A very sick child

     A two year old boy was carried into the clinic on Friday morning. He was in what is called “status epilepticus,” meaning that he was in a continual state of seizure activity. The story is as follows: this 2 year old boy had been, according to the mother, a completely normal two year old boy until three days prior to his arrival in the clinic. He did all the things that any two year old boy does: walk, run, jump, talk, and, presumably, get into trouble. It was at that point that the mother reported that he developed increasing weakness. The weakness progressed to the point where he could no longer walk, or even sit.

     The child started to have seizures at some point early on the morning he was brought into the clinic. The seizures continued uninterrupted over the next two hours, maybe even three hours. It took the mother that long to get to the clinic. I am not sure how she got here; perhaps she carried her seizing child up the mountain; perhaps she had some form of transportation that got her part of the way here. All I know is that her seizing child remained in her arms the entire time he continued to seize.

     The child arrived in my office late in the morning on Friday. He was unresponsive, and still seizing. The seizure involved primarily the left side of his body, but did extend to his right hand. This is what is called a focal seizure, and often has a worse prognosis than generalized seizures. I cannot explain why his seizures were focal. Perhaps I could explain it if I had access to any of the modern diagnostic modalities that are available at any hospital in the United States, modalities like CT scans or MRI’s. However, there is only one CT scan in the entire country and it is in Bujumbura, and there are no MRI’s.

     We immediately gave the child an intramuscular dose of Diazepam. The seizures stopped very quickly after the Diazepam was given, but the child remained unresponsive. I was able to then examine the child. I was struck by his marked pallor: his nailbeds were chalk-white, as were his conjunctiva (the lining of the eyes and eyelids). His spleen and liver were significantly enlarged. Surprisingly, he did not have a fever.

     We were not sure what exactly was wrong with the child, but our first thought was malaria, despite the absence of fever. In fact, malaria is generally the first, second, and third thoughts in these situations, when you have a critically ill child like this. We did a quick test to document the presence of malaria, and it was instantly positive. I also did a blood test to confirm the anemia. His hemoglobin was 3.7, which meant that he was profoundly anemic. The anemia was caused by acute hemolysis (breakdown) of red blood cells, secondary to the malaria parasite.

      We gave the child twice the usual dose of quinine, because that is the protocol when a patient has severe, life-threatening malaria. We also gave him a high dose of Ceftriaxone, because of the possibility of secondary infection, like pneumonia or even meningitis.

     The child was in dire need of a transfusion. We now have the ability to do transfusions at the clinic. We have not had that ability prior to this year. However, this child had blood type B+, and we did not have any B+ blood. The nearest center that did have B+ blood was at least an hour away in a town called Bururi. The lab tech went down the mountain in the truck to get the blood. I did not expect him back for at least four hours, so I was pleasantly surprised when he returned in three hours. The child was subsequently transfused. We put him on our limited supply of oxygen prior to and after the transfusion.

     It appeared that we had stabilized the child. His breathing, which initially had been rapid and labored, slowed over the next 24 hours. It was not normal, but he showed less evidence of respiratory distress. However, his level of consciousness remained unchanged. He did not open his eyes; he did not respond, except perhaps to deep pain.

     It was approximately 36 hours after he was admitted that the child’s breathing once again became labored and irregular. We increased his oxygen intake; we tried everything we could. It was all to no avail. The child died very soon after his breathing had worsened.

     I do not know exactly the ultimate cause of his death at the end. I do not know why he had such a prolonged seizure. I do not know why the seizure was focal, rather than generalized. I can only surmise about these issues. What I do know for a fact is that malaria killed this child.

I know the numbers about malaria: somewhere between five hundred and six hundred thousand children die in Africa from malaria every year. A child in Africa dies every minute from malaria.

     The statistics are almost inconceivable. What is not inconceivable is to be the doctor who could not prevent a child’s death from malaria. What is not inconceivable is to see first hand a previously healthy two year old child die in his mother’s arms from malaria.

I know now all too well the destructive power of this disease, so ubiquitous here in Africa. But knowing it and seeing it in all of its unmitigated force are two different things. I saw it Saturday night, and I will presumably see it again for I intend to keep coming back here year after year. I can only hope that the scourge of malaria will somehow be lessened at some point here in Africa. I know that malaria will never be eradicated, but perhaps it is reasonable to hope that one day, we will have a lessening of the devastation that it wreaks on the children of Africa.