I have mentioned that having Whitley and Meredith here over the last two weeks was a real treat for me as it significantly reduced my normal duties of staffing essentially four examination teams by myself. Mind you, there was still all of the coordination that must happen to make the neuro clinics run smoothly and, even though Kitashu and Angel always have everything under control, it still requires my oversight for things such as the number of patients we can see in a given day or other more logistical concerns. Despite the need for my presence, though, having them with us for the last two weeks allowed me to break away and attend several meetings as well as work on my blog during clinic when I wasn’t needed. For the next two weeks, the duty of staffing all of the patients will now be mine alone.
Mondays are always the busiest day for us in clinic and today we are also expecting to have more patients from the Food for His Children organization that will be in addition to the normal patient load. Sure enough, patients were already lining up to be seen well before we arrived from morning report and the day continued on like this. In addition, there was a patient in the ward who had arrived the night before and was clearly a neurologic case who would need our assistance in further evaluating before any consideration of treatment. We were all completely rested after the wonderful Sunday we had just had the day before, though thankfully, we were all now well rested for the coming day of patients.
Given the consultation in the ward sounded like they were quite possibly a neuromuscular patient (we were all thinking Guillain-Barre syndrome during morning report), it was decided that one our two soon to be neuromuscular fellows should see the patient, and Alex won the honors. We had been told that the patient had presented after developing numbness and weakness in her lower extremities that had come on over a period of about six hours the day before and, thankfully, she hadn’t decompensated overnight and though she was weak, she was still breathing. Alex took a very good history from the patient and family and performed a thorough examination that demonstrated the patient had primarily proximal lower extremity weakness with no reflexes in the lower extremities, normal to decreased tone, and subtle sensory changes in the legs with definite sensory level.
We discussed the case and there were some atypical features with Guillain-Barre syndrome that bothered us and, so, we asked Sehewa, the nurse anesthetist at FAME who has been there forever, to perform a lumbar puncture that would be primarily for protein and cell counts as we are unable to check anything more sophisticated than that at FAME. They had already done a CT scan of her thoracic and lumbar spine the night before that was reviewed and felt to be essentially normal, though obviously wasn’t the necessary study as that would have been an MRI scan, a much more costly and difficult to obtain study here. Unfortunately, we would have to wait until the end of the day until the lumbar puncture could be performed, and though we were unable to initiate treatment prior to obtaining these results, she did not worsen throughout the day.
Meanwhile, we had a busy outpatient clinic to get through with both our regular patients and those from Food for His Children. Midmorning, a women was brought into clinic by her family who clearly had a significant neurologic problem that has been present for several weeks and had been progressive. She had to be helped into clinic by two family members holding her up and helping her walk and when she was examined, she was encephalopathic and had a mild right hemiparesis. This presentation was worrisome enough, but then we were told that not only was she HIV positive, but that she also had not had a recent CD4 count or viral load performed, test that were only available at the government dispensary and not a FAME. Given this situation, our differential had drastically changed from what it had been, though either way, we knew that she would need an urgent CT scan of the brain. Thankfully, her family had already anticipated the need for this study and were totally on board with getting it sooner than later.
There was little question in our minds that she would have a very abnormal scan and it was just a matter of which one of the neurologic complications seen in HIV patients that we were going to find. There were several that could present this way and though it wasn’t 100% that it would turn out to be a complication, the odds were in favor of that being the case. Dr. Anne and Alex, the team who had seen her in clinic, were right on top of things and had gone to look at her scan after it was completed and had then asked for my opinion of the findings. She had marked edema of the left frontal and parietal lobes and, on post contrast imaging, had multiple ring enhancing lesions that were present at the grey white junction. The findings were very suggestive of CNS toxoplasmosis, a condition that is very prevalent in patients who are immunocompromised, such as those who are HIV positive, though typically patients who have very low CD4 counts and are not responding their HIV medications.
When the findings of the CT scan were discussed with the patient and her family, it turned out that not only did she not have her recent CD4 count or viral load checked, but she had also no been longer taking her medications meaning that she was essentially untreated and fully immunocompromised, capable of developing any number of complications that can be seen. This pretty much cinched the diagnosis after hearing that piece of very helpful, though unfortunate, information and treating her became a more straightforward process at least from the standpoint of what we were dealing with. Had she been in the US, she would have been admitted to the hospital immediately, and most likely at least an intermediate stepdown unit, but the decision was made for her to go to the government dispensary where her treatment would be free as it was related to her HIV. It was a joint decision made with the family, Tanzanian staff and social work and relied heavily on something we don’t have to consider in the US – cost. These are the lessons that can be very difficult and unsettling, and though they will hopefully change for the better in the future, it is the reality now and we must recognize those boundaries.
Towards the end of the day, we were greeted by a truly lovely patient who we had seen last September who had presented with abnormal movements of I believe several weeks duration. The confounding part was that he had a history of mild cerebral palsy and if one looked at him without taking a good history, they would have just attributed the movements to his CP and left well enough alone. The movements, though, were very much of recent onset and he had never had anything like them before. The resident was a bit stumped at first as we don’t see this condition in the US and, even when able to describe the movements as choreaform occurring in an adolescent, still had trouble coming up with the diagnosis. This was Sydenham chorea, a condition caused by a group A beta-hemolytic Streptococcus infection, the same that causes rheumatic fever, and the neurologic manifestations are typically self-limiting and treated with tapering steroids. The problem is, though, that these patient quite often have sub-acute bacterial endocarditis, an infection that can have many complications, among them being severe cardiac valve disease and, if not treated aggressively, can lead to the need for a heart valve replacement.
As I mentioned, this diagnosis is rarely seen in the US due to our often overly aggressive and, at times inappropriate, use of antibiotics, though this is the third case that I’ve seen here at FAME. Each of the cases have been incredibly rewarding as the patients have all done incredibly well. This patient was continuing to receive his monthly IM injections of penicillin that he will be required to take for a number of years and this is to lessen the likelihood of suffering further damage of the heart valves from an infection. Seeing him today was wonderful, not only because he is doing so incredibly well and his mother is so grateful, but also because he is someone who lights up the room the minute he walks in. The residents who saw him last fall, as well as those who have seen our other cases of Syndenham chorea in the past, will never forget what these patients look like and never miss this diagnosis.
Our clinic ended after having seen a good number of patients, the bulk of them with epilepsy, and, thankfully, none were as complicated as the two I’ve spoken about, one in the ward and one that should have been in the ward, but was sent home to be seen at the government dispensary. It was later that evening that we learned of the lumbar puncture results, which were totally normal and, though they did not differentiate between our two main diagnoses, it did help us to exclude the likelihood of this being a purely infectious process. This was important as we were interested in giving the patient high dose steroids with the possibility of an inflammatory process such as transverse myelitis, though the differential for this condition is very different here than it is in the US, as it would include such things as Konzo, a toxic condition related to consuming improperly prepared cassava, among others. Guillain-Barre syndrome was still not off the table either, but we have neither of the therapies here to treat it, those being plasma exchange and IVIG, both very resource extensive and equally expensive treatments. So, we started the steroids and planned to re-evaluate her in the morning with the hope of having additional information as time went on.
I think everyone was thankful for another quiet night at the house with the possibility of downtime, though all were fast asleep, save me, by probably 9 pm, a time where I am usually starting my evening of work at home while, I do my very best to stay away and do some plinking on my computer keyboard.