Monday, 16 September 2013
At any rate, last weekend almost broke me, mentally speaking. I was so tired that I slept from 9pm last night till noon today - 15 hours of bliss. Let me give you a taste of what confronted me over the past week:
In bed 1, we've an 11-day-old female who presented with 48 hours of seizures. She had a home birth and the mother had not received any antenatal care prior to delivery. Diagnostic dilemma: febrile convulsion vs cerebral malaria vs meningitis vs neonatal tetanus. Malaria smear was negative but we had otherwise no way of proving any of the other possibilities so we ended up covering with ampicillin, gentamicin, aciclovir and metronidazole as well as phenobarbital and diazepam (no neuromuscular blockers, paraldehyde or chlorpromazine). At any rate, over the course of her admission, neonatal tetanus became more and more likely as her seizures were tetany-like and were provoked by touch. Pray for us as we'll be deciding in the next few days if treatment should be withdrawn depending on what we think her neurological outcomes could be (which is going to be a challenge since no one can besides God can foretell that with certainty).
In bed 2, we've a two-year-old boy with gross generalised oedema (swelling) and 16 hours of anuria (no urine output). The anuria was later found to be secondary to urinary retention as he had one of the worst cases of penile and scrotal oedema that we've seen and he required a suprapubic tap to relieve the post-renal obstruction. We've finally got the ability to test electrolytes (hallelujah!) but the machine was playing up; our first specimen gave a potassium of 14.2mmol/L (!!!) and the second was so high it could not be recorded. The troubling thing about this was that both samples were arterial in source since none of us could get venous access due to the oedema. However, it's doubtful he would have lasted this long with such severe hyperkalaemia.
In bed 3, we've a one-year-old boy with the same presentation but less severe.
In bed 5, we've a fourteen-year-old boy with worsening dyspnoea and chest pain as well as abdominal pain and distension. Found to be febrile and on examination to have massive hepatosplenomegaly as well as cervical and inguinal lymphadenopathy and CBC showed severe anaemia (Hb 4.9) and thrombocytopenia (Plt 21). Treated for presumptive malaria and transfused one unit but the Hb post transfusion actually dropped to 4.8g/dL and there was bilirubin and urobilinogen +++ in his urinalysis, indicating an ongoing haemolytic process. CXR did not show any obvious cardiomegaly, effusions or consolidation, his WCC was normal, LFTs were only mildly off and both ESR and triglycerides were elevated. At this point, our differentials were leukemia/lymphoma, autoimmune haemolytic anaemia, autoimmune lymphoproliferative syndrome +/- Evans syndrome, haemophagocytic lymphohistiocytosis and macrophage activation syndrome. We started prednisolone on Saturday night but unfortunately, he developed worsening respiratory distress overnight and passed away this morning.
We had a total of five premature infants last week, four born at 31 weeks! Sadly, two died.
- The first died on the night of admission: I wasn't on call that night but the little two-day-old boy (~35 weeks' gestation born at home a/w possible meconium-stained liquor) had been tachypnoeic since birth and apparently had frank haemoptysis/haematemesis before passing on. We still can't figure it out but one hypothesis is the nasal cannulae causing epistaxis which bubs normally swallow and then cough out and another possibility is meconium aspiration syndrome but his respiratory distress seemed more severe than expected if that was the case.
- The second died on Sunday morning; the one-week-old boy had been noted on Friday and Saturday nights to have reflux associated with apnoeas and bradycardia. This was a particularly vexing case for me since the sequence of events was that at 5am, the mother notified the night nurse on duty that he seemed to be in a bit of strife; by the time the nurse arrived, there wasn't any cardiac output but I was only called about it 18 minutes later! By which time, it was way too late. Argh...so frustrating, especially since his twin later developed the same problem that afternoon but we got there within a couple of minutes and basically brought him back, thank God. The poor mum, a 15-year-old primip, was crying into my lap for an hour and a half.
In bed 1, we have a HIV-positive mother who is two weeks post elective C-section (four previous scars) with acute right hemiparesis and facial droop as well as mild dysarthria and confusion. She had only one documented fever, was normotensive without any signs of pre-eclampsia, and had a normal ECG but was surprisingly neutropenic (0.8). Was it a stroke? Cerebral toxoplasmosis/TB? Some autoimmune disease? CNS lymphoma? She was asymptomatic and well besides these neurological deficits so it's a bit of a mystery. We covered with cotrimoxazole and sent her back to the local antiretroviral treatment centre to hopefully be recommenced on HAART.
In bed 2, we had a 20-year-old primip who delivered twin girls; one a stillbirth (foetal death in utero at time of presentation) and the other one of the prettiest babies I've ever set eyes upon. Both mum and baby had malaria and received adequate treatment but the mother was persistently anaemic (with Hb levels < 5.0g/dL!) despite four units, which is a lot in our context (most patients get only one unit even with Hb levels as low as 1.9g/dL). She was later found to also be Hep C positive and had massive splenomegaly; no retained tissue on ultrasound examination. DDx: FDIU-related coagulopathy, hyperreactive malarial splenomegaly (aka tropical splenomegaly syndrome), Hep C-related cirrhosis and some form of autoimmune haemolytic anaemia. None of it was ever proved or disproved but my money's on the first two.
On Friday evening, a two-year-old boy arrived in status epilepticus, later found to be secondary to cerebral malaria. On Saturday morning, we had another primip who proceeded to C-section for foetal distress followed by a VBAC with unproven pelvis (first child was delivered via C-section for breech presentation) that eventually required a vacuum. That evening, a lady arrived near-collapse a day post septic miscarriage at 10 weeks' gestation. And in the early hours of Sunday morning was the death of the second premmie.
Amidst all this madness, we were also taking care of one of our nurses who had the misfortune to be in a hit-and-run pedestrian vs motorcycle accident the week before. He almost certainly had a base of skull fracture (bleeding from both ears and nose as well as left sided LMN facial nerve palsy) but thankfully has gradually recovered with conservative management (the only option available to us considering there isn't a CT scanner or neurosurgical service in this country) and is now fully oriented to TPP with mild persisting dizziness and no further headaches.
God, grant me the serenity to accept the things I cannot change,
The courage to change the things I can,
And wisdom to know the difference.
- Reinhold Niebuhr, 1943
Amen and amen, brother.