Our visit last night to Phillipo’s coffee farm and Mbuga, the woodcarver turned out to be a great hit as we not only replenished the supply of ground coffee (we sadly don’t have a grinder, but it’s not an issue since we can buy it freshly ground here) in the Raynes House as well as more than enough freshly roasted coffee beans to bring home as gifts (I think we purchased nearly 10 kgs between all of us), but all the residents were able to find things to purchase at the woodcarvers. Ebony woodcarvings are a particular specialty of the Makonde tribe of Southeastern Tanzania who live on the border with Mozambique (consequently, the tribe also resides in the northeastern corner of our southern neighbor) where they have special permission by the government to utilize ebony trees that are dead or have fallen for their carvings. The carvings are incredibly intricate and range in size from very small animal carvings of only several inches to life-size carvings and beyond. They are very well-known for their Tree of Life works of art depicting people and/or animals climbing or standing atop one another and encircling the diameter of the piece while the center has been carved completely open. These also vary greatly in size from a foot high to several meters high. The heartwood of Ebony is a lovely black while the surrounding bark, which may or may not be removed, is brown. It is also an incredibly dense and heavy wood that sinks immediately when placed in water.

It turned out to be a moderately busy day despite the continued overcast and often rainy days. On Tuesday, the residents had done a tag team presentation of the neurologic examination, and this morning they would be completing that lecture. Though we get to work with all the translators, who are clinical officers, and Dr. Annie, we don’t get to spend as much time with the other clinicians here at FAME, so it’s imperative that we provide with the bare essentials of how to interpret the neurologic examination – is it in the central or peripheral nervous system, is it upper or lower motor neuron, and so on. To neurologists, the neurologic examination is sacred, and in addition to the history, the main tools in our toolbox to localize a lesion and tell what’s going on with a patient.

Tomorrow morning, we would be heading out for a weekend in the Serengeti, and we all hoped that some of the heavy rains that have been following there had stopped. Over the last days, there had been plenty of videos on the internet of long lines of dozens and dozens of safari vehicles all stuck along the roads, now rivers, and unable to pass due to high water. There were bulldozers and earth movers working both to rescue the vehicles and to cut new roads without a lot of success. One scary video was of a Toyota Land Cruiser full of wageni (tourists) floating down a river after a failed crossing with their guide standing up through the front hatch waving his arms with everyone yelling to him that couldn’t jump as there were clients in the car. Though that would have made a great story to tell for the tourists, similar to our getting stuck in the Serengeti last March in which we had to be rescued by rangers, I’m certain it was not something that any of them would have willingly volunteered or signed up for as part of their vacation.

Needless to say, I was just a bit worried about our plans, though thankfully it seemed that the rain had stopped several days ago and things were drying out there. Vitalis, our safari guide, had spoken to other guides who had just returned and informed him that most of the roads were passable, and that those that were not were the result of mud and not rivers of water. Regardless, I had asked Vitalis to look for several items in Arusha to bring with him today when he came to check out the vehicle – a recovery strap (a long braided nylon strap with elasticity used to pull a stuck vehicle out of the mud using both the kinetic energy of the strap plus the pull from another vehicle), sand ladders, and to look for a controller for our winch. Unfortunately, over the years, I have purchased all of these items, but they go missing over the months I am not here when the car is taken in for maintenance. Going forward, my plan will be to keep these items in Karatu at FAME locked in my two cabinets. Though we have a winch on the front of Turtle, the remote controller used to activate it has been missing for several years. Thankfully, they’re not expensive and I plan to pick one up in the US prior to my next trip here. Though I didn’t get the recovery strap I had asked for, Vitalis was able to find a tow rope that would supply half of what the recovery strap would do and actually came in very handy during our upcoming weekend trip.

One of the last patients seen today was a young man who we had originally seen in 2021 with a very interesting story. At the time, he was a 17-year-old boy with a history of birth injury and a pure motor cerebral palsy with no cognitive issues – he had done well in school and was bright and attentive. His abnormal movements related to his cerebral palsy had been static his entire life, as they should have been, but he was now presenting with the recent onset of additional movements that were best characterized as a chorea. Once his history was clear to us, i.e. these choreaform movements were of recent onset and not a part of what he had for his entire life, it was clear that he was suffering from Sydenham Chorea, also called St. Vitus’s dance, which is a transient autoimmune condition occurring in adolescents, typically girl’s, that is the result of a recent Group A streptococcal infection and an antibody interaction with the basal ganglia. It presents as involuntary choreaform movements of the face and limbs along with neuropsychiatric symptoms.

Though the neurologic symptoms are transient, the most significant feature of the disorder is that it is a manifestation of acute rheumatic fever often occurring with cardiac involvement, and without treatment can result in severe valvular cardiac disease that, if severe enough, can require valve replacements. Therefore, every patient presenting with Sydenham chorea must have a cardiac evaluation (an echocardiogram) and must be placed on antibiotics to treat the acute infection as well as continuous prophylactic antibiotic suppression for at least 10 years. Here, we usually place patients on monthly IM penicillin that negates the issue of inadherence. For the acute presentation of chorea, we will typically treat with high dose steroids for several months which will minimize the length of the abnormal movements. Thankfully, this patient’s cardiac involvement when he was seen initially was minimal as his echocardiogram revealed only mild endocarditis with no valvular involvement.

The reason that he was back in clinic today, though, was that his mother was worried about some behavioral changes that she had noticed, which certainly raised some concern about a recurrent strep infection. In the end, considering the fact he had been compliant with receiving his monthly penicillin injections, and that the behavioral changes they described were merely disagreements between he and his mother, we had little reason for any concerns of a relapse.

Sydenham chorea is a disorder that is now rarely seen in the United States given the widespread use, or more correctly, overuse, of antibiotics. Most neurologists, and even pediatric neurologists, will never see a case during their career, though we have seen three textbook cases here at FAME over the last 10+ years – the first, was a young 11-year-old girl who presented mute and with abnormal movements and a history that she had fallen out of a tree. As I was not here at the time, I was sent a video on WhatsApp, as was Danielle Becker, my colleague who was the first trainee that came to FAME with me and has come several times since. We both received it at the same time, and we both responded, simultaneously, with “that looks like Sydenham chorea.” Sure enough, as many histories go here, the falling out of a tree was a red herring, and we subsequently found her to have a murmur and mitral valve disease that was thankfully not severe enough to require a new valve. She was treated with steroids for her movements, which unfortunately recurred when we were here several months later as they had been tapered too quickly. Her movements eventually completely resolved, and she was kept on long-term penicillin injections, though was lost to follow up after several years.

Having a chance to see these unique patients, so significant in the history of medicine and neurology, and so important from a trainee perspective, is just one of the rewards of practicing in a low resource setting such as East Africa, even if only for three weeks. Most will never have the opportunity to experience diagnostic neurology where there are no MRI scans, limited CT scans, a limited selection of ASMs and no ASM levels, and often limited therapies. The question we ask ourselves here most often before ordering a test isn’t “what can we find?” But rather it is “what can we find that will make a difference in our management and benefit the patient?” Spending money on testing to identify disorders or lesions that would be impossible to treat here most often serves little purpose, and so we refrain from going down that path. These are certainly questions that are equally appropriate to ask back home but are far too seldom asked in lieu of pursuing million-dollar work ups that provide little or no benefit to the patient in the long run.