Though this morning’s lecture, which was given by Mary Ann, our visiting pediatrician and fellow board member, was on the topic of neonatal hyperbilirubinemia, it had quite a bit of relevance to us as neurologists as the significance of this condition is one, that it results in the neurologic syndrome of kernicterus, which produces a condition akin to cerebral palsy, and two, it is completely preventable and often very predictable in certain populations. The incidence of hyperbilirubinemia, and thus, kernicterus, is much higher in patients with glucose-6-phosphate-dehydrogenase deficiency, or G6PD deficiency, an x-linked genetic disorder that is found in a very high incidence in African-American males in the US as well as other regions of the world including Africa. There is also a relationship between G6PD deficiency and sickle-cell trait, both of which will cause hemolytic anemias that, in neonates, will result in hyperbilirubinemia and, if not treated, eventual kernicterus.

Elevated bilirubin occurs in many babies and is most often not harmful and will be cleared on it’s on, but there are many situations in which a babies bilirubin is elevated beyond normal, such as immunologic incompatibilities between the mother and baby, severe bruising of the baby that may have occurred at birth or certain genetic or ethnic factors that may impair clearance of the bilirubin. When the bilirubin reaches severely high levels, it must be treated as an emergency and the babies should be receiving phototherapy immediately for just as in stroke, time is brain. If babies don’t respond to phototherapy in regard to lowering their bilirubin levels, then it may be necessary to perform an exchange transfusion, but this is a life-saving procedure that carries significant risks and is used only in the most severe of cases and those in who the risk of brain injury is immediate.

A number of members of the staff were unable to attend the hyperbilirubinemia lecture as there had been a “mzungu” emergency in the OPD prior to the beginning of the teaching session. A young visiting child from one of the nearby lodges had apparently had something to eat that had caused an allergic reaction with diffuse urticaria and some wheezing, but did not have any significant airway obstruction nor did they have any mucosal involvement to indicated that they were having anaphylaxis. Just the same, no one was really interested in proving the point, so the child was given some steroids and antihistamines just to be safe, but it did require the attendance of several of the doctors right at the point that Mary Ann was giving the talk.

As is usually the case, there was some great discussion on the topic that followed the talk and also some very good questions. One that was asked by Dr. Ken, related to the use of phenobarbitone (phenobarbital) in the baby to help hasten the decrease in the level of bilirubin, something that I had never heard before, nor had Mary Ann, but sure enough, when I did a quick search on the internet during morning report, I found numerous references to both giving the mother prenatally and the baby postnatally the medication. This is not a practice in the United States, but does sound like it is used in some resource limited settings, similar to here at FAME, as the phenobarbitone will induce the liver enzyme pathways to clear the bilirubin quicker. Very ingenious and something that makes a lot of sense once you hear it.

After report, we checked on our little baby with the seizures who was miraculously doing very well and had been seizure-free since noon the prior day and looked very well. We had made some simple adjustments in the baby’s antiseizure medication regimen and the combination was holding – he was still on four medications, but we were weaning one them so he would be going home in a day or two on three medications as long as he continued doing as well as he was now. Again, his mom was incredibly understanding and, though clearly thrilled that he was doing so well, did understand that he was still developmentally delayed and that this was not going to improve necessarily with his seizure control. If his seizure burden prior to coming in to see us had been so excessive that it was limiting his development, though, he could have some subtle improvement and that would be something to hope for, at least.

Our clinic was again rather slow today and though it was not entirely clear as to why, I have seen this in the past typically in times of harvest or the rains, but neither of those were ongoing at present. The effect of the pandemic could certainly be playing a role, though not in the manner most would expect. Tanzania was hit tremendously harder by COVID-19 from a financial aspect than it ever really was from a medical standpoint for as worldwide travel had essentially shut down over the last two years both in regard to the availability of flights and to its safety, the number one industry here, that being the tourist trade, was decimated.

The impact was devastating as the safari companies, the lodges, hotels and restaurants all felt the brunt of the loss of visiting tourists, but also the jobs at these businesses that supported the towns and villages also became non-existent and it was very difficult for people to get by. How a family who had been paying school fees for their children and paying their bills and were just barely making ends meet were going to make do was not entirely clear. Even though over the last several months, the tourist trade has dramatically rebounded and many of these jobs have returned, the financial stability of the country, that is, if one could ever really consider it stable, has not completely returned and many of the businesses that had previously accounted for the job market are not fully up to speed. I’m sure there is also a fear of what would happen if there is again a ban on travel due to a blip in the pandemic – business owners must have this in the back of their minds and are hoping to protect themselves in some manner should it happen again. I am sure that these effects of the pandemic are still in people’s minds after the trauma of the last two years.

Turtle needed some minor repairs and I had wanted to get them taken care of prior to our upcoming trip to Ngorongoro Crater on Sunday, so I drove down to our mechanic’s place in town, though he was unfortunately not in. The young boy who had helped me with the rear door of the vehicle last week was there, though, and proceeded to fashion a gasket for my oil filler cap that had been leaking and at least took care of that problem. Our doors had begun to act up again and we were back to having only two of the four doors working from the outside – these Land Rover conversions to a full on safari vehicle have still not had all the bugs worked out and I wasn’t able to fix that problem today. At least my door and one of the other back doors work and though it’s a pain to lean over and open the doors from the inside, we can do it.

We had dinner on the veranda of Dr. Joyce’s house (the Hoffman House) which is next door to ours and has much more space for us and also has a great view similar to ours. We had wanted to join Mary Ann as she’s staying there by herself and besides, I had promised Joyce when we had built our house that we would continue to have dinners on her veranda as much as possible. The two cats were as annoying as ever despite the fact that our meals were completely vegetarian. I’ve never seen cats who are willing to pounce on chapati, but somehow, these two are more than willing to do so.

After dinner, Mary Ann asked if anyone wanted to play Bananagrams and Taha, Ankita and Sara were up for it, so joined her in the house to play. They came back home later reporting that Mary Ann had won every game and they were very impressed with her skill, which certainly didn’t surprise me at all. I’m just not a game player and will typically do my best to sit out, having been quite successful so far on this trip. After they returned, we decided to watch a movie and everyone decided upon the original Top Gun. Though I had planned to work while watching, I’ll have to admit that I didn’t get much done as it was hard not to pay attention to the movie as we had it playing on quite large on the wall with my inexpensive LCD projector and the sound through a USB speaker which made it quite entertaining.

I did interrupt the movie at one point to share a baby day gecko that I had caught earlier with the others, though I’m not sure how much they appreciated it. They were entirely shocked when I let it go back in the house where I had found it, but given that these little creatures catch the mosquitos, I wasn’t about to put it outside. Later, as everyone was going to bed, I caught another, even smaller, baby gecko and knocked on Taha’s door, though he was again not very appreciative of the gift and wouldn’t let me release it in his room, so it went back to my room in the end. Hopefully, no one had bad Malarone dreams of giant man-eating lizards that night.