Sunday, June 18, 2006

"I Can't Breathe"

Suze was a typical patient-- young, attractive, well spoken, and dying. Suze is Haitian and poor and when Maria and I saw her several years ago, she was very thin and barely able to walk due to severe shortness of breath with any exertion. Her heart exam revealed her mitral valve was not working right. She did not have long to live.

She told us how, not long before seeing us, she passed out one day and woke up on a gurney in and emergency department of a small hospital near her home in one of the slums of Port-au-Prince. She was staring out the slats of a window at her friends that were staring in at her. They had carried her limp body to the hospital after she had lost consciousness and taken up a collection of money to get her admitted for medication to treat her heart failure.

Suze survived and came back to the U.S. with us for a mitral valve replacement. Surgical intervention is usually necessary with people like Suze to give them long term relief from their symptoms. After surgery, her personality changed from someone who was waiting for death, to someone who is very happy to be alive.

In Haiti we hear this complaint all of the time: “I can’t walk up the mountain anymore”. Usually it is not from old people but from teenagers that have come to the clinic and have rheumatic heart disease. It breaks your heart to see these kids suffering so much. They want to go to school and be like normal kids--but they can’t due to their sick hearts.

Rheumatic heart disease has been around as long as strep throat has afflicted humanity. For some reason when one gets strep throat, the immune system can attack the heart, joints, brain, and skin. “Antigenic mimicry” and nasty strains of streptococcus are argued as possible causes for rheumatic fever, but no one knows for sure why some people get strep throat and do fine, and others are crippled with its sequelae. Any part of the heart can be attacked and damaged. We examine kids that had acute acute rheumatic fever when they were much younger and show up when they are 18 years old with valves that are destroyed.

The mitral valve is the valve most likely injured in rheumatic fever and may not close well or may not open well or a combination of both. These kids are in a world of hurt because as they years pass, they become unable to do much requiring physical activity because their lungs fill with fluid.

Rheumatic fever is a major public health problem in many developing countries like Haiti. Two-thirds of the world’s population is considered poor and this is where rheumatic fever is found. The magnitude of rheumatic fever in the developing world is the same as in the United States 60 years ago---before widespread use of penicillin. Rheumatic fever is not gone in the United States, but it is not the first thing I think of in an American kid who presents with joint complaints and fever.

There is a real danger that research regarding atherosclerosis in the developing world will divert resources and attention from rheumatic heart disease, cardiomyopathies, and tuberculous pericarditis. These are the three major causes of heart disease in Haiti and Africa. Of the nearly 2.4 million children with rheumatic heart disease living in developing countries, nearly half live in sub-Saharan Africa. According to Lancet, June 10, 2006, “They cause great morbidity and mortality in young, economically active people, but with isolated exceptions, they are largely neglected targets of epidemiological, etiological, and therapeutic research.”

The Lancet continues, “Eradication of rheumatic fever depends on social changes, including improved primary health-care services, elimination of poverty, better housing, and application of existing knowledge on primary and secondary prevention of the disease”.

There are many patients in Haiti that we are treating for rheumatic heart disease. Few will make it out for definitive surgical repair.

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