Elizabeth

6 months ago we first met 25 year old Elizabeth.  She was being treated for recurrent Tuberculosis.  Unfortunately she developed Hepatitis from INH, one of the five medications in her treatment regimen.  We withheld her medication for a week and then restarted the medication at a low dose and then gradually increased the dose.  At home we would have come up with a replacement drug for the INH but here there are no alternative drugs.  Elizabeth was doing well and sputum tests in January showed no sign of TB.  Last week Elizabeth returned to OPD very sick.  She was jaundiced and her liver was extremely enlarged.  She also was retaining fluid and was in heart failure.  She likely had damage to her heart valves from Rheumatic Fever when she was younger.  Her problems were triggered by the INH medication again.

Elizabeth had a difficult weekend being extremely short of breath.  We prayed all weekend that there would be no power outages as she desperately needed supplemental Oxygen from an oxygen concentrator that requires electricity to run.  We fortunately had fewer outages than normal and we were all encouraged Monday morning when she looked slightly better.  I figured everyday she could manage gave here liver a chance to recover from the INH insult.  Yesterday morning Elizabeth lost her fight and left a grieving family trying to understand why someone so young was no longer with them.  Elizabeth, like so many people here, endured a terrible illness with great dignity.  She and her family remain in our prayers today.

Christmas Gift

While at the OPD this afternoon, there was a faint knock on the exam room door.  We opened it to find an old familiar face smiling at us.  It was Emmanuella who literally was our first patient when we arrived in 2010.  35 year old Emmanuella was in the hospital with HIV and Tuberculosis.  Her hospital course was complicated first by a blood clot in her leg and then a pulmonary embolus.  She nearly died only to recover and then sustain a worse insult.  She had a terrible stroke leaving her with complete paralysis of the right arm and leg and unable to speak.  Despite all these terrible things Emmanuella never lost her beautiful smile.  2 years ago at Christmas, we able to secure a wheelchair for her and she was able to go home for Christmas.

She eventually recovered enough to walk with the aid of a cane and can speak a few words.

Spending a few minutes with Emmanuella today was a wonderful Christmas gift for us.  Emmanuella’s determination and positive outlook is inspirational!

Merry Christmas!

Tuberculosis

TB with large Cavity on X-ray

 The new TB Ward in progress

At any time we usually have one or two patients in the four bed TB Ward.  Today we have seven patients who have contagious TB which is taxing our ability to quarantine these patients from the other patients in the hospital.  With only having the one ward it requires having men and women sharing the same room which is not very ideal.
 
Fortunately we are in the process of building a new TB Ward behind the Medical Ward.  This has been possible with some very generous contributions from MDA supporters.  The new TB Ward will have separate rooms for men and women and will provide more aeration making it safer for staff and families who are caring for the patients.  The facility will also provide us a place to isolate extremely contagious patients such as those with Cholera.

Victorine Update

I have written about Victorine previously.  One year ago she was knocking loudly on Death’s Door with  HIV, recurrent Tuberculosis and a hemoglobin of 2.5.  She amazingly recovered although her weight dropped to 66 pounds.  

She comes in monthly for her HIV medications and I am in awe every time I see here.  She has now gained 75 pounds since her discharge last year.  I think Victorine enjoys the smile her presence puts on my face.

TB, Ever Present

Timothy is a 16 year old boy who presented to the clinic 1 week ago with a history of cough of 3 months duration.  His Chest X-ray and sputum check showed Tuberculosis.  Timothy and his parents initially balked at the recommendation that he be hospitalized.  He is preparing for his A level exams.  It would be like sending someone at home taking his SAT exam while being extremely contagious with Tuberculosis. 

After one week of treatment his cough has dramatically reduced and Timothy has promised to have good cough hygiene next week while taking his exams.  Timothy is fortunately HIV negative.

Dilemma

Emmanuel no longer with rigors and fever

Emmanuel is a 24 year old who was admitted 12 days ago with 2 months of cough and fever.  It was not surprising that he was HIV positive and his chest x-ray was strongly suggestive of Tuberculosis.  Last week we had no HIV or TB medications so it was frustrating watching Emmanuel endure his non-stop cough and recurrent fever.  Out of desperation I placed him on Cipro and Clarithromycin which both have some effect on TB but are not a treatment substitute.  I was able to start him on HIV medications Monday and today TB medications became available.  Hence the dilemma. 

The last 4 days Emmanuel has made a remarkable improvement on my substitute regimen.  With limited resources you frequently have to make best guess decisions.  I think Emmanuel has TB so I initiated his 6 month treatment program today.

Emmanuel's fever chart with sudden clearing of his fever

Abdou and Evette

Abdou after a blood transfusion

Abdou after a blood transfusion

Many of our patients consult with the Native Doctors before ever coming to see us.  One has to accept this as a cultural thing and not get upset about it.

Evette

 2 nights ago I was called to see a child bleeding after a tonsillectomy.  As I walked up to the hospital I wondered why the nurse had called me rather than the surgeon.  When I arrived at the hospital it became clear.  The tonsillectomy was a uvulectomy (remove the hangy down thing in the back of your throat) and it was performed at home by one of the Traditionalists.  It appears many of the Moslem children are subjected to this procedure done at home without anesthesia.  After a blood transfusion this child is doing well.  I hope this practice dies out soon.
 
Yesterday, I had the pleasure of seeing Evette.  She left the hospital 4 months after a stormy course of abdominal TB and HIV.  Today she is doing well and has only 1 more month of TB treatment.  She has gained 42 pounds since discharge, proving Slim's disease can be controlled.

Florence

Florence Happy with Recovery

Florence was admitted last week.  She is 32 and came in with Headache, hearing loss and loss of movement in her foot.  She unfortunately was HIV positive and her Spinal Tap indicated TB.  After 3 days of TB medications and steroids her headache resolved, her hearing returned to normal and her foot movement has recovered by 75 %.

She will get her CD4 count this week which will dictate when we start her ARV's.  She has 2 bad illnesses but is making an unbelievable recovery.

Tuberculosis, again.

When I finished yesterday's blog on TB I really was not sure why I had chosen that topic.  I suppose it was because I had seen a couple of new TB cases yesterday.  

One of those was a 24 year old lady referred from an outlying health clinic.  She looked healthy but was recently diagnosed with HIV and had been coughing for 2 months.  I obtained a chest x-ray which was suspicious for TB.  We obtain 3 sputum samples over 24 hours looking for the TB bacteria.  She submitted her first sample yesterday and was to bring in 2 more this morning.  

While doing rounds this morning the nurse informed me she apparently started coughing up blood during the night and was brought back to the hospital this morning dead.  TB and HIV are deadly and we are reminded of that on a regular basis.

Tuberculosis

Tuberculosis.  A term we are all familiar with in the US but more from a historical viewpoint.  

It is alive and thriving well here.  One of the interesting statistics I read was that patients with HIV have a 15% chance per year of developing active TB.  We see it here everyday.  While most of it is Pulmonary TB it also presents in the neck, pericardium, abdomen, brain, spine, and kidney.  

Terry pointed out to me at Church on Sunday how many people were coughing.  I could not help but wonder how many of those coughs were spreading TB about.  

The government pays for TB treatment which is a good thing to enhance treatment compliance.  This x-ray shows a great cavity in the lung caused by TB.  

One of the millennium goals is to reduce the incidence of TB as it is still responsible for many deaths in developing countries and the economic toll is costly.