification. In Africa, Nigeria and Uganda both have cassava as a common staple and there are reports of a higher incidence of pancreatic calcification among diabetics than occurs in countries like Zambia, Ethiopia and Zimbabwe which consume staples other than cassava>",
Tropical Doctor, July 1990
122 The present report describes the association of pancreatic calcification with diabetes mellitus as seen at Ilorin, Nigeria and presents a review of the literature. PATIENTS AND METHODS
Seventy-seven diagnosed cases of diabetes mellitus were included in this study. All cases were confirmed at the Chemical Pathology Laboratory of the University of Ilorin Teaching Hospital. These patients also had plain radiographs of the abdomen. The study was conducted over a period of one year from October 1987 to October 1988. There were 34 males and 43 females. RESULTS
is encountered frequently in places like Nigeria and Uganda where inhabitants consume high carbohydrate-low protein staples such as cassava'>. In Nigeria, there is geographical variation of staple consumption. The south with rain-forest vegetation has cassava as the main staple but in the far north where savannah grassland predominates, the staple diet consists of grains like millet and sorghum. Tropical pancreatic diabetes is commoner in the southern parts of Nigeria than in the northern areas 10. llorin which is in the midlands of Nigeria has a mixture of rain forest vegetation and savannah grassland. As a result the Ilorin staple consists largely of mixed consumption of tubers like cassava and yam from the south and grains like millet and sorghum from the far north.
The age range of patients studied was 15-75 years with a mean of 48.9 years. Twenty-eight cases (36%) had insulin dependent diabetes mellitus (100M) while 49 cases (64OJo) had non-insulin dependent diabetes mellitus (NIODM). The shortest duration of illness was 2 weeks but one patient had been with the disease for 18 years. The distribution of the duration of illness among cases is shown in Table I. Of the 77 patients in this study, only four cases (5.2%) had evidence of pancreatic calcification on abdominal radiograph. All four patients were males who had 100M. They were aged 25, 32, 43 and 56 years (mean 39 years) and the duration of symptoms or known diabetes were 2 weeks, one month, 7 years and 2 months, respectively. The calcifications were seen as irregular opacities at the level of the 12th thoracic and 1st lumbar vertebrae; usually not conforming to any particular pattern. Figure I shows pancreatic calcification in the abdominal radiograph of the 25-year-old patient. DISCUSSION
Tropical pancreatic diabetes has been attributed to malnutrition and can sometimes result in pancreatic fibrosis and calcification. Among Africans, FCPO
Table 1. Duration of illness among patients Duration (years) Less than I I-S 6-10 II-IS 16-20 Total
Noc of cases
Percentage
13
16.9 SS.8 20.8 S.2 1.3 100.0
43
16 4 I
77
Figure I. Plain abdominal radiograph in the 25-year-old patient showing irregular opacities in the left upper abdominal quadrant and adjacent to the 12th thoracic and 1st lumbar vertebral bodies on the right, resultingfrom pancreatic calcification. A rounded opacity is also noted overlying the left iliac bone and is probably due to calcified pelvic gland
Tropical Doctor, July 1990 Different reports from Nigeria have shown that the incidence of pancreatic calcification in diabetes mellitus ranges from 1.5 to 12.6070 5 ,6, 11. A decreasing incidence of pancreatic calcification among Nigerian diabetics has been observed over the past two decades'', although the 5.2% incidence noted in the present series is slightly higher than the incidence of 1.5% reported from Ibadan, Nigeria". FCPD is commonest in patients under 30 years of age5 ,6; however only one patient in the current series was below 30 years. All four cases with radiological evidence of calcification in the present study were males. This observation agrees with an earlier report from Ibadan which also recorded a preponderance of males over females'>, Recurrent episodes of malnutrition and associated infection in childhood have been suggested as promoting the formation of proteinaceous plugs which block pancreatic ducts and lead to endocrine and exocrine malfunction 10,13. As the disease progresses, the pancreas becomes shrunken and irregularly fibrosed with multiple calcium carbonate and calcium phosphate stones in the major ducts'. However, pancreatic calculi are often difficult to distinguish from disseminated pancreatic calcification clinically, radiologically and pathologically12 . When the pancreas becomes extensivelycalcified, the radiograph usually shows discrete opacities of irregular shapes and sizes which run across the midline from the left upper adbominal quadrant to the right at the level of the twelfth thoracic and first lumbar vertebral bodies (Figure 1). It is noteworthy that all the cases of pancreatic calcification in this study were insulin-dependent male diabetics but presence of calcification did not bear a direct relationship with duration of illness among the 77 cases under review. The latter observation, together with low incidence of pancreatic calcification among diabetics in other recently published reports, suggest that an abdominal X-ray examination should not be a routine baseline investigation in all cases of diabetes mellitus. Such routine radiography is current practice in many parts of the tropics, but is not justified by our findings especially in view of financial restraints and shortage of skilled manpower facing several developing countries. REFERENCES
I Abu-Bakare A, GillGV, Taylor R, Alberti KGMM. Tropical or malnutrition-related diabetes: a real syndrome? Lancet 1986;i:1135
123 2 World Health Organization. Diabetes mellitus. Geneva:WHO Technical Report Series No. 727, 1985 3 Shaper AG. Chronic pancreatic disease and protein malnutrition. Lancet 1960;i:1223 4 Parson W, Macdonald FW, Shaper AG. African diabetics necropsied at Muiago Hospital, Kampala, Uganda 1957-66. East Afr Med J 1968;45:89 5 Osuntokun BO, Akinkugbe FM, Francis rt, Reddy S, Osuntokun 0, Taylor GOL. Diabetes Mellitus in Nigerians. A study of 832 patients. West Afr Med J 1971;20:295 6 Bella AF. Calcific pancreatic diabetes mellitus in Ibadan. Central Afr J Med 1985;31:180 7 Gelfand M. Carr WR. Diabetes mellitus in the African in Rhodesia. Central Afr J Med 1961;7:41 8 Lester FT. The clinical pattern of diabetes mellitus in Ethiopians. Diabetes Care 1984;7:6 9 Rolfe M. Tropical pancreatic diabetesin Zambia. Central Afr J Med 1987;33:126 10 Nwokolo C, Oli J. Pathogenesis of Juvenile tropical pancreatitis Syndrome. Lancet 1980;i:456 11 Kinnear TWG. The pattern of diabetes mellitus in a Nigerian Teaching Hospital. East Afr Med J 1963;40:288 12 Olurin EO, Olurin O. Pancreatic calcification: a report of 45 cases. Br Med J: 1969;4:534 13 Montalegre A, Sarles H, Ricosse JH, Sahel J. Pancreatic lesions due to prolonged malnutrition in Ibo children:possible transition between kwashiorkor and chronic calcifying pancreatitis. Pancreas 1987;2:114
Electrocardiographic changes after recovery from measles A 0 Olowu MBBSFWACPaed 0 Taiwo MBBSMRCP Department of Paediatrics, Obafemi A wolowo University, lle-Ife, Nigeria TROPICAL DOCTOR,
1990, 20, 123-126
SUMMARY
Children with measles seen at our hospital had an initial electrocardiogram (ECG) and a repeat after 3 months. The patients were aged 5 months to 8 years (mean 19 months). The ECG changes observed after clinical recovery included T-wave inversion in eight patients (16%), flattening in eight patients (16%), prolonged PR interval in six (12%), prolonged Q-Tc in three (6%) Correspondence to Dr Olowu, Department of Paediatrics, Ogun State University Teaching Hospital, Sagamu, Nigeria
121 7 Stahel et al. Gastroduodenitis and peptic ulcer in a rural Liberian community. An endoscopic prospective study. Trop Geogr Med 1981;33:155-60 8 Arigbabi AO, Adenkunle A. The value of early endoscopic diagnosis of bleeding from the upper gastrointestinal tract: experience at Ire. East Afr Med J 1985;62:716-19
Pancreatic calcification in diabetes mellitus at Ilorin, Nigeria D A Nzeh MBBS FMCR I R T Erasmus MBBS FMCPath2 Departments of 'Radiology and "Chemlcot Pathology, University of Ilorin Teaching Hospital, florin, Nigeria TROPICAL DOCTOR,
1990,20, 121-123
SUMMARY
Plain abdominal radiograph showed pancreatic calcification in four cases (5.2%) in a total of 77 cases of diabetes mellitus. All patients with calcified pancreas were insulin-dependent male diabetics. No direct relationship was observed between duration of illness and presence of calcification in the pancreas. Low incidence of pancreatic calcification among diabetics in recent reports from Nigeria probably suggests a changing pattern of the disease in the tropics.
ACKNOWLEDGMENTS
I thank Srs Xavieria, Rosa, Felicitas, and Emma, Mr John Fai, Mr Kevin Veranso, Mr Chrysanthus and all other staff of Shisong and Njinikom Catholic Mission Hospitals; also Dr John Dawson and Mr John Hall for help in the preparation of the paper; the Stamford and Rutland Hospital who made the gastroscope available; and the pathology staffs at Peterborough and Plymouth Hospitals who examined biopsies free of charge. REFERENCES
I 2 3 4 5 6
Wierman JA, Snyder CA. The feasibility of using the fibreoptic gastroscope in a small hospital in a developing country. Trop Doct 1978;8:110-11 Currie MA. Upper gastrointestinal endoscopy in a rural hospital: a facility assessed. Trop Doct 1984;14:77-9 Atoba MA. Endoscopy service in a developing country: problems and suggestedsolutions. Trop Doct 1984;14:79-81 Tsega E. Analysis of fibre-optic gastroduodenoscopy in 1084 Ethiopians. Trop Geogr Med 1981;33:149-54 Arabi MAM, Ibrahim S, Hamid MA. Fibre-optic panendoscopy of the upper gastrointestinal tract in a tropical hospital. East Afr Med J 1984;61:456-9 Capdeville P. Vingtmois d'endoscopie digestive a Tananarive. Med Trop (Mars) 1979;39:643-9
INTRODUCTION
Fibrocalculous pancreatic diabetes (FCPD) is a recognized disease in the tropics that is associated with high cassava intake and malnutrition I. In a recent report the WH02 made two distinct subclassifications of malnutrition-related diabetes mellitus which is peculiar to the tropics namely: malnutrition diabetes (MD), characterized by absence of radiographic evidence of calcification, absence of ketosis and early age of onset; and FCPD, in which features of MD are associated with attacks of abdominal pain and pancreatic calcification. In Africa, Nigeria and Uganda both have cassava as a common staple and there are reports of a higher incidence of pancreatic calcification among diabetics than occurs in countries like Zambia, Ethiopia and Zimbabwe which consume staples other than cassava>",
Tropical Doctor, July 1990
122 The present report describes the association of pancreatic calcification with diabetes mellitus as seen at Ilorin, Nigeria and presents a review of the literature. PATIENTS AND METHODS
Seventy-seven diagnosed cases of diabetes mellitus were included in this study. All cases were confirmed at the Chemical Pathology Laboratory of the University of Ilorin Teaching Hospital. These patients also had plain radiographs of the abdomen. The study was conducted over a period of one year from October 1987 to October 1988. There were 34 males and 43 females. RESULTS
is encountered frequently in places like Nigeria and Uganda where inhabitants consume high carbohydrate-low protein staples such as cassava'>. In Nigeria, there is geographical variation of staple consumption. The south with rain-forest vegetation has cassava as the main staple but in the far north where savannah grassland predominates, the staple diet consists of grains like millet and sorghum. Tropical pancreatic diabetes is commoner in the southern parts of Nigeria than in the northern areas 10. llorin which is in the midlands of Nigeria has a mixture of rain forest vegetation and savannah grassland. As a result the Ilorin staple consists largely of mixed consumption of tubers like cassava and yam from the south and grains like millet and sorghum from the far north.
The age range of patients studied was 15-75 years with a mean of 48.9 years. Twenty-eight cases (36%) had insulin dependent diabetes mellitus (100M) while 49 cases (64OJo) had non-insulin dependent diabetes mellitus (NIODM). The shortest duration of illness was 2 weeks but one patient had been with the disease for 18 years. The distribution of the duration of illness among cases is shown in Table I. Of the 77 patients in this study, only four cases (5.2%) had evidence of pancreatic calcification on abdominal radiograph. All four patients were males who had 100M. They were aged 25, 32, 43 and 56 years (mean 39 years) and the duration of symptoms or known diabetes were 2 weeks, one month, 7 years and 2 months, respectively. The calcifications were seen as irregular opacities at the level of the 12th thoracic and 1st lumbar vertebrae; usually not conforming to any particular pattern. Figure I shows pancreatic calcification in the abdominal radiograph of the 25-year-old patient. DISCUSSION
Tropical pancreatic diabetes has been attributed to malnutrition and can sometimes result in pancreatic fibrosis and calcification. Among Africans, FCPO
Table 1. Duration of illness among patients Duration (years) Less than I I-S 6-10 II-IS 16-20 Total
Noc of cases
Percentage
13
16.9 SS.8 20.8 S.2 1.3 100.0
43
16 4 I
77
Figure I. Plain abdominal radiograph in the 25-year-old patient showing irregular opacities in the left upper abdominal quadrant and adjacent to the 12th thoracic and 1st lumbar vertebral bodies on the right, resultingfrom pancreatic calcification. A rounded opacity is also noted overlying the left iliac bone and is probably due to calcified pelvic gland
Tropical Doctor, July 1990 Different reports from Nigeria have shown that the incidence of pancreatic calcification in diabetes mellitus ranges from 1.5 to 12.6070 5 ,6, 11. A decreasing incidence of pancreatic calcification among Nigerian diabetics has been observed over the past two decades'', although the 5.2% incidence noted in the present series is slightly higher than the incidence of 1.5% reported from Ibadan, Nigeria". FCPD is commonest in patients under 30 years of age5 ,6; however only one patient in the current series was below 30 years. All four cases with radiological evidence of calcification in the present study were males. This observation agrees with an earlier report from Ibadan which also recorded a preponderance of males over females'>, Recurrent episodes of malnutrition and associated infection in childhood have been suggested as promoting the formation of proteinaceous plugs which block pancreatic ducts and lead to endocrine and exocrine malfunction 10,13. As the disease progresses, the pancreas becomes shrunken and irregularly fibrosed with multiple calcium carbonate and calcium phosphate stones in the major ducts'. However, pancreatic calculi are often difficult to distinguish from disseminated pancreatic calcification clinically, radiologically and pathologically12 . When the pancreas becomes extensivelycalcified, the radiograph usually shows discrete opacities of irregular shapes and sizes which run across the midline from the left upper adbominal quadrant to the right at the level of the twelfth thoracic and first lumbar vertebral bodies (Figure 1). It is noteworthy that all the cases of pancreatic calcification in this study were insulin-dependent male diabetics but presence of calcification did not bear a direct relationship with duration of illness among the 77 cases under review. The latter observation, together with low incidence of pancreatic calcification among diabetics in other recently published reports, suggest that an abdominal X-ray examination should not be a routine baseline investigation in all cases of diabetes mellitus. Such routine radiography is current practice in many parts of the tropics, but is not justified by our findings especially in view of financial restraints and shortage of skilled manpower facing several developing countries. REFERENCES
I Abu-Bakare A, GillGV, Taylor R, Alberti KGMM. Tropical or malnutrition-related diabetes: a real syndrome? Lancet 1986;i:1135
123 2 World Health Organization. Diabetes mellitus. Geneva:WHO Technical Report Series No. 727, 1985 3 Shaper AG. Chronic pancreatic disease and protein malnutrition. Lancet 1960;i:1223 4 Parson W, Macdonald FW, Shaper AG. African diabetics necropsied at Muiago Hospital, Kampala, Uganda 1957-66. East Afr Med J 1968;45:89 5 Osuntokun BO, Akinkugbe FM, Francis rt, Reddy S, Osuntokun 0, Taylor GOL. Diabetes Mellitus in Nigerians. A study of 832 patients. West Afr Med J 1971;20:295 6 Bella AF. Calcific pancreatic diabetes mellitus in Ibadan. Central Afr J Med 1985;31:180 7 Gelfand M. Carr WR. Diabetes mellitus in the African in Rhodesia. Central Afr J Med 1961;7:41 8 Lester FT. The clinical pattern of diabetes mellitus in Ethiopians. Diabetes Care 1984;7:6 9 Rolfe M. Tropical pancreatic diabetesin Zambia. Central Afr J Med 1987;33:126 10 Nwokolo C, Oli J. Pathogenesis of Juvenile tropical pancreatitis Syndrome. Lancet 1980;i:456 11 Kinnear TWG. The pattern of diabetes mellitus in a Nigerian Teaching Hospital. East Afr Med J 1963;40:288 12 Olurin EO, Olurin O. Pancreatic calcification: a report of 45 cases. Br Med J: 1969;4:534 13 Montalegre A, Sarles H, Ricosse JH, Sahel J. Pancreatic lesions due to prolonged malnutrition in Ibo children:possible transition between kwashiorkor and chronic calcifying pancreatitis. Pancreas 1987;2:114
Electrocardiographic changes after recovery from measles A 0 Olowu MBBSFWACPaed 0 Taiwo MBBSMRCP Department of Paediatrics, Obafemi A wolowo University, lle-Ife, Nigeria TROPICAL DOCTOR,
1990, 20, 123-126
SUMMARY
Children with measles seen at our hospital had an initial electrocardiogram (ECG) and a repeat after 3 months. The patients were aged 5 months to 8 years (mean 19 months). The ECG changes observed after clinical recovery included T-wave inversion in eight patients (16%), flattening in eight patients (16%), prolonged PR interval in six (12%), prolonged Q-Tc in three (6%) Correspondence to Dr Olowu, Department of Paediatrics, Ogun State University Teaching Hospital, Sagamu, Nigeria
