Wednesday, October 12 – An interesting patient on the ward…

Standard

With no lecture this morning, everyone seemed to very much enjoy the extra 30 minutes of sleep and the house was quiet. My routine has been to get up every morning by 6 am for several reasons. Bedtime here is usually much earlier for me than it is at home given the sun setting at 6 pm and the fact that there are no bright lights in the house whatsoever to delay the release of your natural melatonin and staying awake is much more difficult. Another reason is that I love the mornings here as the birds begin their chatter and singing well before sunrise and they are right outside my window, so sitting at my desk and getting work done in the mornings is just the most pleasant and invigorating experience. And the last reason is that 6 am here is 11 pm the night prior on the east coast and a perfect time to video chat with anyone there you’d like to say “lala salama” (sleep safely) to before they are going to bed. “Usiku mwema” in KiSwahili actually means good night, but I so much prefer the other.

At morning report, we were told about an interesting patient who had come in the night before with new onset of a focal seizure and had left sided weakness that had persisted. He was a 62-year-old gentleman with no significant past medical history, but had apparently complained of a right sided headache several weeks prior and had been treated with antibiotics for an ear infection. With this information, the differential was completely wide open – the headache and ear infection might well have been completely unrelated, though it was certainly an enticing connection given the focality of the seizure and the current neurologic deficit, both of which would have lined up with the laterality of presentation. There would have been a number of other things that could have also come to mind with his presentation, such as a simple stroke, which can often present with seizures, or some type of a mass lesion that may have been present to have produced both his focal seizure and weakness.

Non-contrast scan of our patient

He had a CT scan had been done the night before after having presented, and despite the fact that as neurologists, we prefer to evaluate the patient first rather than their scans ( I was always taught that was the difference between a neurologist and a neurosurgeon12), we all trekked over to the radiology suite to have them pull up the study for us to review. It hadn’t been read by our radiologist yet as he is in NY and he time difference, but the offending lesion could easily be seen in the right posterior parietal lobe. It didn’t look like a stroke, though, and made us concerned about the possibility of an infectious process. On the contrasted scan, there was no evidence whatsoever of an enhancing mass, like a tumor, nor abscess, and, in the end, we were all much more convinced that we were looking at a localized infection of the brain, or cerebritis, a much less common process than any of the others that were being considered. Given the history of the possible ear infection weeks before, this also significantly raised our concern for an infectious process.

After looking at the CT scan, Taha volunteered to go evaluate the patient in the ward with Amos, one of our Tanzanian translators who had been working with us since we had started back in September, and who was also himself a clinical officer student in Dodoma with only about six months left until he was to graduate. Amos, as well as Hussein, have been an absolute pleasure to work with since starting here nearly six weeks ago and I’m hopeful that each has learned a good dear of neurology during their time working with us as that wouldn’t have been something they would have picked up in school or clinical rotations even if they had wished to do so as there are simply no neurologists here to work with.

Post-contrast scan showing a bit more detail

On their return, Taha and Amos reported that the patient did not have a history of seizures and was, in fact, still having focal twitching of his left side along with continued weakness and that he was poorly responsive. With no real intravenous antiseizure medication to use here other than phenobarbital, which, for an adult, would be a mess as a loading does would likely cause them to stop breathing and, not having an ICU nor a ventilator here to use, that would not be a good thing. We decided to put an NG tube in the patient and that we would load him enterally with 2000 mg of levetiracetam as well as place him antibiotics that would cover the most likely suspects involved. Unfortunately, we have just recently started running cultures at FAME, so we would not have these to help us in the future with antibiotic selection or narrowing the medications that he was on.  .

Another post-contrast scan

The patient continued to have minor focal seizures through the day and we had a contingency plan to add a second agent, though thankfully, his seizures abated in the evening just about the time we were getting ready to pull the trigger. Over the course of the next several days, the patient began to slowly wake up and by the time we were leaving on Saturday, his neurologic examination went from having a fairly dense hemiparesis to being essentially normal and having had no seizures since being started on the levetiracetam, which, as you may know from previous blogs, is in very short supply here and, when available, tends to be very expensive. Thankfully, we had Elissa here who, even though she’s a pediatrician, is also an infectious disease specialist and could help us come up with an appropriate therapeutic plan despite the fact that we didn’t have the luxury of repeating imaging studies to judge the patient’s response to therapy.

In the end, we left FAME several days after the patient had been admitted in focal status epilepticus with a life-threatening brain infection and he was now awake and pretty much normal neurologically, though would require an course of long term antibiotics for at least several weeks and we would have to come up with a plan of how exactly to assess his response, likely a repeat CT scan, or just take him off his antibiotics and hope for the best, not always the most comfortable position, but sometimes necessary. As for how long to continue his antiseizure medications, we chose to phone a friend (actually an email to Mike Gelfand at Penn who is an excellent epileptologist and I knew would get back to me quickly) , mostly knowing that there was no right answer, but at least I would check. We decided to convert him to carbamazepine and continue it until our return in six months.

I know this is a bit more medical detail that I normally give, but I felt that this case would give even those non-medical readers a chance to experience the medical decision making that occurs at FAME and what makes it such an excellent clinical experience and very different than what goes on at home. Had we been at Penn, it would have been MRIs instead of the CT and he would have likely undergone a dozen of them before he left the hospital.

Meanwhile, it was again my favorite lunch of the week, rice, beans and mchicha, though I must admit that the ugali and nyama (beef) from yesterday was giving this lunch a run for its money and I might just have to reconsider things going forward. Though the pilau was also quite excellent, it just didn’t seem to have the pizzazz (or maybe it just didn’t quite mix as well as the others with the spoonfuls of pili pili that put on everything) as the other two dishes, at least for me. Either way, the lunches here continue to be my favorite meal of the day save for dinners at the Galleria or at Gibb’s Farm.

Teddy at her shop last March helping Alex Pfister

Teddy, the seamstress here in Karatu who has been making clothes for the residents out of the colorful and beautiful kitenge and kanga cloth for the last several years, had come in last night in preparation for a scheduled C-section today. Everything had gone incredibly well, thankfully, and she ended up with a very lovely, though quite large, baby boy weighing in at over 9.5 lbs. who we each got to hold when we visited. His name was Ivan and he seemed to be ever so cozy in all of his blankets as we passed him from person to person and he didn’t make a peep. Teddy looked wonderful and happy and was, of course, all smiles as she normally is at her shop when she greets us with a plate of candies every time.

Mwalimu (teacher) Julius Nyerere

Tomorrow would be our last day in clinic as this Friday will be an official holiday, Nyerere Day, in honor of the country’s founder and first president, Julius Nyerere. Though we all love to keep working and see more patients, we have to be sensitive to those Tanzanians who we are working with and who have been absolutely essential to anything we do here as they may wish to have the day off and be respectful rather than working in clinic with us. It was a quiet day after work today and everyone settled in to begin the mental and logistical process of leaving FAME which I have found is not always an easy thing for the residents, though, for me, I never have to say goodbye, just “see you in six months.”

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