Weekend patients

Snapshots from my weekend call on pediatrics...

Patient A:
This little 5 year old boy first went to a national hospital in February with abdominal pain and swelling. They did an abdominal ultrasound which did not show a mass but did show left kidney "inflammatory process". They also did an echocardiogram which showed a cystic lesion in the right atrium of the heart, possible hydatid disease.

The cystic lesion is on the left in the above echo. Hydatid disease is caused by a dog tapeworm and results in multiple cysts, usually in the liver or maybe the lung. Evidently they can rarely occur in other random places like the heart. Treatment involves a special variety of aspiration as well as albendazole. Obviously it would be pretty difficult to aspirate a cyst in the heart, so A was discharged in March with 1 month of albendazole.

Unfortunately, A completed his medication but continued to have abdominal pain and swelling and then developed poor appetite and weight loss.

He presented to Tenwek with his father (left) and a translator (he and his father only speak Masai). We repeated the echo and did find the above mass in the right atrium. But it seemed more solid than cystic and it didn't explain his abdominal distension. An abdominal ultrasound revealed a large 15x13cm mass involving the left kidney. Based on our surgeon's recommendations, we then sent the child 4 hours away for a CT scan. He returned today with the results: Nephroblastoma (Wilm's tumor) involving the left kidney and extending up the IVC to the right atrium. Unfortunately too extensive for resection without cardiac bypass, so he was sent home. We may try chemotherapy to hopefully shrink the tumor from the heart and then surgery, but we're still researching the possibilities. If only it had been "simple" hydatid disease.

Patient B:

A four day old baby brought in with "spasms". Mother received no antenatal care (ie no tetanus immunization) and the child was delivered at home. The umbilical cord was cut with a non-sterile kitchen knife. Diagnosis: neonatal tetanus. This child will likely remain in the nursery for a month or more. He is being fed by an NG tube & nursed in a dark isolette in the back of the nursery as any touch or stimulation causes spasms.

Patient C:

One of three patients admitted this weekend with congestive heart failure from rheumatic heart disease. Likely the illness began several years ago with a strep throat that was untreated. The result is valvular heart disease that progresses over time. We have a pediatric cardiothoracic team that comes for a week once a year to perform valve replacements for a few of these patients. The rest we manage with medications to help keep the symptoms under control and hopefully improve the quality of life for these children.

Patient D:

5 year old boy with Burkitt lymphoma, a cancer that for some reason is much more common in Africa than in other places. It is also extremely fast growing. This child received his first chemotherapy here last week and is remaining as an inpatient in hopes of improving his nutritional status. He will have more chemo this week and hopefully we will begin to see the tumor shrinking.

Patients E, F, G, H:

A baby with a scalp wound

One of the interns evaluating another rheumatic heart disease patient in Casualty (ER)

The "greeter" on peds - this boy's been here a while and loves to greet everyone who walks by

An orphan who unfortunately was severely neglected and malnourished but is now doing much better and will hopefully go home with a caring relative soon

Patient I: No picture for this one due to the critical nature of her condition. An 8 year old girl has been sick for some time at home and received herbal treatments. She has had multiple seizures over the last 2 days and is now unresponsive, so the family brought her to the hospital. She is lying in bed sweating in an opisthotonic position (neck hyperextended and back arched) with frequent seizures that don't stop until after the third dose of seizure meds. An HIV test comes back positive. A lumbar puncture (spinal tap) reveals 1536 WBCs in her CSF!!! She also has signs and symptoms strongly suggestive for tuberculous meningitis in addition to the obvious bacterial meningitis. She amazingly makes it through the night but her prognosis is still not good.

Patient J: A 10 month old baby is transferred from a nearby district hospital with a diagnosis of intussusception (where the intestines telescope on each other and cause an obstruction). On further evaluation, it turns out the baby has had bloody stools and bloody vomiting for one day. Prior to this, he had a febrile illness and was treated with herbal medications. Our exam and studies reveal a tender, enlarged liver and florid liver failure with an INR of 7 (normal is 1 meaning the child is not able to clot his blood) and a hemoglobin of 3 (meaning significant blood loss). Our suspicion, though we're unable to prove it, is that the traditional herbal medications caused the liver failure. The baby is receiving blood and Vitamin K and hopefully will stop bleeding soon.

Patient K:

14 year old with bacterial meningitis, now well and going home

Almost all of these children are in these conditions due to poverty or due to the fact that they live here. A few of them might have had similar illnesses in other places but wouldn't have taken so long to see a healthcare provider, so the disease wouldn't be so advanced. Lack of education plays a role as does corruption in the traditional healers being quite willing to take people's last shilling without the hope of offering a cure. Many of our patients have been crossing the border to Tanzania lately to see this "miracle healer" on the border who is making money hand over fist (as are the taxi drivers who bring people to see him) and encouraging people to stop taking their HIV meds or diabetes meds or seizure meds. We've had patients die as a result.

It doesn't seem fair. And yet I know I'm not the only one who cares about the injustice of it all. Many are working to fight corruption and injustice and to address poverty around the world. And you can see the hope and joy on these children's and parents' faces just from the limited care we are able to provide. Most of all, God Himself is just and He will bring justice on the earth.

The Lord "executes justice for the oppressed and gives food to the hungry. The Lord sets prisoners free, the Lord gives sight to the blind, he lifts up those who are bowed down, the Lord loves those who live justly. The Lord watches over the immigrant and sustains the fatherless and the widow, but he frustrates the ways of the wicked. The Lord reigns forever." Psalm 146:7-10