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Grimaldi A, Mocumbi AO, Freers J, Lachaud M, Mirabel M, Ferreira B, Narayanan K, Celermajer DS, Sidi D, Jouven X, Marijon E. Tropical Endomyocardial Fibrosis: Natural History, Challenges, and Perspectives. Circulation 2017; 133:2503-15. [PMID: 27297343 DOI: 10.1161/circulationaha.115.021178] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tropical endomyocardial fibrosis (EMF) is a neglected disease of poverty that afflicts rural populations in tropical low-income countries, with some certain high-prevalence areas. Tropical EMF is characterized by the deposition of fibrous tissue in the endomyocardium, leading to restrictive physiology. Since the first descriptions in Uganda in 1948, high-frequency areas for EMF have included Africa, Asia, and South America. Although there is no clear consensus on a unified hypothesis, it seems likely that dietary, environmental, and infectious factors may combine in a susceptible individual to give rise to an inflammatory process leading to endomyocardial damage and scar formation. The natural history of EMF includes an active phase with recurrent flare-ups of inflammation evolving to a chronic phase leading to restrictive heart failure. In the chronic phase, biventricular involvement is the most common presentation, followed by isolated right-sided heart disease. Marked ascites out of proportion to peripheral edema usually develops as a typical feature of EMF. EMF carries a very poor prognosis. In addition to medical management of heart failure, early open heart surgery (endocardectomy and valve repair/replacement) appears to improve outcomes to some extent; however, surgery is technically challenging and not available in most endemic areas. Increased awareness among health workers and policy makers is the need of the hour for the unhindered development of efficient preventive and therapeutic strategies.
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Affiliation(s)
- Antonio Grimaldi
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Ana Olga Mocumbi
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Juergen Freers
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Matthias Lachaud
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Mariana Mirabel
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Beatriz Ferreira
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Kumar Narayanan
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - David S Celermajer
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Daniel Sidi
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Xavier Jouven
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.)
| | - Eloi Marijon
- From Cardiovascular and Thoracic Department, San Raffaele Hospital, Milan, Italy (A.G.); St. Raphael of St. Francis Nsambya Hospital, Kampala, Uganda (A.G.); Paris Cardiovascular Research Center (INSERM U970), Cardiology & Development, Paris, France (M.M., K.N., X.J., E.M.); Instituto Nacional de Saúde, Maputo, Mozambique (A.O.M.); Division of Cardiology, Department of Medicine, Makerere University, Kampala, Uganda (J.F.); Institut du Thorax, Nantes, France (M.L.); Maputo Heart Institute, Maputo, Mozambique (M.L., B.F., D.S., X.J., E.M.); European Georges Pompidou Hospital, Cardiology Department, Paris, France (M.M., X.J., E.M.); Necker Enfants Malades Hospital, Pediatric Cardiology, Paris, France (D.S.); Maxcure Hospitals, Hyderabad, India (K.N.); Sydney Medical School, Sydney, Australia (D.S.C.); and Paris Descartes University, Paris, France (D.S., X.J., E.M.).
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Chelo D, Nguefack F, Menanga AP, Mbassi Awa HD, Nguefack S, Ngo Um S, Gody JC, Koki Ndombo PO. [Endomyocardial fibrosis in Cameroon: Echocardiographic and clinical description of a pediatric series in Yaoundé]. Arch Pediatr 2015; 23:128-35. [PMID: 26724978 DOI: 10.1016/j.arcped.2015.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 10/27/2015] [Accepted: 11/07/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endomyocardial fibrosis is a restrictive cardiomyopathy that causes heart failure. It is characterized by the fibrotic thickening of the endocardium, sometimes involving the myocardium as well. The lesion generally lies at the apices or inflow tracts of one or both ventricles, associated with more or less severe alteration of the valves. It is a disease of the intertropical regions but is not well known in Cameroon. In this study we describe the first series seen in a pediatric hospital in Cameroon. PATIENTS AND METHODS A retrospective study was conducted in a pediatric hospital in Yaoundé involving children who had been diagnosed with endomyocardial fibrosis after echocardiographic investigation. We collected the clinical and paraclinical data from consultation records and medical files. RESULTS Between January 2006 to December 2013, we registered 1430 patients with a cardiac anomaly in our center. Endomyocardial fibrosis was found in 46 patients. Neither sex predominated. Ages at the time of diagnosis varied between 2 and 17 years. Most of the patients were between 5 and 15 years old (80.4 %), with a median of 10 years (interquartile range, 7-13 years). The main complaints were breathlessness, cough, abdominal distension, abdominal, and loss of appetite. Apart from the hyperpigmentation of the lips observed in all our patients, dyspnea was the most frequent physical sign and the diagnosis was made at a time when signs of heart failure were preponderant. Growth retardation was found in all the children examined. All patients were underweight with a median weight for age found below the 25th percentile of the norms according to the National Health Statistics. Lower limb edema was absent even in the presence of voluminous ascites. All subjects had hyperpigmented lips. Despite the cyanotic appearance of the lips, pulse oximetry always gave a normal oxygen saturation level and no cyanosis was seen elsewhere. None of the patients had nail clubbing. Fibrosis more often affected the right ventricle (45/46 patients). The apical obliteration by fibrotic material was found in 43 (93.5 %) patients. Moreover, 36 (78.3 %) patients had pericardial effusion: mild to moderate in 32 subjects and abundant in four subjects. Hypereosinophilia was noted in 57.5 % of the patients. Atrial fibrillation was found in six out of 15 patients who had an electrocardiogram done. CONCLUSION The modes of clinical presentation of endomyocardial fibrosis are not sufficiently well known in our context. Despite its insidious progression, certain signs such as weight loss and hyperpigmented lips could be very helpful for screening and easing orientation of parents and heath personnel, thus enabling early referral for appropriate investigation. The presence of bulky ascites without edema of the lower extremities should be viewed as strongly suggestive.
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Affiliation(s)
- D Chelo
- Unité de cardiologie pédiatrique, centre mère et enfant de la fondation Chantal BIYA, BP 1936, Yaoundé, Cameroun; Département de pédiatrie, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun.
| | - F Nguefack
- Unité de cardiologie pédiatrique, centre mère et enfant de la fondation Chantal BIYA, BP 1936, Yaoundé, Cameroun; Département de pédiatrie, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - A-P Menanga
- Service de cardiologie, hôpital général, Yaoundé, Cameroun; Département de médecine interne, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - H-D Mbassi Awa
- Unité de cardiologie pédiatrique, centre mère et enfant de la fondation Chantal BIYA, BP 1936, Yaoundé, Cameroun; Département de pédiatrie, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - S Nguefack
- Département de pédiatrie, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun; Hôpital gynéco-obstétrique et pédiatrique de Ngousso, Yaoundé, Cameroun
| | - S Ngo Um
- Unité de cardiologie pédiatrique, centre mère et enfant de la fondation Chantal BIYA, BP 1936, Yaoundé, Cameroun; Département de pédiatrie, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
| | - J-C Gody
- Complexe pédiatrique de Bangui, Bangui, République Centrafricaine
| | - P-O Koki Ndombo
- Unité de cardiologie pédiatrique, centre mère et enfant de la fondation Chantal BIYA, BP 1936, Yaoundé, Cameroun; Département de pédiatrie, faculté de médecine et des sciences biomédicales, université de Yaoundé I, Yaoundé, Cameroun
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