complete survival.

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