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.
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