|
 
 |
| EDITORIAL |
|
| Year : 2023 | Volume
: 13
| Issue : 1 | Page : 1-3 |
|
Emerging and newer diseases in India: A perspective
Atul Kakar1, Karun Saathveeg Sam1, Sumanyu Kakar2
1 Department of Medicine, Sir Ganga Ram Hospital, New Delhi, India
2 Manav Rachna Dental College, Faridabad, Haryana, India
| Date of Submission | 04-Jan-2023 |
| Date of Decision | 09-Jan-2023 |
| Date of Acceptance | 16-Jan-2023 |
| Date of Web Publication | 24-Feb-2023 |
Correspondence Address:
Dr. Atul Kakar
Sir Ganga Ram Hospital, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/cmrp.cmrp_3_23
How to cite this article:
Kakar A, Sam KS, Kakar S. Emerging and newer diseases in India: A perspective. Curr Med Res Pract 2023;13:1-3 |
The only constant in life is change. The last century has seen significant advances in various aspects of science and technology that have had a profound impact on human lives directly and indirectly. There is a much deeper impact on the macro and micro environment around us than meets the eye as a result of these changes. The past two decades have also witnessed a plethora of new and emerging diseases culminating in the COVID pandemic. This has made policy-makers and healthcare experts rethink and reshape the healthcare infrastructure.
According to the World Health Organisation, seven diseases have resulted in public health emergencies since 2009. Among these are influenza pandemics in 2009, Ebola outbreaks in 2013 and 2018, Polio outbreaks in 2014, Zika virus outbreaks in 2016, COVID-19 outbreaks in 2020 and monkey pox outbreaks in 2022. It is pertinent to understand why infections are on the rise on a global scale and how our understanding of the matter has evolved over time. In the Hellenistic period, ancient Greeks attributed disease to the wrath of the gods and practiced prayer and rituals to combat it. Since the ancient Romans believed that ill health was caused by contaminated water and sewage, they developed the system of overland pipes and planned cities around the natural water sources.[1] It was during the time of Hippocrates that a more rational approach became prevalent. While we have come a long way since then, the germ theory of disease, put forward by Robert Koch in the 19th century, has enabled us to attribute infections to various micro-organisms that have since been identified. However, that is not all. For a full understanding of this complex issue, it is important to be aware of numerous environmental factors. Climate change and its impact on the emergence of diseases are a debated topic that requires a high degree of attention. As global temperatures rise and ecosystems change, it is logical to expect that the type of organisms colonizing the changing environment will change as well. There are several factors that will further hinder the global initiative to prevent the emergence of diseases that are of public health concern. These factors include the feasibility of international travel, a breakdown in public health measures, war, famine and the lack of political initiative. There is a classic example in the recently found zombie virus in Russia. This virus is nearly 50,000 years old and seems to have re-entered the ecosystem as a result of the thawing of huge swathes of permafrost in the northern hemisphere. They were discovered at the bottom of a lake in Yukecho, Russia, as well as in the intestines of a Siberian wolf.[1] This could only be the tip of the iceberg and what lies ahead can only be speculated about. In general, diseases can be classified into communicable or non-communicable. The vast majority of infectious diseases are communicable, whereas non-infectious conditions are generally non-communicable.
Infectious diseases can be broadly classified into four groups:
- Newly emerging infectious diseases such as HIV/AIDS which were not previously described in humans
- Re-emerging infectious diseases such as methicillin- resistant Staphylococcus aureus and Middle East Respiratory Syndrome which were previously described in humans and have reappeared in newer environments or are not responding to previously effective treatment
- Deliberately emerging infectious diseases that are created as an act of bioterrorism like anthrax
- Accidentally emerging infectious diseases such as vaccine-derived poliomyelitis.
To understand the impact of a few recent diseases of concern on human life, let's take a look at some of the most recent diseases of concern.
In the aftermath of COVID, the tomato flu caused a great deal of concern in households as a new pandemic. The disease affected approximately 100 children in Kerala and Odisha combined. The disease was first identified in Kerala on 6th May 2022 and was attributed to a rare virus, Coxsackie A16.[2] Children under the age of five and adults with a weak immune system are at risk of contracting an infection. This disease manifests as fever, myalgia, rashes and joint pains and has been compared to hand, foot and mouth disease and chikungunya. In the wake of the COVID-19 pandemic, this disease created the waves of panic among the general public who were suffering from painful red blisters throughout their bodies. Transmission of the disease occurs through close contact and fomites. The WHO recommends the isolation of those infected for a period of 5–7 days following the onset of symptoms. As there were no antiviral drugs or vaccines available, treatment was primarily supportive. The WHO estimates that monkey pox, which first appeared in 2022, caused 10% mortality in 102 countries. Like smallpox viruses, the virus belongs to the orthopoxvirus genus and has two distinct genetic clades. Animal to human transmission from rodents, monkeys and apes through bites, scratches or bush meat preparation was identified. In most cases, human-to-human transmission took place through large respiratory droplets, close contact, fomites and direct contact with body fluids. There was only a temporal association between sexual intercourse and the onset of disease, and a correlation between the site of primary lesions and that of sexual contact. The incubation period ranged from 6 to 13 days. Prodrome symptoms include fever, lymphadenopathy, constitutional symptoms and rash. Conventionally, the rash is polymorphic, centripetal, painful, and heals with hyperpigmentation, alopecia, scarring or contractures. In a study of 197 cases of monkey pox in Central London in 2022, about 36% had rectal pain and 15.7% had penile oedema.[3] Proctitis was confirmed by MRI in five cases. An observational study published in New England Journal of Medicine examined 528 cases of monkey pox from 16 countries and found a higher incidence among homosexual contacts.[4] Patients with HIV positive or negative HIV status did not have significantly different distributions of disease. The diagnosis is based on the polymerase chain reaction testing of samples from lesions on the skin. The main treatment was supportive. In 2019, a two-dose vaccine based on a modified attenuated vaccinia strain was approved. The outbreaks of infections only suggest that our understanding of disease patterns, the emergence of diseases and the spread of diseases are primitive and that large-scale public health measures are necessary based on the technology at hand. Another area of diminishing concern, but growing importance, is the identification of newer non-communicable diseases that can cause significant morbidity and mortality in patients. Here are a few emerging inflammatory syndromes that need further research and understanding to improve patient outcomes.
Deficiency of Adenosine deaminase 2 causes vasculitis, bone marrow failure, pure red cell aplasia and immune dysregulation. This is the first vasculitis syndrome identified at a molecular level due to a mutation in the cat eye syndrome critical region protein 1 (CECR 1) gene inherited autosomally recessively. The majority of patients present in early childhood or adulthood. Furthermore, adult onset has been reported. Skin and the central nervous system are the most common sites of vasculitis. Livingo reticularis, macular erythematous rashes and nodular rashes are common. In 50% of cases, there is an infarction in the brain. In addition to the liver, kidneys and muscles, the lungs are also affected. The main treatment is anti-tumour necrosis factor medications, which have been proven to reduce the risk of strokes. In terms of treatment, haematopoietic stem cell transplantation remains the most definitive method.[5] Another rheumatological disease that has gained attention in recent years is immunoglobulin G (IgG) 4-related disease. Although rare, there has been an increase in cases over the past few years. As multisystem involvement and extensive disease burden are characteristic of this condition, awareness of the same is imperative for practicing clinicians. Unlike other autoimmune conditions, this condition is more common in males. It has been postulated that allergic mechanisms could drive the pathogenesis of this disease as evident from raised levels of IgE and eosinophils in 30%–40% of cases. Zhang, et al. noted that eosinophilia was seen in about 50% of patients with IgG 4-related disease (RD). There are four phenotypic forms of the disease, namely pancreato-biliary disease, retroperitoneal fibrosis and/or aortitis, head and neck limited disease and classic Mikulicz syndrome with multisystem involvement. The symptoms include abdominal pain, jaundice, enlargement of lymph nodes and salivary glands, swelling of the eyelids and loss of weight. A retrospective analysis of 147 patients in China showed that 88.3% had multiorgan involvement at the time of presentation.[6] It is crucial to note that elevated serum IgG4 is not essential to diagnose the disease. Tissue IgG4 levels along with the classical histopathological finding of dense lymphoplasmacytic infiltrate, storiform fibrosis and obliterative phlebitis are critical features for establishing the diagnosis. Glucocorticoid therapy remains the first-line drug of choice with documented favourable outcomes. In the event of irreversible organ damage or obstruction, surgical or interventional therapy is warranted. The use of steroids sparing agents such as methotrexate, azathioprine, MMF, leflunomide, tacrolimus and cyclosporin A can improve the chances of remission.[7] With the possibility of a good outcome and considering that IgG4 RD lesions shrink when treatment is initiated early, it is imperative that our awareness and knowledge of the same is on par with the changing understanding of the disease.
VEXAS syndrome is a newly described autoinflammatory syndrome characterised by fever, cytopenias, vacuoles in myeloid and erythroid precursors, dysplastic bone marrow and multisystem involvement. There is an overlap between VEXAS syndrome and myelodysplastic syndromes. Further acquisition of the UBA1 mutation predisposes to multiple myeloma. The identification of VEXAS syndrome is a possible link between clonal haematopoiesis and systemic inflammation.[8] Symptoms are debilitating and refractory to treatment with high-dose corticosteroids. Azacytidine and Janus Kinus inhibitors have been used, but their effects have been far from satisfactory.
Clearly, with evolving research and newer diagnostic tools our ability to identify newer diseases will only improve with time. Tackling such emerging diseases requires a collective effort between healthcare experts and policy-makers in a manner similar to how we dealt with the COVID pandemic successfully.
| References | |  |
| 1. | |
| 2. | Chavda VP, Patel K, Apostolopoulos V. Tomato flu outbreak in India. Lancet Respir Med 2023;11:e1-2.  |
| 3. | Patel A, Bilinska J, Tam JC, Da Silva Fontoura D, Mason CY, Daunt A, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: Descriptive case series. BMJ 2022;378:e072410. |
| 4. | Thornhill JP, Barkati S, Walmsley S, Rockstroh J, Antinori A, Harrison LB, et al. Monkeypox Virus Infection in Humans across 16 Countries – April-June 2022. N Engl J Med 2022;387:679-91. |
| 5. | Meyts I, Aksentijevich I. Deficiency of Adenosine Deaminase 2 (DADA2): Updates on the phenotype, genetics, pathogenesis, and treatment. J Clin Immunol 2018;38:569-78. |
| 6. | Zhang S, Zhang J, Li Y, Jiao J. From suspicion to diagnosis: Analysis on the clinical characteristics of 37 cases of IgG4-related disease (IgG4-RD) in Northeast China. J Inflamm Res 2022;15:4487-97. |
| 7. | Duggal L, Singh BG, Patel J, Gupta M, Grover AK, Jain N. IgG4-related disease: A clinical case series from a tertiary care center in India. J Clin Rheumatol 2022;28:e56-62. |
| 8. | Grayson PC, Patel BA, Young NS. VEXAS syndrome. Blood 2021;137:3591-4. |
|
Search Pubmed for