Dying Young Hearts

When I first met Marie* I had just started my junior clerkship course in pediatrics. It was a warm Monday morning in mid-January. I rushed into the Upendo ward hoping to see what cases had come in over the night. As it was my morning routine, I picked up the new patient file at the nursing station. It read Marie K, a 12 year old girl from Webuye, Kenya. Unlike the other new files, this one was bulky, which made me realize that she had been here before. I walked over to the bed indicated and met a young angel. She lay in a propped-up bed with labored breathing, each breathe heavier than the last. A middle-age lady sat on the side of the bed looking in my direction with despair. ‘What could have gone wrong?’ she was too young to be in such a state: toxic. I exchanged pleasantries with mum and tried to elicit the culprit. As she spoke it became clear. Marie was suffering from Rheumatic Heart Disease (RHD). Her heart valves had completely given up and I could see her chest heave up and down with every beat. She was now in failure.

Rheumatic heart disease is the leading cause of cardiovascular disease in the developing nations. This is 80% of the world’s population. It is considered a disease of poverty. In Kenya alone it is reported that 62 per 1,000 of the population show signs of RHD on Echo (A form of ultrasound that is used to view the heart, its valves and the major vessel). Therefore for every 100 people you meet, six may have the disease, albeit sometimes being silent. It accounts for a quarter of all heart failure cases in endemic countries. Heart failure is when the heart is unable to adequately pump blood.

So what is RHD, how is it acquired, can it be prevented, how will I know whether I, or someone I know suffers from it and what next? RHD is a spectrum of heart damage, either the outer covering of the heart (pericardium); heart muscle (myocardium) or valves, evolving over years after acute rheumatic fever (ARF).   ARF is a non-infective sequela that occurs two to four weeks following bacterial pharyngitis caused by specific bacteria known as group A streptococcus (GAS). The disease may consist of arthritis, carditis, chorea (involuntary rhythmic movements) and skin lesions. It affects children between the age of 5-15 years, which Marie subscribed to. GAS is responsible for 15-30% of pharyngitis in children between 5-15 years. Unfortunately there is no specific symptom other than those of the common cold. It can be transmitted from child to child especially in school going children. Remember I said that ARF is non- infective, let me explain. GAS has molecules that are similar to that of the heart valves, so when the body is busy producing antibodies for its defense against GAS, it targets the heart as well. This results in progressive damage of the heart structures leading to RHD.

Patients slowly progress into failure, which is graded based on its limitation to normal activity. The most common symptom of heart failure is increased fatigue and awareness of heartbeat. In stage one, patients experience symptoms with over the ordinary activity; in stage two, with normal activity; in stage three, less than ordinary and stage four at rest. Marie was in grade IV. She had to watch helplessly as her siblings went out to play. She had dropped out of school a year ago because she couldn’t keep up with her peers. Marie was unable to get out of failure and after relentless attempts at attaining hemodynamic stability she silently passed on three days later.

The truth of the matter is that RHD is preventable. By placing our focus on the cause and addressing ways in which we can alter or stop the sequence of events. Save the young hearts of tomorrow. The first measure is to focus on ventilation, avoid crowding. Always make sure that the windows in a room constitute up to 10-15 percent of the floor area. Please consider this when you are setting up a structure, be it mud, wood, brick or stone. Emphasize on hand washing in all children and handlers. Use of hand sanitizers can also prove beneficial for both children and teachers. If you have a cough, cover your mouth during the episodes or use a face mask while handling children, and remember to wash your hands. If your child has a cough, seek urgent medical attention. A course of penicillin may be all that is required to reduce the risk of developing ARF and subsequent RHD. If your child experiences suspected heart failure symptoms, visit your cardiologist. An echo can go a long way in determining whether this is the case or not. Your cardiologist will also take measures to prevent heart failure and other complications such as infective endocarditis (infection of the inner lining of the heart).

This article is dedicated to all the children who suffer from RHD, all those who have lost their lives and those still fighting the battle…

Infertility: Preventable or Avoidable

I am not a great orator but I choose to launch my blog with this: A message from all the unborn children, some of whom may never come to be. Am sure you are wondering what this is all about, but I have been struck by the rising number of couples who are unable to conceive. Countless of moneys have been spent by partners in an attempt to sire an offspring ending up in divorce and polygamy. But ‘why?’ you ask, is it because some are blessed and others cursed? Well not quite, I believe we often give the devil more credit than where it is due. The sad reality, from my own medical perspective, is that most of these cases are preventable. I want to target an issue that most ladies have constantly ignored because of fear, fear of ‘shame’.

You will agree with me that sex exists in our beloved colleges and universities, but this is a relative non-issue because I don’t expect the prevalence to drop secondary to my article. But I hope to enlighten the men and women of our generation of the impending doomed marriages that result from acquired infertility. I know you are wondering what acquired infertility is, so I will have to define some terms. Infertility  is defined as failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35 years of age; and after six months of regular intercourse without use of contraception in women 35 years and older. Some clinicians use the term subfertility to describe this failure to conceive unless the couple has been proven to be sterile.

The incidence of infertility in developed countries has been dropping steadily but that is not the case for our African population. In most cases the man is normal and is producing enough quality ‘soldiers’. Therefore, I will focus on the reasons why our girls are slowly destroying their chances at healthy families. To understand this, one has to have a basic understanding of the anatomy (structure) and physiology (function) of the female reproductive system. Think of it as a person standing with his arms outstretched horizontally. The space between his legs represent the vagina, the pelvis represents the cervix, the body the uterus, the arms the fallopian tubes and the hands the ovaries. During conception, a male sperm travels up this tract to meet the ova (egg) in the fallopian tube. Subsequent implantation takes place in the uterus approximately 7 days later. A post-pubertal woman produces one ovum every 28-35 days in mid-cycle.


Most cases of infertility are unexplained; others include ovarian dysfunction (21%) and tubal damage (14%). These last two are greatly a consequence of genital tract infections. Yes, I refrain from using the term sexually transmitted infection because of its associated stigma.


What is Pelvic Inflammatory disease. PID is an acute infection of the upper genital tract structures in women, involving any or all of the uterus, fallopian tubes, and ovaries. It is often accompanied by involvement of the neighboring pelvic organs. In order for the ovum to move down into the uterus normally, it requires patent functioning tubes. On the other hand, in order for the sperm to reach the egg, the path must not be obstructed. In PID however, the ovaries may be inflamed to the extent to which they are unable to deliver eggs into the tubes, or the tubes unable to deliver the egg into the uterus. The former may result in ectopic pregnancies which may lead to destruction of tubes or even death. Most sexually active women experience PID at least once in their lifetime. If you experience VD, missed or delayed periods (without pregnancy), pain on urination, spotting or abdominal discomfort, chances are that you suffer from PID. If this is the case then I recommend a visit to your gynecologist.


Up to 85% of all gynecological visits are due to vaginal discharge (VD) and a good number of women experience this at least once in their lifetime. VD may be a little or a lot, and it comes in all different characteristics, enabling us to identify what is the possible cause. Not all discharges are sexually transmitted, but most are. Well, if you have noticed any VD, don’t shy away because this here is information that could change your life. Many ladies assume that VD is just a phase that will soon go away, and most of them are right, the discharge does reduce or completely disappear over time, but not the disease. Unfortunately, this can lead to a silent infection that slowly but surely destroys your chances at a healthy pregnancy. There are generally five main causes of discharge, gonorrhea, chlamydia, trichomona vaginalis (TV), bacterial vaginosis (BV) and candidiasis.
Gonorrhea causes a mild thick yellow VD in women which is mainly associated with discomfort while urinating. Most women however are asymptomatic carriers. Unfortunately, it is purely a human infection and can only be transmitted through intimate sexual contact. It is the second most communicable disease in the US. But is one of those genital tract infections that result in high rates of pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Up to 95% of cases are curable, surely the best news I have given you so far, by use of a single antibiotic injection and some oral antibiotic medication for about 2 weeks.

Chlamydia is a close partner to gonorrhea. Most of the time they are seen in the same patient and hence treatment is similar. Unlike gonorrhea, chlamydia produces copious amounts of grayish-white discharge. It is also associated with abnormal bleeding, either between menses or after sexual intercourse, discomfort during urination and abdominal pain. It does cause pelvic inflammatory disease in 30% of untreated women and has an increased risk of developing cervical cancer. It is completely curable and the regimen is similar to that of gonorrhea.

TV is another culprit. Unlike the others, this is not caused by a bacteria, but by an organism known as a protozoa. It has a classic smelly green-yellow frothy discharge is observed in 10 to 30 percent of affected women. This is associated with burning, itching, increased frequency and pain while urinating. It causes tubal infertility, pelvic inflammatory disease, and an increased risk of cervical cancer. Since it is of bacterial origin, its treatment consists of one antiprotozoal for seven days.

BV and candidiasis are usually opportunistic and not strictly sexually transmitted. They occur when the normal bacterial composition of the vagina is altered.  50% of female university students will have at least had one physician-diagnosed episode of candidiasis by the age of 25. Candidiasis usually presents as a white cudded ‘maziwa lala’ discharge which is associated with intense itching and a foul smell. BV on the other hand presents with a fish smelling, off-white, thin discharge. Candidiasis is treated with a seven day antifungal regimen, whereas BV requires a seven day course of antibiotics.

I hope this far you get the point: do not ignore any genital symptoms, most genital tract infections are curable and if not addressed, may compromise reproductive health. If any of the above conditions apply to you then plan to visit your gynecologist, they don’t bite. Always remember that the treatment of genital infections requires treatment of both partners in order to avoid reinfection. Therefore I call upon all men to accompany their ladies to the gynecologist: you may learn something new. Finally prevention is better than cure. I am a strong believer of ABCs, abstinence, being faithful and finally use of condoms.