TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE. Vol. 55. No. 2. March, 1961.

161

" B A N T U T R O P I C A L A N A E M I A " I N R H O D E S I A

BY

JOHN FORBES, M.B., M.R.C.P. (ED.), AND M I C H A E L GELFAND, Cm.E., M.D., F.R.C.P. ~*

Physicians, Harari Hospital, Salisbury

A n a t t e m p t to analyse the c o m m o n anaemias of t he R h o d e s i a n Af r i can has no t as ye t been u n d e r t a k e n and, as t he re is stil l no clear cause g iven for t he c o m m o n i ron def ic iency or i ndeed mac rocy t i c anaemias of t rop ica l Afr ica , th is s t u d y a p p e a r e d to be jus t i f i ed desp i t e t he m a n y and h igh ly c o m m e n d a b l e con t r ibu t ions a l ready m a d e on the subject .

F o r m a n y years we have been aware of the exis tence of an anaemia in the Af r i can the cause, or p e r h a p s be t t e r still , t he causes of wh ich have so far e luded us. So f r equen t and severe are these t rop ica l anaemias tha t we cons ider they cons t i tu te one of our ma jo r c l in ical p rob l ems . T h e sever i ty of the anaemia m a y be so p r o n o u n c e d tha t one f r equen t ly w o n d e r s how these u n f o r t u n a t e ind iv idua l s are able to con t inue wi th t he i r dai ly rout ine , and w h y they are so s low in r e p o r t i n g to hospi ta l s for t r ea tmen t . A n u m b e r die b u t the m o r t a l i t y has dec reased g rea t ly s ince b lood t rans fus ions have b e c o m e easier. T h e b lood t r ans fus ion service has r evo lu t ion ized our t r e a t m e n t of the disease and its out look.

METHODS AND PROCEDURES

Fifty patients with an initial haemoglobin of 50 per cent. or less admitted over a period of 8 months were studied. The investigation included a history, a physical examination, stool and urine analysis, liver function tests and a full haematological study including the P.C.V., M.C.V., M.C.H.C., reti- culocyte count and, in cases where the picture was not clear, a sternal marrow aspiration.

One can never be certain that any African will remain long enough for investigations to be com- pleted. Nevertheless we managed to carry out most of them required in this study. We followed up our patients until an obvious response to treatment had occurred, but we were unable to continue the follow-up until the blood picture had returned to normal.

The Harari Hospital receives Africans of all classes of society. For the purposes of this study we have divided them into three grades- -Grade I (pre-literate), Grade II (semi-literate) and Grade I I I (literate). Grade I African still lives in his natural environment in close contact with nature, harbours one or more of the common tropical parasites (plasmodia, sehistosomes and hookworm), and eats the traditional African food. This grade African constitutes by far the greatest number of admissions to the wards. Grade II is much less frequent than Grade I comprising probably not more than 15 per cent. of our admissions. This African has removed himself from his natural environment for many years, has probably been brought up in a mission school where he received treatment for his parasites and, although he lives on an African diet, he has been more fortunate than his Grade I brother in that he has usually had an adequate quantity of meat. The Grade I I African is seen in the urban areas among the government messengers, clerks and in business and industry. The third grade of African is even less frequently seen, constituting probably not more than 1 per cent. or 2 per cent. of our admissions. He has adopted the European way of life for many years and is well removed from the African environment.

* We wish to thank Dr. W. Sheffield, Director of Medical Services, Southern Rhodesia, for permission to publish this paper.

162 " BANTU TROPICAL ANAEMIA "

D E S C R I P T I O N OF T H E A N A E M I A

In the majority of cases an obvious cause could not be found. Two subjects had visceral cancer (one of oesophagus and one of stomach) ; two had chronic renal disease ; one had uterine fibroids with vaginal haemorrhage ; and two more had menorrhagia with no obvious cause ; two bled from oesophageal varicies and one from a duodenal ulcer. Two more were admitted with a history of haematemesis for which no cause was demonstrated.

In the remaining 38 cases there was no clear cause for the anaemia, and it is upon this group that we particularly wish to comment, and for which we would suggest the name " Bantu tropical anaemia."

Age. Our patients were mostly younger adults, although it must not be forgotten that most of the African adults in the urban areas are young. The average age of males was 27.6 years, of females 24.5 years, and of all patients 26.2 years.

Sex. It is felt that no conclusions can be drawn with regard to sex because of the great preponderance of males in the Salisbury area.

Diet. Diet does not appear to be a factor in the aetiology of the anaemia. In 38 of our cases (18 males and 20 females) the diet was considered to be average. In six cases it was good and in six it was poor. Five of the patients on good diet were found to have iron deficiency anaemia, compared with only two of the patients on poor diet.

Onset. In 21 subjects (13 males and 8 females) the onset of the patients' symptoms was sudden whereas in 27 cases (15 males and 12 females) it was gradual. Two patients, although anaemic, were asymptomatic.

Duration. In 27 patients (54 per cent.) the duration of symptoms before advice was sought was less than a month ; in 11 (22 per cent.) it was between 1 month and 6 months; and in 10 (20 per cent.) it was over 6 months.

Presenting symptom. There did not seem to be a characteristic mode of presentation of the anaemia. Nine patients presented with severe haemorrhage, and five more with a history of bleeding which did not seem sufficient to account for the degree of anaemia. Eight complained of dyspnoea, four had angina pectoris, and two more had chest pain of a vague nature ; six had symptoms attributed to " flu."

Physicalfindings. The physical signs in our cases were those that might occur in any anaemia. Four patients had signs of heart failure and a further eight had dependent oedema (usually slight). No nail changes were noticed and the Plummer Vinson syndrome was not seen.

A hepatomegaly was present in 12 of our cases (24 per cent.). Analysing these cases further we found that of 33 patients with iron deficiency anaemia six (18 per cent.) had enlarged livers, and nine (27 per cent.) had enlarged spleens ; while of eight subjects of macro- cytic anaemia four (50 per cent.) had hepatomegaly and five (62 per cent.) had splenomegaly. Hepatomegaly and splenomegaly are often found in the general African population quite apart from anaemia. Furthermore, it should be remembered that an enlarged and abnormal liver may in itself produce an anaemia.

The number of cases with macrocytic anaemia in our series was too small for any con- clusions to be reached, but it is a point worth following up as to whether the liver and spleen are more likely to be enlarged in the presence of macrocytic anaemia.

The liver was considered to be cirrhotic in 18 per cent. of all the cases (9 of 50) ; in 12 per cent. of cases with iron deficiency anaemia (4 of 33) ; in 20 per cent. of cases of normo- cytic normochromic anaemia (1 of 5) ; and in 50 per cent. of cases of macrocytic anaemia

JOHN FORBES AND MICHAEL GELFAND 163

(4 of 8). This is perhaps what one might expect--indeed it is suggested that the blood picture in tropical anaemia is partly determined by the state of the liver in the individual concerned.

There were signs of vitamin deficiency in six cases (12 per cent.) and the incidence was the same in both hypochromic and macrocytic types of anaemia.

Parasites. Parasitic infestation was found in 52 per cent. of cases (26 of 50) (see Table), and there was a heavier incidence of infestation in cases with iron deficiency anaemia (64 per cent.), than in cases with normocytic normochromic anaemia (20 per cent.), or those with macrocytic anaemia (37 per cent.). These findings are based on examination of stool and urine in each patient. It is probable that had we carried out rectal biopsy and cystoscopy as well, our incidence would have been very much higher.

Malarial parasites (P. falciparum) were found in peripheral blood smears of four patients, two males and two females, all of whom had iron deficiency anaemia.

The findings in 50 subjects with anaemia in this series are given in the Table : In only 11 patients was a serum iron estimation carried out, and all of these patients

had iron deficiency anaemia. The mean serum iron in these cases was 42 ~tg. per cent. with a range of between 9 and

107 ~g. per cent.

CONCLUSIONS

The anaemia in 33 of 50 subjects was of the iron deficiency type -- 66 per cent. Diet does not appear to be responsible for iron deficiency anacmia--of six patients on

"good" diet, five were iron deficient. Of six patients on "poor" diet, two were iron deficient. Commonest presenting symptoms are blood loss (25 per cent.); abdominal pain (22

per cent.).

Splenomegaly present in 38 per cent. of all cases (19 of 50) 27 per cent. of cases of iron deficiency anaemia (9 of 33). 60 per cent. of cases of normocytic normochromic (3 of 5). 62 per cent. of cases of macrocytic anaemia (5 of 8). (In two cases with splenomegaly the type of anaemia was not determined).

Hepatomegaly present in 24 per cent. of all cases (12 of 50) 18 per cent. of cases of iron deficiency anaemia (6 of 33). 40 per cent. of cases of normocytic normochromic (2 of 5). 50 per cent. of cases of macrocytic anaemia (4 of 8).

Signs of diet deficiency in 12 per cent. of all cases (6 of 50) 12 per cent. of cases of iron deficiency anaemia (4 of 33). 12 per cent. of cases of macrocytic anaemia (1 of 8).

Probable cirrhosis in 18 per cent. of all cases (9 of 50). 12 per cent. of cases of iron deficiency anaemia (4 of 33). 20 per cent. of normocytic anaemia (1 of 5). 50 per cent. of cases of macrocytic anaemia (4 of 8).

Schistosomes or hookworm in 52 per cent. of all cases (26 of 50) 64 per cent. of cases of iron deficiency anaemia (21 of 33). 20 per cent. of cases of normocytic normochromic (1 of 5). 37 per cent. of macrocytic anaemia (3 of 8).

164 " B A N T U T R O P I C A L A N A E M I A "

TABLE. Survey of 50 consecutive cases of anaemia admitted to adult wards at Harari: 27/4/58-25/11/58.

Average age Social grade I

II I I I

Diet Good Average Poor

Onset Sudden Gradual Symptomless

Duration of presenting symptom 1 week or less 1 week-1 month 1 month-6 months More than 6 months Symptomless

Presenting symptom Blood loss

(Haematemesis or melaena) (Epistaxis) (Diarrhoea with blood) (Vaginal haemorrhage)

Effort angina Dyspnoea and/or palpitations (incipient

cardiac failure) Oedema without failure Abdominal pain with or without gastro-

intestinal upset Chest pain (not angina) General pains (flu-like illness) Cough and weight loss No complaints

Physical findings Hepatomegaly

(slight) (gross---4 fingers or more)

Splenomegaly (slight) (gross--4 fingers or more)

Jaundice Congestive cardiac failure Oedema (not part of congestive cardiac

failure) Ascites (not part of congestive cardiac failure) Clinical malnutrition and vit. deficiency

(Mild) (Marked)

Normal pregnancy Gynaecological abnormality

(Recent abortion) (Recent normal delivery) (Uterine fibroids) (Menorrhagia, no cause found)

Other pathological states (Pneumonia)

Male (28)

27.6 yrs. 0 1

27 4

18 6

13 15

0

9 (4) (1) (4) (0)

3

5 1 3 1 0

6 (5) (1)

10 (7) (3)

1 1

4 3 5

(4) (1)

0 0

(o) (o) (o) (o)

6 (1)

Female (22)

24.5 0 2

20 2

20 0 8

12 2

5 10

I 4 1

I 2

y r s .

4 (1) (0) (1) (2)

1

6 (5) (1)

9 (5) (4)

0 3

4 1 1 (1) (o)

4 4

(1) (1) (1) (2)

4 (1)

Total (50)

26.2 yrs. 0 3

47 6

38 6

21 27

2

13 14 11 10

2

13 (5) (1) (5) (2)

4

11 2 6 1 2

12 (10)

(2) 19 (12) (7)

I 4

8 4 6

(5) (1)

4 4

(1) (1) (1) (2)

10 (2)

JOHN FORBES AND MICHAEL GELFAND 165

Average age Physical findings (continued)

(Leg vein thrombosis) (Oesophageal cancer) (Aortic incompetence) (Pemphigus) (Chronic renal disease) (Pulmonary tuberculosis)

Parasites (only 47 tested) Schistosomiasis

(S. haematobium) ( S. mansoni)

Hookworm Whipworm Giardia lamblia Malaria

Neoplasms Oesophageal carcinoma Stomach carcinoma

Duodenal ulcer Oesophageal varicies

Type of anaemia Iron deficiency

(Normocytie hypochromic) (Microcytic hypochromic)

Normoeytic normochromic Macrocytic anaemia

(Macrocytie hyperchromic) (Macrocytic normochromic) (Macrocytic hypochromic)

Type unknown

Male (28)

27.6 yrs.

(o) (1) (1) (o) (1) (1)

13 (7) (6)

6 0 0 2

1 0 1 0 0 1

Female (22)

24.5 yrs.

(1) (o) (o) (1) (1) (o)

i 3 1 probable cirrhotic refused X-ray

19 (16)

(3) 2 4

(1) (3) (0)

3

9 (3) (6)

6 1 1 2

(?4) 0 (?1) [ 1 cirrhotic but barium swallow N.A.D.

14 (8) (6)

3 4

(0) (3) (1)

1

Total (50)

26.2 yrs.

(1) (1) (1) (1) (2) (1)

22 (10) (12)

12 1 1 4

1 1 1 3 (?5)

33 (24)

(9) 5 8

(1) (6) (1)

4

Note : Sternal marrow aspiration showed that three of the eight patients with macrocytic anaemia had megaloblastic marrows ; one had a mixed megaloblastic and normoblastic marrow ; two had normoblastic marrows ; and in two a marrow aspiration was not carried out.

D ISCUSSION

The special anaemias of tropical Africa have been the theme of many research workers and many excellent contributions have been made notably by Foy and Kondi, and Trowell. Whilst Trowell was probably the first worker in the field and for the first time drew attention to the complicated picture present, and in fact proposed that the anaemia be referred to as dimorphic anaemia, Foy and Kondi have carried out excellent research projects covering a large part of tropical Africa including Portuguese East Africa and East Africa.

Discounting ordinary and already well-established types of anaemia, there seems to be a common type in Rhodesia which we have attempted to describe and have tentatively suggested the name of " Bantu tropical anaemia." I t has an acute or subacute onset in a person who is generally between 20 and 40 years of age. Usually the patient can recall the day when he became ill, tired and weak. Th e anaemia becomes progressively worse but the subject who may be either a male or female continues as long as is possible with his

166 " B A N T U T R O P I C A L A N A E M I A "

work and generally within a relatively short space of time finds that he is so weak that he must report to the nearest clinic.

Our clinical experience leads us to believe that the anaemia is unlikely to be caused by a nutritional deficiency as the subjects are usually well nourished. On this score alone we find it difficult to believe that the disorder is associated with a deficiency in a particular food factor.

The subject presents with the usual symptoms associated with an anaemia, namely tiredness, weakness, giddiness or a tendency to faint. A few complain of a pain in the chest which closely resembles that met with in angina pectoris. In the female, a recent pregnancy or the state of pregnancy itself will precipitate the person into an acutely anaemic state.

The blood picture o f " Bantu tropical anaemia " does not point to one aetiological factor, but rather to either an iron deficiency state or, less often, to a deficiency in B12 or folic acid and giving rise to a macrocytic anaemia. In some the blood picture may indicate a dual deficiency. Up till now the authorities have therefore preferred to clasSify these cases according to the blood picture and to treat the deficiency accordingly.

As a result of our work we would prefer to regard all these cases, despite the difference in the blood picture, as having a common origin, although we are unaware of what the primary factor is. It is true that if an iron deficiency anaemia is found, the administration of iron will probably effect a cure, and similarly if there is megaloblastic bone marrow, that vitamin Bt~ is likely to correct the anaemia. Nevertheless up till the present the many researches carried out have failed to provide an adequate explanation for either the hypochromia or the macrocytosis. For instance Foy and Kondi consider such factors as (i) poor absorption of iron on account of the particular type of diet of the African ; (ii) excessive dermal or other losses of iron over long periods on account of climate ; (iii) blood loss due to parasites ; (iv) quantitative and qualitative protein changes in the diet ; and (v) pregnancy and lactation occurring below the age of 19 years and so coinciding with rapid growth and expansion of blood volume.

Probably blood destruction or loss due to parasites is the explanation which has received the greatest attention. Hardly a paper is devoted to the subject of anaemia in Africa without the author's trying to prove or disprove the role of the malarial, hookworm or other tropical parasites as being the cause of the anaemia. Some endeavour to prove that malaria is of great significance, whereas others consider that its importance has been over-estimated. For instance, HENDRICKSE (1958) of Ibadan considers that malaria is the most likely cause of the prevalent anaemia in infants and that the anaemia can generally be corrected by giving chloroquine to the subjects affected. On the other hand MCGREGOR et al. (1956) working in the Gambia believe that there is no difference in the mean haemoglobin of a group of children protected against malaria and a similar group unprotected. There have been publi- cations written in a similar vein on the relationship between hookworm and anaemia. For instance BEET (1949) and MAC~¥ (1953) considered that there was little correlation between the parasite and anaemia.

Within recent years WOODRUFF (1955) has described from West Africa an anaemia occurring in association with protein malnutrition and has suggested that this may be re- sponsible for some cases of tropical anaemia. Foy and Kondi after administering protein to cases of anaemia in East Africa failed to obtain a full haematological response with protein supplements. On the other hand, Foy and Kondi found that protein has some erythropoietic effect in iron deficiency anaemia which may at times, for reasons not clear, fail to respond fully to oral iron alone. By supplementing the diet with protein daily in these cases, the cure was completed. Foy and Kondi also found that a still smaller number of their cases

JOHN FORBES AND MICHAEL GELFAND 167

failed to respond to iron or protein after a certain time unless vitamin BI~ was then given. In iron deficiency cases with erythronormoblastic marrows and giant stab cells there was a n

initial response to iron. These patients could be restored to normal haemoglobin values by giving 5 mg. folic acid for 5 days.

But because the anaemia is either microcytic or macrocytic it does not necessarily rule out--in our view--that there is a single factor operating which under certain circumstances as, for instance, if the liver of the subject be cirrhotic, gives rise to a different bone marrow reaction. In support of this there is evidence that a particular disorder may at times for reasons unknown present with a different type of anaemia. For instance in sprue the anaemia may be either macrocytic or microcytic, and in both scurvy and myxoedema the type of anaemia may vary greatly (WHITBY and BRITTON, 1957).

Bantu tropical anaemia appears in our experience to attack mainly those Africans who have lived closely to their rural environment for many years, and very rarely the African who has adopted the European mode of life. It is the African who lives closely to nature who suffers most, the African who lives on a diet rich in cereal but deficient in proteins, vitamins and animal fats and who at the same time has been exposed from infancy to malaria, schisto- somes and hookworm. We believe it is impossible to say which of these factors has induced the anaemia, and that one can only say that it is the environment which is responsible. In this regard we feel that there is a comparison between " Bantu tropical anaemia " and chlor- osis, albeit they are two separate and distinct diseases. Chlorosis appeared in Europe in a certain society, at a particular period, affecting those living in a certain environment, and was practically confined to women. Its exact aetiology was never determined although it was an iron deficiency type of anaemia. It came and went and still today remains what we may refer to as a primary anaemia. We believe that the same will apply to this very common type of anaemia in Africa and that as the African's environment is improved or altered so will the anaemia become less and less.

SUMMARY

1) Fifty Africans admitted consecutively to the medical wards each with a haemoglobin of under 50 per cent. were studied.

2) In 38 of these (76 per cent.) no clear cause for the anaemia could be found, and for this type of case we suggest the term " Bantu tropical anaemia."

3) Not infrequently the onset in Bantu tropical anaemia is fairly acute and the duration of the illness before admission to hospital is sometimes under 6 weeks.

4) The blood picture varies--usually it is hypochromic microcytic, but it may be macrocytic or occasionally it shows features of both.

5) It is suggested that these cases have a common aetiological factor affecting the African in close contact with the African environment.

REFERENCES

BEET, E. A. (1949). Trans. R. Soc. trop. Med. Hyg., 43, 317. DAvIm, A. H. & PEARSON, F. A. (1956). Brit. med. ft., 2, 686. FoY, H. & KONDI, A. (1957). 07. trop. Med. Hyg., 60, 105. HEt~rDRtCXSE, R. G. & KING, M. A. R. (1958). Brit. med. 07., 2, 662. MACKAY, J. P. (1953). E. Afr. reed. 07, 30, 13. McGREGOR, I. A., GILLIES, H. M., WALTERS, J. H. (1956). Brit. med. 07, 2, 686. WHITBY, L. & BmTTON, C. J. C. (1957). Disorders of the Blood. London: J. & A. Churchill. WOODRUFF, A. W. (1955). Brit. med. 07, 1, 1297.