Fieldset
Complete survival

"I am hoping that some of you might have some tropical medicine experience, or know someone who does."

well, it appears my conversation had some effect.  so far, so good.

I have another child, however, with whom tough talk is not working so

well.  I am hoping that some of you might have some tropical

medicine experience, or know someone who does.

I admitted a 3 year old child to our feeding centre ten days ago.

he has been admitted twice, before my time, for severe

malnutrition.  the previous charts are not available, so it is

unclear if there was a precipitating illness to the previous admissions.

this most recent one was precipitated one month ago by a rash whose

intitial characteristics are  uncertain.  this was followed

by decreased appetite, cough, and intermittent fever.  I am

cautious with interpreting the histories I receive, the same patient’s

can change from day to day.  on further questioning, the mother

reports the child has been ill since shortly after birth when he

developed diarrhea and vomiting.  according to her, he has never

been well enough to walk.  I have been told, however, that during

his previous admissions, he gained some weight with appropriate feeding.

this time it’s different. he is not gaining weight, and is deteriorating.

on presentation, he had a low grade temperature of 37.8 C, and a pulse

rate of 120.   he was severely wasted and had a

non-productive cough.  he had a rash of healed ulcers, primarily

on his face and active ulcers in his ear and on his lip.  he also appeared

to have a serous otitis media.  he had non-supperative cervical

lymphadenopathy, and no other nodes.   his lungs were

clear.  further exam showed splenomegaly with mild

hepatomegaly and no ascites.

as per protocol, he received broad spectrum antibiotics, in this case

intravenous ceftriaxone because he was refusing oral medicines (and we

are out of gentamicin).  this was changed to amoxicillin as he

began to eat nutritional supplement and drink well.  he also

received anti-parasite treatment.  three days after admission, he

developed a high fever, 38.7, and developed more ulcers on his penis

and around his anus.  at this point I was considering disseminated

tuberculosis, immuncompromise from HIV (PCP, fungal skin lesions), and

less likely, but possible, congenital syphilis (though he would have

likely been symptomatic sooner).  I treated him with benzathine

penicillin for syphilis and yaws, and started cotrimoxazole.  we

have no x-ray, and our labarotory technician was away.

once our lab tech returned, the complete work up that is available to

me was normal.  hemoglobin normal, negative malaria

smear/paracheck, urine normal, stool negative, HIV negative, syphilis

negative.  in the past two days, though his mother says his cough

is better, he has developed several mouth ulcers on his lips and buccal

mucosa.  also, the skin around his axillae and antecubital fossa

given his chronic cough, cervical lymphadenopathy, and frequent

readmission to the TFC, I considered the possibility of another chronic

disease, tuberculosis.  the mother denies tubercular contacts, but

in five months, I have only had one patient admit to knowing someone

with a chronic cough.  as he was not improving after seven days of

antibiotics, and had not gained an ounce despite eating, I started him

on tuberculosis treatment.   he has not improved after five

days, and when I left, his temperature was 38.6 and he was listless.

I have seen a response to tuberculosis drugs take longer than this, and

the problem may be poor administration or absorption.  to this

point, I am convinced that the drugs have been effective for most of

our patients,  so I am not questioning efficacy.  it could

also be a version of immune reconstitution syndrome.

I am wondering if I should be more strongly considering

kala-azar.  I have no history of a primary lesion and the ones he

has seem atypical.  there is also a possibility that this is

something non-infectious, and autoimmune (Behcet’s?), though I am

surprised by the high fever.   nutrient deficiency plus

chronic malaria?

so.  stumped.  no more tests.  no google images.

nelson’s textbook of pediatrics, harrison’s principles of internal

medicine, manson’s tropical diseases, and me.  and, somehow, you.

for non-medical types, particularly the squeamish among you, now is a

good time to bounce to facebook.  for the rest of you, please

post, or send your comments to:

james.maskalyk.md@gmail.com