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Polyarthritis in Western Nigeria*

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Polyarthritis in Western Nigeria* Ann Rheum Dis: first published as 10.1136/ard.28.5.488 on 1 September 1969. Downloaded from Ann. rheum. Dis. (1969), 28, 488 POLYARTHRITIS IN WESTERN NIGERIA* I. RHEUMATOID ARTHRITIS BY B. M. GREENWOODt From the Department of Medicine, University College Hospital, Ibadan, Nigeria Rheumatoid arthritis, Still's disease, and gout Material and Methods have all been seen in tropical Africa (Table I), but The town of Ibadan is situated within the forest region little is known of the importance of these conditionis of Western Nigeria approximately 7° north of the equator. in the health of the indigenous population of this The daily temperature rarely falls below 70° F., and tem- region. It was, therefore, considered that a study peratures of 903 F. are reached during the dry season. of patients presenting with polyarthritis at a large The humidity remains high throughout the year. Uni- hospital in Western Nigeria might be of value. This versity College Hospital (UCH) serves the town of Ibadan and the heavily populated surrounding areas, a paper the methods describes employed during this population of over 3 million. A few patients are study and the findings in a group of Nigerian pat- referred to UCH, Ibadan, for specialist opinion from ients with chronic polyarthritis who satisfied the other parts of the country. Patients seen in the specialist American Rheumatism Association (ARA) criteria clinics or admitted to hospital are selected from the (Ropes, Bennett, Cobb, Jacox, and Jessar, 1959) for large numbers attending the daily general out-patients a diagnosis of definite or probable rheumatoid arth- clinic. by copyright. ritis. A second paper describes the features of The case notes and x rays of all patients admitted to Nigerian children with Still's disease, and a third the hospital with polyarthritis since 1957 were reviewed. describes the findings in patients presenting during Nearly all of them had defaulted from the out-patients the course of this survey with other forms of poly- clinic. Although attempts at follow-up were hindered arthritis. by civil disturbance in Nigeria, culminating in a civil TABLE I war, 70 per cent. of these patients were eventually traced, PREVIOUS REPORTS OF THE OCCURRENCE OF and indirect information was available about a number RHEUMATOID ARTHRITIS, STILL'S DISEASE, AND GOUT of others who had fled to the Eastern Region (Biafra). IN AFRICA TROPICAL All new cases of polyarthritis, both in-patients and out- patients, presenting at UCH during the period 1965-1967 http://ard.bmj.com/ Condition Country Authors Date were seen by the author and investigated more fully Rheumatoid arthritis Malawi Goodall 1956 than is usually possible during routine clinical practice Uganda Shaper and Shaper 1958 in a developing country. Records of out-patients Kenya Harries 1962 Liberia Hijmans, Valkenburg, presenting before 1965 were not available. The diag- Muller, and Gratama 1964 noses made in these two groups are shown in Table II Senegal Cave, Sankale, Bobo, and Moulanier 1965 (opposite). Kenya Hall 1966 Nigeria Mohamed 1966 Haematological, biochemical, serological, bacterio- were on September 25, 2021 by guest. Protected Still's disease Senegal Dubois, Guerineau, logical, and parasitological investigations per- Cayret, Grelier, and formed by standard methods. Rheumatoid factor was Ravix 1963 Nigeria Anumonye 1964 assayed by a modified latex-fixation test and by the human erythrocyte agglutination test (HEAT) (Valken- Gou Uganda Trowell 1947 Ruanda Fain, Duren, Ducep, burg, 1963). Synovial biopsies taken from patients and Bein 1956 presenting early in the series were obtained by open Kenya Hall 1959 Rhodesia Shepherd-Wilson and biopsy but subsequent specimens were obtained by punch Gelfand 1962 biopsy. X rays of the affected joints had been taken in Senegal Nne, Bernou, Frament, and Kiesse 1965 all patients. X rays of the hands, feet, pelvis, knees, Uganda Kibukamasoke 1968 cervical spine, and chest were taken routinely in patients Senegal Sankal6, Diop, Qu6num, Frament, and Ancelle 1968 presenting for the first time during the period 1965-1967. X rays of the hands and feet were taken at follow-up examination in the patient's compound using a portable * This paper was presented at a meeting of the Heberden Society in x-ray machine powered by a Land-Rover engine. November, 1968. t Present Address: M.R.C. Rheumatism Research Unit, Canadian Red Cross Memorial Hospital, Taplow, Bucks. Haematological and serological findings in patients 488 Ann Rheum Dis: first published as 10.1136/ard.28.5.488 on 1 September 1969. Downloaded from POL YARTHRITIS IN WESTERN NIGERIA. L 489 TABLE II DIAGNOSES MADE IN PATIENTS PRESENTING AT UCH, 25 IBADAN, WITH POLYARTHRITIS New Patients 20 Diagnosis Admissions1957-66 (In-patientsout-patients)and 1965-67 IV Rheumatoid arthritis 42 35 Still's disease 21 10 Acute tropical polyarthritis 28 12 0 Rheumatic fever 23 8 Septic polyarthritis 19 6 r- Arthritis and Urogenital disease 14 17 Polyarthritis and Tuberculosis 8 3 Gout 6 4 z Generalized osteoarthritis 4 7 Ankylosing spondylitis 3 1 5- Miscellaneous 9 9 Undiagnosed 11 14 Total 188 126 0 16- 20 21 -30' 31 -40' 41 51 60 61 -70 Total for All Diseases 98,454 67,377 Age (years) Total for Specialist Clinics 40,817 Fig. 1-Age distribution of 71 Nigerian patients with rheumatoid arthritis. with polyarthritis have been compared with values ob- tained in healthy Nigerians during the course of a village morning stiffness was rarely elicited on direct ques- survey into the prevalence of rheumatic diseases in tioning, partly because of language difficulties. Western Nigeria undertaken in conjunction with Dr. also of fever but other H. A. Valkenburg and Dr. A. S. Muller of the University Many patients complained of Leiden. complaints were rare. None of the patients gave a history of recent urogenital disease. Two male by copyright. patients gave a history of a recent attack of diarrhoea but neither had any other features of ulcerative PART I. RHEUMATOID ARTHRITIS colitis or post-dysenteric Reiter's syndrome. Sev- Detailed clinical information was available for eral patients had received treatment at their local 71 adult patients with polyarthritis who satisfied government hospital before presenting at UCH and the ARA criteria for a diagnosis of definite or prob- the mean duration of symptoms at the time of pre- able rheumatoid arthritis; 70 per cent. of these sentation was 1 -6 years for females and 1 8 years patients had been admitted to hospital during the for males. period 1957-1967; most of the others presented in the out-patients department during the period Clinical examination showed that wrists, ankles, http://ard.bmj.com/ 1965-1967, and a few were already attending the out- knees, and fingers were all frequently involved patients department at the time that this study com- (Table III). The arthritis was markedly asym- menced. As a result of these selection procedures metrical in only two cases. the series is biased in favour of patients with severe disease. TABLE III Of the 71 patients 38 were male and 33 female; SITE OF JOINT INVOLVEMENT AT THE TIME OF their age distribution is shown in Fig. 1. Analysis PRESENTATION IN 71 NIGERIAN PATIENTS WITH on September 25, 2021 by guest. Protected of the tribal origin, domicile, and occupation of the RHEUMATOID ARTHRITIS patients showed no unusual features. Joints Percentagejointsof patientsinvolvedwith these Wrists 72 Clinical Features of Arthritis Ankles 69 Knees 61 Six patients gave a history of a past episode of Proximal interphalangeal joints of fingers 59 arthritis 8 months to 3 years before presentation at Metacarpophalangeal joints 51 Elbows 44 UCH, Ibadan. Although all had made a complete Metatarsophalangeal joints 24 symptomatic recovery from this initial episode it was Shoulders 18 Cervical spine 18 not known whether their joint signs had completely Interphalangeal joints of toes 10 Distal interphalangeal joints of resolved. All 71 patients presented with a history of fingers 7 joint pain or swelling. Only ten complained spon- Hips 4 Temporomandibular joints 3 taneously of morning stiffness and a history of Ann Rheum Dis: first published as 10.1136/ard.28.5.488 on 1 September 1969. Downloaded from 490 ANNALS OF THE RHEUMATIC DISEASES Extra-articular Findings IS - Mean hoemoglobin values Healthy Nodules were found in only four patients. One Healthy females-118g./lOOml. cntroIs patient had extensive onchocerciasis which was almost a Females with rheumatoid flPatients certainly the cause of his nodules. The remaining three D 10- arthritis-10-5g./lOOml. L with I rheumatoid nodules, which appeared to be due to rheumatoid ° arthritis disease, were biopsied, but one contained the adult worms of 0. volvulus and in another the histological findings were those of tuberculoid leprosy, so that only one appeared to be a rheumatoid nodule. Rheumatoid vascular lesions were not seen. 8 9 10 11 12 13 14 15 16 Peripheral neuritis was found in only one patient, a middle-aged woman who also had diabetes. Haemoglobin (g./lOml.) Pyrexia was observed frequently in patients admitted Fig. 3.-Distribution of haemoglobin levels in 33 female Nigerian to hospital and three ran a high fever with daily tem- patients with rheumatoid arthritis and 34 healthy female controls. perature spikes to over 1020 F. The pyrexia was usually of a remittent type. Splenomegaly was noted in fourteen patients. cases there was usually some other cause for the anaemia. Iritis developed in two patients during the course of The anaemia was found to be normochromic and normo- their illness, and a diagnosis of Reiter's disease was cytic unless there was an associated cause of blood loss suspected but neither had any other clinical or radio- such as a heavy hookworm infestation. logical features that would support this diagnosis. Marrow punctures performed in five patients showed Basal crepitations were heard in three patients.
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