Saturday, May 15, 2010

Medical Vignette

This post has no redeeming value but is just an example of the challenges of diagnosing things here in the Republic of Congo.

Last week we received a 5 yo in a coma. He had a fever for several days, had been seen at another medical facility and started on quinine for malaria. 2 days before he came in he developed a huge mass in his abdomen and his parents brought him to us to see if there was something we could do. He also had developed seizures as well.

When we originally saw him he responded only a little to pain, had a fever but had no other signs of meningitis. He did have a mass in his abdomen that moved pretty easily. He was anemic (hematocrit of 27) on his blood work but other values were ok. I did a spinal tap which was normal as well. We performed an US and found out the mass was actually a huge bladder that went up to his belly button. We placed a urinary catheter and got an urine sample. He had an urinary tract infection. We continued antimalarial treatment and started antibiotics for urinary tract infection.

Our initial thoughts is that he had a partially treated form of cerebral malaria and a secondary urinary tract infection and that with treatment for the malaria he would wake up.
2 days later he did not wake up.


Below are three pictures that should help with the diagnosis (tentative) that we made


Big sluggish eyes bilaterally.
















Chart showing fever curve, without a lot of sweating.














shows the urinary retention


















So what do you think? If you care to respond just leave a comment

4 comments:

Alice said...

consider

Q fever
Yellow fever
Typhoid fever
Trypanosomiasis

PR

Anonymous said...

Not sure there's enough information here to make a real guess as to what is going on (and I really can't interpret the urine output flow sheet). It sounds like the child had some sort of encephalitis which depending on the type of encephalitis can give you a normal CSF. Did the child end up urinating, or did the child have a period of decreased urine output then all of a sudden start urinating again (a sign of herniation)? It must be very challenging, and I admire your work.

jeremy said...

Steven, we prayed today at Faith for your wisdom and the kid's survival. I also emailed it around to some doctors. Keep us updated.

Stephen Wegner said...

I was actually going for more of intoxication. the family had given a suppository of a traditional medicine and eye drops of the same.
I was thinking anticholinergic poisoning (mad as a hatter, dry as a bone, blind as a bat, hot has a hare and red as a beet. Now one week later he is afebrile but has unilateral weakness and still depressed mental status. I repeated the lumbar puncture 4 days ago and still 0 wbc and 0 rbc and no trypansomes in the csf. Also no post cervical nodes.
keep giving thoughts