Letter to the editor The neglected strokes – cerebrovascular complications of neglected tropical diseases Dear editor, Neglected tropical diseases (NTDs) are a group of conditions that affect one billion people worldwide and claim the lives of Correspondence: Oscar H. Del Brutto, Air Center 3542, PO Box 522970, Miami, FL 33152-2970, USA. E-mail: [email protected] Conflict of interest: None declared. Funding: This study was partially supported by Universidad Espíritu Santo – Ecuador, Guayaquil – Ecuador. DOI: 10.1111/ijs.12414
more than half million people every year, with a marked predominance for those living in low-income countries (1). These conditions – not receiving proper attention or being disregarded (hence the term neglected) – trap individuals in a circle of poverty and disease causing annual losses of billions of dollars (2). The neurological burden of NTDs has not been systematically investigated, but is probably significant. Stroke, one of the new epidemics of the developing world, has been associated with at least seven of the NTDs currently recognized by the World Health Organization (http://www.who.int/neglected_diseases/ diseases/en/), including Chagas’ disease (American trypanosomiasis), chronic suppurative otitis media, cysticercosis,
dengue, echinococcosis, schistosomiasis, and snakebites. NTDs-related strokes may be ischemic or hemorrhagic and related to a variety of pathogenetic mechanisms, including angiitis, abnormalities in the coagulation cascade, abnormal platelet function, cardiogenic brain embolisms, venous thrombosis, and mycotic aneurysm formation and rupture (3–5). Little has been done to explore the relationship between NTDs and stroke, and current evidence on this subject is scarce and to some extent conflicting (Table 1). Proper knowledge about the magnitude of the problem, including information on the percentage of patients with NTDs who develop a stroke, as well as on the contribution of each of these conditions to the prevalence of stroke in a given area, is
Table 1 Relationships between neglected tropical diseases and stroke
Pathogenetic mechanisms
Disease
Etiology
Stroke subtypes
Chagas’ disease (American Trypanosomiasis)
Trypanosoma cruzi
Cortical and subcortical Cardiogenic brain infarcts. embolism; Angiitis (rare)
Cerebellar venous Chronic suppurative Pyogenic bacteria infarcts. otitis media (CSOM) Cysticercosis Larval stage of Taenia Lacunar and cortical solium infarcts; subarachnoid hemorrhage (rare).
Dengue
Flavivirus
Echinococcosis
Echinococcus spp.
Schistosomiasis
Schistosoma spp.
Snakebites
Venomous snakes (mostly Vipers)
E14
Vol 10, February 2015, E14–E15
Lateral and sigmoid sinus thrombosis. Angiitis; Rupture of mycotic aneurysms
Estimates of affected persons who develop a stroke
Impact of the disease on stroke prevalence or incidence
18% of patients dying 15% of ischemic strokes in a single with chagasic study; Stroke cardiomyopathy have incidence of 2·7 per a stroke (in Brazil). 100 patients-years. 8% of intracranial Less than 1‰ of venous thrombosis patients with CSOM are related to CSOM. have a stroke. 3% to 7% strokes are 5% of related to neurocysticercosis cysticercosis in patients have a hospital-based stroke; 30% when studies; Lack of only the impact in a single subarachnoid form population-base was assessed study No data available 0·3% of cases of dengue have a stroke (in India)
Abnormalities in Intracranial coagulation cascade; hemorrhages; Thrombocytopenia. cerebral infarcts (rare) No data available No data available Cortical and subcortical Embolic occlusion of infarcts intracranial arteries by hydatid cysts from the heart. No data available No data available Cortical and subcortical Angiitis; Arterial occlusion by larvaes; infarcts; intracranial Cardiogenic brain hemorrhages (rare); embolism; spinal cord infarction Microaneurysm (rare) formation Angiitis; Abnormalities 2·6% of patients bitten 1% of strokes related Intracranial to snakebites in a by venomous snakes in the coagulation hemorrhages; single study have a stroke (in cascade. Cortical and Ecuador). subcortical infarcts
© 2015 World Stroke Organization
Letter to the editor
O. H. Del Brutto mandatory to develop region-specific public health strategies directed to reduce the impact of cerebrovascular complications of NTDs. There is a need for welldesigned hospital- or population-based prospective cohort studies addressing the role of NTDs as responsible for the increasing burden of stroke in underserved populations.
References 1 Hotez PJ, Molyneux DH, Fenwick A et al. Control of neglected tropical diseases. N Engl J Med 2007; 357:1018–27. 2 Mathers CD, Ezzati M, Lopez AD. Measuring the burden of neglected tropical diseases: the global burden of disease framework. PLoS Negl Trop Dis 2007; 1:e114. 3 Carod-Artal FJ. Trypanosomiasis, cardiomyopathy and the risk of ischemic stroke. Expert Rev Cardiovasc Ther 2010; 8:717–28.
4 Marquez JM, Arauz A. Cerebrovascular complications of neurocysticercosis. Neurologist 2012; 18:17–22. 5 Del Brutto OH, Del Brutto VJ. Neurological complications of venomous snake bites: a review. Acta Neurol Scand 2012; 125:363–72.
O. H. Del Brutto1,2 1
School of Medicine, Universidad Espíritu Santo, Guayaquil, Ecuador 2 Department of Neurological Sciences, Hospital-Clínica Kennedy, Guayaquil, Ecuador
© 2015 World Stroke Organization
Vol 10, February 2015, E14–E15
E15
Copyright of International Journal of Stroke is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
more than half million people every year, with a marked predominance for those living in low-income countries (1). These conditions – not receiving proper attention or being disregarded (hence the term neglected) – trap individuals in a circle of poverty and disease causing annual losses of billions of dollars (2). The neurological burden of NTDs has not been systematically investigated, but is probably significant. Stroke, one of the new epidemics of the developing world, has been associated with at least seven of the NTDs currently recognized by the World Health Organization (http://www.who.int/neglected_diseases/ diseases/en/), including Chagas’ disease (American trypanosomiasis), chronic suppurative otitis media, cysticercosis,
dengue, echinococcosis, schistosomiasis, and snakebites. NTDs-related strokes may be ischemic or hemorrhagic and related to a variety of pathogenetic mechanisms, including angiitis, abnormalities in the coagulation cascade, abnormal platelet function, cardiogenic brain embolisms, venous thrombosis, and mycotic aneurysm formation and rupture (3–5). Little has been done to explore the relationship between NTDs and stroke, and current evidence on this subject is scarce and to some extent conflicting (Table 1). Proper knowledge about the magnitude of the problem, including information on the percentage of patients with NTDs who develop a stroke, as well as on the contribution of each of these conditions to the prevalence of stroke in a given area, is
Table 1 Relationships between neglected tropical diseases and stroke
Pathogenetic mechanisms
Disease
Etiology
Stroke subtypes
Chagas’ disease (American Trypanosomiasis)
Trypanosoma cruzi
Cortical and subcortical Cardiogenic brain infarcts. embolism; Angiitis (rare)
Cerebellar venous Chronic suppurative Pyogenic bacteria infarcts. otitis media (CSOM) Cysticercosis Larval stage of Taenia Lacunar and cortical solium infarcts; subarachnoid hemorrhage (rare).
Dengue
Flavivirus
Echinococcosis
Echinococcus spp.
Schistosomiasis
Schistosoma spp.
Snakebites
Venomous snakes (mostly Vipers)
E14
Vol 10, February 2015, E14–E15
Lateral and sigmoid sinus thrombosis. Angiitis; Rupture of mycotic aneurysms
Estimates of affected persons who develop a stroke
Impact of the disease on stroke prevalence or incidence
18% of patients dying 15% of ischemic strokes in a single with chagasic study; Stroke cardiomyopathy have incidence of 2·7 per a stroke (in Brazil). 100 patients-years. 8% of intracranial Less than 1‰ of venous thrombosis patients with CSOM are related to CSOM. have a stroke. 3% to 7% strokes are 5% of related to neurocysticercosis cysticercosis in patients have a hospital-based stroke; 30% when studies; Lack of only the impact in a single subarachnoid form population-base was assessed study No data available 0·3% of cases of dengue have a stroke (in India)
Abnormalities in Intracranial coagulation cascade; hemorrhages; Thrombocytopenia. cerebral infarcts (rare) No data available No data available Cortical and subcortical Embolic occlusion of infarcts intracranial arteries by hydatid cysts from the heart. No data available No data available Cortical and subcortical Angiitis; Arterial occlusion by larvaes; infarcts; intracranial Cardiogenic brain hemorrhages (rare); embolism; spinal cord infarction Microaneurysm (rare) formation Angiitis; Abnormalities 2·6% of patients bitten 1% of strokes related Intracranial to snakebites in a by venomous snakes in the coagulation hemorrhages; single study have a stroke (in cascade. Cortical and Ecuador). subcortical infarcts
© 2015 World Stroke Organization
Letter to the editor
O. H. Del Brutto mandatory to develop region-specific public health strategies directed to reduce the impact of cerebrovascular complications of NTDs. There is a need for welldesigned hospital- or population-based prospective cohort studies addressing the role of NTDs as responsible for the increasing burden of stroke in underserved populations.
References 1 Hotez PJ, Molyneux DH, Fenwick A et al. Control of neglected tropical diseases. N Engl J Med 2007; 357:1018–27. 2 Mathers CD, Ezzati M, Lopez AD. Measuring the burden of neglected tropical diseases: the global burden of disease framework. PLoS Negl Trop Dis 2007; 1:e114. 3 Carod-Artal FJ. Trypanosomiasis, cardiomyopathy and the risk of ischemic stroke. Expert Rev Cardiovasc Ther 2010; 8:717–28.
4 Marquez JM, Arauz A. Cerebrovascular complications of neurocysticercosis. Neurologist 2012; 18:17–22. 5 Del Brutto OH, Del Brutto VJ. Neurological complications of venomous snake bites: a review. Acta Neurol Scand 2012; 125:363–72.
O. H. Del Brutto1,2 1
School of Medicine, Universidad Espíritu Santo, Guayaquil, Ecuador 2 Department of Neurological Sciences, Hospital-Clínica Kennedy, Guayaquil, Ecuador
© 2015 World Stroke Organization
Vol 10, February 2015, E14–E15
E15
Copyright of International Journal of Stroke is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
