One never knows...

WARNING: If graphic medical pictures are not your thing, go directly to the next blog post. There are not going to be that many, but definitely enough to merit the warning.

I have seen diseases here that I have never seen in my twenty-nine years as a pediatrician. I have mentioned some of those diseases, as, for instance, malaria and malnutrition. But I have seen other diseases and medical problems that have left me almost open-mouthed in amazement. I give you some of them.

1) A 30 year old man who was carried into the clinic last week because of profuse watery diarrhea and severe leg cramps. The diagnosis that was immediately made by the doctors here: cholera. How did they know it was cholera? Because all of the symptoms were consistent with cholera: the watery diarrhea and the leg cramps as a result of losing so much calcium and chloride. The diagnosis of cholera is generally made on clinical grounds. Laboratory confirmation of cholera is difficult, and our lab does not have the means to do it. The treatment of cholera is primarily supportive, meaning giving large amounts of I.V. fluids to replace the patient's substantial losses. This was done, as well as giving a single dose of Doxycycline to reduce the diarrhea. Fortunately, the patient's disease was not in the severe category. Therefore, he recovered without incident. But the point is that one does not expect to actually see a case of cholera.

2) Recently, I saw in clinic a fifteen month old with a mass behind the right eye. The mass had been present since birth, but was getting bigger. It had now grown to the point that it was pushing the right eye forward, as you'll see in the photo below. We did not know what the mass was. I thought, based on the history and appearance, that it might be an hemangioma, but I really did not know. I sent the photographs of the patient to an excellent pediatric ophthalmologist in Los Angeles. She was kind enough to respond quickly, and you will see her response just below the photo.

I looked at the images with some fellow ophthalmologists here and we
agree that he definitely needs to see an ophthalmologist. The mass is
most likely lymphangioma or capillary hemangioma but can't rule out a
solid mass (rhabdomyosarcoma would be less likely but still needs to
be ruled out). Would need imaging (orbital MRI w/ contrast to r/o
vascular v solid tumor would be ideal) to see if solid mass or
lymphangioma/hemangioma. Hope this helps!

What she wrote was, as I said, very helpful. Her suggestion that we do an MRI is completely appropriate. Unfortunately, there are no MRI's, or CT scans in Burundi. That makes it unlikely that we will be able to get the orbital MRI that she requested. The other problem we have is that there are only three ophthalmologists in Burundi, and they are all in the capital city of Bujumbura. Moreover, those three are private doctors, and it is unlikely that, if somehow, our patient can get to Bujumbura, she can pay for the services of any of these ophthalmologists. So what happens next to this patient? I really do not know, nor do I have any means of knowing.

3) A seven year old girl named Olive was carried into clinic by her mother two weeks ago. The history is as follows: she was completely healthy until eight months previously. At that time, she developed neck pain, which lasted for a month. The neck pain disappeared, only to be replaced by severe back pain. The location of the back pain was unclear, varying between lumbar and thoracic. She had lost a significant amount of weight in the ensuing six months, and her back was so bowed now it looked like a semi-circle. When she came into the clinic, she was severely malnourished, her arms and legs pencil-thin. She was unable to stand because, one, she did not have the strength, and two, because the back pain became intolerable when she tried to do so. The pain was radiating down both legs. She brought X-rays with her (we do not have an X-ray machine here). The X-rays had been obtained elsewhere, and were of poor quality. However, we did not see any significant changes in the area that was visualized: the lumbar and sacral spine. Of note also is the fact that Olive did not have a history of fever or cough or any other systemic symptoms (other than the weight loss). She did not have vomiting or diarrhea, nor did she have any other bone or joint involvement. Here is her picture.

So what was wrong with Olive? What disease process could possibly cause this degree of malnutrition and spinal deformity? I can tell you it was not a malignancy. I can also tell you it took several weeks before we had the answer. She was sent to Bujumbura to be evaluated by a neurologist. He put her in the hospital, where he did some blood work, and repeated the X-rays of her back. That was about all he could do, because, as I just mentioned, there is no such thing as a CT or MRI here. The repeat spinal X-rays were initially read as normal. However, they were then sent to a radiologist, which accounted for much of the delay in her treatment. There is only one radiologist in the entire country of Burundi. It was only because we had influence that those X-rays were even read at all. But eventually, that one radiologist read Olive's spinal X-rays. He saw an abnormality in the lower thoracic spine: an area of lysis (bone destruction) in the tenth thoracic vertebra. The diagnosis could be made on the basis of the X-ray and the clinical symptoms and history. Olive has extra-pulmonary tuberculosis, which is also known as Pott's Disease. This type of TB is different than the one we are most used to: the one that affects the lungs. The spine, especially the thoracic spine, is affected. Olive did not have any pulmonary involvement.

I should add that my friend, Melino, made the diagnosis almost immediately after seeing her. However, we could not start treatment until we had radiological confirmation that Olive did indeed have Pott's Disease. The good news is that Olive should do well. She will be on several anti-tubercolous medications for a long time, and she will get appropriate nutritional support. But the end result should be a favorable one.

4) The following picture says it all. This is obviously a woman with untreated goiter. .

One thing that I have noticed here is that the presence of physical deformities does not cause people to shy away from the camera. As you can see, she looks directly into the camera as the picture is taken. One other thing, people here love having their picture taken, especially if you show it to them afterward. I have never had a patient refuse to allow me to take his picture.

There was a possibility for this woman to have surgery last year, but it never happened for unknown reasons.

5) The following story occurred today:

A woman in labor came into the clinic last week to deliver her baby. It was her first baby. She was progressing well, until, for unknown reasons, her contractions stopped. We ultimately had to transfer her via our ambulance to an obstetrical center an hour away, where she could have a C-section, if necessary. She did end up having a C-section, and was discharged from the hospital three days ago.

Today she came into the clinic to have her stitches removed. The baby, now one week old, was, of course, with her. We asked how the baby was doing, she replied, fine, that there were no problems. I happened, simply by chance, to look down at the baby's right forearm. It was then that I knew, despite the mother's claims to the contrary that something was seriously wrong.

We sort of pieced the story together. The mother said that the baby was "quiet" at birth. Perhaps the doctor at the hospital thought that the baby had low blood sugar. In any case, an I.V. was placed in the baby's right forearm, and we think that the baby got a strong solution of Dextrose (probably something called D10) to correct the presumed hypoglycemia. We don't know if they even checked the baby's blood sugar. The I.V. was kept in the baby's arm for two days. We don't know why. Perhaps they gave the baby antibiotics. What we do know, however, is that the I.V. infiltrated into the surrounding skin, causing extensive tissue damage. The damage could have been the result of the D10 not going directly into a vein, but, instead, going directly into the skin itself. The cause does not matter. What does matter is that no one checked on that baby's I.V. No one monitored whether the I.V. had infiltrated. You see the result below. What you are seeing is essentially a burn almost down to the layer of bone.

The mother was told, presumably by the nurse taking care of the baby, that there was nothing to worry about when she took the baby home; that the skin would heal itself over time; that she did not have to do anything with the arm. How was she to know differently? She took the nurse's word at face value. Remember, this is not a sophisticated population. A doctor or nurse tells you something here, you believe it.

I can and do accept many things in Kigutu: the paucity of medical resources, the lack of supplies and medication, the logistical difficulties of providing medical care to the population we serve. But what I will never accept, whether it be here in Burundi or at home in Los Angeles, is bad medical care.This was not just bad; this was a complete, callous disregard for another human being's health and welfare; even worse, this was a newborn baby's health and welfare. This was medical negligence of the worst kind. I am convinced that the baby would have died at home, if not for the fact that, serendipitously, he had not come in today. That wound would have unquestionably gotten seriously infected.

Sadly, it is unlikely that anyone will be held accountable for the actions that caused that baby's wound: neither the nurses who did this, nor the doctors who are ultimately responsible for the baby's care. We will try to find out who did what, but it is unlikely that we will get any answers. Even if we do, what difference will that make? Burundi is not what you'd call a litigious society.

So what will happen to the baby? Surprisingly, he looked well. But what we did today was to immediately start two antibiotics, Gentamicin and Ceftriaxone, via injection. We will also do daily dressing changes to the right arm. I expect, from an infection point of view, the baby will do well. I also expect that he will lose some permanent function in that right arm.

6) This next one is more in the human interest category, rather that medical. I saw a nine month old baby girl in clinic yesterday by the name of Irene Igirineza. She had been brought in by the grandmother because of concern that she was losing weight. The reason that the grandmother had brought the baby in, rather than the mother, was because Irene's mother had died when Irene was only seven months old. We think that perhaps the mother had died of breast cancer, but we can't be sure. In any case, the grandmother had assumed care of the baby. When I say she had assumed care, I mean that she had really assumed care. She was now breast-feeding the baby. The grandmother was now 45 years old, and her youngest child was now twelve years old. That meant that she had not breast-fed for at least ten years. However, there was no doubt that she was breast-feeding; no doubt from the baby's point of view anyway, as this picture shows.

The baby was avidly breast-feeding every chance that she could get. Unfortunately, whatever milk she was getting, (and she must have been getting some, because she was not dehydrated), was not enough. She had lost weight in the two months since the mother had died. Irene was now malnourished to the point that we had to admit her to the malnutrition ward. However, she should do well at this point, and I fully expect a satisfactory outcome. She will need nutritional supplementation when she goes home. The grandmother's milk is clearly not sufficient to sustain her.

A corollary of that story is one that Melino told me. He had taken care of a baby in a similar situation. The mother had died and the grandmother had nursed the baby. That baby had also been admitted for malnutrition. I say that the grandmother was nursing the baby, but it actually may have been the great grandmother. I say that because the woman who was nursing the baby was 80 years old. Of course, you presume that I am making this story up, that it must be apochryphal in nature. It is not, for I saw the picture. However, I think it is a fair assumption that a baby being nursed by an 80 year old woman is not getting a whole lot of milk.