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.
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