We were all reasonable fatigued following our day long safari to Manyara, though luckily, we didn’t have an educational conference in the morning so got an extra half hour of sleep with morning report beginning at 8 am. Interestingly, our baby who looked for all the world to have meningitis per physical exam (bulging fontanelle and meningismus) didn’t have the most important finding necessary for the diagnosis, abnormal spinal fluid. Both the red and white blood cell counts were normal as was the protein. The baby was still no awake and the diagnosis was now in question, but he had received phenobarbital for his seizures and may have been sedated from the medication. We kept him on his antibiotics as he remained febrile and we were now considering that this may have been a case of bacteremia or sepsis rather than meningitis so continued he antibiotics. The baby’s head had also appeared slightly large and there were thoughts of doing a CT scan on the child, though an ultrasound of the head would certainly give us a clue as to whether there were enlarged ventricles or not and that study would be far less expensive for the family. The ultrasound was done and the ventricles looked perfectly normal so we took that issue off the table.
Clinic was again quite busy and on our arrival at 8:30 am following morning report, there were many, many patients who had already lined up to see us that day. Angel sat outside calling names and doing some triage so we would not see non-neurological patients, but the charts continued to pile up. We began as we did the other mornings, using three stations to see patients until Angel had screened everyone and completed the charts for us. Once she was done with that, we were in high gear once again with four stations to see patients. We have the doctor’s night office, the emergency room and the hallway in between where we have one exam table that is shared by the two groups seeing patients on either end of the hallway. It actually works very well and as each resident has finished their patient and is ready to present, they come outside where we either sit or stand to discuss their findings and a plan. I definitely have the most beautiful office in the world here with the fresh air, sounds of basket weavers and love birds and the incredibly relaxing nature of seeing outpatients here who come to clinic and are grateful to see us. It is impossible not be affected in a positive way by the nature of practicing medicine here despite the fact that we have so little resources at our disposal.
Perhaps one of the most interesting patients we’ve seen here arrived sometime around lunchtime to the hospital ward. She was a woman in her early 20’s who had reportedly suffered a spontaneous abortion about 2-3 weeks ago and came in to the hospital after complaining of a severe headache and then beginning to seize. Lindsay went over to see her right away and she was continuing to have discreet seizures, but was not waking up in between and was therefore in status epilepticus, a true neurological emergency. She, herself, had a history of multiple spontaneous abortions, all occurring later in each pregnancy than early, and both her mother and aunt had had a similar problem of later term spontaneous abortions.
With this clinical information, Lindsay came to several conclusions regarding this woman’s history and her current course. First, the timing of this event along with the seizures were very concerning for the presence of sagittal sinus thrombosis, a disorder that is often seen in pregnancy and post-partum, where blood clots form within the sagittal sinus which drains venous blood from most of the brain and can lead to something called venous infarcts, or strokes. This can often present with seizures and given the situation, it was very concerning that she had sagittal sinus thrombosis. With her history of recurrent late term abortions and her family history of similar issues, it was also pretty clear that she had a condition called anti-cardiolipin antibody syndrome (APLS) which is an autoimmune disorder that causes abnormal clotting leading to stroke, early abortions and other complications.
These patients can have very impressive presentations and most often end up in the neurological intensive care unit, intubated and on IV anticonvulsant medications to treat their seizures at least in the short term until things quiet down. It goes without saying that they undergo multiple imaging studies including a CT venogram and regular CT scans of the head to monitor, typically on a daily or more frequent basis. In rural East Africa, though, we have access to very few of these interventions. Although we have access to a CT scan, it must be paid for by the family in advance. We have no ventilators to place patients on and, therefore, intubation is not an option here. The only IV anticonvulsant medication we have here is phenobarbital which, if we tried to load an adult on this for status, would certainly suppress their breathing to the degree that they would require intubation and ventilation. We only have oral anticonvulsants available to us and there was no way that she was going to be able to take any PO given her mental status and continued seizures.
So, in these situations, you must be creative and think outside the box. Lindsay and our Maasai interpreter (Kitashu) spoke with the family about the gravity of the situation and whether they would be willing for us to do a CT scan. The issue we had was that she was not awake and, therefore, we really couldn’t confirm her examination in regard to worrying about her having a large hemorrhage that may preclude us from anti-coagulating her. Meanwhile, we put in a naso-gastric tube so we could get an anticonvulsant into her and even though we had levetiracetam and valproate, I elected to use phenytoin as I was most comfortable with this from past experience in these situations. We gave her one gram to start down the tube and crossed our fingers.
Thankfully, her family was agreeable to obtaining the CT scan as were really hesitant to anticoagulate her without imaging. There was little question in our minds that she had venous sinus thrombosis, the real issue was just that we didn’t want to hurt her. Venous sinus thrombosis and venous infarcts are treated with anticoagulation even if there is some bleeding present, but the difference is that the patient is in an ICU and being scanned every six hours to rule out and chance of the hemorrhage worsening which could easily cause significant harm or death. She went for her CT scan and we went back to look at it as soon as she was back from the scanner. She had a right frontal hypodensity consistent with a venous infarct as well as some wisps of blood associated, but she didn’t have any significant frank hemorrhage that would have precluded us from anticoagulating her. We were also quite confident that her scan demonstrated superior sagittal sinus thrombosis as it stopped abruptly at its midpoint and approximately where we saw the right frontal infarct to be present.
We had decided that we would anticoagulate her regardless of whether we had seen anything that looked like sinus thrombosis or not, just as long as we didn’t see anything that would prevent us from treating her. In the end, though, we felt very confident in the diagnosis and our plan and forged ahead in treating her with enoxaparin 1 mg /kg twice daily to anticoagulate her and prevent any further propagation of the clot and, hopefully, any new strokes from occurring. She was now fully anticoagulated and had received a gram of phenytoin that would hopefully break her seizures. We would have to wait overnight to see how she did with our treatment and hope for the best. We had done all that we could at this point with the resources available to us.
We had no plans for the evening and I think each of us was more than happy to take a break from our busy schedule. We had plans to go out for the next two nights to dinner so we all settled in for the evening with our wonderful meals of grilled chicken, potatoes and green beans that has been prepared by Samwell here at FAME. Just a touch of chili sauce and it became a feast. Tomorrow night, we would be visiting my dear friend Daniel Tewa and his family for a visit and dinner. This is one of the highlights of our trip here.