Emily Hall (PL3) shares 3 memorable cases

 Posted on behalf of Emily Hall, DO (PL3)

To be truthful, I have no sense of who reads these blog posts. Perhaps you're

• a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?" 
• or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital" 
• or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making." 

Regardless, I hope you've found my ramblings both interesting and of some value. 

I have packed my bag with the anticipated return to (the frigid) Minnesota and find myself with a few moments for reflection prior to catching a taxi to the airport. I have had incredible opportunities to see the country, develop relationships, and further my knowledge of medicine. I'll highlight some of the memorable patients that have taught me most about the art of medicine and the unique challenges of medicine in low-resource settings. I should note: the following pictures were obtained with parent permission and an understanding the photos would be shared with others who were interested in tropical medicine.  

CASE ONE: 9 year old with unilateral eye swelling. 

Clinical Course. Febrile, sick appearing child (39.7) presents with 4-day history of fever and unilateral eye swelling. Temporal relationship to fever and initiation of eye swelling was unknown. Eye swelling progressed with bilateral involvement the day of admission with associated active serious drainage from the superior eyelid. No obvious skin lesion. Child reports eating cooked meat from a deceased calf approximately 1 week ago, the calf was notably sick prior to dying. No one else in the family or village has been ill; other individuals ate the same meat and did not develop illness or facial swelling.

On admission, the intern overnight believed this was a case of cutaneous anthrax (despite there being no classic eschar lesion). Child was started on high dose Penicillin.  Two days later, child's fever and facial swelling was persistent. Differential diagnosis was considered including H. flu or staph pre-septal vs orbital cellulitis. Antibiotics were empirically broadened. Within 1 week she developed a classic eschar involving the superior eyelid and her fever curve normalized. She was discharged home on mono therapy with high dose Penicillin. She was instructed to follow up within 2 weeks; she was lost to follow-up, presumed continued resolution of her bilateral eye swelling. 

 

Lesson Learned: Trust your colleagues, regardless of their 'rank' in medicine. The intern overnight reported seeing a similar presentation of cutaneous anthrax. Despite this, many (including myself) thought broadly about the differential and given the sick-appearance of the child promptly advocated for empiric antibiotic coverage. In the end, the intern made the astute and correct diagnosis. In retrospect, he had much more to say regarding how he came to this conclusion and demonstrated a sound thought process that was initially overlooked. 

CASE TWO: 4 year old with chronic constipation

Clinical Course: Child with developmental delay presents for repeat admission for withholding stool and abdominal mass. On presentation he last passed stool 14 days ago. No history of vomiting, anorexia, or weight loss. Review of systems notable for gross hematuria. Abdominal ultrasound obtained to rule out mass was normal. Abdominal x-ray with dilated bowel loops filled with stool, no bezoars noted. 

Despite aggressive attempts at a bowel clean out (NG placement, repeated enemas, etc). A bowel regimen was established, but would be required for many months duration. A referral to pediatric surgery was obtained to rule out low-lying Hirshprungs disease. Decision was made for colectomy--which came as quite a surprise to me. 

Lesson Learned: Accept clinical management differences. Though a colectomy seems like an incredibly invasive treatment approach for a child with chronic constipation, it prompted investigation into management options and approaches in Tanzania. Turns out, a colectomy is not an uncommon treatment modality in this area. Instead of trying to be understood--I found in this instance and many others the value of seeking first to understand...and then if prompted invite further discussion. There are many ways of 'solving' problems in medicine. It's refreshing and interesting to see new approaches even if at times they are counter to previous ideas.

CASE THREE: 26 month old with bilateral lower extremity pitting edema

Clinical Course: Well appearing child was brought to the hospital from a rural by family after a medical worker had seen and strictly advised the family to seek medical evaluation for the child. Mother reports personal history of bilateral lower extremity pitting edema as well as siblings (child's aunts & uncles) with similar presentation since birth. No facial swelling. No change since birth. Does not bother the infant. On exam the child has 3+ bilateral pitting edema from the toes extending past the patella. 

Within 20 seconds of seeing the patient, the Australian pediatrician looked at all the trainees and said "there is only one diagnosis possible, I know what it is--and so should you." I looked at her blankly as if to say, "Please don't call on me." None of us came to the correct diagnosis--but after she stated the obvious, my love for physiology resurfaced. Congenital lymphedema. 

Lesson Learned: Hold dear in your heart the knowledge of physiology--and take time to think through problems for yourself. Even if it is a diagnosis you have never seen or read...you can still come to the most logical answer, even when no or limited lab/imaging studies are available.

These cases illustrate both the challenge and the privilege of augmenting traditional pediatric training to include a global health focus. Building relationships and working with physicians who have diverse training and experience is eye opening and valuable. It isn't always easy to find time to make an International Elective experience come to fruition, but experiences such as this I find to be professionally enriching. If you ever find yourself contemplating spending time in East Africa, I certainly would encourage you!