Dr
MFONFU Daniel
Independent
Researcher
Tel:
+237 677601207
Website: www.mfonfudaniel.blogspot.com
1.
INTRODUCTION
Congenital hypothyroidism (CH) is
defined as thyroid hormone deficiency present at birth (Maynika V Rastogi,
Stephen H LaFranchi).
Congenital hypothyroidism is a
condition where the thyroid gland does not make enough thyroid hormone. The
thyroid gland is a small butterfly-shaped gland located in the neck. Normally,
it uses iodine from food we eat to make thyroid hormone. This thyroid hormone
is also known as thyroxin (T4). T4 is needed for normal growth and development.
If congenital hypothyroidism is left untreated, it can lead to growth failure,
mental retardation and other serious health problems (Julie J. Gordon).
If the child thrives he/she will
grow up to be a cretin. A cretin is one who is severely stunted physically and has
a severe retarded mental growth due to untreated congenital hypothyroidism.
The author clinically diagnosed a
case of congenital hypothyroidism on 22 September 1983 at Divisional Hospital
at Edea in the Sanaga and Maritime Division in Cameroon. The treatment of the
child with thyroxin produced such a spectacular recovery that spurred the
author to document the case in 1984, with the consent of the mother of the
child, in order to encourage clinicians working in areas with limited
diagnostic facilities to always think about the existence of such a rare
endocrine disease. A copy of this report was given to the mother to use for
consultation as the child developed; she also provided me the pictures as the
child grew up and permitted me to publish them.
In 1984 there was not enough
literature to identify neither the cause nor the contributing factors to the
disease; but as time evolved, the arrival of internet permitted me to consult literature
on congenital hypothyroidism that provided among others the nutritional causes
and risk factors of the congenital hypothyroidism. Of recent, community
traditional believes and practices revealed that raw juice of cassava leaves is
consumed by pregnant women believing that it provides blood to the pregnant
woman and the in-utero baby. This traditional believe is being promoted by the
increasing number of homoeopaths, naturopaths, and traditional healers in
Cameroon. Even health care providers have joined the chorus by encouraging pregnant
women during ante natal clinics to drink raw cassava leaves juice.
This traditional doctrine was
greatly practised by the community at Edea; it is still being practised in that
community and it is spreading in Cameroon. It is for this rapid growing
doctrine that I am writing this report to draw the attention of healthcare
providers and the community of the ill effects of noxious traditional believes
without a scientific background such as the consumption of raw cassava leaves
juice by pregnant women.
This article on congenital hypothyroidism
will be based on the nutritional causes of congenital hypothyroidism. The references
used in this article are meant to backup and prove the goals and objectives of
this study for the good of humanity.
2.
REVIEW OF LITERATURE
ON CONGENITAL HYPOTHYROIDISM
a)
Nutritional causes of
congenital hypothyroidism (CH)
There
are several nutritional causes of CH cited in the literature but we shall
consider two food stuffs which are largely consumed in the Southern part of
Cameroon; these are cassava leaves and soya bean which cause congenital
hypothyroidism (Georgia Ede MD).
a)
Pathophysiology
Cassava leaves contain cyanide and soya bean contains soy flavonoids that are perhaps better known as “soy isoflavones”, which we are usually told are good for us (Georgia Ede). In an overview of thyroid hormone synthesis the Pearls for Clinicians of the University of Wisconsin have demonstrated the roles of thiocyanate from cassava and soy isoflavones play in causing congenital hypothyroidism (FigureI); they vividly describe the pathophysiology of cassava cyanide and soy isoflavones in the inhibition of the production of thyroid hormones. Thiocyanate, from cyanide in cassava leaves, blocks the transportation to and absorption of dietary iodine by the thyroid gland. Soy isoflavones inhibit the action of the enzyme thyroid peroxidase in the synthesis of T4 and T3.Thyroid hormones are vital for normal growth and development before and after birth. Because the unborn baby receives thyroid hormones from the mother, most babies with congenital hypothyroidism will have normal growth measurements at birth, including their weight and length(Maynika V Rastogi, Stephen H LaFranchi). However, if a baby’s hypothyroidism is not treated, they will remain small through infancy and childhood and end up being very short. This slowness of growth not only affects the skeleton but all parts of the body.
Brito, V.H.S.; Ramalho et al showed that cassava leaves contain most of the cyanide in the cassava plant; the mean values (mgHCN
equivalent kg-1 fresh basis) for free cyanide were 40.34 for cortex, 35.02 for
parenchyma and 49.40 for roots (cortex + parenchyma). The potential cyanide was
higher 49.40 for cortex, 39.43 for parenchyma and 45.10 entire roots. Cassava leaves
presented 49.08 as free cyanide and 63.85 as potential cyanide.
Raw cassava contains two cyanogenic glycosides,
linamarin and lotaustralin, which can release prussic acid (hydrogen cyanide -
HCN). Generally, the cyanogenic glycosides are not considered toxic. Once ingested
by a person, the following reactions occur: Linamarin → Glycoside + Cyanohydrin
→ HCN. The HCN is the toxic form of cyanide. It targets the ferric iron (Fe+3)
of the "a"-cytochromes of the electron transport system in the
mitochondria. As a result, electron transport to oxygen is inhibited and energy
production stops (no ATP being produced) resulting in rapid cell death. The
body is able to detoxify low levels of cyanide in the body through the action
of an enzyme, rhodenase, by the following reaction: HCN + sulfur → SCN
(thiocyanate). This is an important reaction since the formation of thiocyanate
contributes to the chronic toxicity problems of cyanide. It is excreted by the
kidney. Health problems can result from cassava ingestion. Acute death has occurred
from eating raw roots due to high levels of cyanide. Death is due to the lack
of energy production in the brain and heart (Michael E. Mount).
According
to Georgia Ede MD, ‘Soy flavonoids are perhaps better known as “soy
isoflavones”, which we are usually told are good for us. Soy flavonoids reduce
the activity of thyroid peroxidase, the enzyme required to insert iodine into
thyroid hormone. Cooking does not destroy the goitrogenic activity of soy
isoflavones’.
S
C Conrad, H Chiu, B L Silverman concluded in their study that “Based on our
findings of prolonged TSH increase in patients with CH on soy formula diets, we
recommend that when soy based diets are clearly indicated in patients with CH,
the provider must be aware of the possibility of prolonged increase of TSH
despite seemingly appropriatedoses of levothyroxine. The infant should receive
close followup with free T4 and TSH measurements, and if necessary,increased
levothyroxine dose to achieve normal thyroidfunction tests”.
a)
Signs and symptoms:
CH presents the same signs and symptoms despite the
cause.Signs and symptoms of Congenital Hypothyroidism in literatureaccording to
(Maala S Daniel et al; Mary Shomon; Maynika V Rastogi et al):
Infants with congenital hypothyroidism are usually
born at term or after term. Most
new-borns with congenital hypothyroidism do not have any signs or symptoms of
the condition. This is due to the presence of some maternal thyroid hormone,
but gradually as maternal thyroid hormone is depleted, clinical signs and
symptoms can include the following: large anterior fontanel; feeding problems; lethargy (lack of energy, sleeps
most of the time); jaundice; hypotonia; hoarse cry; coarse facial
features; Macroglossia (Picture 2); and other features as shown in Picture 3; umbilical hernia; low
body temperature; distended abdomen due to persistent constipation; mottled, cool, and dry skin; developmental delay; pallor; little to no growth,
failure to thrive; myxoedema may be present; thick coarse hair that goes low
on the forehead; goitre may be present.
3. GOAL
The purpose of
publishing this article in 2015 on congenital hypothyroidism diagnosed on 22
September 1983 in Edea-Cameroon is to prevent congenital hypothyroidism due to
consumption of raw juice of cassava leaves, and soya bean by sensitizing health
care providers and the community.
4. OBJECTIVES
i)
Review
literature of congenital hypothyroidism
(CH)
ii)
Present
the case of CH diagnosed at Edea
iii)
Discuss
CH due to soya bean,
iv)
Present
“Bamenda huckleberry leaves” which is a save edible vegetable
5.
METHOD
The CH due cassava leaves will be demonstrated by
the case diagnosed at Edea (Picture 4) while that due to soy bean will be
obtained from literature reviewed.
In
the previous documentation there were no facilities such as the internet to
consult in order to obtain literature on the exhaustive causes of CH and pathophysiology
of CH. Some books were consulted locally. Presently most of the references were
obtained from downloading documents from the internet. The diagnosis of CH was
made on the basis of a picture of CH seen in a paediatric text book ‘Disease in
infancy and childhood’ by Ross G. Mitchell.
6. RESULTS
a)
Case of Congenital
hypothyroidism
The
child N.E, delivered normally on 23 March 1982 with a birth weight of 2.885kg,
was admitted into the paediatric ward at the Divisional Hospital at Edea in
Cameroon, on 14 June 1982 for marasmus malnutrition (Picture 4).
During
a casual round in this ward the features of the child struck me. On closer
examination the child presented the following features as shown in Picture 4:
·
Marked
muscular wasting,the child’s weight on admission on 14 June 1982 at the age of 3
months was 2.470kg, macroglossia protruding
from the mouth; a distended abdomen; an umbilical hernia; a flat nose; thin dry
and lustreless hair; a lethargic expression, and a wrinkled forehead.
·
The
mother declared that the child was also suffering from constipation and
difficulty in feeding.
The
pathognomonic sign of ‘macroglossia that protrudes from the mouth’in CH led me
to make the clinical diagnosis of CH. The child was put on thyroxin 0.05mg
daily. There was no facility to carry out laboratory thyroid function tests and
radiological explorations.
There
was a spectacular recovery, confirming the clinical diagnosis of
hypothyroidism. After treatment for a month with thyroxin he weighed 3.730kg,
and there was rapid regression of macroglossia (Picture 2).
On
22 September 1983, at the age of 18 months the child had attained both normal
physical and mental development under thyroxin treatment. His weight was
11.000kg (Picture 3)
He
had five brothers, and all of them had umbilical hernia (Picture 7).
Neither
the mother nor the father presented symptoms or signs of the thyroid gland
pathology.
Although
CH is rare, it should be borne in mind especially in areas where there is high
incidence of malnutrition because cases of advanced hypothyroidism could always
be mistaken for marasmus malnutrition.
At
18 months, Picture 6, N.E was very normal and continued normal development as
shown in Pictures 8 at 4 years and in Picture 9 at the age of 5years 2months.
It
should be emphasized that during Infant Welfare Clinics (IWC) babies should be carefully
examined for macroglossia, umbilical hernia,
loss weight and distended abdomen. Those presenting the above signs should be
investigated for hypothyriodism. The early diagnosis of CH would prevent the
profound physical and mental retardation that could occur in an untreated child
and death.
The fact that all the five
brothers have umbilical hernia (Picture 7) might underline the presence of some
hereditary defect. However in this community and elsewhere in Cameroon there is widespread
use of palm kernel oil (manyang) as a rubbing oil for babies; this oil causes improper healing of
the umbilicus consequently causing umbilical hernia (Dr Mfonfu Daniel, July – August 2007).
b) CH
due to soya bean
Abigail Gelb Fruzza, Carla Demeterco-Berggren,
and Kenneth Lee Jones give the history of the goitrogenic effect of soy, “The first documentation of a
goitrogenic effect of soy occurred in the 1930s with the development of goiters
in rats fed with raw soybeans. This was followed by soy-induced goitre in
humans a quarter of a century later. In 1959, Van Wyk et al described an infant
who had been fed a soy-based formula beginning shortly after birth and
presented at 10 months of age with “cretinism” and a goiter. After
discontinuation of this formula, the goitre and features of hypothyroidism
disappeared, and the infant’s growth rate recovered a normal track”.
7. DISCUSSIONS
The case of CH diagnosed
clinically and treated at Edea was considered a miracle by the family and
immediate population who attributed this case of CH to witchcraft. The parents
permitted me to follow up the child for over five years old. The spread of the
doctrine to pregnant women to consume raw cassava leaves juice in Cameroon is a
cause for concern after about 33 years of diagnosing this case of CH at Edea. The
eating of raw juice of cassava leaves should be stopped.
I really hope that health research institutes, and universities of medicine with more modern sophisticated equipment and reagents would carry out studies on the new born babies in this vulnerable group who consume raw cassava leaves juice during pregnancy. Carrying out research on cassava tubers will not be very helpful in this domain because the tubers are well treated in Southern Cameroon before they are eaten in various forms such as garri, water fufu, and batton de manioc.
I have never seen any bird eating cassava leaves.
Concerning soy bean, Conrad, Chiu
and Silverman declare that ‘In our population, with CH who was fed soy
formula had prolonged increase of TSH. Since normal development is critically
dependent on rapid normalisation of thyroid function, this finding has important
implications for infants with CH fed soy formula. Based on our findings of
prolonged TSH increase inpatients with CH on soy formula diets, we recommend
that when soy based diets are clearly indicated in patients with CH, the provider
must be aware of the possibility of prolonged increase of TSH despite seemingly
appropriate doses of levothyroxine. The infant should receive close follow up
with free T4 and TSH measurements, and if necessary,increased levothyroxine
dose to achieve normal thyroid function tests’.
Abigail Gelb Fruzza, Carla Demeterco-Berggren, and Kenneth Lee Jones state that ‘Based on our experience, we would make the following recommendations for children requiring levothyroxine replacement. Avoid the use of soy products unless necessary. If soy products must be used, carefully monitor thyroid function and use the dose necessary to maintain euthyroid T4 and TSH, even though it may be higher than usual recommended dosage. If soy products are discontinued, in someone receiving levothyroxine replacement, monitor thyroid function to avoid iatrogenic hyperthyroidism’.
Georgia Ede MD states that“In my experience, most people are unaware of the connection between soy and thyroid problems. If a study like this had been about an ingredient in red meat, you can bet you’d see a giant headline in the New York Times trumpeting that red meat causes thyroid disease, and everyone would be talking about it…’
California State Law requires that
all babies have the new-born screening test before leaving their hospital of
birth (California Department of Health Services).
Delange F. concludes that “1. Primary
TSH screening for congenital hypothyroidismis a particularly sensitive index in
the evaluation of degree of iodine deficiency.
2. Neonatal TSH has the major
advantage of being the single indicator allowing prediction of possible
impairment of mental development at a population level.
3. Neonatal thyroid screening is
also an excellent monitoring tool in the evaluation of the impact of programs
of iodine supplementation.
4. However, the implementation of
a thyroid screening program raises serious technical and financial problems.
Urinary iodine remains the most universal and recommended indicator for the
degree and correction of IDD”.
Presently there is global
consumption of soya bean oil and its products because of the false
advertisement that soya bean contains proteins whereas it contains mostly fat
with very long chain fatty acids that is difficult to be metabolised by our body
thus it only accumulates in the body causing obesity with the consequences that
come with the obesity (Dr Mfonfu Daniel Thursday 20 April 2012).
Neonatal Screening for congenital
hypothyroidism by determining the blood titre of TSH would be difficult to be
generalised in all countries because the high cost.
The health burden caused by the
consumption soya bean is enormous, first in the management of obesity and secondly
in the systematic screening and treatment of new born at birth for congenital
hypothyroidism.
8.
Presentation of a
friendly vegetable consumed in Bamenda and in the entire North West Region in
general
The leaves of huckleberry(Picture
10) which are friendly vegetables are widely eaten in North West Region. In
certain communities such as Bali Nyonga it said that eating cassava leaves
causes dizziness. The huckleberry vegetable is exported
from Bamenda to other Regions of Cameroon.
9. CONCLUSION
I have tried to describe the
contribution of the raw juice of cassava leaves and soy bean as a result of the
clinical diagnosis of the congenital hypothyroidism that responded spectacularly
to treatment with thyroxin, in Edea.
It may really true that we may be ignorance of the effects of soy intake and drinking of raw juice of cassava leaves on Congenital Hypothyroidism or we may just ignore them because of big money that soya bean and cassava leaves produce.
These causes of CH can be
prevented for there is a saying that ‘Prevention is better than cure’; let us
stop consuming raw juice of cassava leaves and soy bean. Let us eat friendly
vegetables such the leaves of huckleberry leaves.
I will also recommend that research institutes
and universities who have sophisticated equipment and reagents should carry out
studies on cyanide and thiocyanate in the vulnerable group of pregnant women who
drink raw cassava leaves juice and their new-born babies in order to concretely
educate the population on the negative effects of the consumption of raw
cassava leaves juice; and soya bean products.
I pray that my experience will
inspire us to improve the health the population of Cameroon and of the world in
general by preventing CH due to the consumption of raw cassava leaves juice;
and soya bean products.
Glory be to the Almighty God, NE survived
the congenital hypothyroidism; May we prevent CH caused by food items in world
in the name of Jesus Christ – Amen!
10. REFERENCES
1)
Abigail
Gelb Fruzza, Carla Demeterco-Berggren, Kenneth Lee Jones; 2012, Unawareness of
the Effects of Soy Intake on the Management of Congenital Hypothyroidism; http://pediatrics.aappublications.org/content/130/3/e699.full
2)
Brito,
V.H.S.; Ramalho, R.T.; Rabacow, A.P.M.; Moreno, S.E.; Cereda3, M.P;
Colorimetric method for free and potential cyanide analysis of cassava
tissue.Agricultural College, Catholic University (UCDB), Campo Grande, MS,
Brazil, Correspondent Author cereda@ucdb.br
3)
California
Department of Health Services, Genetic Disease Branch: Parents’ Guide To
Primary Congenital Hypothyroidism: www.dhs.ca.gov/gdb
4)
Conrad
SC, Chiu H, Silverman BL; Soy formula complicates management of congenital
hypothyroidism; Arch Dis Child. 2004 Jan;89(1):37-40: http://www.ncbi.nlm.nih.gov/pubmed/14709499, www.archdischild.com
5)
Delange
F. Neonatal thyroid screening as a monitoring tool for the control of iodine
deficiency. ActaPædiatr 1999; 88 Suppl 432: 21–4. Stockholm. ISSN 0803–5326
6)
Dr
Mfonfu Daniel, July – August 2007, Skin rashes in children and palm kernel oil
(manyanga), at Bamenda, Cameroon: www.mfonfudaniel.blogspot.com
8)
Dr
Mfonfu Daniel, Thursday 20 April 2012, Soya bean and soya bean oil contribute
to the obesity pandemic: www.mfonfudaniel.blogspot.com
9)
Georgia
Ede MD, Foods that Cause Hypothyroidism, http://diagnosisdiet.com/foods-and-hypothyroidism
10)
Julie
J. Gordon, American Thyroid Association, The Hormone Foundation: Congenital
Hypothyroidism, www.netnet.net/mums/, www.thyroid.org, www.hormone.org
11)
Maala
S Daniel, MBBS; Chief Editor: Stephen Kemp, MD, PhD el al,
Congenital Hypothyroidism; http://emedicine.medscape.com/article/919758-overview#showall
12)
Maynika
V Rastogi, Stephen H LaFranchi
Congenital hypothyroidism; Rastogi and LaFranchi, Orphanet Journal of
Rare Diseases 2010, 5:17; http://www.ojrd.com/content/5/1/17
13)
PEARLS
FOR CLINICIANS, Integrative Treatment of Hypothyroidism; University of
Wisconsin Integrative Medicine; www.fammed.wisc.edu/integrative
14)
Ross
G Michel, 1973; Disease in Infancy and Childhood, page 208;
15)
S
C Conrad, H Chiu, 2004, B L Silverman; Soy formula complicates management of
congenital hypothyroidism; Arch Dis Child 2004;89:37–40. doi:
10.1136/adc.2002.009365; www.archdischild.com
1 comment:
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