Unfortunately, the young Maasai boy in the ward, who had been here now for well over a week with some form of meningitis and mild hydrocephalus, wasn’t improving despite significant courses of antibiotics and anti-TB medications. His CT scan before hadn’t been overly helpful in further elucidating a likely suspect as it demonstrated mostly a full brain (slightly swollen) with generous ventricles, but no other tell-tale signs. It was decided that we would obtain an EEG to be certain that he was not in non-convulsive as an explanation for his continued depressed mental status and lack of improvement. The EEG was obtained later in the morning and uploaded to the cloud, but we had to wait for Cat in the US to download and read it (not only have I not read EEGs in nearly 15 years, but I also do not have the required software, Persyst, that would allow me to look at the files) which would be at least 2:00 pm our time, and that didn’t account for the fact that she was also on service back at home meaning that she had a very busy schedule.
When she was finally able to take a look at the study, it was fairly clear that he wasn’t in non-convulsive status, but the study was also very abnormal demonstrating high voltage, rather disorganized, generalized slowing that almost looked like hypsarrhythmia, though wasn’t in the right clinical situation. The other issue we were having, was that he was also significantly hyponatremic (low sodium) which could have certainly been contributing to his abnormal EEG and needed to be corrected. The decision was made to give him 3% hypertonic saline (it took a team effort to calculate a combination of fluids of make up the exact concentration as we didn’t have it pre-made in stock) as his hyponatremia was not chronic and could be corrected a bit more quickly.
Thankfully, our young boy who had presented last night in status epilepticus was back to normal this morning and on a full therapeutic dose of sodium valproate that he was tolerating quite well. He looked so well, in fact, that we were able to discharge him to home this morning. There is a significant difference here than at home as far as discharging patients home – most patients and/or families are requesting to go home as soon as possible as they are paying for the admission rather than in the U.S. where it is very often insurance and, even if uninsured, the bill will usually get written off and the patient won’t be responsible to pay their bill. Here, the first question from a very sick patient requiring admission is, “when can I go home,” which is a completely different mindset than at home.
Another patient who Leah evaluated in clinic was a young adult whose seizures semiology suggested a focal onset epilepsy, though he also described possibly having myoclonus. That is a major distinction for us – whether someone has focal onset or primary generalized epilepsy – as the medications can be very different. A number of medications have a broader spectrum, meaning that they can treat both equally well, but these medications tend to be the more expensive of the anti-seizure medications (e.g. levetiracetam). It would be very important for us to know which type of epilepsy the patient had as that would significantly affect which medication we would start him on and continue going forward. Since we had access to the EEG, we decided to obtain one as this would help to clarify this question and could be done very efficiently while we were in clinic, and we could even have a formal read quite quickly through our Brain Capture colleagues. The patient’s EEG was normal which was very suggestive that they did not have a primary generalized epilepsy as these patients nearly always have generalized discharges on their EEG. In the end, the patient was placed on carbamazepine, as this would be a very effective medication for focal seizures.
Natalie saw a very interesting gentleman who presented merely for neuropathy (not one of the most interesting diagnoses that we see, in general) and whose examination was consistent with a generalized sensorimotor neuropathy such as is commonly seen in patients with diabetes, but he did not have that pre-existing diagnosis. The first pass labs for neuropathy that we send off here are somewhat different than at home given the different prevalence of co-morbid disorders that are common – specifically, there is far more HIV and syphilis that we see here than back in the US. Interestingly, the patient came back with a negative HIV, but a positive RPR for syphilis, prompting the need for treatment which meant that he would need several IM penicillin injections into the buttocks. We saw no other possibly etiologies found in his lab work and so it looked very convincing that his neuropathy was the result of his underlying syphilis and, based on further history, he had acquired the infection a number of years ago and it had never been reported or treated.
Perhaps the most interesting patient of the day was a young girl whose parents brought her in for a longstanding issue with ambulation. There had been a clear delay in motor development as she hadn’t walked until three years of age, though she didn’t have any cognitive issues, so it wasn’t a global delay issue. When she walked, there was an obvious instability in her pelvic girdle, and on examination, she had both subtle weakness in her lower extremities as well as hyperreflexia and upgoing toes bilaterally, consistent with an upper motor neuron issue. The young girl was very cute and animated such that she had attracted a crowd observing her ambulation, even including a video consultation with Lauren Breslow from CHOP, who had been on the phone for some other issue, but was asked to comment on the child’s gait from the US. Though we wanted to image her brain as it seemed the most likely place for etiology of her ambulation difficulties, such as possible periventricular leukoencephalopathy, or PVL, a disorder often affecting premature babies, though can also occur full-term, where there is ischemic injury to the white matter adjacent to the ventricles. Her injuries though were chronic, and identifying PVL wouldn’t lead to any treatment options, so when this was discussed with her parents to either consider a CT scan or pursue rehabilitation at Monduli, they opted for the latter, which was a perfectly reasonable course and the one that all of us would have chosen were we in their place.
It was the end of Leah’s first week (though we did have half a day of clinic in the morning tomorrow) and Natalie had been here for nearly two weeks, so we had accomplished quite a bit in that time. Our trip seemed to have a varied focus given the staggered arrival of the junior faculty and the resident distribution. For the first two weeks, we had focused on getting the EEG up and running (which was a huge success), and now it was having two pediatric neurologists with both Natalie and Leah here, so our emphasis shifted a bit. LJ would be arriving tomorrow and would overlap with Natalie for a week, and then for the last week it would be both LJ and Leah. It was very different than our normal schedule where I have one team here for three weeks and then the second team, though it seemed to make things a bit more interesting, to be honest.
With Mama Samia having been in Karatu today campaigning for the upcoming elections in three weeks, there were lots of rallies both for and against with a tremendous influx of people, giving us every reason we needed not to head into town for the evening. Instead, Frank and Susan had invited all the current volunteers up to their house to have some light snacks and drinks at 6:00 pm just before sunset. Their home is a lovely open layout in the main room with a large kitchen and living room flowing together and onto a giant veranda that surrounds the house and has a perfect view to the west for sunset. There were beef and vegetable samosas, a huge fruit tray, and lots of little bites such as popcorn, cashews, and chips, all of which was out on the veranda awaiting our arrival. Veronika and her family were there, including her two children who had to be the most well-behaved young adolescents I have seen given that they were sitting patiently for nearly two hours while the rest of us talked, and they only speak Italian! Of course, they did have some things to eat, but even still, any well-respected child in the US of the same age would have been sitting on their phone, or, if they didn’t have one, would have complained until their parents would have given them one. Perhaps this was a bit of a cultural commentary we were watching. Jeannie, the ultrasonographer, was there, as were my neurology colleagues. We left shortly after 8:00 pm, which is Frank’s bedtime and not to be threatened, though he has never had a problem just disappearing from a gathering when that time is approaching. We had dinner waiting for us at home, though I’m not entirely sure how much I ate given what I had eaten earlier at our get together.