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Spencer PS, Valdes Angues R, Palmer VS. Nodding syndrome: A role for environmental biotoxins that dysregulate MECP2 expression? J Neurol Sci 2024; 462:123077. [PMID: 38850769 DOI: 10.1016/j.jns.2024.123077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 05/15/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
Nodding syndrome is an epileptic encephalopathy associated with neuroinflammation and tauopathy. This initially pediatric brain disease, which has some clinical overlap with Methyl-CpG-binding protein 2 (MECP2) Duplication Syndrome, has impacted certain impoverished East African communities coincident with local civil conflict and internal displacement, conditions that forced dependence on contaminated food and water. A potential role in Nodding syndrome for certain biotoxins (freshwater cyanotoxins plus/minus mycotoxins) with neuroinflammatory, excitotoxic, tauopathic, and MECP2-dysregulating properties, is considered here for the first time.
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Affiliation(s)
- Peter S Spencer
- Department of Neurology, School of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Gulu University School of Medicine, Gulu, Uganda.
| | - Raquel Valdes Angues
- Department of Neurology, School of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Valerie S Palmer
- Department of Neurology, School of Medicine and Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA; Gulu University School of Medicine, Gulu, Uganda
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2
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Kamoen O, Jada SR, Rovarini JM, Abd-Elfarag G, Amaral LJ, Bol Y, Siewe Fodjo JN, Colebunders R. Evaluating epilepsy management in an onchocerciasis-endemic area: Case of Maridi, South Sudan. Seizure 2024:S1059-1311(24)00133-X. [PMID: 38714396 DOI: 10.1016/j.seizure.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/09/2024] Open
Abstract
PURPOSE The epilepsy prevalence in Maridi County, South Sudan, in 2018 was 43.8 (95% CI: 40.9-47.0) per 1000 persons; 85.2% of the identified persons with epilepsy (PWE) met the criteria of onchocerciasis-associated epilepsy. To address this health problem, an epilepsy clinic was established at Maridi County Hospital in 2020. In August 2023, the impact of the clinic on the lives of PWE and their families was evaluated. METHODS At the Maridi epilepsy clinic, data routinely collected by primary healthcare workers as part of patient care was reviewed. We also analyzed findings from two household surveys conducted in 2018 and 2022, which assessed the impact of the clinic on epilepsy care. Moreover, four households, each with four PWE, were visited in a high epilepsy prevalence area. PWE were examined by a neurologist, and in-depth interviews were conducted with family members. RESULTS The proportion of PWE on anti-seizure medication increased by 39.7% (95%CI: 35.3-44.2) between 2018 and 2022. The proportion of PWE reporting daily seizures decreased from 27.3% in 2018 to 5.3% in 2022. Of the 754 PWE seen in the clinic in July 2023, only 17 (2.3%) reported side effects. During household visits in July 2023, 13/173 (7.5%) of the visited PWE were found without remaining anti-seizure medication. A high level of epilepsy-related stigma was observed in all visited households. CONCLUSION The Maridi epilepsy clinic positively impacted the lives of PWE in Maridi. Similar initiatives should be accessible for all PWE living in onchocerciasis-endemic areas. Evidence-based information about OAE is needed to decrease misconceptions and epilepsy-related stigma.
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Affiliation(s)
- Olivia Kamoen
- Department of Neurology, Heilig Hart Ziekenhuis, Lier, Belgium
| | | | | | - Gasim Abd-Elfarag
- Access for Humanity, Juba, South Sudan; School of Public Health, University of Juba, Juba, South Sudan; Health and Social Sciences Research Institute-South Sudan, Juba, South Sudan
| | | | - Yak Bol
- Neglected Tropical Disease Programme, Ministry of Health, Juba, South Sudan
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3
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Van Cutsem G, Siewe Fodjo JN, Hadermann A, Amaral LJ, Trevisan C, Pion S, Colebunders R. Onchocerciasis-associated epilepsy: Charting a path forward. Seizure 2024:S1059-1311(24)00123-7. [PMID: 38677953 DOI: 10.1016/j.seizure.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
This narrative review intends to inform neurologists and public health professionals about Onchocerciasis-Associated Epilepsy (OAE), a neglected public health problem in many remote onchocerciasis-endemic areas. For epidemiological purposes, we define OAE as sudden-onset of convulsive and non-convulsive seizure types, including head nodding seizures (nodding syndrome) in a previously healthy child aged 3 to 18 years in the absence of any other obvious cause for epilepsy, all happening within an area with high ongoing Onchocerca volvulus transmission. Several OAE pathophysiological mechanisms have been proposed, but none has been proven yet. Recent population-based studies showed that strengthening onchocerciasis elimination programs was followed by a significant reduction in the incidence of OAE and nodding syndrome. Treating epilepsy in onchocerciasis-endemic regions is challenging. More advocacy is needed to provide uninterrupted, free access to anti-seizure medication to persons with epilepsy in these remote, impoverished areas. It is crucial todevelop policies and increase funding for the prevention and treatment of OAE to reduce the associated burden of disease, notably via the establishment of morbidity management and disability prevention programs (MMDP). Moreover, effective collaboration between onchocerciasis elimination and mental health programs is imperative to alleviate the burden of OAE. This synergy promises reciprocal advantages and underscores the need for a comprehensive approach to address this multifaceted challenge.
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Affiliation(s)
- G Van Cutsem
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg; Faculty of Science, Technology and Medicine, University of Luxembourg, Luxembourg; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
| | - J N Siewe Fodjo
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - A Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - L-J Amaral
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - C Trevisan
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - S Pion
- Institute of Research for Sustainable Development, Montpelier, France
| | - R Colebunders
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
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4
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Spencer PS. New clues to the elusive aetiology of nodding syndrome. Brain Commun 2023; 5:fcad236. [PMID: 37731902 PMCID: PMC10507742 DOI: 10.1093/braincomms/fcad236] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 07/21/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023] Open
Abstract
Nodding syndrome is a paediatric epileptic encephalopathy of unknown aetiology that affects children in impoverished communities of Eastern Africa subject to internal displacement. Set in southcentral South Sudan, where nodding syndrome first surfaced circa 1990, an important new study of recent-onset cases of nodding syndrome examined parasitic, bacterial, viral, immune-mediated, metabolic and nutritional factors associated with the brain disease. Infection with the nematode Mansonella perstans, but not with Onchocerca volvulus, was the most prominent finding in nodding syndrome cases versus controls. While M. perstans is unlikely to be causal of nodding syndrome, investigation of the freshwater habitats, where insect-to-human transmission of the filarial larvae takes place, may reveal a clue as to the aetiology of this neurodegenerative disease. The culpable environmental agent(s) must be able to induce neuroinflammation and tau pathology preferentially in infants and children.
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Affiliation(s)
- Peter S Spencer
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA
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5
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Arndts K, Kegele J, Massarani AS, Ritter M, Wagner T, Pfarr K, Lämmer C, Dörmann P, Peisker H, Menche D, Al-Bahra M, Prazeres da Costa C, Schmutzhard E, Matuja W, Hoerauf A, Layland-Heni LE, Winkler AS. Epilepsy and nodding syndrome in association with an Onchocerca volvulus infection drive distinct immune profile patterns. PLoS Negl Trop Dis 2023; 17:e0011503. [PMID: 37535695 PMCID: PMC10426931 DOI: 10.1371/journal.pntd.0011503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 08/15/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023] Open
Abstract
Previous studies have described the association of onchocerciasis (caused by Onchocerca volvulus) with epilepsy, including nodding syndrome, although a clear etiological link is still missing. Cases are found in different African countries (Tanzania, South Sudan, Uganda, Democratic Republic of the Congo, Central African Republic and Cameroon). In our study we investigated immunological parameters (cytokine, chemokine, immunoglobulin levels) in individuals from the Mahenge area, Tanzania, presenting with either epilepsy or nodding syndrome with or without O. volvulus infection and compared them to O. volvulus negative individuals from the same endemic area lacking neurological disorders. Additionally, cell differentiation was performed using blood smears and systemic levels of neurodegeneration markers, leiomodin-1 and N-acetyltyramine-O, β-glucuronide (NATOG) were determined. Our findings revealed that cytokines, most chemokines and neurodegeneration markers were comparable between both groups presenting with epilepsy or nodding syndrome. However, we observed elevated eosinophil percentages within the O. volvulus positive epilepsy/nodding syndrome patients accompanied with increased eosinophilic cationic protein (ECP) and antigen-specific IgG levels in comparison to those without an O. volvulus infection. Furthermore, highest levels of NATOG were found in O. volvulus positive nodding syndrome patients. These findings highlight that the detection of distinct biomarkers might be useful for a differential diagnosis of epilepsy and nodding syndrome in O. volvulus endemic areas. Trial-registration: NCT03653975.
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Affiliation(s)
- Kathrin Arndts
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
| | - Josua Kegele
- Hertie Institute for Clinical Brain Research, Department of Neurology and Epileptology, University of Tübingen, Tübingen, Germany
| | - Alain S. Massarani
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
| | - Manuel Ritter
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
| | - Thomas Wagner
- Center for Pediatric and Adolescent Medicine, University Heidelberg, Heidelberg, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Germany
| | - Kenneth Pfarr
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Christine Lämmer
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Peter Dörmann
- Institute of Molecular Physiology and Biotechnology of Plants, University of Bonn, Bonn, Germany
| | - Helga Peisker
- Institute of Molecular Physiology and Biotechnology of Plants, University of Bonn, Bonn, Germany
| | - Dirk Menche
- Kekulé Institute of Organic Chemistry and Biochemistry, University of Bonn, Bonn, Germany
| | - Mazen Al-Bahra
- Kekulé Institute of Organic Chemistry and Biochemistry, University of Bonn, Bonn, Germany
| | - Clarissa Prazeres da Costa
- German Center for Infection Research (DZIF), Partner Site Munich, Germany
- Institute of Medical Microbiology, Immunology and Hygiene, Technical University of Munich, Munich, Germany
- Center for Global Health, School of Medicine, Technical University of Munich, Munich, Germany
| | - Erich Schmutzhard
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - William Matuja
- Department of Neurology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Achim Hoerauf
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
- German-West African Centre for Global Health and Pandemic Prevention (G-WAC), Partner Site Bonn, Bonn, Germany
| | - Laura E. Layland-Heni
- Institute of Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn (UKB), Bonn, German
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Andrea S. Winkler
- Center for Global Health, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Neurology, Technical University of Munich, Munich, Germany
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Amaral LJ, Bhwana D, Mhina AD, Mmbando BP, Colebunders R. Nodding syndrome, a case-control study in Mahenge, Tanzania: Onchocerca volvulus and not Mansonella perstans as a risk factor. PLoS Negl Trop Dis 2023; 17:e0011434. [PMID: 37339148 DOI: 10.1371/journal.pntd.0011434] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Nodding syndrome (NS) has been consistently associated with onchocerciasis. Nevertheless, a positive association between NS and a Mansonella perstans infection was found in South Sudan. We aimed to determine whether the latter parasite could be a risk factor for NS in Mahenge. METHODS Cases of epilepsy were identified in villages affected by NS in Mahenge, Tanzania, and matched with controls without epilepsy of the same sex, age and village. We examined blood films of cases and controls to identify M. perstans infections. The participants were also asked for sociodemographic and epilepsy information, examined for palpable onchocercal nodules and onchocerciasis-related skin lesions and tested for anti-Onchocerca volvulus antibodies (Ov16 IgG4) by ELISA. Clinical characteristics of cases and controls, O. volvulus exposure status and relevant sociodemographic variables were assessed by a conditional logistic regression model for NS and epilepsy status matched for age, sex and village. RESULTS A total of 113 epilepsy cases and 132 controls were enrolled, of which, respectively, 56 (49.6%) and 64 (48.5%) were men. The median age in cases and controls was 28.0 (IQR: 22.0-35.0) and 27.0 (IQR: 21.0-33.3) years. Of the persons with epilepsy, 43 (38.1%) met the probable NS criteria and 106 (93.8%) had onchocerciasis-associated epilepsy (OAE). M. perstans infection was absent in all participants, while Ov16 seroprevalence was positively associated with probable NS (odds ratio (OR): 5.05, 95%CI: 1.79-14.27) and overall epilepsy (OR: 2.03, 95%CI: 1-07-3.86). Moreover, onchocerciasis-related skin manifestations were only found in the cases (n = 7, p = 0.0040), including persons with probable NS (n = 4, p = 0.0033). Residing longer in the village and having a family history of seizures were positively correlated with Ov16 status and made persons at higher odds for epilepsy, including probable NS. CONCLUSION In contrast to O. volvulus, M. perstans is most likely not endemic to Mahenge and, therefore, cannot be a co-factor for NS in the area. Hence, this filaria is unlikely to be the primary and sole causal factor in the development of NS. The main risk factor for NS remains onchocerciasis.
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Affiliation(s)
| | - Dan Bhwana
- National Institute of Medical Research, Tanga, Tanzania
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7
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Miyauchi Y, Shiraishi A, Abe K, Sato Y, Kita K. Excitatory amino acids, possible causative agents of nodding syndrome in eastern Africa. Trop Med Health 2023; 51:30. [PMID: 37202788 DOI: 10.1186/s41182-023-00520-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Nodding syndrome (NS) is one type of epilepsy and a progressive disease characterized by nodding symptoms with children in sub-Saharan Africa. The burden for NS children is heavy, not only mentally but financially for themselves and their families, and yet, the cause and cure of NS remain unknown. The kainic acid-induced model in experimental animals is a well-known epilepsy model that is useful for studying human diseases. In this study, we examined similarities of clinical symptoms and histological brain changes between NS patients and kainic acid-treated rats. In addition, we argued for kainic acid agonist as one of the causes of NS. METHODS Clinical signs in rats were studied after kainic acid administration, and histological lesions including the expression of tau protein and gliosis, were examined at 24 h, 8 days, and 28 days after dosing. RESULTS Kainic acid-induced epileptic symptoms were observed in rats, including nodding accompanied by drooling and bilateral neuronal cell death in the hippocampus and piriform cortex regions. In the regions that exhibited neuronal cell death, an increase in tau protein expression and gliosis were found immunohistochemically. The symptoms and brain histology were similar in the NS and kainic acid-induced rat models. CONCLUSION The results suggest that kainic acid agonist may be one of the causative substances for NS.
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Affiliation(s)
- Yasushi Miyauchi
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, 852-8523, Japan.
- Department of Bio Research, Kamakura Techno-Science, Inc., Kamakura, Kanagawa, 248-0036, Japan.
| | - Ayaka Shiraishi
- Department of Bio Research, Kamakura Techno-Science, Inc., Kamakura, Kanagawa, 248-0036, Japan
| | - Konami Abe
- Department of Bio Research, Kamakura Techno-Science, Inc., Kamakura, Kanagawa, 248-0036, Japan
| | - Yasuaki Sato
- School of Global Humanities and Social Sciences, Nagasaki University, Nagasaki, 852-8521, Japan
| | - Kiyoshi Kita
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, 852-8523, Japan
- Department of Host-Defense Biochemistry, Institute of Tropical Medicine, Nagasaki University, Nagasaki, 852-8523, Japan
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8
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Van Cutsem G, Siewe Fodjo JN, Dekker MCJ, Amaral LJ, Njamnshi AK, Colebunders R. Case definitions for onchocerciasis-associated epilepsy and nodding syndrome: A focused review. Seizure 2023; 107:132-135. [PMID: 37023626 DOI: 10.1016/j.seizure.2023.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
Onchocerciasis-associated epilepsy (OAE) is an important but neglected public health problem in onchocerciasis-endemic areas with insufficient or inadequate onchocerciasis control. Hence, there is a need for an internationally accepted, easy-to-use epidemiological case definition of OAE to identify areas of high Onchocerca volvulus transmission and disease burden requiring treatment and prevention interventions. By including OAE as a manifestation of onchocerciasis, we will considerably improve the accuracy of the overall onchocerciasis disease burden, which is currently underestimated. Hopefully, this will lead to increased interest and funding for onchocerciasis research and control interventions, notably the implementation of more effective elimination measures and treatment and support for affected individuals and their families.
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9
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Hadermann A, Amaral LJ, Van Cutsem G, Siewe Fodjo JN, Colebunders R. Onchocerciasis-associated epilepsy: an update and future perspectives. Trends Parasitol 2023; 39:126-138. [PMID: 36528471 DOI: 10.1016/j.pt.2022.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
Onchocerciasis-associated epilepsy (OAE) is an important neglected public health problem in areas with high ongoing onchocerciasis transmission. The risk that children in such areas develop epilepsy is related to their Onchocerca volvulus microfilarial (mf) load. Before the implementation of mass treatment with ivermectin, microfilariae were detected in cerebrospinal fluid (CSF). More recently, neither O. volvulus microfilariae nor DNA were detected in CSF or brain tissue; however, these samples were obtained years after seizure onset. It is possible that during fever-induced increased blood-brain barrier permeability, microfilariae enter the brain and, upon dying, cause an inflammatory reaction inducing seizures. Including OAE in the onchocerciasis disease burden estimation may mobilise extra resources for onchocerciasis disease elimination and treatment/care of OAE-affected persons/families.
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Affiliation(s)
- Amber Hadermann
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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10
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Spencer P, Okot C, Palmer V, Valdes Angues R, Mazumder R. Nodding syndrome: A key role for sources of nutrition? eNeurologicalSci 2022; 27:100401. [PMID: 35480298 PMCID: PMC9035392 DOI: 10.1016/j.ensci.2022.100401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 12/16/2022] Open
Abstract
Nodding Syndrome (NS) has occurred among severely food-stressed communities in northern Uganda and several other East African populations that, with their forced physical displacement, have resorted to nutritional support from available wild plants and fungi, some of which have neurotoxic potential. Among the latter is an agaric mushroom with an unknown content of hydrazine-generating agaritine, namely Agaricus bingensis, the unusually wide consumption of which may relate to the low serum levels of vitamin B6 in Ugandan NS subjects relative to controls. Hydrazine-related compounds induce patterns of DNA damage that promote neuropathological changes (tauopathy) reminiscent of those associated with established NS. While the cause of this childhood brain disease is unknown, we encourage increased attention to the role of malnutrition and B6 hypovitaminosis in the etiology of this devastating brain disease. Idiopathic epileptic encephalopathy with tauopathy (Nodding syndrome) impacts East African children Associated factors include nematode infection, food insecurity, and food use of wild plants and fungi Food use of hydrazinic fungi induces B6 hypovitaminosis, which may be marked in Nodding syndrome Vitamin B6 deficiency promotes tau phosphorylation in mouse models of human tauopathy Hydrazine generates carbon free radicals associated with DNA-damage and neurodegenerative disease Increased research attention to nutritional practices associated with Nodding syndrome is merited.
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Affiliation(s)
- P.S. Spencer
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
- Corresponding author at: Oregon Health & Science University (Neurology), S.W. Sam Jackson Park Road, Portland, OR 97239, USA.
| | | | - V.S. Palmer
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - R. Valdes Angues
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - R. Mazumder
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, USA
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11
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Ndondo AP, Eley B, Wilmshurst JM, Kakooza-Mwesige A, Giannoccaro MP, Willison HJ, Cruz PMR, Heckmann JM, Bateman K, Vincent A. Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective. Front Immunol 2022; 13:833548. [PMID: 35356001 PMCID: PMC8959857 DOI: 10.3389/fimmu.2022.833548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
The direct impact and sequelae of infections in children and adults result in significant morbidity and mortality especially when they involve the central (CNS) or peripheral nervous system (PNS). The historical understanding of the pathophysiology has been mostly focused on the direct impact of the various pathogens through neural tissue invasion. However, with the better understanding of neuroimmunology, there is a rapidly growing realization of the contribution of the innate and adaptive host immune responses in the pathogenesis of many CNS and PNS diseases. The balance between the protective and pathologic sequelae of immunity is fragile and can easily be tipped towards harm for the host. The matter of immune privilege and surveillance of the CNS/PNS compartments and the role of the blood-brain barrier (BBB) and blood nerve barrier (BNB) makes this even more complex. Our understanding of the pathogenesis of many post-infectious manifestations of various microbial agents remains elusive, especially in the diverse African setting. Our exploration and better understanding of the neuroimmunology of some of the infectious diseases that we encounter in the continent will go a long way into helping us to improve their management and therefore lessen the burden. Africa is diverse and uniquely poised because of the mix of the classic, well described, autoimmune disease entities and the specifically "tropical" conditions. This review explores the current understanding of some of the para- and post-infectious autoimmune manifestations of CNS and PNS diseases in the African context. We highlight the clinical presentations, diagnosis and treatment of these neurological disorders and underscore the knowledge gaps and perspectives for future research using disease models of conditions that we see in the continent, some of which are not uniquely African and, where relevant, include discussion of the proposed mechanisms underlying pathogen-induced autoimmunity. This review covers the following conditions as models and highlight those in which a relationship with COVID-19 infection has been reported: a) Acute Necrotizing Encephalopathy; b) Measles-associated encephalopathies; c) Human Immunodeficiency Virus (HIV) neuroimmune disorders, and particularly the difficulties associated with classical post-infectious autoimmune disorders such as the Guillain-Barré syndrome in the context of HIV and other infections. Finally, we describe NMDA-R encephalitis, which can be post-HSV encephalitis, summarise other antibody-mediated CNS diseases and describe myasthenia gravis as the classic antibody-mediated disease but with special features in Africa.
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Affiliation(s)
- Alvin Pumelele Ndondo
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Paediatric Infectious Diseases Unit, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Jo Madeleine Wilmshurst
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.,Department of Paediatric Neurology, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maria Pia Giannoccaro
- Laboratory of Neuromuscular Pathology and Neuroimmunology, Istituto di Ricovero e Cura a CarattereScientifico (IRCCS) Instiuto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Hugh J Willison
- Institute of Infection, Immunity and Inflammation (3I), University of Glasgow, Glasgow, United Kingdom
| | - Pedro M Rodríguez Cruz
- Centro Nacional de Analisis Genomico - Centre for Genomic Regulation (CNAG-CRG ), Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain.,Department of Neuromuscular Disease, University College London (UCL) Queen Square Institute of Neurology, London, United Kingdom.,Faculté de Médecine, de Pharmacie et d'Odontologie, Université Cheikh Anta Diop, Dakar, Senegal
| | - Jeannine M Heckmann
- Neurology Division, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa.,The University of Cape Town (UCT) Neurosciences Institute, University of Cape Town, Cape Town, South Africa
| | - Kathleen Bateman
- Neurology Division, Department of Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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12
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Abstract
Purpose of the review Neurocysticercosis (NCC) has been well recognized as a leading cause of epilepsy. More recently, studies of other parasitic diseases such as cerebral malaria (CM) and onchocerciasis are yielding novel insights into the pathogenesis of parasite-associated epilepsy. We compare the clinical and electrophysiological findings in epilepsy associated with these highly prevalent parasites and discuss the mechanisms involved in epileptogenesis. Recent Findings Electrophysiological and imaging biomarkers continue to emerge, and individuals who are at-risk of developing parasite-associated epilepsies are being identified with greater reliability. While both Taenia solium and Plasmodium falciparum directly affect the brain parenchyma, Onchocerca volvulus is not known to invade the central nervous system. Thus, the causal association between O. volvulus and epilepsy remains controversial. Summary Both NCC and CM have a well-defined acute phase when the parasites directly or indirectly invade the brain parenchyma and lead to local inflammatory changes. This is followed by a chronic phase marked by recurrent seizures. However, these stages of epileptogenic process have not been identified in the case of O. volvulus.
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Affiliation(s)
- Rajarshi Mazumder
- Department of Neurology, David Geffen School of Medicine, University of California, 710 Westwood Plaza, C109, Los Angeles, CA, 90095, USA.
| | - John K Lee
- Department of Neurology, David Geffen School of Medicine, University of California, 710 Westwood Plaza, C109, Los Angeles, CA, 90095, USA
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13
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Jada SR, Dusabimana A, Abd-Elfarag G, Okaro S, Brusselaers N, Carter JY, Logora MY, Rovarini JM, Newton CR, Colebunders R. The Prevalence of Onchocerciasis-Associated Epilepsy in Mundri West and East Counties, South Sudan: A Door-to-Door Survey. Pathogens 2022; 11:pathogens11040396. [PMID: 35456071 PMCID: PMC9025150 DOI: 10.3390/pathogens11040396] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 02/05/2023] Open
Abstract
A two-phase survey of epilepsy was conducted in selected villages in Mundri West and East Counties (26 June–8 July, 2021), an onchocerciasis-endemic area in Western Equatoria State in South Sudan. In the first phase, households were visited by a trained research team to identify persons suspected to have epilepsy. In the second phase, persons suspected to have epilepsy were interviewed and examined by a clinician to confirm the diagnosis. A total of 364 households agreed to participate in the survey, amounting to 2588 individuals. The epilepsy screening questionnaire identified 91 (3.5%) persons with suspected epilepsy, of whom the diagnosis of epilepsy was confirmed by a clinician in 86 (94.5%). The overall prevalence of confirmed epilepsy was 3.3% (95% CI: 2.7–4.1%), and of nodding syndrome was 0.9% (95% CI: 0.6–1.4%). In 61 (16.8%) households there was at least one person with epilepsy. Only 1212 (46.9%) of 2583 people took ivermectin during the last distribution round in 2021. The annual epilepsy incidence was 77.3/100,000 (95% CI: 9.4–278.9/100,000) and the annual epilepsy mortality was 251.2/100,000 (95% CI: 133.8–428.7/100,000). In conclusion, a high prevalence and incidence of epilepsy was observed in villages in Mundri. Urgent action is needed to prevent children from developing onchocerciasis-associated epilepsy by strengthening the local onchocerciasis-elimination programme.
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Affiliation(s)
- Stephen Raimon Jada
- Amref Health Africa, Juba P.O. Box 410, South Sudan; (S.R.J.); (S.O.); (J.M.R.)
| | - Alfred Dusabimana
- Global Health Institute, University of Antwerp, 2016 Antwerp, Belgium; (A.D.); (N.B.)
| | - Gasim Abd-Elfarag
- Amsterdam Center for Global Health, Department of Paediatrics and Department of Global Health, Amsterdam UMC, 1105 AZ Amsterdam, The Netherlands;
- Amsterdam Institute for Global Health and Development, 1105 AZ Amsterdam, The Netherlands
| | - Samuel Okaro
- Amref Health Africa, Juba P.O. Box 410, South Sudan; (S.R.J.); (S.O.); (J.M.R.)
| | - Nele Brusselaers
- Global Health Institute, University of Antwerp, 2016 Antwerp, Belgium; (A.D.); (N.B.)
- Centre for Translational Microbiome Research, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Jane Y. Carter
- Amref Health Africa Headquarters, Nairobi P.O. Box 30125, Kenya;
| | - Makoy Yibi Logora
- Neglected Tropical Diseases Unit, Ministry of Health, Juba P.O. Box 410, South Sudan;
| | | | | | - Robert Colebunders
- Global Health Institute, University of Antwerp, 2016 Antwerp, Belgium; (A.D.); (N.B.)
- Correspondence:
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14
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Reducing onchocerciasis-associated morbidity in onchocerciasis-endemic foci with high ongoing transmission: a focus on the children. Int J Infect Dis 2022; 116:302-305. [PMID: 35074518 PMCID: PMC8866381 DOI: 10.1016/j.ijid.2022.01.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/22/2022] Open
Abstract
Efforts are being directed toward the elimination of onchocerciasis transmission in endemic areas with community-directed treatment with ivermectin (CDTI) in Africa, which greatly reduces onchocerciasis-associated disease. However, onchocerciasis remains a major public health problem in areas of South Sudan, the Democratic Republic of the Congo, Cameroon, and the Central African Republic. Strengthening onchocerciasis elimination efforts in areas with a high prevalence of disease burden is crucial to decrease transmission, morbidity, and mortality. We argue that clinical trials are needed to investigate the safety and efficacy of ivermectin treatment of Onchocerca volvulus-infected pregnant women and children younger than 5 years. Crucially, 6-monthly administration of ivermectin in school-age children at risk of onchocerciasis-associated epilepsy could be achieved by supplementing annual CDTI with an extra round of ivermectin treatment during Child Health Days in schools and/or other distribution sites every year. These strategies would help achieve the elimination of onchocerciasis and its associated disease burden.
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15
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Siewe Fodjo JN, Njamnshi WY, Ngarka L, Nfor LN, Ayuk C, Mundih NN, Ekwoge HT, Nganchfu K, Njamnshi KG, Yerema R, Ngoundjou P, Awasume E, Ashu G, Tabah EN, Colebunders R, Njamnshi AK. Association Between Ov16 Seropositivity and Neurocognitive Performance Among Children in Rural Cameroon: a Pilot Study. JOURNAL OF PEDIATRIC NEUROPSYCHOLOGY 2021; 7:192-202. [PMID: 34868828 PMCID: PMC8602181 DOI: 10.1007/s40817-021-00111-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/13/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022]
Abstract
Infection with Onchocerca volvulus was recently reported to increase the risk for epilepsy in Cameroonian children. We investigated whether infection with O. volvulus may alter the cognitive function of children who may or may not develop epilepsy later in their lifetime. Using rapid diagnostic tests, we determined the presence of Ov16 antibodies in 209 school-aged children without epilepsy recruited from three Cameroonian villages, as a proxy for onchocerciasis exposure. In addition, the neurocognitive performance of these children was assessed using a battery of validated tools. Participants were aged 6–16 years, and 46.4% were Ov16 seropositive. Upon standardizing age-specific neurocognitive scores and investigating predictors of neurocognitive performance using multiple linear regression models (adjusted for gender, education level, previous ivermectin use, and anthropometric parameters), we found that being Ov16-positive was significantly associated with reduced semantic verbal fluency (estimate –0.38; 95% confidence interval –0.65 to –0.11; p = 0.006) and lower scores on the International HIV Dementia Scale (estimate –0.31; confidence interval –0.56 to –0.04; p = 0.025). Furthermore, an increasing frequency of past ivermectin use was associated with increased neurocognitive scores. Our findings suggest that exposure to O. volvulus may affect neurocognitive performance of children.
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Affiliation(s)
- Joseph Nelson Siewe Fodjo
- Global Health Institute, University of Antwerp, Antwerp, Belgium.,Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Wepnyu Y Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon.,Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Leonard Ngarka
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon.,Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon.,Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Leonard N Nfor
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon.,Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon.,Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Constance Ayuk
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Noelar N Mundih
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Hilda T Ekwoge
- Buea Regional Hospital, Buea, Cameroon.,HILPharma Organization, Yaoundé, Cameroon
| | - Kevin Nganchfu
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Kongnyu G Njamnshi
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Rachel Yerema
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Pernelle Ngoundjou
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Edward Awasume
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - George Ashu
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
| | - Earnest N Tabah
- Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon.,Faculty of Medicine & Pharmaceutical Sciences, The University of Dschang, Dschang, Cameroon.,Ministry of Public Health, Yaoundé, Cameroon
| | | | - Alfred K Njamnshi
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon.,Neuroscience Lab, Faculty of Medicine & Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon.,Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
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16
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Roach M, Cantu A, Vieri MK, Cotten M, Kellam P, Phan M, van der Hoek L, Mandro M, Tepage F, Mambandu G, Musinya G, Laudisoit A, Colebunders R, Edwards R, Mokili JL. No Evidence Known Viruses Play a Role in the Pathogenesis of Onchocerciasis-Associated Epilepsy. An Explorative Metagenomic Case-Control Study. Pathogens 2021; 10:pathogens10070787. [PMID: 34206564 PMCID: PMC8308762 DOI: 10.3390/pathogens10070787] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
Despite the increasing epidemiological evidence that the Onchocerca volvulus parasite is strongly associated with epilepsy in children, hence the name onchocerciasis-associated epilepsy (OAE), the pathophysiological mechanism of OAE remains to be elucidated. In June 2014, children with unprovoked convulsive epilepsy and healthy controls were enrolled in a case control study in Titule, Bas-Uélé Province in the Democratic Republic of the Congo (DRC) to identify risk factors for epilepsy. Using a subset of samples collected from individuals enrolled in this study (16 persons with OAE and 9 controls) plasma, buffy coat, and cerebrospinal fluid (CSF) were subjected to random-primed next-generation sequencing. The resulting sequences were analyzed using sensitive computational methods to identify viral DNA and RNA sequences. Anneloviridae, Flaviviridae, Hepadnaviridae (Hepatitis B virus), Herpesviridae, Papillomaviridae, Polyomaviridae (Human polyomavirus), and Virgaviridae were identified in cases and in controls. Not unexpectedly, a variety of bacteriophages were also detected in all cases and controls. However, none of the identified viral sequences were found enriched in OAE cases, which was our criteria for agents that might play a role in the etiology or pathogenesis of OAE.
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Affiliation(s)
- Michael Roach
- College of Science and Engineering, Flinders University, Adelaide, SA 5001, Australia; (M.R.); (R.E.)
| | - Adrian Cantu
- Computational Sciences Research Center, Biology Department, San Diego State University, San Diego, CA 92182, USA;
| | - Melissa Krizia Vieri
- Global Health Institute, University of Antwerp, 2160 Antwerp, Belgium; (M.K.V.); (R.C.)
| | - Matthew Cotten
- Wellcome Trust Sanger Institute, Hinxton CB10 1RQ, UK;
- MRC/UVRI and London School of Hygiene and Tropical Medicine, Entebbe, Uganda; (P.K.); (M.P.)
- Centre for Virus Research, MRC-University of Glasgow, Glasgow G61 1QH, UK
| | - Paul Kellam
- MRC/UVRI and London School of Hygiene and Tropical Medicine, Entebbe, Uganda; (P.K.); (M.P.)
| | - My Phan
- MRC/UVRI and London School of Hygiene and Tropical Medicine, Entebbe, Uganda; (P.K.); (M.P.)
- Centre for Virus Research, MRC-University of Glasgow, Glasgow G61 1QH, UK
| | - Lia van der Hoek
- Laboratory of Experimental Virology, Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, 1012 WX Amsterdam, The Netherlands;
| | - Michel Mandro
- Provincial Health Division Ituri, Ministry of Health, Ituri, Congo;
| | - Floribert Tepage
- Provincial Health Division Bas Uélé, Ministry of Health, Bas Uélé, Congo;
| | - Germain Mambandu
- Provincial Health Division Tshopo, Ministry of Health, Tshopo, Congo;
| | | | | | - Robert Colebunders
- Global Health Institute, University of Antwerp, 2160 Antwerp, Belgium; (M.K.V.); (R.C.)
| | - Robert Edwards
- College of Science and Engineering, Flinders University, Adelaide, SA 5001, Australia; (M.R.); (R.E.)
- Computational Sciences Research Center, Biology Department, San Diego State University, San Diego, CA 92182, USA;
- Viral Information Institute, Biology Department, San Diego State University, San Diego, CA 92182, USA
| | - John L. Mokili
- Viral Information Institute, Biology Department, San Diego State University, San Diego, CA 92182, USA
- Correspondence:
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17
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First description of Nodding Syndrome in the Central African Republic. PLoS Negl Trop Dis 2021; 15:e0009430. [PMID: 34143783 PMCID: PMC8244846 DOI: 10.1371/journal.pntd.0009430] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 06/30/2021] [Accepted: 04/30/2021] [Indexed: 12/18/2022] Open
Abstract
Background The term Nodding Syndrome (NS) refers to an atypical and severe form of childhood epilepsy characterized by a repetitive head nodding (HN). The disease has been for a long time limited to East Africa, and the cause is still unknown. The objective of this study was to confirm the existence of NS cases in Central African Republic (CAR). Methodology/Principal findings This was a cross-sectional descriptive study in the general population. The identification of NS cases was conducted through a door-to-door survey in a village near Bangui along the Ubangui River. Based on Winkler’s 2008 and the World Health Organization (WHO)’s 2012 classifications, the confirmation of cases was done by a neurologist who also performed the electroencephalograms. No laboratory tests were done during this investigation. Treatment was offered to all patients. A total of 6,175 individuals was surveyed in 799 households. After reviewing the cases, we identified 5 NS cases in girls aged between 8 and 16. The age of onset of the seizures was between 5 and 12 years of age. Two cases were classified as "HN plus" according to Winkler’s 2008 classification. Four NS cases were classified as probable and one as confirmed according to the WHO’s 2012 classification. Three of them presented with developmental delay and cognitive decline, and one had an abnormally low height-for-age z-score. Electroencephalographic abnormalities were found in four patients. Conclusions/Significance Nodding Syndrome cases were described in CAR for the first time. Despite certain peculiarities, these cases are similar to those described elsewhere. Given that only a small part of the affected area was investigated, the study area along the Ubangui River needs to be expanded in order to investigate the association between Onchocerca volvulus and NS and also evaluate the real burden of NS in CAR. Nodding Syndrome (NS) is a form of severe epilepsy that affects children in Africa. Thousands of children have been affected since its first description 60 years ago in East Africa, particularly Tanzania, South Sudan, and Uganda. Its evolution is marked by the appearance of many serious complications such as stunting, wasting, delayed sexual development, and psychiatric illness that can lead to death in some cases. Both the future of the affected children and the present of the adults in charge of them are hampered by an intolerable level of social and economic harm. Here, we describe new cases of NS that emerged in a context of extreme poverty in the Central African Republic (CAR). Because the area at risk of NS was partially investigated in this study, we urge to carry out a larger-scale study in order to assess the real burden of NS in CAR and draw the attention of public authorities.
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18
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Ogwang R, Ningwa A, Akun P, Bangirana P, Anguzu R, Mazumder R, Salamon N, Henning OJ, Newton CR, Abbo C, Mwaka AD, Marsh K, Idro R. Epilepsy in Onchocerca volvulus Sero-Positive Patients From Northern Uganda-Clinical, EEG and Brain Imaging Features. Front Neurol 2021; 12:687281. [PMID: 34149607 PMCID: PMC8209377 DOI: 10.3389/fneur.2021.687281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
Globally, epilepsy is the most common chronic neurological disorder. The incidence in sub-Saharan Africa is 2-3 times higher than that in high income countries. Infection by Onchocerca volvulus may be an underlying risk factor for the high burden and based upon epidemiological associations, has been proposed to cause a group of disorders—Onchocerca associated epilepsies (OAE) like nodding syndrome (NS). To improve our understanding of the disease spectrum, we described the clinical, electroencephalographic (EEG) and magnetic resonance imaging (MRI) features of children with epilepsy and sero-positive for Onchocerca volvulus (possible OAEs other than nodding syndrome). Twenty-nine children and adolescents with non-nodding syndrome OAE in northern Uganda were enrolled. A diagnosis of OAE was made in patients with epilepsy and seizure onset after age 3 years, no reported exposure to perinatal severe febrile illness or traumatic brain injury, no syndromic epilepsy diagnosis and a positive Ov-16 ELISA test. Detailed clinical evaluation including psychiatric, diagnostic EEG, a diagnostic brain MRI (in 10 patients) and laboratory testing were performed. Twenty participants (69%) were male. The mean age was 15.9 (standard deviation [SD] 1.9) years while the mean age at seizure onset was 9.8 (SD 2.9) years. All reported normal early childhood development. The most common clinical presentation was a tonic-clonic seizure. The median number of seizures was 2 (IQR 1–4) in the previous month. No specific musculoskeletal changes, or cranial nerve palsies were reported, neither were any vision, hearing and speech difficulties observed. The interictal EEG was abnormal in the majority with slow wave background activity in 52% (15/29) while 41% (12/29) had focal epileptiform activity. The brain MRI showed mild to moderate cerebellar atrophy and varying degrees of atrophy of the frontal, parietal and occipital lobes. The clinical spectrum of epilepsies associated with Onchocerca may be broader than previously described. In addition, focal onset tonic-clonic seizures, cortical and cerebellar atrophy may be important brain imaging and clinical features.
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Affiliation(s)
- Rodney Ogwang
- College of Health Sciences, Makerere University, Kampala, Uganda.,KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Coast, Kilifi, Kenya.,Centre of Tropical Neuroscience, Kitgum, Uganda
| | - Albert Ningwa
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda
| | - Pamela Akun
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda
| | - Paul Bangirana
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Ronald Anguzu
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda.,Division of Epidemiology, Medical College of Wisconsin, Institute for Health and Equity, Milwaukee, WI, United States
| | - Rajarshi Mazumder
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Noriko Salamon
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Oliver Johannes Henning
- Division of Clinical Neuroscience, The National Centre for Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Charles R Newton
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Coast, Kilifi, Kenya.,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Catherine Abbo
- College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Kevin Marsh
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Richard Idro
- College of Health Sciences, Makerere University, Kampala, Uganda.,Centre of Tropical Neuroscience, Kitgum, Uganda.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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19
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Case-Control Study of Nodding Syndrome in Acholiland: Urinary Multi-Mycotoxin Screening. Toxins (Basel) 2021; 13:toxins13050313. [PMID: 33925470 PMCID: PMC8145943 DOI: 10.3390/toxins13050313] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/21/2021] [Accepted: 04/24/2021] [Indexed: 11/17/2022] Open
Abstract
This case-control study adds to the growing body of knowledge on the medical, nutritional, and environmental factors associated with Nodding Syndrome (NS), a seizure disorder of children and adolescents in northern Uganda. Past research described a significant association between NS and prior history of measles infection, dependence on emergency food and, at head nodding onset, subsistence on moldy maize, which has the potential to harbor mycotoxins. We used LC-MS/MS to screen for current mycotoxin loads by evaluating nine analytes in urine samples from age-and-gender matched NS cases (n = 50) and Community Controls (CC, n = 50). The presence of the three mycotoxins identified in the screening was not significantly different between the two groups, so samples were combined to generate an overall view of exposure in this community during the study. Compared against subsequently run standards, α-zearalenol (43 ± 103 µg/L in 15 samples > limit of quantitation (LOQ); 0 (0/359) µg/L), T-2 toxin (39 ± 81 µg/L in 72 samples > LOQ; 0 (0/425) µg/L) and aflatoxin M1 (4 ± 10 µg/L in 15 samples > LOQ; 0 (0/45) µg/L) were detected and calculated as the average concentration ± SD; median (min/max). Ninety-five percent of the samples had at least one urinary mycotoxin; 87% were positive for two of the three compounds detected. While mycotoxin loads at NS onset years ago are and will remain unknown, this study showed that children with and without NS currently harbor foodborne mycotoxins, including those associated with maize.
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20
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Potential Parasitic Causes of Epilepsy in an Onchocerciasis Endemic Area in the Ituri Province, Democratic Republic of Congo. Pathogens 2021; 10:pathogens10030359. [PMID: 33803565 PMCID: PMC8002919 DOI: 10.3390/pathogens10030359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
A high burden of epilepsy is observed in Africa where parasitological infections are endemic. In 2016, in an Onchocerciasis endemic area in the Logo health zone, in Ituri province in the Democratic Republic of Congo, a door-to-door study showed an epilepsy prevalence of 4.6%, and 50.6% of persons with epilepsy were infected with Onchocerca volvulus. In the current study, the serum of 195 people infected with O. volvulus persons with epilepsy were tested to determine the proportion of co-infections with Taenia solium, Toxocara canis and Strongyloides. These proportions were, respectively, 8.2, 18.5 and 12.8%. Persons with a T. solium co-infection were older than those without co-infection (p = 0.021). In six (37.5%) of the T. solium co-infected persons, the first seizures appeared after the age of 30 years compared to three (2.1%) persons without a co-infection (p < 0.0001). Our study suggests that an O. volvulus infection is the main parasitic cause of epilepsy in the Ituri province, but in some persons, mainly in those with late onset epilepsy and with focal seizures, the epilepsy may be caused by neurocysticercosis. As the population in the area rears pigs, activities to limit T. solium transmission should be implemented.
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21
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A systematic review and an individual patient data meta-analysis of ivermectin use in children weighing less than fifteen kilograms: Is it time to reconsider the current contraindication? PLoS Negl Trop Dis 2021; 15:e0009144. [PMID: 33730099 PMCID: PMC7968658 DOI: 10.1371/journal.pntd.0009144] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/13/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Oral ivermectin is a safe broad spectrum anthelminthic used for treating several neglected tropical diseases (NTDs). Currently, ivermectin use is contraindicated in children weighing less than 15 kg, restricting access to this drug for the treatment of NTDs. Here we provide an updated systematic review of the literature and we conducted an individual-level patient data (IPD) meta-analysis describing the safety of ivermectin in children weighing less than 15 kg. METHODOLOGY/PRINCIPAL FINDINGS A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for IPD guidelines by searching MEDLINE via PubMed, Web of Science, Ovid Embase, LILACS, Cochrane Database of Systematic Reviews, TOXLINE for all clinical trials, case series, case reports, and database entries for reports on the use of ivermectin in children weighing less than 15 kg that were published between 1 January 1980 to 25 October 2019. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42017056515. A total of 3,730 publications were identified, 97 were selected for potential inclusion, but only 17 sources describing 15 studies met the minimum criteria which consisted of known weights of children less than 15 kg linked to possible adverse events, and provided comprehensive IPD. A total of 1,088 children weighing less than 15 kg were administered oral ivermectin for one of the following indications: scabies, mass drug administration for scabies control, crusted scabies, cutaneous larva migrans, myiasis, pthiriasis, strongyloidiasis, trichuriasis, and parasitic disease of unknown origin. Overall a total of 1.4% (15/1,088) of children experienced 18 adverse events all of which were mild and self-limiting. No serious adverse events were reported. CONCLUSIONS/SIGNIFICANCE Existing limited data suggest that oral ivermectin in children weighing less than 15 kilograms is safe. Data from well-designed clinical trials are needed to provide further assurance.
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Hotterbeekx A, Lammens M, Onzivua S, Lukande R, Olwa F, Kumar-Singh S, Van Hees S, Idro R, Colebunders R. Neuropathological Changes in Nakalanga Syndrome-A Case Report. Pathogens 2021; 10:pathogens10020116. [PMID: 33498763 PMCID: PMC7912209 DOI: 10.3390/pathogens10020116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 11/24/2022] Open
Abstract
Nakalanga syndrome is a clinical manifestation of onchocerciasis-associated epilepsy characterized by stunting, delayed or absent secondary sexual development and skeletal deformities, and is often accompanied by epileptic seizures. The pathophysiology of Nakalanga syndrome is unknown. Here, we describe the post-mortem findings of a 17-year-old female who died with Nakalanga syndrome in northern Uganda. Macroscopic and histopathological examination of all major organs (liver, lungs, kidney and heart), including the brain and the pituitary gland, was performed. The suspected cause of death was malaria, and all major organs and pituitary gland appeared normal, except the lungs, which were edematous consistent with the malaria. Neuropathological changes include signs of neuro-inflammation (gliosis and activated microglia), which co-localized with tau-reactive neurofibrillary tangles and threads. The pathology was most abundant in the frontal cortex, thalamic and hypothalamic regions, and mesencephalon. The choroid plexus showed psammoma bodies. These findings indicate accelerated aging, probably due to repeated seizures. The neuropathological findings were similar to other persons who died with onchocerciasis-associated epilepsy. Examination of the pituitary gland did not reveal new information concerning the underlying pathophysiological mechanism of Nakalanga syndrome. Therefore, more post-mortem studies should be performed.
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Affiliation(s)
- An Hotterbeekx
- Global Health Institute, University of Antwerp, 2100 Antwerp, Belgium; (S.V.H.); (R.C.)
- Molecular Pathology Group, Laboratory of Cell Biology & Histology, Faculty of Medicine and Health Sciences, University of Antwerp, 2100 Antwerp, Belgium;
- Correspondence: ; Tel.: +32-32-65-89-15; Fax: +32-3-265-26-63
| | - Martin Lammens
- Department of Pathology, Antwerp University Hospital, 2100 Antwerp, Belgium;
- Department of Neuropathology, Born-Bunge Institute, University of Antwerp, 2100 Antwerp, Belgium
| | - Sylvester Onzivua
- Department of Pathology, Makerere University Medical School, Kampala P.O. Box 7072, Uganda; (S.O.); (R.L.)
| | - Robert Lukande
- Department of Pathology, Makerere University Medical School, Kampala P.O. Box 7072, Uganda; (S.O.); (R.L.)
| | - Francis Olwa
- Department of Diagnostics, Faculty of Health Sciences, Lira University, Lira P. O. Box 1035, Uganda;
| | - Samir Kumar-Singh
- Molecular Pathology Group, Laboratory of Cell Biology & Histology, Faculty of Medicine and Health Sciences, University of Antwerp, 2100 Antwerp, Belgium;
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, 2100 Antwerp, Belgium
| | - Stijn Van Hees
- Global Health Institute, University of Antwerp, 2100 Antwerp, Belgium; (S.V.H.); (R.C.)
| | - Richard Idro
- Department of Pediatrics, Makerere University Medical School, Kampala P.O. Box 7072, Uganda;
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, 2100 Antwerp, Belgium; (S.V.H.); (R.C.)
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Luna J, Metanmo S, Boumediene F, Mbelesso P, Auditeau E, Ajzenberg D, Preux PM. Onchocerciasis in tropical neurology: A scoping review. J Neurol Sci 2021; 421:117314. [PMID: 33493958 DOI: 10.1016/j.jns.2021.117314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Onchocerciasis is a serious problem in tropical areas. The role of the parasite as a factor associated with neurological diseases needs to be addressed because it might involve a reduction of the risk via elimination strategies. We performed a systematic scoping review to identify available studies on this association and put into perspective the different methodological approaches for interpreting the evidence. METHODOLOGY A literature search was conducted using MEDLINE (Pubmed) through October 1, 2020. We included all the studies evaluating the association between onchocerciasis and four neurological diseases (epilepsy, nodding syndrome, Nakalanga syndrome, and encephalitis) in tropical countries. A descriptive and critical summary of the results was conducted to provide an overview of the findings. RESULTS Overall, 161 articles were identified in the literature search. After full-length examination, we included twelve articles for epilepsy and three for nodding syndrome. Two meta-analyses of case-control studies found a modest strength of the association between O. volvulus and epilepsy. Recent meta-analyses and original studies support a significant association. Epidemiological studies suggest an association between onchocerciasis and nodding syndrome, however, the level of evidence from case-control studies was relatively low. No measure of association was reported for Nakalanga syndrome. There was no specific study on the association between O. volvulus and encephalitis. CONCLUSION The association between onchocerciasis and epilepsy seems increasingly likely. However, there are still many unanswered questions about the different clinical presentations of this epilepsy. Strong international collaboration is essential to improve our understanding of risk factors and physiopathological mechanisms of these intriguing conditions.
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Affiliation(s)
- Jaime Luna
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Salvatore Metanmo
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Farid Boumediene
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Pascal Mbelesso
- Department of Neurology, Amitié Hospital, Bangui, Central African Republic
| | - Emilie Auditeau
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Daniel Ajzenberg
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, Limoges, France.
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Colebunders R, Njamnshi AK, Menon S, Newton CR, Hotterbeekx A, Preux PM, Hopkins A, Vaillant M, Siewe Fodjo JN. Onchocerca volvulus and epilepsy: A comprehensive review using the Bradford Hill criteria for causation. PLoS Negl Trop Dis 2021; 15:e0008965. [PMID: 33411705 PMCID: PMC7790236 DOI: 10.1371/journal.pntd.0008965] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The possibility that onchocerciasis may cause epilepsy has been suggested for a long time, but thus far, an etiological link has not been universally accepted. The objective of this review is to critically appraise the relationship between Onchocerca volvulus and epilepsy and subsequently apply the Bradford Hill criteria to further evaluate the likelihood of a causal association. METHODS PubMed and gray literature published until September 15, 2020, were searched and findings from original research were synthesized. Adherence to the 9 Bradford Hill criteria in the context of onchocerciasis and epilepsy was determined to assess whether the criteria are met to strengthen the evidence base for a causal link between infection with O. volvulus and epilepsy, including the nodding syndrome. RESULTS Onchocerciasis as a risk factor for epilepsy meets the following Bradford Hill criteria for causality: strength of the association, consistency, temporality, and biological gradient. There is weaker evidence supporting causality based on the specificity, plausibility, coherence, and analogy criteria. There is little experimental evidence. Considering the Bradford Hill criteria, available data suggest that under certain conditions (high microfilarial load, timing of infection, and perhaps genetic predisposition), onchocerciasis is likely to cause epilepsy including nodding and Nakalanga syndromes. CONCLUSION Applying the Bradford Hill criteria suggests consistent epidemiological evidence that O. volvulus infection is a trigger of epilepsy. However, the pathophysiological mechanisms responsible for seizure induction still need to be elucidated.
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Affiliation(s)
- Robert Colebunders
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- * E-mail:
| | - Alfred K. Njamnshi
- Neurology Department, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé Cameroon
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Charles R. Newton
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Pierre-Marie Preux
- Institute of Epidemiology and Tropical Neurology, INSERM UMR1094, University of Limoges, Limoges, France
| | - Adrian Hopkins
- Neglected and Disabling Diseases of Poverty Consultant, Kent, United Kingdom
| | - Michel Vaillant
- Competence Center in Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
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Kaiser C, Mugisa C, Kisembo D, Gumisiriza N, Colebunders R, Tukesiga E, Kipp W, Asaba G. Case Report: Nakalanga Syndrome Revisited: Long-Term Follow-Up of a Patient Living in Western Uganda, 1994-2018. Am J Trop Med Hyg 2020; 104:902-906. [PMID: 33350373 DOI: 10.4269/ajtmh.20-0979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/03/2020] [Indexed: 11/07/2022] Open
Abstract
Nakalanga syndrome is a childhood developmental disorder that has been reported from various parts of sub-Saharan Africa with the major sign of retarded growth, regularly combined with physical deformities, impaired mental and pubertal development, and epilepsy. We present a follow-up over a 24-year period of a patient living in the Itwara onchocerciasis focus of western Uganda. We demonstrate the strong similarity of Nakalanga syndrome to the more recently described Nodding syndrome, and we discuss the possible causation of both disorders by onchocerciasis. We suggest that the growing knowledge about the tight interconnections between Nakalanga and nodding syndrome, other forms of epilepsy, and onchocerciasis should be taken into consideration in a revised classification system.
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Affiliation(s)
| | | | | | | | | | | | | | - George Asaba
- Department of Pediatrics, Regional Referral Hospital, Fort Portal, Uganda
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26
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Latio LSY, Nam NH, Shah J, Smith C, Sakai K, Stonewall Shaban K, Idro R, Makoto N, Huy NT, Hamano S, Moji K. Economic burden of the persistent morbidity of nodding syndrome on caregivers in affected households in Northern Uganda. PLoS One 2020; 15:e0238643. [PMID: 32991607 PMCID: PMC7523991 DOI: 10.1371/journal.pone.0238643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nodding syndrome (NS), is an unexplained form of epilepsy which leads to stunted growth, cognitive decline, and a characteristic nodding of the head. Current data about its impact on households in Uganda is scarce. Therefore, this study aims to assess the economic burden of the persistent morbidity of NS on caregivers in affected households in Northern Uganda. METHODS A cross-sectional cost-of-care study was conducted from January 2019 to February 2019 in Lakwela village-Northern Uganda in 14 households, who are members of a community-based organization (CBO) established in the village with the support of a Japanese research team, (Uganda-Japan Nodding Syndrome Network). Data was collected through questionnaires. Both direct (medical and non-medical) and indirect (informal care) costs of caregiving were assessed. Indirect costs were valued using the human-capital method as loss of production. RESULTS Direct costs constituted a higher proportion of costs for NS households, accounting for on average 7.7% of household expenditure. The annual weighted mean cost per NS patient was estimated at 27.6 USD (26.4 USD direct costs, 96.2% and 1.2 USD indirect cost, 3.8%). Average time spent on informal caregiving was 4.4 ±1.7 (standard deviation) hours/week with an estimated annual informal caregiving cost of 24.85 USD and gross domestic product (GDP) loss of 412.40 USD. CONCLUSION Direct costs due to NS are still high among households in this study. More studies are needed to investigate measures that could help bring down these costs and equally reduce the day-to-day disruption of caregiver's activities; consequently, improving the lives of these affected households and communities.
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Affiliation(s)
| | - Nguyen Hai Nam
- Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jaffer Shah
- Online Research Club (http://www.onlineresearchclub.org), Nagasaki, Japan
- Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Chris Smith
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kikuko Sakai
- Liberal Arts and Science, Kanazawa Seiryo University, Kanazawa, Japan
| | - Kato Stonewall Shaban
- Department of Environment and Natural Resources, Faculty of Agriculture and Environment Gulu University, Gulu, Uganda
| | - Richard Idro
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nishi Makoto
- Graduate School of Asian and African Area Studies, Kyoto University, Kyoto, Japan
| | - Nguyen Tien Huy
- Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- * E-mail: (KM); (NTH)
| | - Shinjiro Hamano
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Kazuhiko Moji
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- * E-mail: (KM); (NTH)
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Gumisiriza N, Kaiser C, Asaba G, Onen H, Mubiru F, Kisembo D, Siewe Fodjo JN, Colebunders R. Changes in epilepsy burden after onchocerciasis elimination in a hyperendemic focus of western Uganda: a comparison of two population-based, cross-sectional studies. THE LANCET. INFECTIOUS DISEASES 2020; 20:1315-1323. [PMID: 32598869 DOI: 10.1016/s1473-3099(20)30122-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 01/13/2020] [Accepted: 02/13/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 1994, prevalence and incidence of epilepsy were high in the Itwara onchocerciasis focus (western Uganda), and cases of nodding and Nakalanga syndrome were documented. Onchocerciasis transmission was interrupted successfully in 2001. 17 years later, we re-investigated the epilepsy burden in this area. METHODS From Dec 11 to Dec 15, 2018, a door-to-door survey was done in the three villages (Kabende Centre, Masongora South, and Rwesenene) with the highest epilepsy rates in 1994 to identify people with suspected epilepsy. Epilepsy diagnoses were confirmed by an interview and physical examination by a study clinician. The prevalence and incidence of epilepsy were measured using methods consistent with those used in 1994. Results from 2018 were compared with those from 1994. FINDINGS The overall crude prevalence of epilepsy in the study villages decreased from 3·0% (35 of 1169) in 1994 to 1·2% (27 of 2325) in 2018 (p=0·0002), with a concomitant decrease in the proportion of people with epilepsy with unknown cause (p=0·037). Between 1994 and 2018, the overall incidence of epilepsy decreased from 418 cases per 100 000 person-years (95% CI 265-626) to 73 new cases per 100 000 person-years (32-114; p<0·0001); this reduction was more pronounced for cases having the first seizure between ages 3 years and 18 years (p<0·0001). No new case of nodding or Nakalanga syndromes had occurred since the interruption of onchocerciasis transmission. INTERPRETATION Our findings support the existence of a negative association between onchocerciasis elimination and epilepsy burden in previously hyperendemic areas. Therefore, onchocerciasis elimination efforts should be intensified in endemic regions with a high prevalence of epilepsy, which might reduce the burden of epilepsy. FUNDING Flemish University Development Cooperation and the European Research Council.
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Affiliation(s)
| | | | - George Asaba
- Department of Pediatrics, Regional Referral Hospital, Fort Portal, Uganda
| | - Henry Onen
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Frank Mubiru
- Infectious Disease Institute, Makerere University, Kampala, Uganda
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Hotterbeekx A, Lammens M, Idro R, Akun PR, Lukande R, Akena G, Nath A, Taylor J, Olwa F, Kumar-Singh S, Colebunders R. Neuroinflammation and Not Tauopathy Is a Predominant Pathological Signature of Nodding Syndrome. J Neuropathol Exp Neurol 2020; 78:1049-1058. [PMID: 31553445 PMCID: PMC6839030 DOI: 10.1093/jnen/nlz090] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Indexed: 11/15/2022] Open
Abstract
Nodding syndrome (NS) is an epileptic disorder occurring in children in African onchocerciasis endemic regions. Here, we describe the pathological changes in 9 individuals from northern Uganda who died with NS (n = 5) or other forms of onchocerciasis-associated epilepsy (OAE) (n = 4). Postmortem examinations were performed and clinical information was obtained. Formalin-fixed brain samples were stained by hematoxylin and eosin and immunohistochemistry was used to stain astrocytes (GFAP), macrophages (CD68), ubiquitin, α-synuclein, p62, TDP-43, amyloid β, and tau (AT8). The cerebellum showed atrophy and loss of Purkinje cells with hyperplasia of the Bergmann glia. Gliosis and features of past ventriculitis and/or meningitis were observed in all but 1 participant. CD68-positive macrophage clusters were observed in all cases in various degrees. Immunohistochemistry for amyloid β, α-synuclein, or TDP-43 was negative. Mild to sparse AT8-positive neurofibrillary tangle-like structures and threads were observed in 4/5 NS and 2/4 OAE cases, preferentially in the frontal and parietal cortex, thalamic- and hypothalamic regions, mesencephalon and corpus callosum. Persons who died with NS and other forms of OAE presented similar pathological changes but no generalized tauopathy, suggesting that NS and other forms of OAE are different clinical presentations of a same disease with a common etiology.
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Affiliation(s)
- An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Martin Lammens
- Department of Pathology, Antwerp University Hospital, Antwerp, Belgium
| | - Richard Idro
- Department of Neuropathology, Born-Bunge Institute, University of Antwerp, Antwerp, Belgium
| | - Pamela R Akun
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Robert Lukande
- Department of Pathology, Makerere University, Medical School, Kampala, Uganda
| | | | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological, Disorders and Stroke, National Institutes of Health, Bethesda
| | - Joneé Taylor
- Department of Forensic Medicine, New York University, School of Medicine, New York City Office of the Chief Medical Examiner, New York, New York
| | - Francis Olwa
- Department of Diagnostics, Faculty of Health Sciences, Lira University, Lira, Uganda
| | - Samir Kumar-Singh
- Molecular Pathology Group, Laboratory of Cell Biology & Histology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Robert Colebunders
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Zoonotic and vector-borne parasites and epilepsy in low-income and middle-income countries. Nat Rev Neurol 2020; 16:333-345. [PMID: 32427939 DOI: 10.1038/s41582-020-0361-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 12/22/2022]
Abstract
Zoonotic and vector-borne parasites are important preventable risk factors for epilepsy. Three parasitic infections - cerebral malaria, Taenia solium cysticercosis and onchocerciasis - have an established association with epilepsy. Parasitoses are widely prevalent in low-income and middle-income countries, which are home to 80% of the people with epilepsy in the world. Once a parasitic infection has taken hold in the brain, therapeutic measures do not seem to influence the development of epilepsy in the long term. Consequently, strategies to control, eliminate and eradicate parasites represent the most feasible way to reduce the epilepsy burden at present. The elucidation of immune mechanisms underpinning the parasitic infections, some of which are parasite-specific, opens up new therapeutic possibilities. In this Review, we explore the pathophysiological basis of the link between parasitic infections and epilepsy, and we consider preventive and therapeutic approaches to reduce the burden of epilepsy attributable to parasitic disorders. We conclude that a concerted approach involving medical, veterinary, parasitological and ecological experts, backed by robust political support and sustainable funding, is the key to reducing this burden.
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Spencer PS, Mazumder R, Palmer VS, Pollanen MS. Nodding syndrome phenotypes. Rev Neurol (Paris) 2019; 175:679-685. [PMID: 31753452 DOI: 10.1016/j.neurol.2019.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Abstract
Nodding syndrome (NS) is a progressive encephalopathy of children and adolescents characterized by seizures, including periodic vertical head nodding. Epidemic NS, which has affected parts of East Africa, appears to have clinical overlap with sub-Saharan Nakalanga syndrome (NLS), a brain disorder associated with pituitary dwarfism that appears to have a patchy distribution across sub-Sahara. Clinical stages of NS include inattention and blank stares, vertical head nodding, convulsive seizures, multiple impairments, and severe cognitive and motorsystem disability, including features suggesting parkinsonism. Head nodding episodes occur in clusters with an electrographic correlate of diffuse high-amplitude slow waves followed by an electrodecremental pattern with superimposed diffuse fast activity. Brain imaging reveals differing degrees of cerebral cortical and cerebellar atrophy. Brains of NS-affected children with mild frontotemporal cortical atrophy display neurofibrillary pathology and dystrophic neurites immunopositive for tau, consistent with a progressive neurodegenerative disorder. The etiology of NS and NLS appears to be dominated by environmental factors, including malnutrition, displacement, and nematode infection, but the specific cause is unknown.
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Affiliation(s)
- P S Spencer
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA.
| | - R Mazumder
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - V S Palmer
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - M S Pollanen
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada
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Siewe Fodjo JN, Mandro M, Mukendi D, Tepage F, Menon S, Nakato S, Nyisi F, Abhafule G, Wonya’rossi D, Anyolito A, Lokonda R, Hotterbeekx A, Colebunders R. Onchocerciasis-associated epilepsy in the Democratic Republic of Congo: Clinical description and relationship with microfilarial density. PLoS Negl Trop Dis 2019; 13:e0007300. [PMID: 31314757 PMCID: PMC6663032 DOI: 10.1371/journal.pntd.0007300] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/29/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background High epilepsy prevalence and incidence were observed in onchocerciasis-endemic villages in the Democratic Republic of Congo (DRC). We investigated the clinical characteristics of onchocerciasis-associated epilepsy (OAE), and the relationship between seizure severity and microfilarial density. Methods In October 2017, ivermectin-naive persons with epilepsy (PWE) were recruited from onchocerciasis-endemic areas in the Logo health zone in the DRC. Additional PWE were enrolled in the Aketi health zone, where ivermectin had been distributed annually for 14 years. Past medical history, clinical characteristics and skin snips for Onchocerca volvulus detection were obtained from participants. Bivariate and multivariable analyses were used to investigate associations with microfilarial density. Results Of the 420 PWE in the Logo health zone, 392 were skin snipped (36.5% positive). Generalized motor seizures were most frequent (392 PWE, 93.3%), and nodding seizures were reported in 32 (7.6%) participants. Twelve PWE (3.1%) presented Nakalanga features. Sixty-three (44.1%) skin snip-positive PWE had a family history of epilepsy, compared to only 82 (32.9%) skin snip-negative PWE (p = 0.027). Eighty-one onchocerciasis-infected PWE were recruited in the Aketi health zone. Positive correlations between seizure frequency and microfilarial density were observed in Logo (Spearman-rho = 0.175; p<0.001) and Aketi (Spearman-rho = 0.249; p = 0.029). In the multivariable model adjusted for age, gender, and previous treatment, high seizure frequency was associated with increasing microfilarial density in Aketi (p = 0.025) but not in Logo (p = 0.148). Conclusion In onchocerciasis-endemic regions in the DRC, a wide spectrum of seizures was observed. The occurrence of Nodding seizures and Nakalanga features, as well as an association between seizure severity and O. volvulus microfilarial density suggest a high OAE prevalence in the study villages. Trial registration ClinicalTrials.gov NCT03052998. Several epidemiological surveys suggest that onchocerciasis (a disease resulting from an infection with the parasite Onchocerca volvulus) is a cause of epilepsy. We conducted a study to describe the clinical characteristics of persons with epilepsy (PWE) living in onchocerciasis-endemic villages in the Democratic Republic of Congo. In some study sites, the frequency of seizures increased with increasing number of O. volvulus microfilariae detected in the skin snips of participants. A wide spectrum of seizures was observed, including generalized tonic-clonic seizures, absence seizures, and focal seizures. Growth retardation and household clustering of PWE were common. Specific clinical presentations such as nodding seizures and Nakalanga features were encountered. These results suggest a high prevalence of onchocerciasis-associated epilepsy (OAE) in the study villages.
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Affiliation(s)
| | - Michel Mandro
- Ministry of Health, Ituri, Democratic Republic of Congo
| | - Deby Mukendi
- Mont Amba Neuropsychopathologic Center, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | | | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Swabra Nakato
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Françoise Nyisi
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Democratic Republic of Congo
| | - Germain Abhafule
- Centre de Recherche en Maladies Tropicales de l'Ituri, Rethy, Democratic Republic of Congo
| | | | - Aimé Anyolito
- Hôpital Général de Référence de Logo, Ituri, Democratic Republic of Congo
| | - Richard Lokonda
- Mont Amba Neuropsychopathologic Center, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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Kaiser C, Mmbando BP, Siewe Fodjo JN, Suykerbuyk P, Mnacho M, Kakorozya A, Matuja W, Hendy A, Greter H, Makunde WH, Colebunders R. Onchocerciasis-associated epilepsy: another piece in the puzzle from the Mahenge mountains, southern Tanzania. Infect Dis Poverty 2019; 8:35. [PMID: 31122275 PMCID: PMC6533739 DOI: 10.1186/s40249-019-0545-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/29/2019] [Indexed: 11/10/2022] Open
Abstract
In a study from the onchocerciasis-endemic area of Mahenge in southern Tanzania, Mmbando et al. [Inf Dis Poverty. 2018;7:64] demonstrate that in four selected villages the overall epilepsy prevalence was high, and significantly more elevated in the two villages of higher onchocerciasis endemicity compared to those of lower endemicity. This is replicating earlier findings from many other areas of tropical Africa. The authors are also providing data indicating that in the Mahenge focus, the prevalence of nodding syndrome may be related to that of onchocerciasis in the same way as epilepsy in general. The application of a clinical case definition for onchocerciasis-associated epilepsy (OAE) as used in the study of Mmbando et al. [Inf Dis Poverty. 2018;7:64] faces some difficulties; indeed, its precision in discerning cases of OAE from epilepsy due to other etiologies is not known, and it does not allow for a specific diagnosis in the individual patient. Because an operational surveillance tool for assessing the number of patients in the population could mean substantial advance for better estimating the burden of OAE, the proposed definition should be tried in different settings and its performance reviewed in the process.
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Affiliation(s)
- Christoph Kaiser
- Pediatric Practice, Balzenbergstrasse 73, 76530, Baden-Baden, Germany.
| | - Bruno P Mmbando
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania.
| | | | | | | | | | - William Matuja
- Muhimbili University of Health and allied Sciences, Dar es Salaam, Tanzania
| | - Adam Hendy
- University of Texas Medical Branch,, Galveston, TX, USA
| | - Helena Greter
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Williams H Makunde
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
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Mukendi D, Tepage F, Akonda I, Siewe JNF, Rotsaert A, Ndibmun CN, Laudisoit A, Couvreur S, Kabutako B, Menon S, Hotterbeekx A, Colebunders R. High prevalence of epilepsy in an onchocerciasis endemic health zone in the Democratic Republic of the Congo, despite 14 years of community-directed treatment with ivermectin: A mixed-method assessment. Int J Infect Dis 2019; 79:187-194. [PMID: 30711145 PMCID: PMC6353816 DOI: 10.1016/j.ijid.2018.10.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/14/2018] [Accepted: 10/26/2018] [Indexed: 11/24/2022] Open
Abstract
A high epilepsy prevalence in the Aketi health zone was observed despite 14 years of community-directed treatment with ivermectin. The high prevalence of OV16 antibodies in children is indicative of high ongoing onchocerciasis transmission. High onchocerciasis transmission is the consequence of high exposure to blackflies and low intake of ivermectin. Head nodding seizures were observed in 13.8% of the persons with epilepsy. Ivermectin coverage needs to be increased and bi-annual distribution should be considered.
Objectives To investigate the reasons for the high prevalence of epilepsy (>6%) discovered in 2015 in the Aketi health zone in the north of the Democratic Republic of the Congo. Methods Persons with epilepsy (PWE) diagnosed in a door-to-door survey in 2015 were traced and re-examined in 2017 by a neurologist. Confirmed PWE were paired with matched controls. For onchocerciasis assessment, children 7–10 years old were tested for IgG4 Onchocerca volvulus (OV16) antibodies, a rapid epidemiological mapping of onchocerciasis (REMO) study was performed, and ivermectin coverage was investigated. Results Forty-three (61.4%) previously diagnosed PWE were traced; the neurologist confirmed the epilepsy diagnosis in all of them. The overall OV16 positivity rate was 64.5%. Poor ivermectin coverage (55.9%) and a high prevalence of onchocercal nodules (>70%) were observed. The prevalence of epilepsy was 5.7% in Aketi rural town, with nine PWE (13.8%) experiencing head nodding seizures. A case-control study showed that PWE had lower body weight and higher ivermectin coverage in 2017 than healthy controls. Conclusions The high prevalence of epilepsy in the Aketi health zone, despite 14 years of community-directed treatment with ivermectin (CDTI), was found to be associated with high onchocerciasis transmission and low ivermectin use. An awareness programme to increase ivermectin coverage and the introduction of a bi-annual CDTI programme should be considered.
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Affiliation(s)
- Deby Mukendi
- Neuropsychopathologic Centre of Mont Amba, University of Kinshasa, Kinshasa, Congo.
| | | | | | | | - Anke Rotsaert
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | | | - Anne Laudisoit
- Global Health Institute, University of Antwerp, Antwerp, Belgium; EcoHealth Alliance, New York, USA.
| | - Simon Couvreur
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | - Blandine Kabutako
- School of Medicine, Bel-Campus Technological University, Kinshasa, Congo.
| | - Sonia Menon
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium.
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Siewe Fodjo JN, Dekker MCJ, Idro R, Mandro MN, Preux PM, Njamnshi AK, Colebunders R. Comprehensive management of epilepsy in onchocerciasis-endemic areas: lessons learnt from community-based surveys. Infect Dis Poverty 2019; 8:11. [PMID: 30738437 PMCID: PMC6368958 DOI: 10.1186/s40249-019-0523-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 01/23/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Onchocerciasis-endemic regions are known to have a high epilepsy prevalence. Limited resources in these areas and poor access to healthcare by persons with epilepsy (PWE) result in a wide anti-epileptic treatment gap, poor seizure control and a high burden of seizure-related complications. Recent community-based surveys highlight the need for epilepsy management strategies suitable for remote onchocerciasis-endemic villages to ensure better health outcomes for PWE. In this paper, we propose a feasible approach to manage PWE in such settings. MAIN TEXT Improved management of PWE in onchocerciasis-endemic areas may be achieved by decentralizing epilepsy care. Simplified approaches for the diagnosis and treatment of epilepsy may be used by non-physicians, under the supervision of physicians or specialists. To reduce the treatment gap, a regular supply of subsidized anti-epileptic drugs (AED) appropriate for different types of onchocerciasis-associated epilepsy should be instituted. Setting up a community-based epilepsy surveillance system will enable early diagnosis and treatment of PWE thereby preventing complications. Community awareness programs on epilepsy must be implemented to reduce stigma and facilitate the social rehabilitation of PWE. Finally, strengthening onchocerciasis elimination programs by optimizing community-directed treatment with ivermectin (CDTI) and considering alternative treatment strategies might reduce the incidence of epilepsy. CONCLUSIONS A community-based approach with task-shifting of epilepsy care from specialists to non-physician health workers will reduce epilepsy-associated morbidity. Increased advocacy and collaboration with various stakeholders is needed to establish a sustainable, cost-effective chronic care model for epilepsy that will significantly improve the quality of life of PWE in onchocerciasis-endemic regions.
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Affiliation(s)
| | - Marieke C. J. Dekker
- Department of Internal Medicine and Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Department of Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Michel Ndahura Mandro
- Global Health Institute, University of Antwerp, Antwerp, Belgium
- Provincial Health Division Ituri, Ministry of Health, Bunia, Democratic Republic of the Congo
| | - Pierre-Marie Preux
- INSERM, Univ. Limoges, Tropical Neuroepidemiology, Institute of Neuroepidemiology and Tropical Neurology, GEIST, 87000, Limoges, CHU, UMR 1094 Limoges, France
| | - Alfred K. Njamnshi
- Department of Neurology, Yaoundé Central Hospital / FMBS, The University of Yaoundé 1, Yaoundé, Cameroon
- Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
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Siewe JNF, Ukaga CN, Nwazor EO, Nwoke MO, Nwokeji MC, Onuoha BC, Nwanjor SO, Okeke J, Osahor K, Chimechefulam L, Ogomaka AI, Amaechi AA, Ezenwa CI, Ezike MN, Ikpeama C, Nwachukwu O, Eriama-Joseph AI, Nwoke BEB, Colebunders R. Low prevalence of epilepsy and onchocerciasis after more than 20 years of ivermectin treatment in the Imo River Basin in Nigeria. Infect Dis Poverty 2019; 8:8. [PMID: 30670093 PMCID: PMC6343278 DOI: 10.1186/s40249-019-0517-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/06/2019] [Indexed: 12/02/2022] Open
Abstract
Background High epilepsy prevalence and incidence have been reported in areas with high onchocerciasis transmission. Recent findings suggest that proper community-directed treatment with ivermectin (CDTI) is potentially able to prevent onchocerciasis-associated epilepsy (OAE). We assessed the epilepsy prevalence and onchocerciasis transmission in two Nigerian villages following more than 20 years of CDTI. Methods A cross-sectional door-to-door survey was performed in two villages in the Imo River Basin reported to be mesoendomic for onchocerciasis (Umuoparaodu and Umuezeala). Individuals were screened for epilepsy using a validated 5-item questionnaire. Persons suspected to have epilepsy were examined by a neurologist or a physician with training in epilepsy for confirmation. Onchocerciasis was investigated via skin snip microscopy and rapid diagnostic tests for Ov16 antibodies. Results were compared with previous findings from the Imo river basin. Results A total of 843 individuals from 257 households in the two villages were encountered. We detected four persons with epilepsy (PWE) giving a crude epilepsy prevalence of 0.5%. This finding differs from observations reported 14 years ago which showed an epilepsy prevalence of 2.8% in the neighbouring village of Umulolo (P = 0.0001), and 1.2% from 13 villages in the Imo river basin (P = 0.07). The seroprevalence of Ov16 antibodies was found to be 0%. Only 4.6% of skin snips were positive compared to 26.8% in previous surveys (P < 0.0001). Ivermectin mass distribution coverage in the study sites in 2017 was 79.7%. Conclusions A low epilepsy and onchocerciasis prevalence was observed following more than 20 years of CDTI in the Imo River Basin. Absence of Ov16 antibodies indicates minimal transmission of onchocerciasis. These results contrast with observations from areas of high onchocerciasis transmission, where epilepsy prevalence and incidence remain high. Findings from this study suggest that sustained efforts could eventually achieve elimination of onchocerciasis in these villages. Electronic supplementary material The online version of this article (10.1186/s40249-019-0517-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph N F Siewe
- Global Health Institute, University of Antwerp, Campus Drie Eiken, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium.
| | | | - Ernest O Nwazor
- Federal Medical Centre, Owerri, Nigeria.,Madonna University Teaching Hospital, Elele, Nigeria
| | | | | | | | | | - Joel Okeke
- Imo State Ministry of Health, Owerri, Nigeria
| | | | | | | | | | | | | | | | | | | | | | - Robert Colebunders
- Global Health Institute, University of Antwerp, Campus Drie Eiken, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium
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Siewe JFN, Ngarka L, Tatah G, Mengnjo MK, Nfor LN, Chokote ES, Boullé C, Nkouonlack C, Dema F, Nkoro GA, Njamnshi WY, Tabah EN, Zoung-Kanyi Bissek AC, Colebunders R, Njamnshi AK. Clinical presentations of onchocerciasis-associated epilepsy (OAE) in Cameroon. Epilepsy Behav 2019; 90:70-78. [PMID: 30513438 DOI: 10.1016/j.yebeh.2018.11.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/16/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND A high prevalence of epilepsy has been observed in several onchocerciasis-endemic countries, including Cameroon. However, little is known on the clinical presentations of the affected persons with epilepsy (PWE). A community-based study was conducted with the aim of describing the spectrum of seizures in selected onchocerciasis-endemic villages in Cameroon and documenting relevant medical history in patients with onchocerciasis-associated epilepsy (OAE). METHODS We carried out door-to-door surveys in 5 onchocerciasis-endemic villages in Cameroon and recruited all consenting PWE. Epilepsy was diagnosed using a 2-step approach consisting of the administration of a standardized 5-item questionnaire followed by confirmation of the suspected cases by a neurologist. Onchocerciasis-associated epilepsy was defined as ≥2 seizures without an obvious cause, starting between the ages of 3-18 years in previously healthy persons having resided for at least 3 years in an onchocerciasis-endemic area. Ivermectin use by PWE was verified. Seizure history, relevant past medical, and family history, as well as neurological findings, were noted. RESULTS In all, 156 PWE were recruited in the 5 villages. The modal age group for epilepsy onset was 10-14 years. The diagnostic criteria for OAE were met by 93.2% of the PWE. Participants had one or more of the following seizure types: generalized tonic-clonic seizures (89.1%), absences (38.5%), nodding (21.8%), focal nonmotor (7.7%), and focal motor seizures (1.9%). One case (0.6%) with the "Nakalanga syndrome" was identified. More than half (56.4%) of PWE had at least one seizure per month. In one village, 56.2% of PWE had onchocercal skin lesions. CONCLUSION People with epilepsy in onchocerciasis-endemic villages in Cameroon present with a wide clinical spectrum including nodding seizures and Nakalanga features. A great majority of participants met the diagnostic criteria for OAE, suggesting that better onchocerciasis control could prevent new cases. Epilepsy management algorithms in these areas must be adjusted to reflect the varied seizure types.
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Affiliation(s)
| | - Leonard Ngarka
- Neurology Department, Yaoundé Central Hospital, Cameroon; Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon
| | - Godwin Tatah
- Neurology Department, Yaoundé Central Hospital, Cameroon; Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon; Neurology Department, CH Saint Nazaire, France
| | - Michel K Mengnjo
- Neurology Department, Yaoundé Central Hospital, Cameroon; Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon
| | - Leonard N Nfor
- Neurology Department, Yaoundé Central Hospital, Cameroon; Neurology Department, CHU Brugmann, Belgium
| | - Eric S Chokote
- Neurology Department, Yaoundé Central Hospital, Cameroon; Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon
| | - Charlotte Boullé
- Institut de Recherche pour le Développement, UMI 233-Inserm U1175-Montpellier University, France
| | | | | | - Grace A Nkoro
- Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon
| | - Wepnyu Y Njamnshi
- Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon; Faculty of Science and Medicine, University of Fribourg, Switzerland
| | | | | | | | - Alfred K Njamnshi
- Neurology Department, Yaoundé Central Hospital, Cameroon; Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Cameroon; Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon.
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Baseline characterization of epilepsy in an onchocerciasis endemic area of the Democratic Republic of Congo. Brain Res Bull 2018; 145:45-52. [PMID: 30468846 DOI: 10.1016/j.brainresbull.2018.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 11/03/2018] [Accepted: 11/13/2018] [Indexed: 11/22/2022]
Abstract
Increased epilepsy prevalence is reported in onchocerciasis (OC) endemic areas and is associated with the occurrence of distinct syndromes such as nodding disease and Nakalanga syndrome. To date, a causal relationship between OC and epilepsy is still a matter of controversy. We conducted a case-control study of participants with epilepsy and age- and gender-matched presumably healthy controls to elucidate the relationships between OC and epilepsy and explore the role of inflammation and growth factors in an OC endemic area in the Democratic Republic of Congo (DRC). Eighty-two participants with epilepsy (mean age ± SD: 23.2 ± 8.7 years) and 27 controls (mean age ± SD: 22.3 ± 12.0 years) underwent snip skin biopsies to determine Onchocerca volvulus infection status. Serum concentrations of cytokines, chemokines, and growth factors were measured using a Luminex Multiplex Assay kit. Children <19 years of age underwent neurocognitive assessments using the Kaufman Assessment Battery for Children, 2nd edition (KABC-II). Overall, epilepsy was associated with OC (OR = 4.51, z = 3.11, p = 0.0019), and children with OC were more likely to be severely stunted (OR = 11.67, z = 2.62, p = 0.0087). The relationship between epilepsy and OC was no longer significant (z = 1.27, p = 0.20) when stunting was included as a correcting covariate. Epilepsy was associated with poor KABC-II test scores, high serum levels of IL-17, and low levels of IL-1RA, IL-8, and EGF. KABC-II testing scores correlated with serum levels of IL-10, MCP-1 and HGF. Familial history of epilepsy occurred frequently. Future studies should consider cytokines and/or growth factors when assessing susceptibility to epilepsy in OC endemic areas. Additional investigations, preferentially in low-prevalence OC areas, may provide further insights into the concept, risk, and burden of river epilepsy.
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Kaiser C, Asaba G, Rubaale T, Tukesiga E, Kipp W. Onchocerciasis-Associated Epilepsy with Head Nodding Seizures-Nodding Syndrome: A Case Series of 15 Patients from Western Uganda, 1994. Am J Trop Med Hyg 2018; 99:1211-1218. [PMID: 30226148 PMCID: PMC6221207 DOI: 10.4269/ajtmh.18-0511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/05/2018] [Indexed: 11/07/2022] Open
Abstract
Nodding syndrome (NS) is an encephalopathy characterized by the core symptom of epileptic head nodding seizures, affecting children at the age between 3 and 18 years in distinct areas of tropical Africa. A consistent correlation with onchocerciasis was found, but so far, the causation of NS has not been fully clarified. With a systematic analysis of features of a cohort of epilepsy patients examined in the Itwara onchocerciasis focus of western Uganda in 1994, we provide evidence that NS actually occurred in this area at this time, and we demonstrate a correlation between prevalence of NS and that of onchocerciasis in different villages. Following the elimination of onchocerciasis by community-directed treatment with ivermectin and ground larviciding, our data provide a baseline to examine the question whether NS will disappear once its putative cause has been removed.
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Affiliation(s)
- Christoph Kaiser
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - George Asaba
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - Tom Rubaale
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - Ephraim Tukesiga
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
| | - Walter Kipp
- Basic Health Services Kabarole and Bundibugyo Districts, Fort Portal, Uganda; Vector Control Unit, Ministry of Health, Fort Portal, Uganda; Department of Public Health Sciences, University of Alberta, Edmonton, Canada
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Lenaerts E, Mandro M, Mukendi D, Suykerbuyk P, Dolo H, Wonya'Rossi D, Ngave F, Ensoy-Musoro C, Laudisoit A, Hotterbeekx A, Colebunders R. High prevalence of epilepsy in onchocerciasis endemic health areas in Democratic Republic of the Congo. Infect Dis Poverty 2018; 7:68. [PMID: 30064504 PMCID: PMC6069757 DOI: 10.1186/s40249-018-0452-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/14/2018] [Indexed: 11/15/2022] Open
Abstract
Background A high prevalence of epilepsy has been observed in many onchocerciasis endemic regions. This study is to estimate the prevalence of active epilepsy and exposure to Onchocerca volvulus infection in a rural population in Ituri province, Democratic Republic of Congo. Methods In August 2016, a community-based cross-sectional study was conducted in an onchocerciasis endemic area in the rural health zone of Logo, Ituri Province. Households within two neighbouring health areas were randomly sampled. To identify persons with epilepsy, a three-stage approach was used. In the first stage, all individuals of the selected households were screened for epilepsy by non-medical field workers using a validated 5-item questionnaire. In the second and third stage, suspected cases of epilepsy were examined by non-specialist medical doctors, and by a neurologist, respectively. A case of epilepsy was defined according to the 2014 International League Against Epilepsy (ILAE) guidelines. Exposure to O. volvulus was assessed by testing for IgG4 antibodies to an O. volvulus antigen (OV16 Rapid Test,) in individuals aged 3 years and older. Results Out of 1389 participants included in the survey, 64 were considered to have active epilepsy (prevalence 4.6%) (95% confidence interval [CI]: 3.6–5.8). The highest age-specific epilepsy prevalence estimate was observed in those aged 20 to 29 years (8.2%). Median age of epilepsy onset was 10 years, with a peak incidence of epilepsy in the 10 to 15 year-old age group. OV16 test results were available for 912 participants, of whom 30.5% (95% CI, 27.6–33.6) tested positive. The prevalence of OV16 positivity in a village ranged from 8.6 to 68.0%. After adjusting for age, gender and ivermectin use, a significant association between exposure to onchocerciasis and epilepsy was observed (adjusted odds ratio = 3.19, 95% CI: 1.63–5.64) (P < 0.001). Conclusions A high prevalence of epilepsy and a significant association between epilepsy and exposure to O. volvulus were observed in the population in Ituri province, Democratic Republic of Congo. There is an urgent need to implement a CDTI programme and to scale up an epilepsy treatment and care programme. Electronic supplementary material The online version of this article (10.1186/s40249-018-0452-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Evy Lenaerts
- Global Health Institute, University of Antwerp, Antwerp, Belgium. .,Global Health Institute, Faculty of Medicine and Health Sciences, Gouverneur Kinsbergen Centrum, Doornstraat 331, 2610, Wilrijk, Belgium.
| | - Michel Mandro
- Global Health Institute, University of Antwerp, Antwerp, Belgium.,Provincial Health Division of Ituri, Ministry of Health, Bunia, Democratic Republic of Congo
| | - Deby Mukendi
- Centre Neuro Psycho Pathologique, Université de Kinshasa (CNPP-UNIKIN), Kinshasa, Democratic Republic of Congo
| | | | - Housseini Dolo
- Global Health Institute, University of Antwerp, Antwerp, Belgium.,International Center of Excellence in Research, Faculty of Medicine and Odontostomatology, Bamako, Mali
| | - Deogratias Wonya'Rossi
- Neglected Tropical Diseases Control program, Ministry of Health, Bunia, Democratic Republic of the Congo.,Centre de Recherche en Maladies Tropicales, Hôpital Général de Référence de Rethy, Rethy, Democratic Republic of Congo
| | - Françoise Ngave
- Centre de Recherche en Maladies Tropicales, Hôpital Général de Référence de Rethy, Rethy, Democratic Republic of Congo
| | - Chellafe Ensoy-Musoro
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, University of Hasselt, Hasselt, Belgium
| | - Anne Laudisoit
- Global Health Institute, University of Antwerp, Antwerp, Belgium.,EcoHealth Alliance, New York, USA
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Robert Colebunders
- Global Health Institute, University of Antwerp, Antwerp, Belgium. .,Global Health Institute, Faculty of Medicine and Health Sciences, Gouverneur Kinsbergen Centrum, Doornstraat 331, 2610, Wilrijk, Belgium.
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41
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Colebunders R, Nelson Siewe FJ, Hotterbeekx A. Onchocerciasis-Associated Epilepsy, an Additional Reason for Strengthening Onchocerciasis Elimination Programs. Trends Parasitol 2017; 34:208-216. [PMID: 29288080 DOI: 10.1016/j.pt.2017.11.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
Abstract
A high prevalence of epilepsy has been observed in onchocerciasis-endemic regions with high onchocerciasis transmission. Recent epidemiological studies suggest that Onchocerca volvulus infection is the trigger causing the seizures, which appear in previously healthy children between the ages of 3 and 18 years. Persons with onchocerciasis-associated epilepsy present with a wide spectrum of seizures, including atonic and myoclonic neck seizures; but also absences and most frequently generalized tonic-clonic seizures. Often individuals present with intellectual disabilities and psychiatric disorders and occasionally with 'Nakalanga' features such as severe stunting with delayed or absent external signs of sexual development. Onchocerciasis-associated epilepsy, because of its importance as a public health problem, is an additional reason for strengthening onchocerciasis elimination programs.
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Affiliation(s)
| | - F J Nelson Siewe
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - An Hotterbeekx
- Global Health Institute, University of Antwerp, Antwerp, Belgium
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42
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Kaiser C, Pion SDS. River blindness goes beyond the eye: autoimmune antibodies, cross-reactive with Onchocerca volvulus antigen, detected in brain of patients with Nodding syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:459. [PMID: 29285492 DOI: 10.21037/atm.2017.08.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Sébastien D S Pion
- UMI 233, Institut de Recherche pour le Développement (IRD) and University of Montpellier 1, Montpellier, France
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43
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Colebunders R, Njamnshi AK, van Oijen M, Mukendi D, Kashama JM, Mandro M, Gumisiriza N, Preux PM, Suykerbuyk P, Idro R. Onchocerciasis-associated epilepsy: From recent epidemiological and clinical findings to policy implications. Epilepsia Open 2017; 2:145-152. [PMID: 29588943 PMCID: PMC5719844 DOI: 10.1002/epi4.12054] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 11/12/2022] Open
Abstract
A high prevalence of epilepsy is reported in many onchocerciasis‐endemic regions. In this paper we discuss recent epidemiological and clinical aspects as well as public health implications of onchocerciasis‐associated epilepsy (OAE) and propose a strategy to reduce the burden of disease. OAE probably presents in a variety of clinical manifestations, including the nodding syndrome and the Nakalanga syndrome. The most common clinical presentation, however, is generalized (primarily tonic‐clonic) seizures. A characteristic of OAE is the onset of seizures between the ages of 3 and 18 years and clustering in certain families and villages close to rapid‐flowing black‐fly‐infested rivers. A strategy combining active surveillance for epilepsy with early treatment with antiepileptic drugs and prevention of onchocerciasis by increasing the geographical and therapeutic coverage of community‐directed treatment with ivermectin (CDTi) may considerably decrease the burden of disease.
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Affiliation(s)
| | - Alfred K Njamnshi
- Neurology Department Central Hospital Yaoundé Faculty of Medicine and Biomedical Sciences the University of Yaoundé IYaoundé IRepublic of Cameroon
| | - Marieke van Oijen
- Global Health Institute University of Antwerp Antwerp Belgium.,Department of Neurology Academic Medical Center Amsterdam the Netherlands
| | - Deby Mukendi
- Neuro-psycho-pathological Centre University of Kinshasa Kinshasa Democratic Republic of the Congo
| | - Jean Marie Kashama
- Neuro-psycho-pathological Centre University of Kinshasa Kinshasa Democratic Republic of the Congo
| | - Michel Mandro
- Provincial division of Health of Ituri Ministery of Health Bunia Democratic Republic of the Congo
| | | | | | | | - Richard Idro
- College of Health Sciences Makerere University Kampala Uganda.,Nuffield Department of Medicine Centre for Tropical Medicine and Global Health University of Oxford Oxford United Kingdom
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