An unusual cause of headache in a medical tourist.

With booming medical tourism, Indian doctors are seeing a lot of patients from other countries for varied medical conditions. A citizen of Nairobi presented for treatment of his complaints consisting of severe episodic headache, with abdominal pain, spermatorrhea, decreased libido, constipation, and impotence. On detailed evaluation, he was found to have developed dependence to khat chewing; a social habit in his native country and his symptoms were attributed to effects of khat withdrawal. He improved after treatment with topiramate and escitalopram and lifestyle modification. Physicians need to be aware about various cultural habits of addiction in different parts of the world and their common presentations in view of globalization of health care.

Introduction

Medical tourism has seen as exponential growth in last 5 years in India and is a growing source of foreign exchange as well as reputation and goodwill in other countries.[12] A study by ASSOCHAM reported that the year 2011 saw 850,000 medical tourists in India and projected that by 2015 this number would rise to 3,200,000.[3] Indian doctors need to be acquainted about different diseases, cultural practices and health hazards in various parts of the world as there can be rare infrequent presentations of diseases commonly seen in different epidemiological setting not common to India. We present a case report of a medical tourist from Nairobi who presented with ill health secondary to a cultural habit of “khat” chewing in his native place.

Case Report

A 32-year-old male, resident of Nairobi came to India for treatment of his multiple medical complaints ranging from headache, abdominal pain, and constipation for the last 4 months. His headache was episodic, throbbing in nature, with nausea, photophobia, phonophobia, without any aura, precipitated by stress, loud noise, bright light, and lasting for 8-12 h relieved by analgesics. He had such headaches for the last 4 months with a frequency of 18-20 episodes/month. He had undergone multiple evaluations in his native country including hemogram, liver function, renal function, electrolytes, abdominal sonogram which were all normal and came to India contemplating doing magnetic resonance imaging of the brain and gastrointestinal endoscopy, for detailed evaluation. On detailed interview for other co-morbidities, he was also found to have chronic constipation, gastritis, loss of libido, impotence, spermatorrhea, anxiety, insomnia and depression. In view of all this symptoms, he was further inquired regarding any addiction to any drugs, which he denied. However, it was found that in Nigeria there is a social tradition in which on every weekend, the males of the community would gather and chew leaves of a plant called miraa/khat continuously for 12-16 h from Saturday afternoon until late night up to about 3 AM. He had been following this custom for the last 20 years. According to him, chewing this leaves would provide an aphrodisiac effect, making one feel euphoric and keep awake to socialize with peers of the community until late night. However, due to a recent illness in his sister (who had chronic renal failure), he was busy in care giving for the last 4 months and was not been able to follow the custom of chewing khat leaves in social weekend gatherings. According to him, his symptoms had started after stopping this custom. On examination, he was found to have greenish staining of teeth [Figure 1]. His neurological examination was normal. His contrast enhanced computer tomography head was normal. He was diagnosed to have chronic migraine without aura for the last 4 months, with associated anxiety and depression precipitated by withdrawal of exposure to khat leaves. He was treated with 25 mg/day topiramate, which was increased to 50 mg/day in 10 days along with 10 mg/day of escitalopram along with paraffin syrup for constipation and explained about lifestyle modification. On a follow-up at 3 and 6 weeks, he had significant improvement in his headache episodes as well as mood and other somatic problems.

Figure 1

Greenish staining of teeth due to khat use

Discussion

The khat plant is a tree of the family Celastraceae that is frequently cultivated in certain areas of East Africa and the Arabian Peninsula. The leaves of the khat plant contain phenylalkylamine compounds (alkaloids) such as norpseudoephedrine (cathine) and alpha aminopropiophenone (cathinone), which are pharmacologically related to amphetamine.[14] The habit of khat chewing is a part of social and cultural life amongst the people of Africa. It is a common custom of chewing khat at social meetings such as writing poetry, singing, watching television in groups and also for working and studying.

Khat has psychological, medical, social and economic effects on human beings. Cathinone releases catecholamaines from presynaptic storage sites resulting in central nervous system (CNS) stimulation and a variety of peripheral sympathomimetic effects such as tachycardia and hypertension. Habitual users report increased levels of energy, alertness and self-esteem, sensations of elation, enhanced imaginative ability and capacity to associate ideas. An improvement in the ability to communicate is also reported, which explains the tendency to group interaction and social contact, while under the effect of the drug. Common side-effects of khat use include insomnia, anorexia, gastritis, with euphoria, loquacity, logorrhea occasionally leading to hypomania, and psychosis.[56]

A group of expert in WHO has concluded that khat consumption may induce “moderate but often persistent psychic dependence” the withdrawal symptoms after prolonged khat use seem to be limited, however, to lethargy, mild depression, slight trembling, and recurrent bad dreams.[7] Few case reports have shown an association of khat chewing and ischemic stroke in young.[8] CNS tolerance is not usual in khat users probably due to the physical limits on the amount that can be chewed. Mydriasis occurs as a sympathomimetic effect of khat, which also induce hyperthermia and causes dryness of the mouth. At the cardiovascular level there may be arrhythmia's and a moderate increase in blood pressure, which can become chronic upon long-term use.[9] There is exaggerated cardiovascular response to physical effort under the effect of khat;[10] it can also cause acute cardiovascular problems particularly in elderly people. Khat stimulates the respiratory center and bronchodilation, which can explain the feeling of comfort for asthmatic users. Khat affects the urinary system by relaxation of the bladder wall and closure of the internal sphincter. The digestive tract is mainly affected by the presence of tannins in this plant. Gastritis and constipation are some of the main complains of its users, loss of appetite is also a characteristic of khat. The malnutrition and constipation are attributed to both tannins and norpseudoephedrine. Khat use is also associated with periodontal disease and greenish/brownish coloration of the teeth. Khat consumption is also known to cause spermatorrhea and chronic use may lead to impotence.[9]

The addictive potential of khat is less when compared to amphetamines, but it causes psychological dependence rather than a physical one. Withdrawal symptoms consist of lassitude, lethargy, nightmares, tremors, depression, headaches, and loss of interest in activities. Tolerance to khat practically does not occur; if it does, the doses are increased only very slowly. This may be due to the intrinsic properties of khat or to the physical limits on the amount that can be consumed.

Conclusion

With booming medical tourism, Indian doctors need to be aware about various cultural habits of addiction in different parts of the world and their common presentations. Such patients may be misdiagnosed or given only symptomatic relief, rather than a cure. Knowledge about this ancient habit of khat chewing is important to be considered as differentials, especially in immigrants and tourists.