I think we were all quite exhausted on Monday morning after our weekend safari and despite a good night’s rest we were all dragging a bit. We had already spent nine full days seeing neurology patients at FAME and four days of mobile clinic yet it seemed that our patients were still coming in droves. When clinic opened at 8:30am (in Swahili time that’s 2:30 as the day begins at 6am with the sunrise) we immediately had over twenty neurology patients to see us and they were still coming.
Meanwhile, there had been an admission last Friday of a young boy who presented with seizures and altered mental status who they wanted us to see. They had done a lumbar puncture on Friday, but not all studies had been run on the fluid and all we were told was that the fluid had been cloudy and there too many white blood cells per HPF (high powered field on the microscope) meaning that he very like had a meningoencephalitis and probably viral given some of his other labs such as elevated liver function tests. He had been put on antibiotics, but when we asked about acyclovir they hadn’t considered it. When I tracked down our pharmacist to ask about obtaining the medication we always put these patients on in case of herpes encephalitis, I discovered that it is virtually unobtainable here having to purchase it from Nairobi at a cost well beyond FAME’s means as it would have cost $500 dollars a day for fourteen days to treat this child. Luckily, it didn’t appear that he needed it though he continued to have some seizures and did remain intermittently febrile. We wracked our brains throughout the day to make sure we weren’t missing anything with this child as he was very ill and we certainly wanted to give him the best chance to improve. We did add one other antibiotic on our way home that evening to cover one other possible infection, but otherwise we had no new thoughts.
We had our usual compliment of patients that included one Maasai woman who I have seen for several years with seizures. She has remained well controlled on lamotrigine which is the best drug for her given her age and likelihood that she’ll become pregnant in the coming years. She did have a baby last January who I had seen in March as her husband brings her back for follow up religiously every time that I am here. He had invited me to his boma for a goat roast last time I was here and wanted us to come this time, but I explained to him that we were leaving in several times and unfortunately didn’t have time to make it there. We both agreed that we would do it for certain in March and Sokoine now has his phone number and location so we’ll visit earlier in the trip next March. I haven’t yet had someone cook me a goat so that should be very exciting indeed.
Sometime in the mid morning ( I can’t recall if it was before or after chai), Frank called me over to his office to see a patient who had been brought from a fair distance to see him. It has been billed as a psychiatric patient, but he wasn’t certain and as I walked through the door of his office I immediately recognized what the patient had. She was a fifteen-year-old Maasai girl brought by someone from her school and she had been having strange behaviors and movements for several days. Her family thought that she was possessed, but thankfully she hadn’t yet been touched by any local healers. As soon as I saw her movements I recognized that she had Sydenham’s chorea, a very rare disorder in the States that is caused by an untreated Strep infection. It causes neuropsychiatric manifestations in patients in addition to the infection which is very dangerous as it can cause a bacterial endocarditis that has a predilection for the mitral valve, often destroying it and causing a serious problem if left untreated. I asked Frank to check and he said that she did indeed have a murmur. I explained to the situation to the American teacher who had brought her here and we suggested that she stay here at FAME for several days while we initiated both the antibiotic treatment as well as treatment for her uncontrolled movements. Her mother was called and agreed to travel to FAME from the Arusha area as she wanted to be here if she was going to be admitted. Her movements were very impressive and it took 30 mg of diazepam to get her some rest that night and that dose was repeated again during the night amazingly.
We had diagnosed a young girl with the same disorder back in December 2012, and after over a year of treatment she was finally without any movement or issues, though the last time I saw her was in March of this year. We had impressed upon her family that she would need continuous prophylactic antibiotics for many years to ensure that she didn’t develop another episode of endocarditis, but they moved to Mto wa Mbu and it become more difficult for her to come back here for her checkups. I am hopeful that she’s still receiving the antibiotics to protect her heart. This young woman I saw today will also require the same treatment with immediate antibiotics for the acute infection, long term prophylactic antibiotics (until the age of 40!) and a long course of steroids to control her movements which are the result of an immune-mediated response. It is very rare to see these patients here and extremely rare to see them in the States, so I was quite happy that both Kelley and Laurita would be able to see this patient with such a classic and now rare neurological disorder. It is something that will remain with them forever.
Laurita also had a very complicated patient that came to see us from Arusha and required well over an hour of her time. She was a young woman who had developed eclampsia following a delivery around the first of the year and had suffered two intracranial hemorrhages. She underwent surgery to evacuate them with an excellent recovery initially, but then developed an intracranial abscess requiring additional surgery, suffered seizures, then hydrocephalus needing a shunt placed. She underwent an immediate replacement of her shunt and subsequent to that lost her ability to speak. We had most of her CT scans to review and an MRI that she had obtained in Dar es Salaam as well as her examination. Unfortunately, it appeared that she had suffered some damage from the placement of her first shunt that explained her difficulty speaking and there was very little that we had to offer her as far as treatment or therapy. She was extremely abulic as a result of the frontal lobe damage she had from the initial hemorrhages and with all the deficits, she was extremely disabled. It was a very sad case as even with rehabilitation she will likely recover very little.
Given the complexity of cases today, things were moving a bit slow in the afternoon making it necessary for us to work well into the evening which also meant that Sokoine and Selina would miss the staff bus to town at 4:30 and had to find an alternative means of getting home. Luckily that was taken care of by one of the other FAME staff vehicles as I had work to do this evening along with Laurita and Kelley. We ended up staying in the volunteer office until 8:30pm as they both had to work on their talk for tomorrow morning and needed the use of the Internet, which if you remember, runs incredibly slow if it runs at all. Starvation finally got the better of us, and especially Laurita, so we all went home to eat our prepared dinners of roasted chicken, potatoes and green beans. Somehow, Kelley managed to go back up to the volunteer office to complete her talk, but I’ll have to admit that I was far too exhausted to do any more work and chose rather to go to bed and set my alarm for well before sunrise. We had all worked very hard today and I sensed a bit of frustration in everyone with the late hour that we finished so decided to make sure we wouldn’t run into the same situation tomorrow and planned to speak with Sokoine regarding this in the morning. Regardless, we had seen some very interesting patients once again and fulfilled our purpose for being here, not only in regard to educating the doctors here as well as my residents, but also myself included.
One thought on “October 24, 2016 – And back to neurology clinic at FAME….”
Hi Dr. Rubenstein,
I’ve been keeping up to date with your blog since you mentioned it when I was shadowing you in July. I have found it very interesting, especially the post about clinic days. I wanted to comment on this post however because I was able to make the point in my cased based learning group today about Strep related mitral valve damage. Thanks for sharing your experiences and I hope that you are doing well.