Beans, Grains and Madura Foot: Tasty Food, Tasty Medicine

I’m eating quite alot of beans at the moment.

‘Ful’ is the most widely-eaten meal in Sudan. It is made from black beans, cooked until they are soft, and then eaten with cheese, salt, onions and bread. Fasulya is made from white beans, and is cooked in the pot with some meat on the bone for flavour. They, along with some saucy dishes of potatoes, courgettes and peppers form the basis of diet, supplemented by a rather delicious range of fruit juices and the odd half-chicken.

There are many restaurants around Khartoum, serving a range of Sudanese, regional (as in Egyptian, Lebanese etc) and Western food. However due to burgeoning US sanctions, no American companies (like MacDonalds) can set-up shop here.

Being so ‘ful’ of beans (ho ho ho) can be rather useful for long ward rounds. I’ve seen a number of very interesting clinical cases over the past couple of weeks. Briefly, I’ve seen patients with pellagra (vitamin B6 deficiency with the clinical triad of dementia, diarrhoea and dermatitis); with Guillain-Barre Syndrome where polio and mercury- and lead-poisoning from mining were real differentials; with severe, quinine-resistant falciparum malaria and acute renal failure; with a bad drug-reaction to anti-malarial quinine therapy; and with complicated portal hypertension, resulting in different patients from chronic hepatitis, schistosomiasis and alcoholism. At the clinical meetings, I’ve also heard two interesting case presentations, firstly of a patient diagnosed with Churg-Strauss Syndrome (in the textbook this is late onset asthma, eosinophilia, small vessel vasculitis and a range of other potential features), presenting with joint pain, purpuric rash, dyspnoea, peripheral neuropathy, loss of vision and fever. The second case was a patient brought in from Jezira State, south of Khartoum, with DIC (blood clotting inside the blood vessels) resulting from a cobra bite. All these  cases were of  patients on the general medical ward.

I also spent some time at a specialist institute, the Mycetoma Research Centre, at Soba University Hospital. Mycetoma  is also called Madura Foot, named by British physicians in the Indian city of Madurai, Tamil Nadu State. It is found across the world in the ‘Mycetoma Belt’, stretching around Brazil and Mexico, through Africa and Arabia to India and South-East Asia.

It is a progressive, granulomatous inflammatory disease caused by particular species of bacteria (actinomycetes) or fungi (eumycetes). It still most commonly affects patients’ feet and legs since the most common route of inoculation is via a thorn, carrying the bacteria or fungi, piercing the skin.

It presents as a clinical triad of a painless, subcutaneous (under the skin) mass, sinus formation and the discharge of yellow and red (actinomycetoma) or black (eumycetoma) grains. As it is painless, many patients present relatively late (i.e. several months or even years after inoculation). This can lead to devasting consequences, as the mycetoma may spread beneath the skin and destroy deeper structures such as bones. Following evidence-based management guidelines developed at the centre, patients have a set of diagnostic and staging investigations and may then undergo medical (taking medicines) and surgical (cutting bits out or off) therapy. Over months, patients can make a full recovery, although recurrence rates are high.

Both the Mycetoma Centre at Soba, and the Institute of Endemic Diseases at the University of Khartoum conduct  ground-breaking, cutting-edge research in their respective fields – fields which are comparatively neglected in other, richer countries with different burdens of disease. They are staffed by well qualified, highly motivated and internationally published and respected scientists and clinicians.

But a small footnote to this is the effect of the unilateral US sanctions, renewed annually by the US Senate, despite promises to repeal them after the signing of the peace agreement in 2005. These sanctions do not just prevent MacDonalds from doing business here, but also prevent a spectrum of American industries, including scientific, technological and manufacturing companies from engaging in Sudan. As is so often the case, the sanctions are hurting the wrong people. That’s not cool beans.

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Picture Credit: http://pmj.bmj.com/content/75/889/671.full – Akhtar, M., Latief, P. (1999) Actinomycetoma Pedis. Postgraduate Medical Journal (75) 671 

Fahal, A. (2006) Mycetoma: Clinical Monograph. Khartoum University Press. Sudan

Manson, K. (23 July 2012) US Sanctions take toll on Khartoum. Financial Times.

Institute of Endemic Diseases, University of Khartoum – http://www.iend.org/

Mycetoma Research Centre, Soba University Hospital – http://mycetoma.uofk.edu/

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