I had fended off having the residents give a talk on Tuesday since they had just arrived, but they had no issues with giving the educational talk this Thursday morning. Theandra spoke about the red flag signs in headache, meaning the pieces of history that a patient reports that makes one concerned their headache may be secondary rather than primary. Primary headaches are the common ones that you think about – tension-type headache, migraine, cluster, etc., and are not an indication that a patient has some other cause for it such as a mass lesion or a vascular etiology. You don’t want to miss a secondary headache and so, we are very careful to screen for anything that might make us think of a more malignant cause such as a brain tumor.

At home, there is a tremendously lower threshold to order imaging studies on patients complaining of headaches and even those patients who have no red flag signs and a normal examination may be imaged due to underlying anxiety by either the patient, the clinician, or both. Meanwhile, sending a patient for a CT scan will mean that they or their family will be hit with a 250,000 TSh (just north of $90) charge that is typically paid prior to the scan being done. That is a huge chunk of a family’s income and something that will have to be discussed by all parties involved. Though our threshold is high, and we obtain far fewer scans than we do at home, our screening process is quite reasonable, and we order substantially fewer normal scans here and that’s perfectly reasonable. For how long the practice at home can be continued with its massive deficit it is accruing year after year remains uncertain.

Theandra’s talk was well-received and will hopefully help the clinicians at FAME going forward in making these decisions rather than just making a knee-jerk reaction to perform an unnecessary study with huge repercussions impacting their financial stability.

It was at morning report that we first learned about the young boy who had been attacked by a leopard, but it was not until later after he had been seen by us that we learned all the details. The boy had apparently been at school in the conservation area and had left class to go to the bathroom behind the school. At some point, the leopard jumped out of the surrounding vegetation and immediately attacked the boy without warning, grabbing him by the head and neck. He tried to fight off the predator, suffering wounds to both of his hands, and began screaming which thankfully alerted his schoolmates who immediately summoned security at the school. Despite his continued trying to fight off the leopard, it had begun to drag him into the surrounding forest. Thankfully, the teachers and security arrived in time to intervene and get the leopard to finely release the boy who by that time had been badly injured. He was put in an ambulance and brought directly to FAME for treatment.

A CT scan was done that demonstrated a small fracture of the left temporal bone along with a small parenchymal contusion or hemorrhage just underlying the fracture. He also had a significant amount of subcutaneous emphysema within his scalp and the soft tissues over the back of his neck. It wasn’t until I looked at the reconstruction of the CT scan that I realized the actual nature of the skull fracture. The shape of the fracture and the wound made it very clear that it could only have been caused by the canine tooth of the leopard and that this was one incredibly lucky young boy for had he not been reached before the leopard dragged him off, he definitely would not have survived.

Given the head and neck injuries that the boy had, I thought it best that we fully evaluate him to be certain there were no neurological deficits as a result of his attack and, fortunately, his neurologic examination was normal, and he had no real complaints other than pain. It would just take some time, and he would be as good as new, though I am certain that he will have some significant PTSD following an episode such as this. The episode reminded me of something I had learned many years ago in my physical anthropology courses as an undergrad and graduate student and has remained in my brain these 50 years. I believe that it was in South Africa, though I suppose that it would have been in other regions of Africa. Bones of our early ancestors, the australopithecines, were often found in sediment beds that would have been at the base of trees in which leopards lived, and that a number of skull fragments had been found with penetrating wounds from leopards’ canines. Just to remind everyone that leopards drag their prey up into their tree to eat them as a way to prevent having to fend off other predators such as lions and hyenas from stealing their kill. Certainly, a chilling thought.

Ashley saw another fascinating patient who was a six-month old child that was referred to us for a bulging fontanelle. The child was developmentally normal and had no significant birth history, but the mother had first noticed the fontanelle bulging the night before she brought them to clinic, and that in the morning the fontanelle felt even a bit fuller to the mother. The uniqueness of the fontanelle in a baby is that when it’s open, it can be a good monitor of increased intracranial pressure and will usually align with disorder that can cause increased ICP, such as hydrocephalus or meningitis. The trouble was that this baby was perfectly fine other than their bulging fontanelle – no fever, no fussiness, feeding and acting normally, and no proceeding illness. The only other piece of information was that the baby had been given their first dose of vitamin A (which is standard here at 6 months and one year as early diets here are deficient in vitamin A) the morning prior.

One of my mentors in residency was perhaps the most amazing diagnostician that I have ever known, and his name was Fritz (Fred) Dreifuss. He was born in Germany, though his family fled to New Zealand when he was 15. He studied medicine and neurology initially in New Zealand but finished his training at Queen’s Square in London (The Mecca for neurology) and had then come to the US where he joined the faculty in 1959 at the University of Virginia in Charlottesville where I trained. Fred was an amazing teacher and I recalled one morning when he had included hypervitaminosis A in the differential for increased intracranial pressure, and to this day, I can still hear him saying in his German/Kiwi accent, “hypervitaminosis A.” Fred passed on a number of years ago, but will always be remembered by those of us he mentored, as well for pinning his name on Emery-Dreifuss dystrophy, even though he was his real contributions in neurology were in epilepsy, having contributed greatly to the classification of epilepsy and worked closely with Kiffin Penry and others to develop early video-EEG. He was an absolutely incredible individual and I was honored to work with him during my three years of residency.

With this piece of information, I began googling vitamin A and bulging fontanelle and, low and behold, there were several papers including a study in Pakistan showing that 10% of infants supplemented with vitamin A developed bulging fontanelles as a side effect of their treatment. Additionally, the WHO information sheet on vitamin A supplementation in infants lists a bulging fontanelle as a known side effect of the supplementation. Prior to this search, Ashley and I had discussed possibly imaging the child with either an ultrasound or a CT scan and then doing an LP to rule out any infectious or inflammatory etiology. Thankfully, having recalled Fred Dreifuss discussing hypervitaminosis A led us down the correct path.

As it turned out, vitamin A is supplied in capsules of 200,000 IU, but the recommended dose for a six-month-old child is considerably less, and our patient was actually small for age. The practice here at FAME has been to give most of the capsule to each child and, up until now, there had never been an issue that anyone knew of. It’s unclear that a bulging fontanelle in a six-month-old as a result of receiving vitamin A supplementation, which is transient, has any negative consequences, though it is certainly reasonable to avoid if possible. In reviewing the WHO recommendations for vitamin supplementation, the dosing for children 6-11 months is 100,000 IU every 4-6 months and the benefit of supplementing is borne out as there are an estimated 3 million pre-school age children suffering from vitamin deficiency each year, while there are only 200 cases of hypervitaminosis A reported each year.

In looking at this child, there was no question that her fontanelle was bulging as could be easily seen from her examination, though she was otherwise perfectly happy, interactive, attentive, and afebrile. It is very likely that her month was very observant and vigilant which led to her being seen. We both felt entirely comfortable after our review of the literature that this child merely had a bulging fontanelle as a result of her receiving her vitamin A and possibly a greater than recommended dose. We sent mom and baby home with lots of reassurance that she would be fine. We do not supplement with vitamin A, though now having this knowledge will certainly be quite helpful going forward.

Having finished with clinic, we decided it would be a good day to head over to Teddy’s for the residents to pick out some clothing for her to make. They had all picked out fabric on Tuesday and it was now just a matter of relaying to Teddy what they wanted, and, for that, we would need Annie along with us as Teddy’s English, though reasonable, is not good enough for us to accomplish this with an appropriate level of accuracy. Annie makes up for the language barrier and always enjoys coming along with us, though she now has her baby, Denzel at home.

Teddy also has a little one, Alan, who is a real character. He is a very serious young boy who is 2-1/2 now, and while we were there, he came home from school with his backpack on and greeted me with Babu (grandfather), which is what Teddy calls me all the time and has been perfectly fine with me. In his backpack, I found the book, Goodnight Moon, and proceeded to read that to him as he sat quietly on my lap looking at every page. It certainly brought memories of having read this to my own children then they were of a similar age, though I haven’t had the opportunity yet to read it to my own grandchildren as that wonderous event has not occurred yet. Alan’s pack was actually totally empty other than two books, one being Goodnight Moon, and the other being a composition book in which the teacher had drawn various objects for each day, and he would have to color them. We patiently went through each page that he had colored, repeating what the object he had colored was.

I typically sit out in front of Teddy’s shop as the residents each go through their requests and what fabrics they wish to use for each item. As the fabrics are often six meters worth, the residents will often share them because they can make so much from each one. I was amazed at how quickly it went tonight, to be honest, but then I realized there were only three of them as opposed to the five I had last time (which included Jill). We departed from Teddy’s in what I thought was record time and were about to head home, I thought, until Annie told me that she needed to go into town for a short errand.

We drove into town as the sun was setting and Annie told me she needed a loaf of bread, at which point she and the three residents got out of the car. Jill realized that we also needed a loaf of bread for our safari lunch in the crater, so she joined the rest of the party at which point I was sitting in the car by myself for what I thought was going to be a quite visit to the market. Apparently, there were other intentions that must have been on a need-to-know basis as I was sitting in the car for at least twenty minutes waiting. Based on the photos that were sent to our WhatsApp group, they were shopping for things other than bread, but I was fine sitting in the car as it was a very busy evening in the market area and watching every hustle about was very entertaining. Everyone finally made it back and we were off to home and dinner.