Dear family and friends,
It is with mixed emotions that Marilyn and I approach the
end of our time at Tenwek. As always, we
have experienced some profound tragedies and some joyous successes (too many of
the former it seems). One patient in
particular has been very moving to me personally, and serves as a reminder that
God has been orchestrating our time here, and preparing our hearts and minds for
this years’ challenges. This story
begins even prior to our departure from San Antonio. Earlier this year, I helped care for a young
woman who came to see me in clinic in S.A. after her wellness screening came
back with some unexpected abnormalities.
She was relatively asymptomatic, but was diagnosed with a condition that
is almost uniformly fatal if not recognized and treated promptly. She was referred to a hematologist, who
confirmed her diagnosis and promptly hospitalized her and performed what is
called a plasma exchange transfusion (the process of totally replacing a
patient’s plasma volume with donor plasma, in order to remove some harmful
antibodies which cause the illness). She
received a total of 59 units of plasma, and was started on high dose steroids
and her condition stabilized. She has
continued to do well since that time.
Her condition is called TTP and is quite rare. The incidence is 3 /per 1 million population/
per year. She was only the second
confirmed patient that I have seen in 32 years of practice. As a result, I thought it would be
interesting to present her case to the students here in Kenya, and do a teaching
session about this illness, other similar illnesses, and how to tell them apart. For a few months prior to departure, I spent
some time researching TTP and similar conditions, and preparing a PowerPoint
presentation for the interns’ teaching conference. After arrival at Tenwek, I was asked to
present my talk on TTP at the Tuesday conference on 9/19/17. A short time before this (9/8/17), a patient L.B.,
was admitted to the male medical ward with an acute febrile illness of unknown
cause. L.B. is 34 years old, and had
been diagnosed with HIV at the time of his admission. The list of possible
causes for his febrile illness was quite extensive. The medical team caring for him had
extensively investigated his illness with a series of spinal taps (on 3
separate occasions, all negative), x-ray evaluations of his chest and head, and
laboratory evaluations of his urine and blood, and had not been able to arrive
at a diagnosis. He had investigations
for meningitis, TB, cryptococcal (fungal) infection, malaria, and bacterial
infections, and had been treated with broad spectrum antibiotics, anti-TB meds,
antifungal meds, anti-malarial drugs, and despite all this, continued to
deteriorate with fevers, decreasing mental status, and inability to eat or to
communicate verbally. The family members
had begun to express a sense of hopelessness and had begun to prepare
themselves mentally for his death. After
my presentation on TTP on 9/19, I was assigned to round with the intern who had
been caring for him. She asked me if I
thought he might possibly have TTP and began to build a case for this diagnosis. Much to my astonishment, the patient had all
5 of the “classic pentad” of findings associated with TTP! A patient with TTP will only exhibit all five
signs 20% of the time; it is much more common to find 2, 3, or 4 of the classic
signs, but not all 5 together. Despite
this, I was not convinced that this could possibly be TTP, since it is so rare,
and I had just seen a case in the U.S a few months prior….what are the odds?! Being
skeptical by nature, I asked for some additional tests to try to disprove the
diagnosis (or to identify some other similar, but more common conditions). Meanwhile L.B. continued to deteriorate, and
as more evidence accumulated that his condition might in fact be TTP, we were
faced with the dilemma of what to do about it once it was suspected? In a country like Kenya, with low resources
for medical care, it is not possible to perform a plasma exchange transfusion
(which is recommended treatment), even with a solidly confirmed diagnosis
(which is not possible here, since confirmatory testing is not available). In view of his progressive decline, despite
all that had been tried for him, we decided to transfuse him with several units
of whole blood (which would provide some plasma), and to start him on high dose
steroids as a “last ditch” effort to save his life. Unlike the U.S., Tenwek Hospital does not
have a blood bank with donated, processed blood ready for use at any time. Here, a transfusion means that a family
member or relative must come in and donate blood for the patient’s use. This was done, but obviously took some time
to accomplish. In the meantime, the
steroids were started, and we continued to monitor him for signs of
improvement. After 2-3 days, the blood
became available and was administered.
As we have monitored him this last week of our stay here, he has begun
to show signs of improvement. His fevers
have ceased and the destruction of his red blood cells and platelets has begun
to slow. His mental status is improving,
and he is now awake, talking, following commands, and feeding himself. He is far from well and has many remaining
obstacles to overcome, not the least of which is his HIV disease. In spite of this, we are beginning to be
hopeful! We know that our God is the
great physician, and that “We treat, Jesus Heals” (The Tenwek motto,
prominently displayed throughout the hospital).
Looking back on this situation, it is clear to me and to my interns,
that this was a “God orchestrated” event.
I don’t know what will happen with L.B….whether he will survive, or
ultimately succumb to his disease…but I am confident that God continues to use
this situation for His purposes and through it, has demonstrated His presence,
His provision, His mercy, and His love….for L.B., myself, and for the interns
caring for L.B. What an amazing God we
worship! Please join us in continuing to
pray for L.B.’s recovery. Pray also that
his family would be comforted and supported, and that those who witnessed this
event might have their faith strengthened (and yours as well!). Thanks to all who have been praying for our
time here and who have made it possible for us to come. Looking forward to being together again soon.
With love,
Randy.
