Wednesday, March 22 – Marburg virus for the first time in Tanzania and a patient with Alice in Wonderland Syndrome…


Yesterday afternoon brought the report from the Ministry of Health that an outbreak of the Marburg virus, a cousin of Ebola and also a hemorrhagic fever, had now been confirmed in Tanzania. The report was from the Kagera region, which is in the far northwest section of Tanzania adjacent to the Lake Victoria and Uganda and had originally been reported last week, but without confirmation of the virus. The report noted that there had been eight cases of Marburg and that there had been five deaths, one of which had occurred in a health worker caring for the patients.

An overcrowded morning report (notice the windows)

Considering the previous Ebola outbreak that had occurred in West Africa with countless deaths and an international response that included the United States, this report of a possible hemorrhagic fever now being present in Tanzania wasn’t something that we could take lightly and there was an immediate response here at FAME that included stricter triage than we had already been using since COVID and heightened awareness by the everyone seeing patients, especially those who had traveled far to reach us. The fact that the virus had been first reported and now confirmed in a region of the country far away from FAME was certainly reassuring, though nothing can be taken for granted in this post-COVID world of ours.

It was reassuring, though, that in addition to the Ministry of Health, the WHO was also assessing the current risk of spread of the virus to other regions. There seemed to be little worry here in our little paradise of Karatu, but unfortunately, two of our team had plans to travel to Gombe Stream National Park to visit the chimps who reside in the mountains surrounding that area and where Jane Goodall had done her monumental work that totally mystified the scientific world. Gombe Stream, which is on the far northeast coast of Lake Tanganyika, though still far from the Marburg outbreak, was closer than Karatu to it, and in a much more remote and less medically developed region of Tanzania.

I had followed the outbreak over our weekend in the Serengeti, hoping to glean from the news any information that would make me feel more comfortable or, if not, more definite about having to cancel the resident’s plans to visit Gombe for safety reasons. There was almost no news in either direction, which, though frustrating, was not overly surprising. The fact that it had now been confirmed to be Marburg was at least some information, but any more details regarding further spread or additional cases was entirely lacking from any of the news reports. I had originally not wanted to stress either Mark or Anya regarding the situation, but they became aware of it not surprisingly. We would have to keep an eye on things, and it would be a moment to moment or game time decision once there was more information. They were scheduled to head to Arusha in two days, so hopefully we would know something shortly.

Clinic today included several interesting patients, one of whom had a relatively rare syndrome called Alice in Wonderland Syndrome, which I’ll describe shortly. First, though, we had a young Maasai patient who only spoke Maa, or the Maasai language, and was seeing us for seizures. “Maasai” actually means speakers of Maa, and it is often that Maasai patients who do not leave the boma, which are primarily the women, will not speak Swahili and will either require a Maasai interpreter or, at times, an additional interpreter if the first does not speak English. In that case, we do double translation, or Maa to Swahili, and then Swahili to English. Thankfully, we are usually working with Kitashu whose grasp of English is very good and is Maasai. This patient reported that they had seizures since 7 years of age following an episode of severe cerebral malaria. This is not at all an unusual situation and is one of the explanations for why epilepsy is so much more common in low to middle income countries – childhood infections including cerebral malaria as well as trauma and limited perinatal care.

The other interesting seizure patient we saw today involved a 22-month-old child who had been suffering from seizures with prolonged automatisms (automatic behavior like chewing) which are atypical in and of themselves, but more significantly had a seizure here in clinic for us and it was decided that it would be best to admit the child to the hospital here just in case they were going to have more seizures or, worse yet, go into status epilepticus which would put them significant risk of harm. The child was started on an antiseizure medication right away and stopped having seizures over night and was fine for discharge the following day.

We see so many epilepsy patients here who have never been treated for their condition or have been treated with inadequate medication dosing and never went back to see the doctor because treatment had been ineffective. As I have mentioned so often before, the epilepsy treatment gap (those patients with the condition who are either not receiving treatment or who are not being treated effectively) is greatest in low to middle income countries where the greatest amount of epilepsy exists because of childhood infections, poor perinatal care, and head trauma. And this is exactly where there are the fewest neurologists to treat these patients, so it is almost a perfect Catch-22 scenario. Not only have we identified epilepsy as one of the most common diagnoses that we treat here, but it is also a diagnosis where many of the patients have previously sought medical attention but were placed on the wrong medication or too low of a dose. Therefore, epilepsy is the condition in which we can make the greatest impact here, not only providing treatment for the patients, but also providing the education for the caregivers at FAME to use in our absence when they see these patients.

Now for our most interesting patient of the day and, thankfully, one whose native language was English as I’m not entirely certain how her history would have been portrayed had we been translating from Swahili, or worse yet, Maa or Iraqw. This was a young patient with a history of headaches that sounded very migrainous but was now complaining of new symptoms that were very specific. She noted that recently she was having episodes of headache that were associated with abnormal visual perceptions in which objects or her own body parts appeared too large or too small. This syndrome, coined Alice in Wonderland Syndrome (AIWS), for fairly obvious reasons, has been well-described in the literature over the years, and though no unifying diagnosis has been confirmed, it mostly consistently felt to be migrainous in nature and most often in the pediatric population.

The syndrome is considered to be rather rare, though our patient today seemed to describe the necessary symptoms in a very unprompted manner and the migraine association in this particular patient seemed to be quite convincing such that it was decided to treat the patient with preventive therapy for migraine. Given the lack of a definite and unifying pathophysiologic process, though, we did recommend that the patient obtain an MRI scan of the brain once they returned home, which would be in the near future.

At the end of the day, we all had the pleasure of traveling up to visit a good friend who lives just below Gibb’s Farm and has a wonderful coffee business, preparing and roasting his beans onsite along with his numerous hives of stingless bees who pollenate his coffee plants. Phillipo and his family have always been incredibly gracious to the groups I bring there, demonstrating the process of preparing the beans and then roasting them fresh for us. From his wife, who sits tirelessly at her manual sewing machine making the kanga cloth bags for the coffee they sell, to his lovely children who are often helping when we are there as long as their school is not in session, everyone is just so absolutely pleasant that you just can’t help from having a huge smile on your face.

We stumbled upon Phillipo and his family somewhat serendipitously while on a walk towards Gibb’s Farm in the last few years and were visiting the woodcarver next door when he took me to visit his friend, who happened to be Phillipo. It was a quick friendship and we have not missed a visit with him since. The Ngorongoro Highlands is a premier coffee growing region where coffee plantations dominate the landscape, though most of the coffee from here has been traditionally exported to East Asia, just like most everything else that is produced in Tanzania.  

Phillipo describes the entire process of processing the beans from bringing them in off the bush, to pulping them and then fermenting them. Once they are then dried on screen racks, they are hulled by pounding them in a large container while singing “twanga, twanga, twanga kahawa, twanga,” in unison. The hulled beans are then separated from the chaff by tossing them in the wind with a winnowing tray and are then ready for roasting in a large cylindrical container over an open fire and turned by hand for 40 minutes to yield a medium roast. If you’d like your coffee ground, he then grinds it for you with plate grinder. Most of our coffee is purchased as who beans, but we also buy several bags of ground to use at the house or to bring home.

Myrtle parked at Phillipo’s house

And then there is the honey he harvests from one of his many beehives he has hanging all around and are home to the stingless bees that pollenate his coffee bushes. He must have nearly two dozen hives hanging around his home and his coffee equipment, each hive yielding two honey harvests a year. He just happened to have honey available, and Mark was more than happy to have purchased some from him for he doesn’t drink coffee and he wanted to participate in the visit in some way. After more than an hour of having learned and participated in the coffee production, honey, and coffee tasting, it was finally time for us to head home and think about dinner.

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