Aetiology

This is the fourth of 6 guest posts on infection and chronic disease.

By Ousmane Diallo

Last week in class we tackled an interesting topic, the role of Mycobacterium Avium Paratuberculosis (MAP) in the genesis of Crohn's disease (CD) and ulcerative colitis (UC). The authors Saleh E. Naser (oops the name means in Arabic 'The virtuous helper') and colleagues detected using Polymerase Chain Reaction (PCR) techniques in a lab based case controls study "viable MAP in peripheral blood in higher proportion of individuals with Crohn than controls". Not surprising after all since the pathology of Crohn's mimics strangely the awful Johne's disease in cows.

As noted earlier, I am from West Africa, the "black continent", 'the infectious disease belt', 'where people go around naked', 'TB and AIDS world' etc., all those nice adjectives, which aren't the purpose of this 'discourse', and, not yet known, I belong to the Fulani Nation, herders and shepherds of men. During the course, I kept wondering how come during my 12 years of medical experience (7 as a med. student, 2 as a urology spec. student, and 3 as a poor family practice doc) before migrating, like a good Fulani, to green pastures I have not seen more than one suspected case of Crohn's disease.

(Continued after the jump...)

I bet some will say that we did not know how to diagnose such diseases. Indeed, as I used to call my fellow comrades, not medical doctors but Laennecists. Only armed with clinical knowledge and a stethoscope, we would discuss a medical case during rounds, propose a plan of treatment and, at the autopsy, congratulate each other for giving a good "etiological diagnosis". We won epic battles against hernia, volvulus of the colon, prostate, pulmonary tuberculosis, malaria, did biopsies, but sometimes, due to the International Monetary Funds (IMF), people who couldn't afford medications would die and become a number in poorly maintain statistics. The internal medicine ward where I "made my bones", named after Laennec, was famous for being the "death ward", from hepatic carcinoma to leukemia patients not to mention colon cancer, all were served "pain killers" with the utmost dedication, any how... memories of the old times, no Crohn's.

We certainly had people suffering from dysentery (amoebic infection which is translated by abdominal pain, tenesmus, mucous excretion and sometimes bloody), is it possible that we have misdiagnosed it? I wouldn't be surprised, we were so confident that Crohn's Disease and ulcerative colitis were the White men disease (no offense intended).

Crohn's disease and ulcerative colitis are chronic inflammatory disease of the colon, affecting both the mucosa (epithelial lining) and submucosa. Although they are both coined the Idiopathic Inflammatory Bowel Syndrome (IBS), they are now two different entities. The differential diagnosis is made clinically (medical history, physical exam, X-rays and endoscopy) and at the pathological examination (biopsy). The hallmarks at the pathology exam are the ulcerations visualized at the inflammation sites during endoscopy and the micro-abscesses of the crypts of Lieberkuhn at the microscopic exam for Ulcerative colitis. For Crohn's, the granuloma closely resembles the granuloma tuberculosis, but without casein. The same granuloma is seen in leprosy, in auto-immune disorders and genetic disorders such as chronic granulomatous disorders and seborrheic dermatitis.

Therefore missing out Crohn's, which has an estimated prevalence of 144 per 100,000 in Western Countries such Britain is possible. We had other emergencies, real killers!

If the premise that UC and CD are diseases of the western countries as reported by most prevalent studies, I think the issue of breast feeding needs to be addressed not as a mechanism for transferring MAP, but as a protecting factor in the development of UC or CD. In a controversial meta-analysis, Klement and Reif found that breast feeding was significantly protective for UC, and presented a clinically protective (but not statistically significant) association with CD . Still the evidence for Breast feeding protection is not clearly cut.

At least, knowing the fact that bottle feeding became widespread with the "pinup" culture, Mary Boobs and others, and the technological feast of pasteurization, one can only suspect that Africans may have been protected by their cultural taste and disregard for breast, the difference symbolized by the Venus of Milo and the Old Fanti Fertility Statue. Perhaps, that's another story, which calls upon the spirit of Emile Durkheim, father of the collective consciousness rather that of Freud or more specifically Jung.

Despite the horrors felt by westerners when facing "the pouching" of the breast, the World Health Organization (WHO) is recommending exclusive breast-feeding up to 6 months. Every single researcher is calling for more research on the causation and risk factors of CD. As a believer of the determinism of the environment on our culture and being, I call for facing the fundamental question: what is this all about? Are we trying to run away from death!

A great religious leader in Senegal, hence unknown, said one time at the utmost bewilderment of his followers, "I know something that whoever does it will never die". Some followers doubted for one moment the soundness of their leader and look at him as if he was crazy and others went into a deep religious trance like here (Lord have mercy). When time stopped and people waited for deliverance, he said: "not to be born".

The great forgetting concept of Daniel Quinn, in the best seller "Story of B, is a key to re-understanding the futility of eternal life for all. What a hypocrisy when we end up killing each other for resources, yesterday crops, today oil, tomorrow water...

God bless the World

Ousmane Diallo is a physician from Senegal seeking a PhD in infectious disease epidemiology at the University of Iowa. After obtaining his master in Public Health in 2005 from St. Louis University, he works as an epidemiologist in injury and substance abuse prevention.

Naser SA et al. 2004. Culture of Mycobacterium avium subspecies paratuberculosis from the blood of patients with Crohn's disease. Lancet .364:1039-44. Link.

Klement and Reif. 2005. Breastfeeding and risk of inflammatory bowel disease. Am J Clin Nutr. 2005 82:486. Link.

www.antiquemed.com/monaural_stethosocope.htm

www.netdoctor.co.uk/travel/diseases/amobic_dysentery.htm