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Podoconiosis, a society and medical community neglected disease
Podoconiosis: enfermedad olvidada por la sociedad y la comunidad médica
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(10x): Apréciese la hiperplasia epidérmica con importante esclerosis de la dermis y proliferación y ectasias linfáticas. Detalle (40x): infiltrado linfoplasmocitario perivascular. Las biopsias fueron realizadas en 2 pacientes que previamente se habían ofrecido voluntarios. La información acerca del procedimiento fue aportada de forma verbal, debido a la elevada tasa de analfabetismo, dando ambos pacientes su consentimiento. Con el fin de evitar complicaciones infecciosas en el medio rural, fueron ingresados durante una semana en el hospital, extremando las medidas de asepsia e higiene local. 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A. Intraglomerular thrombosis. B. Ischaemic and retracted glomerulus. C. Artery occluded by platelet thrombi. D. Arteriole with complete occlusion by thrombi. Images courtesy of Dr. M. Sole (Department of Pathology, Hospital Clínic, Barcelona).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Miquel Blasco Pelicano, Santiago Rodríguez de Córdoba, Josep M. Campistol Plana" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Miquel" "apellidos" => "Blasco Pelicano" ] 1 => array:2 [ "nombre" => "Santiago" "apellidos" => "Rodríguez de Córdoba" ] 2 => array:2 [ "nombre" => "Josep M." 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(10×): Note the epidermal hyperplasia with significant dermal sclerosis and lymphatic ectasia proliferation. Detail (40×): perivascular lymphoplasmacytic infiltrate. Biopsies were performed in 2 patients who had previously volunteered. Information about the procedure was provided verbally, due to the high rate of illiteracy, both patients giving consent. In order to prevent infectious complications in rural areas, they were hospitalised for a week, taking extreme antisepsis and local hygiene measures. There were no complications and the wounds healed without any problems.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Podoconiosis, whose history dates back 20 centuries before our era, was confused for a long time with leprous and filarial elephantiasis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The first observation that related it to a specific area (or type of soil) was made by Guatemalan doctor Rodolfo Robles (1878–1939), who in 1938 published his work on 150 patients diagnosed with Hansen's disease and housed in the leprosarium of the capital of Guatemala. He noted that the patients came from the volcanic highlands of the country and that all went barefoot, and wrote: “Affects people living between 1000 and 2000<span class="elsevierStyleHsp" style=""></span>m above sea level… first occurs between the age of 5 and 20 as a red spot on the lower third of the leg with local heat and swelling of the foot… eventually, the toes also swell, as well as the soles, so that the toe tips do not touch the ground and the skin becomes coarse, wrinkled and tough.” Bacteriology and filarial evidence tests resulted negative in all cases and he called it “seudolepra” (<span class="elsevierStyleItalic">punudos</span> in indigenous terminology).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Also, between 1934 and 1956, Loewenthal, in Uganda, Macfie in Ethiopia, Clark in Kenya and Jordan in Tanzania, described cases of non-filarial and non-leprous endemic elephantiasis in the highlands of these East African countries.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a> In turn, Oomen, in 1969, studied 6770 cases of elephantiasis in different areas of Ethiopia, confirming Robles observation that most patients lived between 1000 and 2000<span class="elsevierStyleHsp" style=""></span>m above sea level, and had a prevalence, depending on the area, between 2.7% and 8.8%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the 70s, the British surgeon Ernest W. Price studied the environmental and social factors in 800 patients in Ethiopia. He dismissed his filarial aetiology, confirmed that it was located in volcanic areas, found that the regional lymph nodes of patients contained mineral microparticles and described the symptoms and developmental stages of this disease to which he baptized with the name of <span class="elsevierStyleItalic">Podoconiosis</span> (Gr.πóδóζ -<span class="elsevierStyleItalic">podos</span>: foot; κóν¿ωζ -<span class="elsevierStyleItalic">coneos</span>: dust, sand). He noticed the subendothelial oedema, endolymphangitis, collagenisation and those vessels’ light obstruction in the lower limbs and verified the presence of iron and aluminium silicates and oxides within the macrophages of the femoral nodes in patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,11–14</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Geology, epidemiology and socioeconomics</span><p id="par0020" class="elsevierStylePara elsevierViewall">Podoconiosis is a geochemical disease and its geographic distribution is closely related with soil formed by the disintegration of basaltic volcanic rocks over time. By action of environmental factors (altitude over 1500<span class="elsevierStyleHsp" style=""></span>m above sea level, an average temperature of 20<span class="elsevierStyleHsp" style=""></span>°C with low night temperatures and rainfall patterns over 1000<span class="elsevierStyleHsp" style=""></span>mm/year,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> similar to a wetland area of northern Spain), the lava ends up fractioning in particles of less than 2<span class="elsevierStyleHsp" style=""></span>μm in diameter composed of quartz, clays (silicates), metal hydroxides and minerals like beryllium and zirconium, substances involved in the formation of granulomas in vessels and lymph nodes. These microparticles of moist, soft and sticky clays, adhere, encrust and penetrate the skin of the foot sole and dorsum (especially through the folds), the reiteration throughout the years of those microtraumas, which promote transcutaneous penetration of the microparticles, the cause of the disease<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">.</span><a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–19</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">There are endemic areas in tropical Africa (Sudan, Ethiopia, Kenya, Uganda, Tanzania, Rwanda, Burundi, Cameroon, Equatorial Guinea and islands of Sao Tome and Principe, Bioko and Cape Verde), Central and South America and northern India, and it is estimated that at least 4 million people suffer from it, one million in Ethiopia and half a million in Cameroon.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,20</span></a> Those areas are not normally affected by filarias because insects and arthropod vectors cannot bear the cold night temperatures of those highlands. In endemic areas of Ethiopia, its prevalence ranges between 2.8% and 7.4%<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Symptoms usually begin between the second and third decade of life and most of those affected are farmers, illiterate and poor, without access to hygiene or footwear. Almost everyone suffers recurrent secondary infections of the skin and subcutaneous cell tissue of the feet and legs favoured by stretching and skin lesions resulting from chronic lymphedema. Infections can be caused by bacteria, fungi and viruses, annually suffering several episodes of acute cellulitis, lymphangitis and lymphadenitis, preventing patients to work for several weeks each year. This affects Ethiopia's economy. It has been estimated that the cost of this disease in terms of productivity loss is about 200 million dollars a year.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> To this, the social stigma should be added, since children are marginalized and expelled from schools, young women can not marry, adults are excluded from social or religious meetings and the appearance of one case in a family becomes a scourge for the whole. Many of those affected isolate themselves, hide their illness and do not seek local medical aid, which in most cases is limited.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Family and genetic distribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">Not all who live or work barefoot in volcanic irritant terrains or all members of the same family suffer Podoconiosis. Price already said in 1972 that there must have been some genetic susceptibility,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> but it was not until 2007 when a study conducted in Ethiopia in several generations of affected population showed that siblings of a patient with Podoconiosis have 5 times greater a risk of suffering it than the general population.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In addition, a genetic study in that country showed that susceptibility to the disease is found in variants of the HLA locus on chromosome 6. Thus, single nucleotide polymorphisms have been found in these patients located at or near to the histocompatibility antigen class <span class="elsevierStyleSmallCaps">ii</span> genes (HLA-DQA1, HLA-DQB1 and HLA-DRB1 alleles) with a significantly higher frequency than in healthy controls of the same region, which shows that the basis of its pathogenesis is a T cell-mediated inflammation.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> These alleles may play a role in antigen presentation to T cells, inducing the immune response and THE development of disease in response to a soil antigen or mineral still undefined.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pathogenesis and pathology</span><p id="par0040" class="elsevierStylePara elsevierViewall">Taking into account the associated geological factors, its symptoms and the proven protective role of footwear, the pathogenesis of this disease seems to be due to an inflammatory response induced by mineral microparticles on a genetic predisposition basis. After penetrating the skin, these micro- or nanoparticles are captured by macrophages in the lymph nodes, with the subsequent release of inflammatory cytokines and free oxygen radicals in its wall leading to fibrosis and obstruction of those vessels.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17,19,27–30</span></a> This theory is supported by the fact that high concentrations of TGFβ1 have been found in serum, a marker of oxidative stress.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Also, electron microscopy has shown the presence of these microparticles and foreign body granulomas in the patient's ganglion biopsies.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,32</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Histopathology of the skin shows the following findings: compact hyperkeratosis with epithelial hyperplasia, fibrous expansion of the dermis and obvious lymphangiectasia; fibrosis around the sweat glands as well as a striking perivascular lymphoplasmacytic infiltrate. These findings, sclerosis of the dermis along with fibrosis and dilation of lymphatic vessels, explain both Pachydermia as well as the irreversibility of the lesions<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical signs and symptoms</span><p id="par0050" class="elsevierStylePara elsevierViewall">The disease usually has its onset during the second decade of life, however, there are cases described in young children with few years of soil exposure; in our experience the youngest affected was an 8 year-old and 12 year-old patients have been found with injuries that seemed chronic and of long progression. Before lymphedema appears there is a prodromal period that can last for months or even years with itching and burning sensation in one foot, which subsequently extend to the ankle and lower third of the leg and are accompanied by fever and increased tenderness in the femoral lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> These episodes usually resolve after a few days of rest and elevation of the affected limb. They repeat erratically over time. Frequent scratching results in lichenification or reactive skin thickening and breaking of the epidermal barrier with recurring cellulitis or lymphangitis. It may take months before these symptoms appear on the other foot (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">After that prodromal phase, Podoconiosis usually progresses in 5 stages. (1) Soft oedema appears only on the foot and below the ankle, which is reversible during sleep; oedema in the anterior third of the sole causes separation of the fingers, alters their morphology (adopting a sausage-like form), with their distal part not touching the ground; (2) the oedema no longer disappears completely during the night and, if any, hyperkeratotic nodules with deep furrows appear just below the ankle; (3) the oedema is persistent, but just below the knee, but the nodules or tumours already surpass the ankle; skin in the dorsum and lateral side of the foot resembles firm moss with a shoe-like distribution; (4) the oedema, besides being persistent, already exceeds the knee and there are signs of lymphangiectasia in the thigh; and (5) virtual ankle and foot joint ankylosis occurs.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Sensitivity is preserved during all stages and lymphorrhea can be seen through skin cracks, resulting in maceration and repeated episodes of cellulitis and lymphangitis due to bacterial and/or fungal infection. 97% of patients suffer an average of 5 episodes of acute febrile lymphangitis throughout the year, being forced to rest. Sometimes, retractable deep scars appear on the dorsum of the foot with areas of depigmentation and reabsorption in the toes, which can be confused with leprosy.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis and differential diagnosis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Podoconiosis has a simple diagnosis based on epidemiological data: geological characteristics and altitude above sea level in endemic areas, usually non-filarial; clinical data: the type of symptoms at onset and their asymmetry, along with the lymphedema's progression since its inception in one foot and the distal third of the ipsilateral leg up to the knee, usually without exceeding the knee and without involvement of the upper limbs; and dermatological data: hard and nodular hyperkeratosis and slow and progressive increase of the leg's perimeter, rarely with groin involvement.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Differential diagnosis arises mainly with: (1) leprotic lymphedema (where there are usually other injuries of that disease, such as alopecia, areas of depigmentation, thickened peripheral nerves, loss of sensation, arthropathy and neuropathic ulcers)<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>; and (2) the filarial elephantiasis, in which lymphedema, although it is also usually unilateral, normally exceeds the knee and often affects the inguinal nodes; moreover, in doubtful cases, a rapid filaria antigen detection<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>; it is important to stress that lymphatic filariasis occurs in areas below 1000<span class="elsevierStyleHsp" style=""></span>m of altitude, unlike Podoconiosis. The differential diagnosis should also be considered with: (3) the chronic venous insufficiency oedema, and (4) with the <span class="elsevierStyleItalic">mycetoma pedis</span>, an infectious, chronic, granulomatous skin and subcutaneous tissue disease caused by filamentous bacteria such as actinomycetes (actinomycetoma), or fungi (eumycetoma), usually saprophytes. It is endemic between 30°<span class="elsevierStyleHsp" style=""></span>N and 15° south of the equator (“mycetoma belt”) and affects mostly men working barefoot who step on acacia thorns or cactus. Is painless, it usually affects the bones and presents with swelling, nodule formation and abscesses which fistulise and overinfect with serious functional sequelae, sometimes even requiring foot amputation.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Prevention and treatment</span><p id="par0075" class="elsevierStylePara elsevierViewall">Primary prevention starts with proper home and school education, with emphasis on hygiene, the need for footwear and doing away with the idea, deeply rooted in the population, that Podoconiosis is a “curse”, making people realize that it has to do with walking barefoot on a soil with certain characteristics. Geography, illiteracy and shortage of drinking water should be taken into account when trying to ensure hygiene and foot care in a usually large and very poor population, among which economic resources are so limited that almost all is used for food subsistence. Being able to get shoes for all members of the household would still be a luxury.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients should be taught to wash their feet daily with soap and water and antiseptic solution for 10<span class="elsevierStyleHsp" style=""></span>min, rinsing with clean water afterwards. As for footwear, it must be robust and also cover the dorsum of the foot. Farmers should be advised to wear sturdy shoes or boots. Wearing socks and covering the soil inside the huts with wooden planks or tiles complete the primary prevention measures.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Secondary prevention and treatment, in addition to patient awareness in self-care, comprising: (a) daily washing of the feet with soap and water and diluted bleach, antiseptic and emollients solution (petroleum jelly, urea); (b) raising the feet above the hip overnight; (c) exercises appropriate for the movement of the ankle and foot; (d) oedematous feet and ankles compression bandage, a measure that limits or reduces the progression of the oedema, which the patient must learn to apply; (e) daily massage; (f) lymphatic drainage, and (g) making special footwear, appropriate to the foot, until the patient could wear conventional shoes again. Surgery, with removal of the toughest and most prominent tumours, is reserved for selected cases.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41,42</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Along with this, it is necessary to inculcate the benefits associated to treatment and rehabilitation adherence, so that the patient can regain a sense of belonging to a people, to be able to have a proper job, which would secure resources for him/her and his/her family, and that, finally, regain self-esteem and is no longer considered a “plague-ridden person” by his family and community.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43–45</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to get the local health workers (and non-health workers) involved in the prevention and treatment in order to minimize the personal and social impact of this disease. Since 2011, the World Health Organization has included Podoconiosis as one of the unattended or neglected diseases. In endemic areas, such as Ethiopia, various governmental and non-governmental organizations are working on Podoconiosis: <span class="elsevierStyleItalic">Action on Podoconiosis Association</span> (Wolaita, Gamo Gofa and Dawro Zones, SNNPR); <span class="elsevierStyleItalic">Catholic Church, Nekemte & Wollega Dioceses</span> (Quelem, West and East Wollega Zones, Oromía); <span class="elsevierStyleItalic">Internacional Orthodox Christian Charities</span> (East Gojam Zone, Amhara); <span class="elsevierStyleItalic">Nekane Yesus-Ethiopian Evangelical Church</span> (West Wollega and Illubabor Zones, Oromía); <span class="elsevierStyleItalic">Mossy Foot Project</span> (Wolaita Zone, SNNPR), <span class="elsevierStyleItalic">OpenWay</span> (Sidaza Zone, SNNPR) and hospital centres such as the Gambo Rural General Hospital.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Podoconiosis is, ultimately, a forgotten disease and practically unknown by the international medical community, even though it has a very significant impact of clinical and social consequences. Prevention is as simple as the use of shoes from childhood, but the reality is that the affected population cannot afford the cost of shoes for all family members.</p><p id="par0105" class="elsevierStylePara elsevierViewall">At the beginning of the century <span class="elsevierStyleSmallCaps">xxi</span>, it is our duty to show the effects of the disease and to convince all social and economic actors that this disease can only be eradicated with the cooperation of all. Countries like ours, with a very powerful footwear industry, should know more about this problem and contribute more towards solving it.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres630803" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec643618" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres630802" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec643617" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Geology, epidemiology and socioeconomics" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Family and genetic distribution" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Pathogenesis and pathology" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical signs and symptoms" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis and differential diagnosis" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Prevention and treatment" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interests" ] 13 => array:2 [ "identificador" => "xack212606" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-02" "fechaAceptado" => "2014-12-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec643618" "palabras" => array:5 [ 0 => "Elephantiasis" 1 => "Lymphedema" 2 => "Neglected" 3 => "Volcanic soil" 4 => "Preventable" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec643617" "palabras" => array:5 [ 0 => "Elefantiasis" 1 => "Linfedema" 2 => "Olvidada" 3 => "Suelo volcánico" 4 => "Prevenible" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Podoconiosis, <span class="elsevierStyleItalic">mossy foot</span> or endemic non-filarial elephantiasis, is a geochemical disease that causes lower limb lymphedema; it is directly related to walking barefoot over soils of volcanic origin, in areas with a high pluviometric annual index. It has a specific geographical distribution, affecting around 5% population in areas where it is endemic. It is debilitating and disfiguring disease, which frequently leads to social margination. Podoconiosis is totally preventable and, once a diagnosis is established, it may improve with simple therapeutic measures.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La podoconiosis, o «elefantiasis endémica no filariásica», es una enfermedad geoquímica que produce un tipo de linfedema de los miembros inferiores relacionado directamente con caminar descalzo por terrenos de origen volcánico en áreas con un alto índice pluviométrico anual. Posee una distribución geográfica concreta, afecta aproximadamente a un 5% de la población de las áreas endémicas, es debilitadora y desfigurante y con frecuencia lleva a la marginación social de los que la sufren. Es una enfermedad prevenible y, una vez establecida, puede mejorar con medidas terapéuticas sencillas.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Prieto-Pérez L, Soriano Cea JJ, Górgolas Hernández-Mora M. Podoconiosis: enfermedad olvidada por la sociedad y la comunidad médica. Med Clin (Barc). 2015;145:446–451.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 736 "Ancho" => 995 "Tamanyo" => 256444 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In rural areas, the vast majority of the population regularly walk barefoot or engage in farming barefoot, an essential factor in the disease development.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Deribe et al.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1155 "Ancho" => 1949 "Tamanyo" => 259831 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Podoconiosis worldwide distribution map. Permission for the possible future publication of <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> has been granted by <span class="elsevierStyleItalic">PLoS Neglected Tropical Diseases</span>.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1319 "Ancho" => 995 "Tamanyo" => 421391 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Haematoxylin-eosin. (10×): Note the epidermal hyperplasia with significant dermal sclerosis and lymphatic ectasia proliferation. Detail (40×): perivascular lymphoplasmacytic infiltrate. Biopsies were performed in 2 patients who had previously volunteered. Information about the procedure was provided verbally, due to the high rate of illiteracy, both patients giving consent. In order to prevent infectious complications in rural areas, they were hospitalised for a week, taking extreme antisepsis and local hygiene measures. There were no complications and the wounds healed without any problems.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 859 "Ancho" => 995 "Tamanyo" => 346747 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Stage <span class="elsevierStyleSmallCaps">iii</span> Podoconiosis patient; note the characteristic appearance of the skin, similar to moss; and the distal oedema and the presence of wounds, facilitating bacterial overinfection and acute lymphangioadenitis episodes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:45 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The elephantiasis story" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.W. 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Pérez Tanoira, Cabello Úbeda and Ramos Rincón, for their support and tireless work. Dr. Francisco Reyes also, medical director of the Gambo Rural General Hospital, for his warm welcome and providing the necessary infrastructure for the study of Podoconiosis in the field, and Dr. Abraham Tesfamarian and Dr. Seble Balcha for their invaluable help in detecting cases. Also, we want to thank the Podoconiosis patients and staff at the Gambo Rural General Hospital; of course, thanks to the Master of Tropical Medicine and International Health at the Autonomous University of Madrid and the <span class="elsevierStyleItalic">Mossy Foot Association</span> of Wolaita Zone (Ethiopia).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000014500000010/v1_201604230100/S2387020616002060/v1_201604230100/en/main.assets" "Apartado" => array:4 [ "identificador" => "43313" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Reviews" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000014500000010/v1_201604230100/S2387020616002060/v1_201604230100/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616002060?idApp=UINPBA00004N" ]
