Case 1

A 59-year-old man, a known hypertensive (7 years) and diabetic (5 years), presented to us with acute chest pain. This proved to be due to acute myocardial infarction. He had been in the betel profession for well over 40 years, spending about 8–12 h sitting, selling and consuming betel quid 16/day and gutkha for 15 years. His waist–hip ratio (96/92) and blood pressure (150/90 mm/Hg) were elevated; his lower teeth were missing and/or mutilated and his hands showed brick-brownish coloured finger pulp, thickening and erosion of the skin of the fingertips and palms of the hands, more marked on the right than the left. He had raised blood sugar and triglycerides and low high-density lipoprotein cholesterol.

Case 2

A 29-year-old man who had been in the profession for 15 years and was a chronic quid and gutkha chewer, had nicotine stains all over the teeth, premature balding, central obesity (waist 99 cm), marked brownish discolouration of the fingers, hypertension, dysglycaemia and dyslipidaemia.

Case 3

A 54-year-old man, who had been in the betel profession for more than 30 years and was a known hypertensive, had discoloured lips, damaged teeth, stains from coloured saliva, brownish discolouration of the tips and pulp of the fingers as well as central obesity, hyperglycaemia and low high-density lipoprotein. He also demonstrated left ventricular hypertrophy on electrocardiogram (ECG).

All our subjects had belonged to the betel quid selling profession for more than 15 years, which requires sitting for 10–12 h/day. They were constantly exposed to betel quid, containing resinous extract of Acacia catechu, baked shell lime, betel nut and tobacco.1 In the process of preparing quid they apply baked lime and liquefied Acacia catechu paste to the betel leaf, varying from 100 to 1000 times a day. The overlying skin surface that comes into direct contact with the shell lime and Areca catechu gets roughened, denuded and brick-red coloured. It is speculated that the denuded epithelium may be the source of absorption of nicotine and arecoline in the betel quid sellers. They also took betel quid, gutkha and pan masala. Betel nut and tobacco contain potent psychoactive alkaloids such as arecoline and nicotine, respectively.2 Arecoline present in betel nut is known to cause cardiac arrhythmias and has proatherogenic effects. It may aggravate vasospasm by influencing tissue matrix metalloproteinases and tissue inhibitor of metalloproteinase.2 3 The sedentary nature of their occupation combined with their daily intake of tobacco and betel nut lead to early development of diabetes, hypertension and dyslipidaemia in these people.4 5 Further, keeping quid in the space between the buccal mucosa and lower teeth resulted in the colouring of saliva due to interaction of Acacia catechu with alkaline shell lime and damage to their teeth. Nitrosamines produced due to chemical interactions between areca nut, shell lime and catechu causes early submucosal fibrosis and oral cancers.6

It is suggested that central obesity, brick-brownish pulp and palms of the hands and denuded skin over the tips of the fingers should be considered as features of ‘betel quid seller syndrome’. This is a harbinger of diabetes, hypertension and/or coronary artery disease. Further large studies are required to suggest remedial measures for prevention of premature cardiovascular disorders in betel sellers.