I had hoped that the start of the new week would bring an influx of neurology patients for us to see, but it remained unusually slow for us again which has been a mystery as to an explanation. Typically, Mondays are the busiest day in clinic for the main FAME OPD including our neurology specialty clinic, and even though it was perhaps somewhat slower than normal on both sides, it was still puzzling to me. The only thing we did different this was to advertise more days for our neurology clinic here at FAME and we’re hoping that all the people don’t come on the final days which would pose a problem trying to get them all seen in a short time.
Despite this, we did have an interesting day with several good patients and an emergency patient in the late afternoon/evening that required our assistance. We always attend morning report so that we get the scoop on what happened overnight and, specifically, to see whether there are any neurology consults for us to see in the wards. Nan has been providing quite a bit of general pediatric help as there is now a void in that department after the departure of Dr. Verena several weeks ago. She had been a fixture at FAME for some time and has developed numerous protocols to help with standardizing pediatric care here and she will be sorely missed for certain.
On this occasion, though, Dr. Mary presented a case that came in yesterday (Sunday) and who we had seen in clinic on Saturday. He was a new seizure patient who we had started on carbamazepine and he came in to the ward vomiting and was mildly hyponatremic (low sodium), both adverse reactions that can be specifically associated with that medication. It’s always easy to blame the medication, but it was far too early for him to have become hyponatremic from the medication and we had started him on a very low dose so the vomiting would also be very surprising. As we finished morning report, we decided that Jamie would go see the gentleman in the ward and Chris would begin seeing patients in the outpatient clinic. Nan, meanwhile, would start her day rounding with the ward team as she has been providing so much general pediatric help in addition to her peds neurology. Jamie discovered that the patient had been having intermittent vomiting for seven days and hadn’t told us when he was seen and he had thought the carbamazepine would also help that. Perhaps more importantly, we had prescribed 1/2 tablet twice a day for one week to him and in further questioning of the patient, he had taken TWO tablets twice a day which is what he thought he was supposed to do. So it was quite clear that it was not the fault of the carbamazepine and we ended up proceeding with our original plan albeit at a much slower and proper titration.
Chris began his day with a patient that we watched walk in with a very stooped posture, completely bent forward at the waist. It was an elderly woman who was complaining of tremor primarily in the upper extremities, though in actuality, it involved her head and neck and, to a lesser degree, her lower extremities. The tremor was a fairly classic 3-5 Hz resting tremor that improved with use and intention, just the type of tremor you like to see in a patient with idiopathic Parkinson’s disease, though it’s certainly not the best of news for them. Her examination, of course, was completely consistent with this diagnosis and explained her slow gait, stooped posture and loss of facial expression that were all quite evident and symptomatic. We do have carbidopa/levodopa here, but it’s not a dosage that we prefer to start patients on right away. With no other resources at the moment, we would have to make that work so started her on 1/2 tablet twice daily for one week and then 1/2 tablet three times a day until she comes back to see us in two weeks before we have to hit the road.
We did see a young Maasai boy come in for possible regression, but after a detailed history was undertaken it become more and more clear that there really was no regression, but rather the child had been abnormal since birth with delayed milestones all along the way and a likely diagnosis of cerebral palsy. Later in the day we had seen another Maasai youth who had epilepsy but he also had some significant periorbital edema that had reportedly occurred during a seizure, but we were very concerned regarding an abuse potential. There is a fair amount of domestic abuse as a normal component of the Maasai life so this is always a concern. As I have mentioned in the past, though, that if we were to pursue this in some fashion either in the line of specific questioning or asking the parent to leave, we might end up triggering a situation where the patient may not be brought back to see us again which wouldn’t benefit anyone. This is very much the case with Maasai women who are brought to the clinic by their husbands or male relatives. The women often only speak Maa which means the men are interpreting for them and this may lead to a significant conflict of interest.
Last week, Jamie had seen an HIV+ patient who came in reporting that he had had two seizures followed by right sided weakness and had a very low CD4 count despite being compliant with his ARVs. We had wanted him to have a CT scan as we were very concerned about a mass lesion related to his immunocompromised state and he returned today to have the study performed. Unfortunately, we found exactly what we were looking for and will now have to work out a mechanism to have him treated for presumed toxoplasmosis as the therapy provided in most government centers is third line and we’d like to be able to offer him more than that. After further discussion and considering that he remained perfectly stable and non-toxic, he was sent home to allow us more time to come up with his treatment plan.
Life in the bush for the Maasai can be very difficult at times and that was no more evident in the case of woman who had been admitted to FAME a week ago, just prior to our arrival. She was the young mother of an infant and a five year-old child who had been killed and taken by a hyena who had also attacked her while defending her children causing very serious damage to one of her hands with multiple compound fractures. The woman had been in the hospital here over the week and was now in need of repair to her hand so it was eventually decided to transfer her to a center with a more specialized surgeon to do this. The hyena who had killed her two children when the men in the boma were away turned out to be rabid after it had been caught and killed and sent to the government lab for testing. She had initially been treated by the dispensary in the Ngorongoro Conservation Area where she had received rabies vaccine and would hopefully be OK from that standpoint. What a horrible situation, though, however it turns out. There is no silver lining to a story like that.
We had actually finished our day rather early and we’re all up in the administration building working on the internet when Alex came running in telling us that we were wanted in the ward for a neurology emergency. We gathered our belongings and all walked down to inpatient ward where we were directed to Room 1 and a young two year-old female and were told that she had fallen, struck her head and had been unresponsive. He mother was out near the nurses station and was in no shape to give us any history as she was quite distraught, but we were eventually able to discern that the young girl had been sitting in a low chair when her mother briefly walked out of the room and then found her on the ground having a convulsion. By the time her father arrived minutes later she was no longer convulsing, but was now unresponsive. They brought her immediately to FAME where her mental status remained impaired and she would fall asleep if left alone, but could be easily awakened, though quite irritable. After some further digging it became clear that she had had an upper respiratory process prior to the event, but we were still very uncomfortable with her mental status and were unable to tell whether it was from the fall and striking her head or whether she was post-ictal from the seizure.
We had decided to get a CT scan on her since she was so lethargic, but in the end, she began to wake up so we were able to forgo obtaining the CT scan. This decision did not occur, though, until after several tries at getting her into the scanner, very much fraying our nerves along the way. We made the decision to watch her over night and in the morning she was up and walking around. She had been febrile on admission and it became quite clear that she had actually presented with a febrile convulsion, fallen off of a low chair in the process and presented lethargic from her seizure. She left the next day with her parents much relieved and will be watched quite closely.
We didn’t get home until very late that night and though we were all quite exhausted, it had all been well worth it.