Leprosy and other diseases of old still affect Canadians
Published Tuesday, June 25, 2013 8:09AM EDT Last Updated Tuesday, June 25, 2013 8:09AM EDT
TORONTO -- It started with strange patches on the skin and small nodules on the legs that baffled even the family doctor. Prescription creams seemed to help at first, but the lesions kept coming back.
"I had an itchy feeling in the evening on my whole body, not really itchy, it's hard to explain," recalls Raghu, who asked that his real name not be used.
He was referred to a dermatologist, who tried other skin treatments, but to little effect. And the condition was getting worse -- Raghu developed a small bluish nodule on one leg. It was totally numb: he could have stuck a pin in it, he says, and there would have been "no feeling at all."
A skin biopsy finally gave him an answer -- but it was one that shook him to his very core, says Raghu, who has lived in Canada for roughly three decades since immigrating to the Toronto area from India.
Raghu had leprosy.
Leprosy? In Canada?
It may come as a surprise, but several age-old diseases that many believe have been eradicated or affect people only in far-away, impoverished countries still occur in Canada, where good nutrition and state-of-the-art health care is considered a birthright.
Few diseases spawn the kind of fear engendered by leprosy, a bacterial infection that for millennia led to social ostracism and forced segregation to prevent the contagion passing to others.
Today, that kind of reaction is completely unwarranted, says Dr. Jay Keystone, a tropical medicine specialist at Toronto's University Health Network who treats up to about a half-dozen cases of leprosy a year.
"Essentially, I think the public needs to know that it's an absolutely curable infection," says Keystone. "It's certainly less contagious than tuberculosis and way less contagious than influenza."
Although rare -- there are an estimated two to 10 cases diagnosed in Canada each year -- leprosy is still around. Most cases are among people who have come to Canada from India, Indonesia, the Philippines or Myanmar, countries where leprosy has a greater foothold.
Also known as Hansen's disease, most cases of leprosy worldwide are caused by the rod-like micro-organism Mycobacterium leprae, which is thought to be transmitted via droplets from the nose and mouth during close contact with untreated cases.
Because M. leprae multiplies very slowly, leprosy's incubation period is about five years, but symptoms can take 20 to even 40 years to appear.
About 95 per cent of people never develop symptoms because their immune system shrugs off the infection.
Those who can't clear the bug get a range of disease: from tuberculoid, a minimally contagious infection primarily in the lungs, to lepromatous, "where they have gazillions of organisms and therefore are much more infectious," says Keystone.
At the lepromatous end of scale, the disease can involve the entire body and multiple nerves. Left untreated, it can cause permanent damage to the skin, nerves, limbs and eyes.
But with the advent of powerful sulfa drugs in the early 1940s, the once-deadly disease could be successfully treated. Today, patients are given a cocktail of drugs for six months to two years, depending on the nature of their infection.
Yet, despite being curable, the dread of leprosy remains.
"Among people from developing countries, the stigma has not changed," says Keystone. "It has not changed in centuries, because what they do, they picture people ... who have claw hands and other deformities and they're worried it's going to happen to them.
"So I spend a lot of time with every new patient going over what it is, what we can expect, that no, you're not going to look like these people ... I spend time making sure they understand it's not a curse from God. It's not something from sexual transmission. It's just a curable infection."
Even so, Raghu has told few people besides his wife that he is being treated for leprosy. His young children don't know and he wants to keep it that way. He doesn't want them shunned.
"I've seen with my own eyes back in India people with leprosy, but they are the poorest of the poor, going on the street, begging. They are missing their parts like fingers and toes and their noses sunk in.
"Luckily none of my parts are amputated yet," says Raghu, who's confident of a cure. "Everything is there ... I'm fully still in one piece."
In a wealthy country like Canada, it's hard to believe that a disease of malnutrition could still affect some children, leading to skeletal deformities that will persist throughout life.
But rickets has not been eradicated, even though its prevention can be as simple as healthy doses of sunshine and inexpensive supplements when sunlight is at an ebb during the fall and winter months.
Malformed bones in infants were described by Greek physician Soranus as early as the first century AD, but rickets was not defined as a specific medical condition until the mid-1600s by English doctor Daniel Whistler.
The disease is a softening of bones in babies and young children, usually due to a prolonged vitamin D deficiency.
Rickets can cause badly bowed legs and knock knees, thickened wrists and ankles, delayed tooth development and an abnormal breastbone. Such skeletal deformities can lead to delayed growth, pain in the spine, pelvis and legs, and weakened muscles.
Because vitamin D promotes the absorption of calcium and phosphorus needed for strong bones, deficiency of the so-called sunshine vitamin can lead to the disease.
A 2007 study led by Dr. Leanne Ward turned up 104 confirmed cases of rickets among Canadian children over a two-year period. While the highest incidence occurred in Nunavut, Yukon and the Northwest Territories, cases were reported in cities and rural areas across the country.
Children who live in northern latitudes where there is less sunshine year-round have an elevated risk of rickets. Darker-skinned youngsters also have a higher risk because their bodies don't produce as much vitamin D in response to sunlight as do children with lighter skin.
Another major risk factor is exclusive breastfeeding. While recommended for six months by major health organizations around the globe, there's a critical caveat about feeding a baby only breast milk.
"The message is not fully out that breastfed infants require vitamin D supplementation, as there is little vitamin D that passes through breast milk," says Ward, a specialist in pediatric bone health at the Children's Hospital of Eastern Ontario in Ottawa.
Health Canada and the World Health Organization recommend giving infants a supplement of 400 IUs daily for the first year of life, and the Canadian Paediatric Society advises raising that to 800 IUs during the fall-winter months when there is minimal sunlight.
Children continue to need vitamin D -- especially from age three months to three years when bones are rapidly growing -- but it can be obtained through supplements and diet.
Fatty fish like salmon and egg yolks contain vitamin D, which is also added to foods such as milk, cereal and some fruit juices.
And the need for vitamin D continues throughout adulthood, for all kinds of health reasons.
"In adults, rickets doesn't exist, but vitamin D deficiency causes bone pains," says Ward. "There is a body of literature which suggests that vitamin D deficiency may also be linked to chronic diseases in adulthood."
It's been called "the king of diseases, and the disease of kings." Henry VIII was thought to have it, and it was known to affect Charles V of Spain, Charles Darwin and Benjamin Franklin.
While gout may be an age-old condition, it is still causing its share of pain among Canadians in the 21st century.
Gout is caused by an excess in the body of the waste product uric acid. Too much uric acid in the blood causes deposits of crystals in the joints, which can lead to severe inflammation and often excruciating pain.
About five to six per cent of Canadian men and about two per cent of women will experience a bout a gout in their lifetimes, says Dr. Gregory Choy, a rheumatologist at Sunnybrook Health Sciences Centre in Toronto.
The condition tends to run in families. For males, gout typically hits in the 40s and 50s, while women are more prone to an attack after menopause, when a drop in protective estrogen makes it more likely, says Choy.
The onset of gout can be sudden, characterized by severe pain, redness and tenderness in a joint --often the joint at the base of the big toe.
But this form of arthritis can also erupt in the ankle, knee, foot, hand, wrist or elbow.
"An acute attack of gout can wake you up in the middle of the night with the sensation that your big toe is on fire," says the Mayo Clinic website. "The affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable."
Urate crystal can also form under the skin, causing spots called white tophi, which can cause damage into subcutaneous tissues below the skin. A tophus can develop in fingers, hands, feet, elbows or the Achilles tendon at the back of the ankle.
"What happens with the tophus is it can break open and then it can get infected and it does produce ulcers," says Choy, noting that gout can also lead to kidney stones.
So what causes the excess of uric acid and subsequent symptoms of gout?
Historically, the disease was known to mostly afflict middle-aged men overly fond of the drink and meat-rich meals. But more recent research has added a few other diet no-nos to the list for treating and preventing the inflammatory disease.
"We have been speculating about diet and gout for centuries," concedes Choy.
"Alcohol is still trouble," as are sugary drinks, especially those that are fructose-based or corn syrup-based, he says. Meat, poultry and fish are high in proteins called purines, which can promote uric acid production.
But recent studies suggest some foods may be protective, among them coffee, citrus-based foods like oranges and orange juice, and even cherries, though the reason for the latter is unknown.
Choy says diet plays a role in treating the condition, but if severe enough "medication is almost a necessity."
Drugs include anti-inflammatories, such as corticosteroids, to treat the pain and swelling.
Sometimes doctors will also prescribe medications to lower the uric acid to prevent recurrence and to avoid complications.
For those prone to gout, one simple piece of diet advice is to drink plenty of fluids, particularly water, aiming for eight to 16 glasses a day. Fluids help flush uric acid out of the body, preventing the build-up of needle-sharp crystals in the joints and skin.