HERNIAS AND ONCHOCERCIASIS EDUNGBOLA1, BABATA2, A. L., PARAKOYI3, B. D. OLADIRAN2, A. O., JENYO2, M. S., and ASAOLU4, S. O. 1. 2. 3. 4. Department of Microbiology & Parasitology Department of Surgery Department of Epidemiology & Community Health Faculty of Health Sciences, University of Ilorin, Ilorin. Department of Zoology, Obafemi Awolowo University, Ile-Ife. ABSTRACT Eight hundred and sixty cases of hernias seen at the University of Ilorin Teaching Hospital (UITH) between 1984 and 1987 and 152 similar cases encountered during surveys of onchocerciasis among 7,726 subjects in 5 rural districts of Kwara State between 1983 and 1988 were reviewed for a possible evidence of an association between onchocerciasis and hernias. Four hundred and twenty-one (49%) of the hospital cases had skin snip records while all the subjects in the field survey group were skin snipped. Whereas 48% of the hospital cases had positive skin snips, 75.4% of the survey group were positive for skin microfinance (mf). Although there was no data on the prevalence of onchocercomata and leopard skin (LS) for the hospital group, 61.8% and 7.6% of the survey group had onchocercal nodules and/or hanging groins and LS respectively. These observation seem to support the literature contentions that high prevalence of hernias are closely associated wit high endemicity of onchocerciasis. The pathogenesis of onchocerciasis-related hernias and hanging groins is briefly reviewed. INTRODUCTION RESULTS Blindness, hernias, leopard skin, hanging groins and elephantiasis have been identified as important complications of onchocerciasis in areas where the disease is endemic (1-14). While the association between hanging groins and hernias has been reported (10,14), it has also been established that hernia is a definite and major complication of onchocerciasis (7,14). More than 60% of remaining cases of onchocerciasis in West Africa occurs in Nigeria and several highly endemic communities have been identified in kwara State, including some communities around Ilorin, the State capital. Because of the high prevalence of hernias seen in the Nigerian hospitals and encountered in field surveys, this study was made to review the available hospital and survey record for any possible evidence of an association between onchocerciasis and hernias. Prevalence of hernias and onchocerciasis were relatively high both in the hospital record and in the results of the epidemiological field surveys. MATERIALS AND METHODS Hospital records were reviewed for types and cases of hernias seen between 1984 and 1987 in the University of Ilorin Teaching Hospital (UITH). Similarly records of the epidemiological survey of onchocerciasis made in 5 rural farming communities in Kwara State between 1983 and 1988 were reviewed for prevalence of hernias skin mf, hanging groins, onchocercal nodules, leopard skin and blindness. The results were analysed statistically tabulated. Table 1: Cases of Hernias Reviewed at the UITH between 1984 and 1987. Year 1984 1985 1986 1987 TOTAL No. of Cases 343 148 215 154 860 % Cases 39.9 17.2 25.0 17.9 100.0 Table 2: The Classification of Cases of Hernias Reveiwed in the UITH between 1984-1987 Types of Hernias No. of Cases % Cases Right inguinal 429 49.9 Left inguinal 228 26.5 Bilateral inguinal 43 5.0 Unclassified inguinal 95 11.0 Femoral 20 2.3 Incisional 9 1.0 Umbilical 25 2.9 Others* 11 1.3 * = Gluteal, Ventral, Lumbar and Epigastric hernias. 1.2 1.8 Hypo .8 0.5 2.8 6.9 Hypo 4.6 3.8 7.5 42.8 Meso 9.8 7.5 7.6 38.6 Meso 9.2 8.3 6.3 45.0 Meso 8.9 11.6 Prevalence Blindness (%) Prevalence Hanging Groin (%) Prevalenc e Nodules (%) Prevalenc eLS(%) Onchocerca l Endemicity 42 11 8 2468 1887 1060 Ile-Ife Shagunu Agwara 22 2018 Shao 48 Babana 993 NO. of Hernia Cases No. Examined Study Area Table 3: Cases of Hernias in Relations to Onchocercal Endemicity Prevalence of Leopard skin, Nodules, Hanging Groins and Blindness DISCUSSION Onchocerciasis is primarily an occupational disease of farmers, animal rearers and fishermen and is widespread and highly prevalent in different foci in Nigeria. Being a polymorphic disease onchocerciasis could manifest as skin lesions, onchocercomata, hanging groins and blindness. There are strong indications that scrotal elephantiasis and hernias are important complications of onchocerciasis. Hanging groin has been shown to be related to heavy onchocercal infection and quite distinct from elephantiasis and hernias (7). While the association of hanging groin with hernia has been reported (7,14). Both Hospital and epidemiological field records show high prevalence of hernias for high endemicity of onchocerciasis. Of the various health constitute a leading problem confronting adult farmers in highly endemic rural communities, hernias constitute a leading problem for which rural farmers frequently seek treatment. Also, many cases of advanced hernias, some resulting in death, have been encountered during our field surveys. Until recently, vector control larviciding, micro and macro-filaricidal chemotherapy and blindness have dominated the focus of human onchocerciasis. This is because of the medical and socioeconomic seriousness of the disease. Whereas other complications of onchocerciasis, such as hernias, elephantiasis hanging groins, onchocercomata and different types of skin Figure 1 – 7: Some major manifestations of onchocerciasis which can predispose to severe morbility. Pretibia onchocercal depigmentation (“Leopard skin”) Tables 1 and 2 show the cases of hernias reviewed in the University of Ilorin Teaching Hospital (UITH) by year and Classification. Table 3 also shows cases hernias in relation to onchocercal endemicity, geographical areas and prevalence of onchocercomata, hanging groin, leopard skin and blindness. 2. Bilateral hanging groins 7. Blindness, the worst and most dreadful complication of onchocerciasis lesions (Fig. 1-7) are well recognized and reported, the disfiguration, embarrassment and severe morbidity caused by these complications have not been given adequate attention for intervention. Like blindness, the irreversibility of these conditions and the absence of a simple, cheap and effective intervention, make them as frightening as blindness itself. The advent of ivermectin (an effective microfilaricidal and an in utero microfilaria suppressant) for the large scale treatment of onchocerciasis and the commitment to the development of a macrofilarcide e.g, amocarzine (15) and/or an effective vaccine, reaffirms the good prospects for the control and, possibly, the eradication of human onchocerciasis. 3&4. Front and back views of an advanced scrotal elephantiasis While implementing the large scale treatment of onchocerciasis e.g. with ivermectin, appropriate intervention programme to deal with other disabling manifestations on onchocercisasis, such as hernias, elephantiasis, hanging groins and severe skin lesions, should be integrated into the chemotherapy control strategy. Whereas the groin pathology is known to be associated with onchocerciasis (1,3), its pathogenesis and those of other manifestations of the disease remain poorly understood and controversial. The onchocercal hanging groins have been attributed to obstructive lymphadenitis (16). 5 & 6: Inguino-femoral hernias. Based on their pathophysiology, the two main types of groin hernias are 1) indirect inguinal hernias of congenital origin and 2) acquired and direct inguinal hernias (17). The aetiology of acquired hernias, especially those associated with onchocerciasis, remains a subject of debate. Nelson (7). Suggested that hernias in onchocerciasis are caused by the weight of hanging tissues which weakened the femoral or inguinal canals. On the other hand, Gibson and Connor (16) contended that hanging groins are caused by the deposition of immune-complexes of microfilariae in the tissues which elicites obstructive lymphadenitis. However, strong reservations for the validity of these concepts have been expressed (17). The general concensus is that the aetiology of the acquired hernias is the weakness in the transversalis fascia of Hesselback’s triangle in the inguinofemoral region, (17,18). Thus, Guderian and Kerrigan (17) believed that the presence of microfilariae of O. volvulus in the groins of an infected individual could induce local disorder of collagen metabolism which in turn results in the weakening of the transver-Salis fascia of the Hesselbach’s triangle. They (17) based their ascertion on experimental results which attributed acquired groin hernias to a connective tissue abnormality, specific to disorders of collagen metabolism as well as to other established clinical and laboratory conditions which are related to higher prevalence of hernias. Two of such conditions which are related to higher prevalence of hernias. Two of such conditions are the Marfan’s syndrome and Ehler. Danlos Syndrome (Type v). both syndromes are inherited diseases characterized by disorders of collagen metabolism (17). According to Pinnell and Murad (19), increased prevalence of hernia formation is one of the clinical manifestations of this abnormality in collagen metabolism. Also, it has been shown (20) that Lathyrism. (the experimental administration of beta-amino proprionitrile to laboratory animals to induce a derangement of collagen metabolism), is characterized by an increased prevalence of hernias as one of its important manifestations. Further studies are required to ascertain the existence of collagen disorders in onchocerciasis or whether the condition is attributable to the deposition of antigen-antibody immune-complexes in the tissues and thereby, producing obstructive lymphadenitis. Acknowledgment We thank Mr. Johnson T. Ore and Dr. Bada for their assistance. REFERENCES 1. Browne, S. G. (1960) onchocercal depigmentation Trans. R. Soc. Trop. Med. Hyg. 54, 325-334. 2. Buck, A. A. (1974) Onchocerciasis, Sympatomatology, Pathology, Diagnosis, World Health Organization, Geneva. 3. Connor, D.H., Morrison, N. E., Kerdel-Vegas, F. Berkoff, H. A. Johnson, F., Tunnicliffe, R., Failing, F.C. Hale, L. N. & Lindquist, K. (1970) Onchocercal dermatitis, lymphadenitis, and elephantiasis in the Ubanji Territory. Human Pathol. 1, 553 – 579. 4. 5. Cowper S. F. & Hughlings, J. (1964) Onchocercal hydrocoele without cutatenous man festations J. Trop. Med. Hyg. 67, 69-71 Edungbola, L. D., Oni, G. A. & Aiyedun, B. A. 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