Sunday, 16 September 2018

Where a Sore Throat Becomes a Death Sentence

Death body

KIGALI, Rwanda — Neighbors whisper that she is pregnant, a disgrace for a young, unmarried woman. The rumors mortify her. She hates her swollen belly.

But Florence Ndimubakunzi is not pregnant. Her heart is failing. It pumps so poorly that blood backs up in her veins, bloating her liver and spleen, and filling her abdomen with fluid. She is only 18.

For millions like her in poorer parts of Africa, Asia, and other regions, this devastating heart disease began insidiously. During childhood, they contracted strep throat — an infection caused by streptococcal bacteria.

In us and other rich countries, children with sore throats are routinely tested for strep and quickly cured with penicillin or other cheap antibiotics.

But in poor countries, a streptococcal sore throat often goes undiagnosed and may become an extended, slow death sentence.

Without treatment, it can cause infectious disease and rheumatic heart disease, in which the immune system attacks the heart valves — intricate flaps of tissue that must open and shut properly 100,000 times each day for the guts to figure normally.

As the valves deteriorate, the heart struggles and gradually wears out. Patients become weak, in need of breath and unable to attend school or work. Many die before they reach 30. Women with the illness who become pregnant can suffer severe and sometimes fatal complications.

Worldwide, 33.4 million people had a rheumatic heart condition in 2015, and a minimum of 319,400 died from it, consistent with estimates published last year — a public health the disaster caused by a preventable disease that has been largely wiped out in the United States and Western Europe.

Earlier this year, hoping to beat the chances, Florence and her mother consulted doctors from a humanitarian group, Team Heart, that flies in from the us and Canada once a year to perform valve replacement surgery.

About 100 people showed up to be screened for the lifesaving operation. The team could operate on only 16.

Lying on an examining table, eyes huge in her gaunt face, Florence looked impossibly
fragile, her arms thin as broomsticks, her shoulders jutting up sort of a skeleton’s. She had
wasted away to 78 pounds; five were fluid.

Dr. Pat Come, a Harvard cardiologist, pressed a stethoscope to Florence’s chest, back and neck, and palpated her belly. A sonographer, Marilyn Riley, from Beth Israel Deaconess Hospital in Boston ran an ultrasound probe over Florence’s chest, showing her heart valves in motion and measuring the pressure gradients across them, the blood flow through her heart and therefore the size of its chambers.

“She has the significant disease of two valves,” Dr. Come finally said. “But the operative mortality is likely too high. Medical therapy is the best option.” A translator explained in Kinyarwanda that Florence was too sick for surgery. Florence asked if the medicines would cure her.

No, but they might keep her “on a good keel,” Dr. Come said. Would her big belly go away? Florence asked. A drug, Lasix, that helps rid the body of excess fluid might help, Dr. Come said. As Florence sat up, buttoning her dress, Ms. Riley said, “She’s so tiny I’m afraid she’ll fracture getting off the table.”
A nurse helped her down.

Outside the examining room, Florence said she’d had to prevent attending school because she was too weak to get there. She was eager to go back. She hoped to be a pediatrician.

She has been ill since she was about 8. Doctors warned that only surgery could cure her.
Now, they were saying it was impossible.

“It’s a disappointment,” Florence said.

‘The entry point is heart failure’ 


Experts say programs to teach people about sore throats and strep and to distribute penicillin widely to local clinics could help greatly to stop a rheumatic heart condition in poor regions. But even those efforts probably would not wipe it out completely, because not everyone with strep seeks medical attention.

The World Heart Federation, which works with the planet Health The organization, calls rheumatic fever and therefore the heart damage causes “neglected diseases of marginalized communities.” Poverty, crowded living conditions and lack of medical aid create breeding grounds for strep.

In 2013, the federation set a goal of decreasing deaths from the condition by 25 percent in people under 25 by 2025. The group also called for a strep vaccine.

Little is spent on studying the illness, but $1 million globally in 2013. From 500 to 1,000 times the maximum amount of research money is spent on tuberculosis, malaria, and H.I.V. — which each kill three to 5 times as many of us as strep, consistent with an article in The New England Journal of Medicine.

If an infectious disease is detected early, long-term treatment with penicillin can prevent valve
damage. But many cases are already advanced.

“Unfortunately, the entry point is a coronary failure,” said Dr. Joseph Mucumbitsi, a pediatric cardiologist at the King Faisal Hospital in Kigali, and a consultant to Team Heart. “We have many rheumatic heart disease patients below 17. We have some as young as 5.” He estimated that there could be as many as 20,000 people with advanced disease who need surgery.

Though prevention would be ideal, the rapid tests widely utilized in us to diagnose strep are too expensive in Rwanda, and throat cultures aren't widely available.

Some doctors advocate skipping the tests and just giving penicillin shots to all or any children
with sore throats. Others worry that antibiotic resistance and penicillin allergies would result.

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