Dear Friends,
As has been the case on every previous visit to Tenwek
hospital, there are a few particularly heartbreaking and painful cases that
capture our hearts and bring out a desire to do our very best on behalf of
these unfortunate individuals. This is
not to say that ALL patients do not receive our very best efforts…they do…but
some elicit more time, more thought, more frequent visits, and more fervent
prayer… and SEEM more tragic when things go poorly. Often this is due to the fact that these
individuals have been young, healthy, and unprepared for medical tragedy before
becoming ill. Two such patients stand
out among those being cared on the medical service recently. Their stories follow.
J.O. is a 21-year-old young Kenyan woman who developed
rheumatic valvular disease (of her heart) as a consequence of repeated bouts of
streptococcal infections and associated rheumatic fever over the course of her
childhood. This is a very common problem
seen here in East Africa, and results in some very severe end-stage heart
problems occurring at very young ages.
It is a very easily preventable disease when these strep infections are
treated early with antibiotics, and when antibiotics are administered
appropriately to prevent recurrent infections.
It is noteworthy that these problems are rarely seen in the U.S. and
other developed countries but remain a problem in areas of the world where
access to medical care remains limited.
J.O.’s heart lesions have been moderately severe thus far, and she has
been able to bear children and function relatively normally. A few weeks ago, she noted a blister-like
lesion on her right foot, as well as some itching. She scratched the area and thought nothing
more about it. Over the next few days,
the foot became more painful and began to swell. She waited a few more days and noted the
swelling and pain to be spreading up the inner aspect of her foot, calf, and
inner thigh. She began to have fevers
and weakness, followed by skin breakdown and ulceration in the areas of
swelling and tenderness. She did not
recall any bites or stings, any contact with sick or diseased animals or
livestock. She ultimately came into the
hospital when she became too weak to walk.
She was evaluated in our emergency department and was diagnosed as
having septic shock related to an overwhelming soft tissue infection in her
right lower extremity. It was not clear
if she had septic thrombophlebitis (a bacterial infection in the superficial
veins of the leg), or possibly a case of cutaneous anthrax (usually seen in
individuals with some exposure to diseased/or dying livestock- particularly
cattle.) She was started on antibiotics
aimed at covering these possibilities.
She also required administration of large quantities of IV fluids, as
well as medications to support her blood pressure. She was critically ill and was admitted to
the ICU for close observation and care.
The surgical team was consulted, and she underwent extensive debridement
(removal of dead, and/or infected, non-viable tissue) extending from her foot
to her right groin. After surgery, she
has been gradually stabilizing and improving, but remains very tenuous from the
standpoint of her blood pressure and heart rate control. This is complicated by the presence of her
rheumatic valvular disease. Because she
has a narrowed mitral valve, she cannot tolerate very high heart rates – if the
heart rate is very high, she does not have enough time for blood to cross the
narrowed valve and fill the left ventricular chamber – this results in a drop
in her cardiac output, and a drop in her blood pressure. The medications used to slow her heart rate,
can also drop her blood pressure; additionally the infectious process has caused
a drop in her blood pressure – therefore her post-operative course has been a
delicate balancing act between giving her adequate IV fluids to maintain her
vascular volume without overloading her, keeping her heart rate under control
to allow her heart to maximally function without dropping her blood pressure
too low, and gradually weaning her off
medications which have been supporting her blood pressure. While giving her broad-spectrum antibiotics
to cover all possible causes of infection, she has now developed an
antibiotic-induced colitis – another serious, and sometimes life- threatening
infection. Consequently, she is having
fluid losses from diarrhea, as well as fluid losses from the large open wound
of her right leg. She has been making
gradual progress on all fronts over the past 2 weeks but remains very ill. Many of the decisions that we are making for
her will also have to take into account the considerable costs that are
accruing to her young family. Most of
these families have few resources, and government health insurance (if they
have it) covers only very basic costs.
If she survives her infection, she is going to have a very long period
of wound healing and recovery, only to have to face the need for valvular heart
surgery at some point in the not-too-distant future. Our medical team continues to watch over her
carefully, and to pray for her daily.
Perhaps you could be praying for her as well – pray that we will make
wise decisions on her behalf; pray that she will heal well and quickly; pray
that she will be provided with adequate resources to deal with her mounting
expenses; pray that she knows (or comes to know) and has placed her faith in
the God that we serve.
V.O. Is a 30-year-old previously healthy Kenyan male who
started complaining of headaches about 3-4 weeks ago. He was evaluated in an outlying facility and
had a CT scan of the head which was within normal limits. He was treated with analgesics but continued
to complain of headaches. He subsequently
began having seizures 2 days ago and was brought into Tenwek Hospital for
evaluation. He was obtunded at the time
of presentation and was loaded with anticonvulsant medications and a repeat CT
scan of the head was done. An area of
hemorrhage was noted, and the scan was sent (electronically) to the U.S. for
interpretation by a consulting radiologist.
He was admitted to the hospital and observed. The CT scan was read as showing a thrombosis
of the venous sinus of the brain, with some associated hemorrhage into the
adjacent brain tissue. Additionally, he
was found to have a low platelet count, and the possibility of thrombotic
thrombocytopenic purpura (TTP) was entertained.
(Basically, this is a rare condition, affecting about 3 patients/million
population, having a >90% mortality if not appropriately treated. “Appropriate treatment” involves a plasma
exchange transfusion, which is not available at Tenwek Hospital, or most other
hospitals in Kenya). If this diagnosis was
to be confirmed, this would essentially be a death sentence for this young man
with no prior health problems. We
reviewed his peripheral blood smear and determined that he did not really have
a low platelet count (rather had “clumping” of his platelets) and had no other
evidence for TTP. This meant that he likely
had a diagnosis of spontaneous venous sinus thrombosis – another rare
condition, but with a lower mortality rate, and treatable with blood thinners
(which are readily available at Tenwek).
The problem in this situation is that if the diagnosis is wrong, and you
administer blood thinners to someone who has had a bleed in the brain for other
reasons, you can worsen the bleeding, and even cause death. This is only the third case of venous sinus
thrombosis that I have seen in my career, but both of the other cases have done
surprisingly well with anticoagulation.
With some trepidation, the orders were written to anticoagulate him last
evening. On rounds this morning he has begun to open his eyes, mumble a few
words, and follow some commands. He has
had no further seizure activity and is moving all his extremities. He has no prior hx of spontaneous clotting,
and no history to suggest a cause for his current venous sinus thrombosis. He is probably going to turn out to be one of
the many Kenyans that we have seen over the years that have spontaneous blood
clotting, and a hypercoagulable state of unknown cause. It is too early yet to tell if he is going to
have a full recovery and return to normal functioning, but early signs are
encouraging. Please add him to your
prayers as well.
As in previous years, it always seems that we have just the
right people in place to deal with the unusual problems as they occur. This year, we had a visiting rheumatologist (who
is also an ordained pastor!) from North Carolina who is nearing retirement age
and has been feeling the call to missions.
This has been his first international mission experience. He has been a wealth of experience and
knowledge and has been invaluable in managing the two patients above. In addition, there have been several other
unusual rheumatologic patients that have come through the pediatric service and
the outpatient clinics this week (including Marilyn’s gyn clinic) …he has been extremely
helpful in these cases as well. It has
been humbling and awe-inspiring to see how God continues to orchestrate these
encounters over the years. Marilyn and I
continue to be grateful to be able to serve in Jesus’ name through Samaritan’s
Purse and Tenwek Hospital. What a good
and mighty God we serve! All praise and
glory be to Him!!
Love to all,
Randy and Marilyn
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| V.O.'s CT scan showing area of hemorrhage and evidence of venous sinus thrombosis. |
