Thursday, March 12, 2020 – A slow start to a busy day….

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It was another slow morning that was very likely the result of the rains overnight, but it once again made me worry about the volume that we were seeing. I did have some concern that the local population may be worried about seeing a bunch of mzungu doctors at FAME when they were certainly becoming more aware of what was going on in the rest of the world with the coronavirus. Africa has been relatively spared to date, but the tightening travel restrictions have been in the headlines of recent and it would not be unreasonable for them to worry about us having brought something other than enthusiasm along with us. The news of our country’s new travel restrictions, not accepting anyone from Europe other than the UK, was something of a shock to the rest of the world and certainly to the European countries it affected and probably on further heightened the extreme anxiety over the situation without actually having made anyone safer. The fact that the decision was also a surprise to many of those in the administration and had been made unilaterally by our president was anything but a shock to me. It is questionable to me just how US citizens will be able to get home from Europe once the airlines begin cancelling flights since the majority of the passengers booked will not be allowed to enter the final destination being the US. That remains a mystery to me.

Molly’s tremor talk in the education room of the admin building

Since it was Thursday, it was a day for our educational lecture. Dan and Marin were going to present, though Marin had to take an examination online for her PhD program and given that she was a bit preoccupied with that, Molly traded the day with them and was going to present on tremor. Again, they had asked that our presentations be more case based now, which was perfectly fine with everyone here as that gives a much better platform along with greater relevance when you think about these things in relation to a specific patient and trying to come up with a differential diagnosis, etc. The nurses were having their education meeting in the large conference room, so we were relegated to the smaller room in the education building which always happens to be locked up at 7:30 am while no one has the key to the front door. Luckily, someone had the side door key and upon entering the building with Molly a few minutes early so she could set up, a bat came swooping down the hallway directly for her, then thankfully made a hard about face and decided to hang onto an unlit light bulb on the ceiling for security. Bats are incredibly numerous here, which is a good thing, as they gobble mosquitos and other insects by the thousands to make our life better. On the other hand, they are not something that is good to come in contact with as are also known to be a reservoir for rabies. Thankfully, we don’t have to choose between malaria or dengue and rabies, but if we did, it would definitely be the former.

Registering our patient and getting vital signs

Molly’s lecture was well received and an excellent review of tremor that that doctors here could use going forward as we see a number of patients with movement disorders including both Parkinson’s disease and essential tremor. They will now have an excellent strategy for when they encounter these patients enabling them to differentiate their underlying movements and treat them with the appropriate medications as the treatments are very different, but both very effective. FAME had actually participated as the only non-neurologic center in a global project of the Movement Disorder Society for providing online consultations, and had submitted several, but in the end, the cases that were sent were those that we could deal with on our own and it became easier for them to send me videos of the cases with their questions. The online consultation service was an excellent option for a neurological center with complicated cases in which a neurologist has already evaluated the case and was in need of further assistance.

As we all made our way over to clinic, it was again apparent that there was no mob scene outside and it would be another slow morning. By late morning, though, things started to pick up and we ended up with numerous interesting cases. One of the cases was a young women in her thirties who was brought in by her cousin with symptoms of psychosis and was incredibly catatonic throughout her interview and examination. There was little question that she was floridly psychotic and with her catatonia, Alice wanted to give her a benzodiazepine challenge which in a catatonic patient will cause them to paradoxically awaken. Sure enough, she received 2 mg of lorazepam and, in a very short time, was back to her normal self and asking what had happened. She was sent home on a short lorazepam course along with olanzapine in the hope that it would best control her symptoms going forward and to come back in two weeks when we’ll still be here to see how she’s doing before we leave.

Young Maasai with the skull deformities and recurrent infections

Probably one of the more interesting patients we have seen here was a young Maasai who was otherwise normal developmentally and began to have abnormal growth of his skull about twelve years ago that has continued and several years ago, he began to develop either abscesses or boils that would drain regularly and appeared to be infected. The abnormal bony growth was so significant that it has affected the alignment of his eyes and he is now seeing double. In addition, he was now having difficulty fully opening his mouth and this was also becoming a concern. He had apparently seen doctors in Dar es Salaam before who had told him that it was not cancer, but they had suggested no other treatment. He had undergone a CT scan of the head back in 2018 here at FAME, which we had reviewed earlier and which demonstrated very abnormal bone thickness of the skull among other things.

He came in to see us today, having come from the Loliondo district which is about a seven hour drive away and close to the Kenyan border to the north. I have there in the past and it is a very remote region that is populated by the Maasai and is just south of the Maasai Mara in Kenya, an extension of the Serengeti that is north of the border. We had sent his CT scan images to CHOP to get more information from them, but had initially felt that this may have represented very early Paget’s disease. The other possibility after speaking with the CHOP folks, though, was that this may represent late onset Osteopetrosis. Either way, it was not something that was malignant and both conditions can often be complicated by osteomyelitis which is what we thought the recurrent infections were likely related to. We checked an erythrocyte sedimentation rate that returned at >140, an extremely high number that is most often seen in cancers or inflammatory conditions and was quite consistent with osteomyelitis of the skull which we had already thought was present. In the end, we decided to admit him to the ward for IV antibiotics, but prior to that, someone would aspirate what felt like loculated lesions on the scalp to gram stain them to get some additional information. Unfortunately, we really didn’t get any additional information from the gram stain. So, he was admitted overnight  and placed on the appropriate IV antibiotics for a week or so and then will have to be on a long term antibiotic course for his chronic osteomyelitis. None of this will help his abnormal bone growth, but it will hopefully help the chronic infection that he has with the osteomyelitis.

Our little girl with swollen knees

Another patient that was seen today was a young girl with swollen knees bilaterally that had been going on for some time. She had been brought to us for knee pain, which certainly isn’t neurological, but between the number of pediatrics we had here, it was decided that we would evaluate her and try come up with a plan. We spend a great deal of time communicating to the staff here and to the population exactly what are the diagnoses and symptoms that we evaluate and treat, but we still have to triage many patients who come to see us for several reasons. First, patients who have not been helped elsewhere, or those who feel that we somehow be able to evaluate them “better”  because we are specialists, will come to see us in the hope that we can make them better. The second reason, which is more unfortunate, is that we have chosen to subsidize the neurology clinic, making a single cost for our care, medications for a month and lab tests. This is obviously a situation that is very attractive to anyone as it is often far less than would be paid for any regular visit, and so patients will often come in hopes of being seen in our clinic when, in fact, they have no neurological complaints. Our rationale for subsidizing those with neurological disease is often so important to get them here to diagnose them, especially for the epilepsy patients, that we’ve chosen to continue this practice in an attempt to capture as many of these patients as possible.

The surgical scar on her right knee

The young girl had developed a swollen knee on only one side and had a surgical procedure in the past in which they opened her knee to make a diagnosis, but we had none of this records and when she came to see us she was on no medications or therapy. What she did have was an incredibly large and disfiguring scar over her one knee. Subsequently, her other knee became as swollen as the first and, without treatment, she had developed contractures of the knees and was unable to walk due to the joint abnormalities. We did X-rays of her knees and sent them back to the fundis (experts) at CHOP and she was given a diagnosis of juvenile rheumatoid arthritis and treatment was initiated. Whether she will regain function of her knees at this point is not entirely clear, but perhaps with aggressive physical therapy, which Frances gave to her and her family, she will one day walk again, even if it is with a noticeable limp.

Her swollen left knee

The last patient to mention for this day was a young Maasai boy who had come in with fever and mental status changes. When Dan and Marin had gone to see him yesterday, he had clear meningismus (a stiffness of the neck primarily to flexion indicating inflammation of the meninges) and so they did a lumbar puncture to determine what was going on. The findings were very profound in that he had a very high protein of 300 and a very low glucose of 20. A more typical bacterial meningitis with that low of a glucose would not be seen in a patient that was still responsive, but is much more indicative of TB meningitis, a relatively common disorder here given the high incidence of TB and, even more so, as a complication seen in HIV positive patients . This young boy of 12 was not HIV positive after we tested him, so had TB meningitis as a complication of his TB infection elsewhere and needed to be treated quickly as there is an extremely high mortality for TB meningitis even in treated cases. Another complication that we would have to deal with is that his CT scan demonstrated not only jugular vein thrombosis, but all cavernous sinus thrombosis, a serious complication of a basilar meningitis such as TB, and he would have to be place on anticoagulation in addition to his TB medications. There is a significant interaction between two of them that would require a higher dose of warfarin and he would need to be monitored extremely closely, otherwise his blood could become too thin and he could have serious bleeding. This would be a very difficult situation to manage for someone going back to the boma once he was finished with the IV portion of his treatment and his blood was appropriately thinned here.

Our Thursday evening was spent at home with our macaroni and cheese with massive amounts of garlic, thankfully made that much more cheese by Chef Amisha. Tomorrow would be Angela’s last day in clinic and we would all be sad to see her leave as she has been a very integral part of our team and a great addition with her knowledge of pediatrics. Teamed with Amisha, Dan and Marin, we have had a pediatric neurology dream team here and probably the best anywhere in Africa.

Marin and one of her patients

 

 

 

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