Case Presentation 2

Patient is a 57 yo who has ISS and TB who presented with confusion and decreased intake. The family states the patient was started on medication for the above diagnoses about 2 weeks ago. Patient has become more and more confused and has not said anything in the last 24 hours. He seems to have "hotness of body" and hasn't had anything to eat or drink in 2 days.

When we evaluated the patient, he was not febrile but was minimally responsive to pain and verbal stimuli. He was tachycardic and appeared very dehydrated. He was found to be tachypneic and his oxygen saturation was 92%. The patient was given IV fluids and started on Co-tramazole, Ceftriaxone, and Acyclovir. ECG was performed to evaluate his tachycardia. Complete hemogram, UEC, and chest xray were ordered and a lumbar puncture was performed.

Discussion:

There are a few points that I would like to discuss about this patient. The first is the fact that the patient is "ISS." This stands for "immuno suppression syndrome". There is such a stigma here in Kenya against HIV that even doctors can't discuss this openly with patients. It goes so far that you cannot order a rapid HIV test. Physicians instead order a DTC-diagnostic testing and counciling. Even the HIV clinic has a euphamistic name- the Comprehensive Care Clinic. Apparently if it was called the HIV clinic no one would come. That's not to say that we don't have a stigma in South Carolina as well, but I feel that in SC we can speak more openly about the subject.

This is one of the sicker patients that I have seen here. In the emergency department he's what we would call an easy admission. With the limited resources, it makes it very difficult to treat the acutely ill. We were able to obtain an EKG, but this took several hours. The machine is not very portable and is almost on par with putting the patient's hands and feet into buckets of water. Acutally there are clamps that are attached to the limbs, and the precordial leads are held in place by bulb-suction devices. The leads are printed out one at a time and the clinical officer has to cut them all out and tape them onto another sheet of paper to place in the chart. The process takes anywhere from 30-45 minutes from start to finish not including the cutting out (and you thought it took awhile to get one at Richland).

Oxygen is often difficult to get onto the patient and tanks have to be wheeled to the bedside. This takes a lot longer than you would really want and sometimes makes me nervous, but often there just isn't a tank available. These tanks are not very portable which means if a patient is needs O2 they can't go anywhere. Even getting a simple chest xray is impossible. Forget a stat CT- that requires raising funds and a day of travel. Sometimes I forget how easily these diagnostic studies are obtained at home.

The patient is currently being treated for TB and I asked about placing him in isolation. Basically there is no isolation here. The doctors practice on the theory that it is basically endemic to Kenya. "Everybody has TB here, just not everyone shows it," is what the intern told me. To which I replied, "I don't have TB!" She simply shrugged and told me not to breath too deeply.

We were able to obtain CSF and it was actually negative. I was able to walk the clinical officer through his first successful LP (or more likely he succeeded despite my misdirection). The lumbar puncture kits are very simplistic and they cannot get an opening pressure or perform cultures. However, they can obtain cryptoccal antigens studies and these were negative as well. Still, we threw everything but the kitchen sink at this guy. In addition to antibiotics, patient received IVF and tea through NG tube. Apparently it is customary to place an NG twice a day to make sure the patients get tea time.

Over the last few days, the patient has done very well. He is now off oxygen and has vastly improved, although still confused. We still don't know the underlying eitiology of his illness although the current theory is either sepsis (unknown sources) vs IRIS- immun-reconstitution syndrome. I am glad to see him improve everyday even if he has no idea who I am.