It was hump day of the last week of the rotation for this group of residents who would be departing on Saturday, though the Tarangire group (more below) would be coming today and we could typically expect them to bring a dozen patients for us to see. In morning report today, we heard about a patient who had come in last night with something quite unique to this part of the world – a lion attack! The attack had occurred on the other side of Lake Manyara from us in the Manyara district and a town called Minjugu, where a Maasai had been herding his cattle when he suddenly noticed that a lion had decided to attack one of his cows. He ran towards the lion shaking his walking stick in the hope of scaring it off when suddenly, and perhaps unexpectedly, the lion decided to turn on him rather than run off, attacking him about the head with its paws and causing very significant lacerations and abrasions to his left face and orbit. Apparently, some friends who witnessed the attack ran to his aid and chased the lion away, otherwise the outcome would have been far worse than just the possibility of losing an eye. His CT scan demonstrated a fracture of his left zygomatic bone extending into the frontal and sphenoid bones as well as significant subcutaneous and a small amount of intracranial and intra-orbital emphysema (air).

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Animal encounters are, unfortunately, quite a common occurrence here, and the outcome most often is in favor of the animals. I continually remind everyone that Tanzania’s national parks have been placed where the greatest concentration of animals exist, but that the parks are not fenced meaning that animals can roam freely in and out of the parks and across the countryside. They obviously shy away from heavily populated regions such as the major cities, but here in the more rural districts, the wildlife is ever present. We’ve had baboon monkey bites, hyena bites (a very tragic story of a Maasai woman whose infant was taken from their boma by a hyena during which she was bitten through the hand trying to fight it off), and a rhino attack (thankfully, not with its horn). Last year, we had a young boy that was attacked by a leopard while going to the bathroom outside his school and was thankfully rescued before being dragged into the forest for dinner. There were also several leopard attacks nearby FAME last year – though thankfully, none were fatal. Several years ago, a Maasai herding his cattle in the conservation area ran across a very angry elephant and didn’t fare very well – the elephant attacked him with its tusks that perforated him a number of times, then stood over him not allowing his friends to help him. By the time he was rushed to FAME (at least an hour drive in a bumpy vehicle), he was really beyond help and expired overnight.

(As I’m writing this blog the following week, we were called by multiple individuals to let us know that a leopard was spotted on campus near the volunteer houses and that we should remain indoors this evening. Shannon was just about to go out running – needless to say, she didn’t)

I had mentioned that it was the day we had arranged for our Tarangire group to come visit the neurology clinic. Several years ago, one of the local Maasai chiefs, Chief Lobulu, from the Tarangire region, just outside Tarangire National Park, brought several epilepsy cases for us to see. His village is outside the Karatu district where we have permission to work, and therefore, we were unable to go to his village for a mobile clinic. He was so happy with the care that his villagers were receiving that he continued to bring patients every visit and their numbers have grown. By far, the bulk of the patients from Tarangire that we’re seeing at epilepsy patients, though we have also seen children with CP and hypoxic-ischemic encephalopathy. Several years ago, he had brought two older teenage boys with Down syndrome to see us, and though we had little to offer from a medical perspective, I raised money to send the two to vocational school for them to learn a trade as they were both highly functioning.

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Today, Chief Lobulu had brought around a dozen patients, all wedged into a tiny dala dala, or one of the little minivans that ply between villages and are the main means of transport short of riding a bijaji (a tuk tuk or three-wheeled motorized vehicle) or a boda boda (motorcycle taxi). There were a number of follow up patients, but also a number of new ones to be seen. The group usually comes for much of the day, and the Chief makes certain that all the patients are seen. He has been incredibly dedicated to his villagers, and, because of that, we’ve tried to make sure he’s able to keep these patients coming back, for without his help, I’m sure they would be lost to follow up which would serve no purpose in the long run. The area where their villages are is extremely poor, very similar or perhaps even worse than the conservation area, and the people there have very little to call their own. I had visited the Chief Lobulu’s village and home in the past to visit the two boys with Down syndrome, and it’s a very, very dry and dusty place with very little in the way of local grazing for their cattle.

Meanwhile, the patient in the ward who had suffered the hypertensive hemorrhage with ventricular extension was seen again in the hospital and seemed to be slightly less arousable with some increased weakness. Patients with intraventricular blood are at risk for developing hydrocephalus as the normal drainage, or uptake, of the CSF back into the venous system becomes sluggish as if blocking the drain in your sink – the ventricles enlarge, causing increased intracranial pressure and mass effect, that is manifested initially be worsening mental status and eventual brainstem compression eventually leading to the potential of herniation. Needless to say, this isn’t a good thing to have happen, so the clinical situation prompted us to order a repeat CT scan to confirm whether or not he was developing hydrocephalus, which, if present, would have required an urgent transfer for an EVD, or external ventricular drain, to lower his intracranial pressure by draining his spinal fluid. Thankfully, his only showed the expected evolution of his primary hemorrhage without any evidence of hydrocephalus, and his mental status had merely been fluctuating as so often can occur.

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Meanwhile, Jill and I had been invited out to dinner at the home of our good friend, India Howell, or Mama India, as she is known here. India, with her Tanzanian business partner, Peter Leon Mmassy, had founded the Rift Valley Children’s Village, or RVCV, in 2004, and is one of the principal reasons that Frank and Susan decided on Karatu as the location for FAME when it opened in 2008. Prior to FAME opening, India had been bringing her children to Arusha to see Frank for their medical care, which at the time was a four plus hour drive on dirt roads. RVCV is located about 45 minutes outside of Karatu, so the proximity was key for providing the medical care to the children as well as to the village of Oldeani where it is located. India is now retired and living down the road from FAME, where her children who are now grown and working can often visit her or come for dinner. Whenever I’ve been at her place, there are several of her older children home visiting and sharing dinner. Her story is remarkable and since we’ll be visiting RVCV in several weeks for our mobile clinics, I’ll tell it them. Save it say that dinner and the company this evening was wonderful.

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.

The rains have come a bit earlier than they have in the past with showers, some heavy, now occurring on a daily basis. Though this is seen as a blessing to the Tanzanians, for it means a good planting and growing season to follow, it makes our lives messier given the fact there are few paved roads here, so travel becomes more difficult and merely walking to clinic each morning can be a chore. The timing of our spring trip has generally coincided with a break in the wet weather, between the short rains of January and the monsoons that typically begin in late April, but it seems that this year the rains may have decided to come earlier than normal. I’m not sure we can necessarily blame global warming, at least not for this one, as this is still within the realm of normalcy for the region, though there’s little question that global warming has affected all of Sub-Saharan Africa with wide ranging droughts in the recent years that has decimated many of the large livestock herds.

Travel here can be quite precarious in the rains as I’ve had the opportunity to experience on several occasions in the past. One of the main issues occurs with our mobile clinics to more remote villages in the Karatu district. Our travels to the Mbulumbulu region (Kambi ya Simba and Upper Kitete) have been seriously disrupted in the past as that road can only be likened to a Slip ‘n Slide (for those of you to young to recall the early Wham-O Slip ‘n Slide) in which keeping your vehicle on the road can be related more to luck than skill. In April 2011, our Land Rover (with me driving) slid off the road nearly onto its side, ending upright axle-deep in the thick mud requiring us to dig out each wheel to elevate the vehicle to where it could be yanked out by another Land Rover. After hours of work to free ourselves, clinic was obviously cancelled for the day as just getting back to the tarmac was a major undertaking. The road to Rift Valley Children’s Village, a site where we spend two days, can also be pretty challenging in the rains with the steep up and downhills that we have to navigate on the well-named “African Massage Road” that has very shear drop-offs one would prefer to avoid if at all possible – the trick is always to keep your wheels moving and not to touch your brakes as the minute you lose traction and begin to slide, you have no control of the vehicle. Needless to say, it’s as much of an art as it is a skill.

Last year’s adventure in the Southern Serengeti with Laura, Ashley, and Theandra, in which our vehicle became hopelessly stuck in the mud and water (perhaps it was more of a debacle than an adventure depending on one’s perspective) did have to do with the excessive rainfall that was localized to that region. The road became more and more submerged until we eventually found ourselves in the middle of what was essentially a swollen river with a foot of water on top of mud to the extent that there was absolutely no traction underneath. The rangers from the Conservation Area were looking for us, thanks to Dr. Annie, but with all the water, neither we or they were able to make visual contact despite our nearly hour-long walk with all our baggage through the mud and water in the dark with wild animals all around and swarming termites attracted to our lights to add insult to injury. After failing to find the rangers, or for them to find us, we headed back to the vehicle and were eventually rescued perhaps an hour later when they crossed the river to reach us, but it still required that a scary walk to their vehicle, and an even scarier drive to the Ndutu Safari Lodge where we were supposed to spend the night as it was far too late to return to FAME that night. We were driven to FAME by one of the rangers in his government truck the following morning while Vitalis, our guide, remained back in Ndutu to arrange pulling the Land Rover out of the muck and to safety. If one had tried, I don’t think it would have been possible to plan a better experience, though I’m not sure my fellow passengers felt that way at the time or today.

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All of this discussion of the weather and the roads, of course, greatly affects what our activities will be here both for the neuro team (as far as our outreach mobile clinics) as well as for our group as we have plans to spend two nights and three days in the Central Serengeti. There were recent videos of hundreds of safari vehicles being stuck along the only road into the park due to impassable spots that were too risky for them to drive through. One positive for us is that we’ll be driving a Land Rover, a much more dependable vehicle than the Land Cruiser when it comes to rough roads, water and not getting stuck. Regardless, it’s always a bit of a gamble going out into the bush as you never know what you’ll find or what will come your way. Needless to say, it’s always an expedition.

We had a good volume of patients today – twenty-five in all – with a number of children to keep Yoon Ji happy. It’s always a good mix of disorders for us, though a fair amount of MSK, or musculoskeletal, patients always seem to sneak their way which is not all to dissimilar to what we see back home and much the bane of our existence. To those non-neurologists reading this, musculoskeletal pain, such as back or neck pain, other joint pain, is not a neurological problem, though it often finds its way to us much to our dismay – here we have physical therapy handouts to give patients while back at Penn, we refer these patients to the “spine center” where patients are seen either by orthopedics, neurosurgery, or physical medicine and rehabilitation, after they are triaged by a nurse coordinator. No such luck here as those specialties don’t exist and it is up to us to educate the patient and/or family.

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One very unfortunate patient who we were asked to see at the end of the day, was a 47-year-old gentleman who was brought in after suffering sudden onset of left-sided weakness and depressed mental status a day after having had a severe headache and loss of consciousness. A CT scan was obtained shortly after his arrival and demonstrated a massive right hemispheric stroke involving all of the MCA territory as well as a portion of the ACA with early hydrocephalus and marked midline shift with early herniation. In a nutshell, it was unlikely that he would survive the stroke. On examination, he had already blown his ipsilateral pupil and had a dense left hemiplegia with no response to painful stimuli on that side and was overall obtunded and unable to follow any commands.

In the US, he would have been taken immediately for a hemicraniectomy, possibly, as long as it was felt that he was salvageable, and the family understood that it was merely a lifesaving procedure and would not in any way improve his functional outcome – that is, he had infarcted most of his right hemisphere and that side of his brain was irretrievable. In essence, a hemicraniectomy is a procedure in which half the cranium is removed, relieving the elevated intracranial pressure and the mass effect the swollen infarcted hemisphere is causing that is compressing the healthy intact hemisphere. In fact, by removing the side of the cranium over the infarcted hemisphere, the flood gates for increased edema in that side of the brain are now open and you are sacrificing that hemisphere for the healthy one. Again, it is only performed as a lifesaving procedure and in the correct circumstances where the outcome is well-understood by everyone.

After a discussion with family and informing them of the likely consequences of the patients massive stroke (i.e. complete dependence if he were even to survive), they agreed with a conservative course and palliative care. As to our suspicion for a cause of the patient’s stroke, given his headache and unresponsive episode the day prior, we were reasonably confident that he had suffered a carotid dissection and was having thromboembolic events with the last one occluding his right MCA and most of his ACA. Again, at home, one may have considered mechanical thrombectomy, though the likelihood of its benefit would have been significantly limited and it’s doubtful that it would have been offered.

Heartbreakingly, Elyssa Weisman, my long-time patient, passed away in her sleep last July. I had first met Elyssa and her parents, Robert and Judith Weisman, in November of 2014 as part of my work with Children’s Hospital of Philadelphia and their trisomy 21, or Down syndrome, program. I had been asked to help out from a neurological standpoint with the trisomy 21 patients as they very often have neurological conditions and it was felt that these patients would benefit from having a neurological evaluation as they graduated from the care at Children’s Hospital and entered adulthood, at least medically. There are certain conditions that should be screened regularly, such as hypothyroidism, and others that are common enough to keep an eye on, such as dementia with the same pathology as Alzheimer’s disease, atlanto-occipital subluxation, and cerebrovascular disease. They can also develop a rare, poorly understood disorder called Down Syndrome Regression Disorder (DSRD) that is often mistaken for the early onset of Alzheimer’s disease seen in trisomy 21 patients.

When I first met Elyssa, she was 37 years old and had a history of complete AV canal repair, mitral regurgitation, and paroxysmal atrial fibrillation that were all closely followed closely by cardiology, hypothyroidism, and obstructive sleep apnea, and I had been asked to see her for abnormal behavior and motor tics that were very Tourette-like. It wasn’t long before I had formed a very close relationship with Elyssa and her parents and slowly became their primary contact in the healthcare world. Early on, I had noted that Elyssa had significant difficulties with her ambulation that I felt were unrelated to her body habitus, and after a short evaluation, discovered that she had a high cervical panus formation (as a result of her atlanto-occipital subluxation) that was causing severe cervical spinal stenosis and compressing her high cervical spine. Essentially, she had a cervical myelopathy that was affecting her gait and making her very unsteady.

After lengthy discussions with Robert and Judith, and a consultation with Dr. Sean Grady, chair of neurosurgery at Penn, it was clear to all that it would have been very difficult for Elyssa to have tolerated the type of surgery and fusion required to fix her problem, and the decision was made to monitor her clinically. Over time, as her gait continued to worsen and she began to occasionally fall, she also started to show signs of the early dementia seen with trisomy 21, further complicating the issue. Judith and I repeatedly revisited the decision to forego surgery for her cervical spine, reassuring ourselves that we had made the correct decision. Through all of this, Elyssa continued to persevere, as did her parents, and life continued as it had, with Elyssa bringing joy to everyone she met and maintaining her happy, cheerful self.

Though it seems inevitable that all of these medical issues would eventually have caught up with her, it was still unexpected when Judith had texted me that Elyssa had passed away quietly in her sleep. Of course, it was clear to all that this was a blessing in disguise considering the hardships Elyssa had endured throughout her life, but she had never really complained, and now she was gone. I sat with Judith, Robert, and other members of the family for shiva and grieved the loss of such a special person. For any of us who have cared for trisomy 21 patients, as I have over the years, it is self-evident that these individuals, as well as their families, all have a special place reserved for them in heaven or whatever they believe the afterlife to be. Shortly before our departure for this trip, Jill and I had the opportunity to visit the Weisman home and Elyssa’s room to see if there were things of hers that might be worth bringing with us to Tanzania. As we sifted through her many things, deciding what was feasible to bring, I felt her presence as if she were there offering many of her favorite Disney jigsaw puzzles and books for other children to enjoy.

We received word last night of the Israeli air strike in Doha, Qatar, which was a little close to home for me considering that Patrick Liu, a fourth-year medical student and the final member of our team for the first rotation, was still on his way to FAME but was traveling through Doha. Thankfully, he had departed the airport there only hours before the air strike occurred and had arrived in Tanzania shortly after the actual time of the attack. Eighteen months ago, we were traveling home through Doha at the same time that Israel had launched a drone attack against Iran, obviously cancelling all east bound flights (flying through a drone attack is definitely not recommended), and putting west bound flights (such as our flight home to Philadelphia) in question.

American Airlines, which now flies the Philadelphia to Doha route, decided to outright cancel our flight rather than wait to see where things were the following morning, while Qatar Airlines cancelled none of their flights to the US. Being stranded in Doha was not something that we had planned on, so we were booked on the only available flight with Qatar which happened to be to Houston. The three of us (Jill, myself, and Christina Boada, one of my residents) flew to Houston, without our luggage I might add, had to overnight there as we arrived in the evening and there were no flights back to Philadelphia, and ended up home (again, without our luggage) the following day. It took a full week for American/Qatar to recover and return our luggage to Philadelphia, and other than a good story to tell, we had little else to show for our experience or the miles we had flown.

Patrick spent the night at the airport in the KIA Lodge, as did Jack the night before but with fewer hours to enjoy it, and we had transport arranged for first thing in the morning to bring him to FAME. He eventually arrived as we were beginning clinic, refreshed after his stay overnight in the lodge, though still a bit jet lagged with the time change of seven hours. Our team was now complete – Cat Kulick-Soper, our epilepsy specialist par excellence who had also been to FAME four years ago as a resident; Julian Gal – our epilepsy fellow from Penn; Residents Joe Geraghty and Jack Cook; along with the forementioned Patrick. This team would comprise our “first wave” of neurologists for the fall trip, though Cat and Julian will be departing after two weeks, Joe and Jack will be here for three weeks, and Patrick will be here for four weeks. Others will be arriving in the coming weeks, and I’ll introduce them at that time.

One of our first patients of the day was a fascinating 78-year-old gentleman who we had originally seen in the spring after presenting with a significant encephalopathy and seizures. His CT scan was very impressive and demonstrated numerous calcified and non-calcified lesions throughout both hemispheres with a significant number of the lesions enhancing including some that appeared to be ring enhancing. Neurocysticercosis is a condition in which the larvae of the pork tapeworm infect the brain and typically produce a small number of cystic lesions that eventually calcify as the organisms die and scar over. It is the number one cause of epilepsy worldwide and is highly prevalent in South America as well as other regions where pigs are raised. There is a significant amount of pig farming in the Iraqw areas surrounding Karatu, and neurocysticercosis is prevent here. This patient, though, had a more serious form of neurocysticercosis, called fulminant neurocysticercosis, or cysticercotic encephalitis, in which there is an overwhelming number of organisms causing extensive inflammation and often cerebral edema.

In patients with such an extensive infection, you cannot give them albendazole (a common antiparasitic agent used also for deworming children on an annual basis) as suddenly killing the organisms will result in a massive inflammatory response worsening the edema and very likely killing the patient. The natural history of the infection is for the larvae to die on their own and calcify, leaving a lesion that is certainly epileptogenic (i.e. could cause seizures), but does not result typically result in any neurologic deficits. The treatment of cysticercotic encephalitis, though, is to give steroids to suppress the inflammatory response and, thus, the edema, thereby reducing the risk of complications and allowing the organisms to quietly calcify on their own.

We treated this patient with high dose dexamethasone taper for nearly a month and hoped for the best, not really knowing how he would do and having very little else to offer. We also kept him on levetiracetam (for seizures) as having a convulsion with the amount of edema he had at baseline could be incredibly problematic for him. Seeing him walk into clinic today, albeit with a cane, was near miraculous in my mind as it was really a 50-50 proposition whether he would survive the infection given the burden of disease he had and in the setting in which he was seen. He had spent only a week in the hospital, dramatically short in comparison to what it would have been in the US with the same situation. He will remain on his levetiracetam and come back to see us in six months.

Another very interesting patient that was seen today was a 29-year-old woman with the story that she had undergone an appendectomy a year ago and a month later had developed right-sided weakness that progressed over three months when an MRI and MRA (which we were able to see as they had brought the disc) were done demonstrating very significant encephalomalacia (mostly cortical) in the left greater than right hemisphere that was maximal in the left temporal lobe with loss of the left middle cerebral artery and diffuse vascular irregularities on vascular imaging that was concerning for an inflammatory vasculopathy. It was very difficult to restrain ourselves from getting a CT scan to see exactly where things were at the present, but she had had only some improvement over the last 9 months, not worsening. She was also having episodes of unresponsiveness that were concerning for seizures and had been placed on carbamazepine recently, but at a low, subtherapeutic dose (which is very common here).

With the limited studies that we have here, it was very difficult to conceive of an adequate evaluation, though our main concern was that she had suffered a stroke, possibly in the setting of an underlying vasculitis, but that the latter did not appear to be active at the present time nor did we feel that a CTA would necessarily sort anything out for us. We only had basic infectious and inflammatory labs here – HIV, RPR, ESR, CBC – all of which were normal, so we placed her on stroke prophylaxis therapy and hoped for the best. Oh yes, we also switched her from carbamazepine to levetiracetam as we felt this would be a bit more effective in this situation.

On the more mundane side of things, though equally significant in terms of our comfort here, the refrigerator in the Raynes house went on the fritz. Not only did we not have proper storage for our leftovers and milk, but more importantly, I had no ice to make my gin and tonics when we came home from the clinic. We had decided to visit Teddy today, the seamstress who has been making clothing and other items from the colorful local fabrics for our groups for nearly the last ten years. I loaded everyone into Myrtle, our short Land Rover, since Turtle was still in Arusha undergoing repairs, and off we went to town to first buy fabrics before heading to Teddy’s house on the other side of town. Anytime we are heading to town for shopping, we bring Dr. Annie with us to avoid paying “mzungu” prices, or those that are charged to tourists. In addition, it’s always best to have Annie with us to help with the clothing decisions as Teddy’s English isn’t fluent nor is my Swahili.

On returning home, the sun was low on the horizon, and it would soon be dipping closer with every imaginable hue of orange appearing before us. Our next-door neighbors, Anil, his wife, Izabela, and their two children, had started a campfire, and we all sat around for dinner. The sky was clear, and the stars began to pop, with the milky way soon becoming the most prominent feature in the sky. The night was slightly cool, though incredibly comfortable and we all ate dinner together sitting around the campfire. Life is good!

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FAME’s success over the last 15 years has been predicated on a number of key elements, though there are two that I have always found to be the most important from my perspective. There are also those that are clearly mandatory when undertaking a project such as this – the trust that’s built with the community and the sense of family that I have spoken of previously which has been created by FAME and its employees who come to work each and every day to make this a better world. Of the two key elements that are not so obvious, though, first is our volunteer program and emphasis on education, and the second is the fact that FAME is run by an all-Tanzanian clinical staff and can operate completely independent of the volunteer program as we demonstrated so clearly during the pandemic when there were essentially no volunteers save for our neurology program for a span of two years.

The volunteer program has been an essential component of FAME’s character from its very inception and has continued to attract doctors, nurses, and others from the US and many European countries who come for both long and short-term visits to work with FAME’s clinical staff and provide addition training in their various areas of expertise. It is certainly a bidirectional transfer of information, though, as the volunteers also learn a great deal of information, such as how to practice in a low resource setting, by working with FAME’s dedicated doctors and nurses. At last count, FAME is averaging in excess of 60 volunteers a year in all specialties that continue to provide current practices, though with the continued sensitivity that is always necessary when you are a guest in someone else’s culture and a long, long way from home. That requires an open mind and a willingness to see things through other lenses than our own, as well as the realization that you are not the center of the universe (being humble).

When speaking with anyone about global health, the conversation will always lead to single concept that is often the most important thing to consider and cannot be overlooked – Sustainability. For without sustainability, all is for naught. The fact that FAME has an all-Tanzanian clinical staff was by no means an afterthought, nor has it ever been something that has been reconsidered as FAME developed through the years. If anything, the philosophy has been increasingly reinforced along the way, and its importance has been continuously demonstrated. When the pandemic hit in March 2020 (while I was here at FAME with my team, by the way) and it became readily apparent that the volunteer program would at least be temporarily shutting down as were the borders and flight patterns throughout the world, having a self-contained medical and nursing staff without the need for outside help became a necessity and a God-send.

Even more apparent, though, was the fact that the training and education that had been provided to our clinical staff over the preceding years had now proven to be key to the success of FAME in the coming years, allowing for the long-term sustainability of a rural based healthcare center (hospital) dedicated to providing patient-centered care for a population where access to healthcare had previously been very limited. Over the ensuing months, as it became increasingly clear that the pandemic was here to stay and would change our lives forever, FAME by was called upon by the government (don’t forget that we are an NGO) to provide the necessary training and education to the other healthcare facilities and workers in the region concerning proper practices, providing further proof that the careful planning and sustainability were essential to our success.

This morning’s lecture was provided by Dr. Anil, an emergency medicine physician now volunteering at FAME. Anil is from New Zealand and had learned about FAME as these things always go from a friend of a friend of a friend. Ultimately, it involved Dr. Pete and Dr. Amanda, who had just finished a two-year volunteer stint here at FAME earlier this year. Pete and Amanda were from Tasmania and were being funded by an Australian non-profit, NGO that provides support for volunteer physicians. Amanda, an emergency medicine physician, was here following the completion of our new emergency department, so spent her time developing protocols and teaching just about every aspect of emergency care to the clinicians and nurses at FAME. Pete, a pediatrician, spent his time working with our neonatal intensive care unit and inpatient pediatric population. It was sad to see them go, though they had been here for a full two years. Our lecture today had to do with traumatic head injury, a topic near and dear to our hearts.

Following the lecture, we received report on several interesting patients, though unfortunately, we had very little to offer them. One was a young 45-year-old woman who had presented with a severe headache and was found to have fairly massive intraventricular blood on her CT scan. She subsequently decompensated and passed away, though I am doubtful that anything would have changed the eventual outcome – had someone placed an extra ventricular drain (EVD), she may have survived a bit longer, but her quality of life would have been non-existent, and she would not have survived long, regardless.

The other patient presented at morning report was a bit more troubling as it was a child who had bilateral subdural hygromas and severe atrophy (collections of fluid, not blood) on CT scan. Problematically, though, the imaging also demonstrated severe global atrophy and as expected, the child had severe developmental delay and hadn’t met any of their normal milestones since birth. What had been described to me as chronic bilateral subdural hygromas (which, after reviewing their scan I would have agreed with) are essentially spaces between the brain and inner surface of the skull that become filled with cerebrospinal fluid as something must occupy the space in the absence of brain due to atrophy. The key is that it’s not acute and not under pressure in most circumstances. The child underwent bilateral burr holes, which had been recommended, but what normally happens in these situations, and happened here, is that the fluid just reaccumulates as there is nothing else to fill the space (the brain doesn’t bounce back since it’s a chronic compression).

Inpatient consults for the day included someone who had been advertised as a patient with a basal ganglia hemorrhage, though after looking at the image, both Joe and I were equally concerned that this could represent a lobar hemorrhage, something that would have a broader differential and a different workup. Clinically, the patient was hemiplegic, but this did not add anything to our differential, unfortunately. Jack also evaluated one of the patients (an 8-year-old child) in the ward with suspected TB meningitis who had been receiving his anti-TB meds for several weeks, but still looked very, very sick. It would be fair to say that this child’s prognosis was guarded at best.

Perhaps the most interesting patient in clinic today was a young 4-month-old child who had a very significant perinatal history, had seized shortly after birth and was noted to have a large head circumference concerning for congenital hydrocephalus. They had received a VP (ventriculoperitoneal) shunt for the hydrocephalus at 2-months of age, and it was unclear whether they had improved at all following the procedure. They had brought the child in for us to evaluate because the child was not improving after the shunt and continued to have seizures despite a very high dose of phenobarb. We did not have the previous imaging as it had been done elsewhere along with the shunt, and we were concerned as to whether the shunt was fully functional.

On examination, the child could do very little – they were moving their extremities, but they did not otherwise respond. Our recommendation, in addition to decreasing the phenobarb and adding levetiracetam, was to bring the child back to the other institution to make sure their shunt was functioning, but they told us they had done that already and were told it was. The family requested that we obtain another CT scan here at FAME, and we were all quite happy that we did, for it revealed the fact that the child was missing the vast majority of both of their hemispheres, which was the reason for their failure to reach their milestones and had little to do with hydrocephalus. Ultimately, we had a long discussion with the family regarding the child’s very poor prognosis, and that other than trying to help with the seizures, there was nothing that could be done to improve the child’s devastating neurologic functional status or their prognosis. Though we had little to offer the child, we could certainly explain this to the family and try to prevent them from going to another healthcare facility looking for answers.

We finished clinic early enough to head out on a hike through the fields behind FAME before sunset. The region here is gorgeous with rolling foothills bumping up to the edge of the Ngorongoro Conservation Area that rises more abruptly and eventually meets the crater rim. There are lots of animals in the conservation area, and they will on occasion come down from the slopes, so it is important to be alert. Cape buffalo are very aggressive, but would rarely chase a human here, though not the same for the occasional leopard that comes down from the hills. There have been sporadic leopard attacks in the area over the years, but walking in numbers would drastically reduce the likelihood of any unwanted encounters. Our walk was lovely as is always the case here. The weather over the last few days has been beautiful – cloudy and cool in the mornings, strong equatorial sunshine by midmorning, and a high in the afternoon in the upper 70’s with low humidity. You really can’t beat it.