Pediatric Cases

I have been amazed at the variety of the patients in “Ward Pediatrie”. I love visiting the ward: Children are happy to chase bubbles and mothers display a tenderness that could be missed in other aspects of the culture as they care diligently for their children. However, it is equally overwhelming. The smells are powerful just like the suffering that seems even more heart-breaking in young children. Most are hospitalized for severe diarrhea, pneumonia, or malaria. But we’ve had several rare challenging cases that seem to epitomize the unique formula of African medicine. This does not even include all of them…

Many infants receive Oral Rehydration Solution (ORS) through a naso-gastic tube. ORS is a life-saver for children who can rapidly become dehydrated from diarrhea. It relies on Na-K pump in the GI tract which naturally absorbs the body’s requirements. In a third world setting without labs to measure electrolytes, this is more helpful than IVs requiring calculating electrolytes. It is also a fraction of the cost of IVs. The nasogastric tube ensures that the children get all they need even if the mothers can’t get them to drink it.

When a child is admitted, part of the hospital chart reads: “Grattage” checked OUI or NON. Grattage is a local practice of scrapping or cutting the throat. This tradition is based on the medical practices for diphtheria. Diptheria causes a grayish coating on the throat. Before vaccinations were routine, the disease was common and treated by health workers who would scrape the coating off. I wonder if this tradition also applies the belief in some parts of Africa that cutting an area of pain will “bleed out” the pain.

Now it is a problem because many children come to the hospital after their parents have (out of the best intentions) scrapped or cut the throat which can lead to infection. This child above had pneumonia and had his throat scraped. He is treated with Chloramphenicol. It is not used in the US much because of an extremely rare condition of aplastic anemia (although unlikely, just one case could ruin a career in the states with legal suits). In Africa it is utilized because the chance of aplastic anemia is less than the chance of ototoxicity or renal damage (which in not monitored as carefully here) by the other options: Gentamycin and Ampicillin. Also, cost is always an issue. One drug, Chloramphenicol, is less costly than using the combination of Gent and Amp.

Clarice Musawimana is 7 years old, but her 4 year-old brother has outgrown her. Along with the growth retardation her mother said she has had a chronic cough since she was 1 y.o. Through all the exams I only heard her cough once. At first we were worried about her heart. An echo showed that it could possibly be enlarged, but the interpretation is very subjective. She had no murmurs, rubs, or gallops, just a physiologic split with inspiration. After a day trip to the nearest town we had an X ray that showed a normal heart size. The X ray showed somewhat prominent hilar markings, but otherwise normal. Her lung sounds were clear on auscultation. Eventually we ruled out lung pathology. We worried about HIV, but she tested negative. TB was part of the diagnosis because of the delay in growth and cough. Her PPD was negative, and her three sputum collections showed no Acid-Fast Bacilli.

We moved on to other possibilities of growth retardation. Malaria is always on the differential here, and recurrent bouts could possibly cause growth delay. But her blood smear showed no malaria. An abnormal presentation of Cystic Fibrosis? No other symptoms were present, and there is no cure anyways especially in Africa. We brainstormed hematological causes and malnutrition, but nothing matched the history and symptoms. She came in with a slightly distended abdomen, so we treated for worms; and, after a week in the hospital waiting for tests, she was released with the worm drug that costs pennies. We concluded that some families have small and large children. Maybe she’s the oldest yet smallest and worms delayed her even more.

I loved this case. It was a privilege to work with Dr. Theoneste and Dr. King on it. Her case was such a great example of African medicine: always operating under a wide differential while you wait and wait for tests. Many tests are extremely costly and distant, so you must decide what you will do with the findings. TB, HIV, malaria, malnutrition, and parasites are always in the back of your mind—to treat, to rule out, or to finally accept as a most likely diagnosis.

This was a particularly tragic case to me. Maurice Maniragaba was a 14 y.o. boy. His family noticed his eyes were yellow in February. In May his body became swollen. He had some convulsions and was hospitalized in another district for three days. He came to Shyira in a coma and liver failure. His head was swollen from hepatic encephalopathy. His belly was swollen from ascities. His blood glucose was 25 mg/dL and I could smell ammonia as he breathed.

Most likely, he had an acute hepatitis that made his eyes jaundiced in February. After his release from the hospital his parents used local herbal remedies that are less expensive than medical care. We assume that these local herbs were toxic to his already damaged liver. I drained some fluid from his belly for testing and Dr. Theoneste did a lumbar puncture to make sure the coma was not from another infectious source. I did not see the results because he died before the morning.

This child is 15. His thin frame makes it unbelievable though. A basic test for malnutrition is arm circumference: your fingers should not be able to touch. He is an orphan. He has no farm or land to live on. His parent’s plot may have been taken over in the conflict after their death. He has been hanging around the hospital more since people are helping to take care of him.

See one, do one

Dr. Kohl and his students: two pre-med visitors touring the hospital and moi

One of the experiences I value the most from Shyira has been working in the OR. Dr. Kohl worked in surgery in Niger for three years, and he graciously taught me in the bleached surgery room of this rural Rwandan hospital. I have been able to watch/assist/perform tubal ligations, hysterectomies, hernia repair, a lymph node removal for biopsy, a circumcision, amputations, a skin graft, and C-sections.

Last week I watched Dr. Kohl do a finger amputation of a lady with leprosy. She had lost feeling in her hand, injured it, and it had gotten badly infected. So, when a man presented this week needing a finger amputation Dr. Kohl let me practice what I had seen. This man had an injury several years prior. His index finger had not been kept in extension while healing, and the tendons healed so that his finger was curled. He did not use it much, and when it became infected from a second injury he came to the hospital. After a week he agreed to have the procedure.

Before and After

Case: Osteomyelitis

Today I saw an operation for a skin graft on an 8 y.o. boy, one of my favorite patients at Shyira. He has a playful attitude, a beaming smile, and a limp. His right shin is wide open and has been for years. He has chronic osteomyelitis—infection of the bone.

Osteomyelitis usually infects the bone through 1)bacteria traveling through the blood that finds a home on the bone or 2)through a deep injury (or surgery) that gives the bacteria access to traumatized bone.

In America osteomyelitis is not common. Injection drug users and patients with intravenous catheters are two small groups at risk for bacteria introduced into the blood. However, after working in Uganda and Rwanda, I no longer consider it astonishing to see patients with deep wounds that will not heal, with infections that have persisted for years or children limping because osteomyelitis has kept their infected bone from growing.

Staphylococcus aureus is a bacteria that normally grows on our skin. The Kings have both commented that the Staph in Africa seems unusually vicious. Combined with the differences in sanitation, it causes problems. Just this week I’ve seen a liter in total of pus drained from patients coming in with abscesses caused by Staph. Two patients had fingers amputated that were taken over by the bacteria. It is also the most common cause of osteomyelitis. When in the blood it settles most commonly in the long bones or vertebral bodies. If untreated it can cause an avascular necrosis of bone. In children this is especially disastrous because it causes a stunt in their growth. Another mechanism is through a wound providing direct contact to the bone. If a wound is deep enough the bacteria can settle in the bone, so treatment requires surgical debridement and IV antibiotics. However not all patients in Africa will come in for cleaning of their wounds.

The small boy had skin grafted from his thigh to cover the gaping wound on his shin. With this and antibiotics hopefully his leg will heal and he won’t have to continue his childhood using a cane.

At the orthopedic hospital in Uganda many patients with osteomyelitis wore these devices to allow bones to regrow to normal length.

A patient's death....

Last night I walked to the hospital. Students in their uniforms were crowded around the windows of the hospital wards taking advantage of any escaping light to study for their exams. I was going to visit a critical patient. She had come in on the weekend with labored breathing. On my first time to examine her she was in the tripod position trying to get breath. Drops of sweat were beading on her face and she moaned with each movement. Her lungs were filled with fluid that also swelled in her legs and stretched the skin tight. Because of the fluid she could not lie down to sleep. This woman was on my mind, and I had asked Dr. Louise if she could get more Lasix. Louise said that if her systolic blood pressure was over 95, that I could give more if I wanted. My cuff was too big for her shrunken arm. The last reading from the afternoon was 100/80, and I asked the night guard to give it.

This woman was my age. She was HIV+ and her husband had left. She had two children and worked on their farm. Last year her CD4 count was 266 but she was lost to follow up and never was treated with ARVs. She had been coughing for three months. She came to the hospital because breathing had become painful.

Because of her history and the high incidence with AIDS, Tuberculosis with an effusion was at the top of the differential even though her PPD was negative: in immuno-suppressed patients there are many false negatives because it requires an immune response to show a positive result. Shyira has no Xray, but an exam was sufficient to realize there was a problem. On exam her lungs sounded crackly all over with expiratory wheezes. The oxygen saturation of her blood was 84%. Her lungs were dull to percussion because of the fluid. When fluid was drained it contained 1400 wbc/mm3. TB treatments were begun. Augmentin was added in case the pneumonia was bacterial. Bactrim was added in case the pneumonia was PCP, also common in HIV patients. There was likely cardiac involvement. I could hear an S3 gallop on auscultation. She had been given Lasix to remove the excess fluid and a blood transfusion when she became very anemic.

When I entered the ward this morning I noticed her bed was empty. The nurse noticed my gaze and told me, "The madame has died in the night."

I wonder how, in a hospital room that holds twenty beds side by side, how the death of one affects the others in the dark night. Does the room grow anxious as she cries? Do the others wake to offer condolences to the family staying with her? Do they mourn? Offer help? Or do they remain asleep...just like the rest of us.

Over two million people died of AIDS in sub-Saharan Africa last year. That was 72% of AIDS deaths in the whole world. I wonder what will happen to these countries laden with this burden of HIV. Will others offer help, money, interest? Will we stay comfortably asleep?

More on AIDS

Almost two thirds (63%) of all persons infected with HIV are living in sub-Saharan Africa. An estimated 2.8 million adults and children became infected with HIV in 2006, more than in all other regions of the world combined. (WHO/UNAIDS, 2006)

HIV and Tuberculosis, two modern day public health epidemics, seem to go hand in hand. M. tuberculosis infects a third of the world's population. 95% of TB cases and 98% of TB deaths are in developing countries. In 2000, Sub-Saharan Africa had the highest TB incidence rate. Of the TB deaths in 2000, 12% were attributable to HIV. By the end of 2000 about 11.5 million HIV-infected people worldwide were co-infected with M. tuberculosis. 70% of those were in Sub-Saharan Africa. (WHO, 2004)

It is difficult to miss the impact of HIV at Shyira hospital. A voluntary counseling and testing center sees patients (they encourage couples to come together) and guides them through the emotional process. Social workers screen to identify patients who can be compliant with the medications. I enjoy sitting in with Louise as she sees outpatients who are HIV+. They are given special files to keep a comprehensive record of their health. If their CD4 count is below 350 they are started on antiretroviral (ARV) drugs. Regimens are adapted based on if they are pregnant or have had reactions to certain drugs. Screening for TB is done before starting ARVs. If positive for TB, they are treated for TB first since treating simultaneously can cause an immune reconstitution syndrome. Patients with a CD4 count of less than 200 are started on Bactrim. This is prophylaxis against PCP (pneumonia) and, a more common complication in Africa, Toxoplasmosis. In an outpatient setting, HIV+ patients are seen for treatment. Many dermatological problems are manifest with the patients as well as normal complaints of cough, STDs, fungal infections and diarrhea. Some of the problems, like neuropathy, are a result of the medications, and changes are made in the ARVs.

The work at Shyira reflects a larger work especially strong in the countries of Botswana, Kenya, Malawi, Namibia, South Africa, Uganda, Rwanda and Zambia. Provision of antiretroviral therapy has expanded dramatically in sub-Saharan Africa: more than one million people were receiving antiretroviral treatment by June 2006, a tenfold increase since December 2003. However, the sheer scale of need in this region means that a little less than one quarter of the estimated 4.6 million people in need of antiretroviral therapy in this region are receiving it. (WHO/UNAIDS, 2006)

In Shyira, they are making plans to start a special home to give care and counseling to HIV patients who require a longer stay. We’ve had several patients wasting from AIDS who have been in the hospital as long as I’ve been here, so it the need is great. They have decided not to refer to it as a hospice home because the number of patients dying a long death from AIDS is decreasing as Rwanda is implementing such fervent ARV treatment.

This patient was at the hospital longer than I was! After waiting on results we found her CD4 count was > 350, and she had TB. She has started treatments and her son here stays at her side as her helper.

The woman on the right had a low CD4 count of 76. Fungus infections are common with immunosuppression, and she had a fungal infection of her ear, breast, and thighs. ARVs were started.

Heart Cases at Shyira

This week Dr. Caleb King had to take three pediatric patients to Kigali because of their heart conditions. Apolline is 13. On exam I heard a loud, grade VI systolic murmur radiating to her axilla. I could feel a palpable thrill on her chest. Dr. King took her and two equally impressive cases for an echocardiogram in Kigali and hopes of getting them onto a list of 30 cases that a visiting team of cardiologist surgeons will perform next April. The echocardiogram showed that Apolline had mitral stenosis, mitral regurge, and aortic stenosis. Her heart was enlarged from working so hard to keep up with the demand. She was also in atrial fibrillation most likely because of the extra volume of blood in the atria. She was put on diuretics and an ACE inhibitor to relieve the heart. She was put on digoxin to control the rate and anticoagulants to prevent her atrial fibrillation from throwing a clot into her lungs, brain, or elsewhere in the circulation.

While discharging her I looked over the cardiologist’s notes. He recommended an INR weekly to check her blood’s coagulation since she was on coumadin. I asked Caleb if they did that test here. They do not. But, like a true inventive African doctor, instead of accepting the lack of technology, he headed off to the lab. We discussed what an INR actually measures, then put a drop of his blood onto a slide and timed it to see how long it took to clot. While trying to think how to get a proper control, his wife Louise said, “Why don’t you just use her blood now before treatment as a control?” So thus was born a practical way to check her coumadin levels.

The three children all need cardiac surgery to survive. We hope they make it on the list, survive until the surgeons come, or someone with wealth decides to sponsor their trip to a generous hospital in the states. We assume that the damage to the mitral valve was from an untreated case of Strep throat that has caused rheumatic fever. It seems to me that the hardest part of medicine in Africa is not what you do with your hands, but having your hands tied so frequently…realizing what your facility cannot do.

Violence

My first live birth to see!

A patient with conjunctival hemorrhage

In both Uganda and Rwanda I’ve seen patients suffering from physical beatings. Several have had blows to the head resulting in conjunctival hemorrhages that look horrible, but as long as the vision is intact, they are nothing to worry about. In Uganda a man had been beaten by thugs on the street who stole his phone and money. Here a boy had been beaten and was in the hospital wondering who would pay since it wasn’t his fault for needing care. A boy came in yesterday needing stitches from being stoned.

Today we saw a woman with a displaced fracture of the ulna from domestic abuse. Dr. Kohl said he sees women often who have suffered from abuse from their spouse. In most abuse cases medical reports are filled out for the police, but in spousal abuse the cultural question is, “Well, what did the woman do wrong to deserve it?” Women have a difficult life here. They take on the responsibility of the children, cooking, cleaning and sometimes even a side job. They are “disciplined” like a child by their husband. It is culturally acceptable for husbands to beat them for whatever they do that does not please them. Drunkenness is very common for men in this area. Beautiful banana trees fill the fertile mountains offering a bounty for the malnurished, but half are used to make banana beer. It only makes the violence worse.

I watch these African women with such respect. They walk into the birthing room while in labor and situate themselves on the exam table. Without any pain medications or cries they silently clench their fists and give life. While we suction the newborn and tie off the cord she stands and wipes the blood off her legs with her own skirt. Barefoot, she makes her way down to her bed to nurse the new child. Their strength is nonchalant: it is how they handle all the hardships and injustices. This quiet perseverance begs no one’s pity. It is life and they do what they must.