Burning feet syndrome: An old tropical syndrome revisited

Abstract

Background: Burning feet syndrome (BFS) has been described anecdotally in the literature for over 200 years. Described subjectively by patients as burning, prickling and unremitting with nocturnal exacerbations, the condition draws parallels with the burning dysaesthesia found in diabetic peripheral neuropathy, and appears to display a similar chronicity. Despite being a common symptom, especially among the elderly, its etiology in non-specific and often marked by a lack of objective clinical signs. Historically, burning feet syndrome has been recorded in situations of poor nutrition, including malnourished African populations in the early 20th century, South American plantation workers in the 1920s and during food shortages in the Spanish Civil War. Perhaps the best described and largest outbreak of burning feet occurred amongst prisoners of war (POWs) of the Japanese during the 2nd World War in South East Asia and the Far East. In this review we summarise reports of the condition, in particular amongst Far East POWs (FEPOWs), using both the available literature as well as a unique and previously unknown contemporary study carried out in a POW camp. Materials and Methods: During his stay in the Tandjung Priok POW camp, Nowell Peach recorded 54 cases of burning feet seen over a 4 month period during captivity. This data was concealed from his captors and survived to return home with him. Results: 54 prisoners presented over a 4 month period with a mean age of 28 years and mean duration of symptoms of 12 weeks. Neurological signs were meticulously documented. All were on an inadequate diet, 20 (38%) were on less than a full ration. Accompanying tropical infections were common including malaria (73%), dengue (45%) and dysentery (41%). Discussions: The Peach survey confirmed the frequency of burning feet amongst FEPOWs and was unusual in that the neurological examination and conditions endured were documented in captivity. A paucity of physical signs was noted, and a suggestion that burning feet could be precipitated by intercurrent infection. Conclusions: Burning feet syndrome can be regarding as an antique medical condition as chronic malnutrition becomes less common. This hidden study carried out during captivity provides remarkable new insight into the disease which is now essentially unknown to modern practitioners.

Flight Lieutenant Peach’s observations on Burning Feet Syndrome in Far Eastern Prisoners of War 1942–45

“…Large numbers of BFS patients were found also found by Cruickshank in Singapore 12 and Page in Hong Kong and the Philippines. 6 Others reported a much lower prevalence: in 551 cases of dietary associated scrotal dermatitis seen in Changi camp in Singapore, Frankland, noted only six cases with painful feet.…”

“…Preservation of tendon reflexes was the rule; however there were differences between reports, with some finding an increase in deep reflexes. 4,7,12 As is the case for many painful neuropathies, pain was particularly troublesome at night and often associated with insomnia. 10 Patients were described as sitting in a squatting position, gripping their toes and massaging their feet 'for hours on end.'…”

“…He revealed the existence of the original notes when interviewed by the FEPOW oral history project half a century later. The history and some medical aspects of these records have been reviewed before; 12 here we analyse the pain and related symptoms and signs which Peach reported. Case One This 62-year-old-man was assessed 35 years after release, in 1980.…”

“…Although most medical officers had not experienced BFS previously, its presentation as a painful dysaesthetic polyneuropathy was described 'remarkably consistently by different authors', often in distinct terms from the peripheral paraesthesiae of thiamine deficient beri-beri. 10,12,14 Ascribing a single aetiology for BFS in FEPOW suffering from severe starvation, multiple avitaminoses, and co-existing tropical infections was difficult, and no overall consensus exists. Nevertheless, most doctors reached the conclusion that the poor diet, resulting in a specific B-vitamin deficiency, was to blame, largely because BFS often presented alongside signs of other B-vitamin deficiency diseases which were well recognised by the doctors.…”