Daktari wa damu

Welcome back to Daktari Cases.  These cases are NOT Ebola Virus Disease, and there are not (yet) any cases in Kenya.  We rejoice with Kent Brantley and Nancy Writebol in their recovery, and continue to remember those who are suffering in West Africa, and the brave men and women who are serving them.

No, today’s cases are examples of some mystery cases that I’ve seen of late that have ended up being outside my areas of expertise.  Life here stretches beyond your predetermined boundaries in many respects, and here are a couple of stories to illustrate.

John is a 52-year-old man from the other side of Nairobi with a 3-year history of a rash.  This itchy outbreak began on his hands and progressed to involve the entirety of his upper body, trunk, and lower extremities.  He had been seen at many health facilities, given many empiric treatments, and even had some response to topical steroids.  He had also variously been diagnosed with fungal infections of the skin and even leprosy, or a WTDNOS (weird tropical disease not otherwise specified), and that’s how he ended up coming to my attention at Tenwek.

 

After a glance and a gasp, I put on my gloves and had a feel.  A wise dermatologist once told me this, “If you know what it is, you don’t have to touch it.  If you don’t know what it is, for heaven’s sake, don’t touch it.”  Well, I once again ignored this good advice, and through this exam discovered that he had lymphadenopathy (swollen lymph nodes, lumps and bumps all over his body).

So, thinking there must be more here than meets the eye, and assuming it’s an indolent and potentially treatable disease, I rang over to my friends the surgeons to send off a skin biopsy.  “Tissue is the issue,” they say.  Anyhow, it turned out to be a Cutaneous T-cell Lymphoma, otherwise known as mycosis fungoides.  It turns out, since 1806 we have been mislabeling this slow-growing lymphoma as an infectious disease.  And if you’re going to get a lymphoma, this is one of the kinder gentler, and even treatable in Kenya ones.  And the treatment (here): nitrogen mustard.  If that sounds to you like a gas that killed people in trenches in World War 2, I think you’re right.

Our next patient is named Mary.  She is a 56-year-old Massai lady referred to me by my friends in an outlying clinic.  An aside, I get to go out to these clinics usually about one day per month, and it’s awesome: there’s no electricity, no running water, it’s just your wits and your stethoscope, and a handful of medicines.

Back to the story, this lady has a 1 month history of headache, with a pain in her left side “that is growing.”   So, I ask “what do you mean, ‘it is growing.’” At which she replies, “feel this.”  Protruding from the left upper quadrant of her abdomen is a subcutaneous American football.  But I’m not fooled, there’s not a real football in there, this is a massive spleen.  Ah, massive splenomegaly, the hallmark of many tropical infectious diseases.  This is a slide from a really smart guy from Mayo Clinic who taught us in Greece at the CMDA conference.

So, I ordered a complete blood count, and this is what we found.  So, I’m astonished by all of these results.  But most startling is her hematocrit.  We live in a land of chronic anemia, and it’s not surprising to see a patient walk into the hospital with some general malaise and a hematocrit of 7%.  This lady has a hematocrit of 70%.  She has the red blood cells of at least 3 Massai ladies.  This is abnormal.  The disease is called polycythemia vera.  It’s a myeloproliferative disorder (confusion in the bone marrow that makes too many red blood cells, and can be a precursor to leukemia).  And the treatment?  Very high-tech and modern: blood-letting, also known as serial phlebotomy.  It reduces the risk of stroke, the blood gets so thick it stops up the blood vessels in the brain.  So, once per week we are removing a unit of blood and keeping an eye on her blood counts.

These stories are ironic on many levels.  And that’s why this entry is called Daktari wa damu: the doctor of blood.

out of orbit

Do you remember motorcycle carnival rides where all the motorcycles ride around and around making lots of noise and lots of little children feel so happy and tough at the same time?

Bomet, our town, looks about like that except the ride spun out of orbit and all the colorful pleather and chrome scattered everywhere.

Motorbike taxis are a main source of income for young men these days.  They are also the main source of orthopedic patients at the hospital.  Driving a car on the highway amongst them can feel like a bird flying in a swarm of bees.

Sometimes the wind here is so strong that I feel like the whole planet is being flung out of orbit on one of those carnival rides.  Or maybe it’s just on the far reaches of a seasonal eclipse around the sun.

You know, we are just right below the equator so when seasons change we are the reverse of you “northerners”  (Did you ever think you’d be called that? Don’t worry I would never call Georgians and Tennesseans and Alabamians by that northerner term usually affixed to a prefix).

Yes, things are often the reverse of “normal” here.  And we are in the southern half of the world now where People are people through people.  That is, Africa is to relationships as North America is to individualism.  Mother T. used to say “loneliness is the leprosy of the West”.  Poverty of relationships is indeed true poverty. 

So I am indeed blessed and thankful in this upside down place.  While nothing good comes in the news out of Africa these days let me tell you, people here are people because of relationships with people.  I can stay holed up in isolation of the different house we’ve just moved into and try to locate where the heck is the scotch tape in this place- or I can walk 50 yards (45 meters), to the shops and shake hands with 10 people who all ask how I’m doing, how is my home, how are my kids, and where am I going. 

I am thankful for the wildness of an African rain that commands such respect all humanity stops together in our tracks until she passes by.  I am thankful for the beauty of obtrusively orange honeysuckle vines climbing over an otherwise gray stone building. It’s like Tennessee orange wisteria, ya’ll.  And I’m thankful for the stark rainbow of colors that African women wear like a kaleidoscope of beautiful black, brown, and boldness.  I like to see their reactions when I try to wear some of that funkytown.  We could say it’s good for building relationships perhaps.

So wild and out of control, that’s kinda what you hear about Africa isn’t it?  The idol of control is not worshipped here anyways.  Maybe that’s why I like it so much.  Maybe I find comfort in the ambiguity of plans as long as everyone is happy.

Can I ask you a favor?  Will you speak kindly and sincerely to someone in the store or on your street today?  Can you alleviate the loneliness of your neighbor by just showing up in your humanness too?  It might be off your normal orbit, but that could be truly a beautiful and wild ride.