Six months ago today, I disembarked a plane on the airstrip of Kathmandu’s Tribhuvan International Airport and walked into this strange and beautiful new world. It’s also now been nearly three months since arriving in Tansen to begin the work for which I came. With that in mind, it seemed fitting to talk about some of the interesting cases I’ve seen already. (No deep reflections tonight; getting a bit too late for that…)
For a while, I was writing these “rare” cases down – until I realized that I was recording nearly every case I saw. By the time my first two weeks were over, I’d already seen more pathology than I would have encountered in two years (or even two decades) of practice back in the States. (Granted – spoiler alert! – this particular entry may be of interest mostly to you medical types out there…) Now, please forgive my medicalese as I go ahead and list some of them:
> Day One in our Male Out-Patient Department, 4:55 pm: A serum-positive case of kala azar (a.k.a. visceral leishmaniasis) in a critically ill 40 year old man. (I‘d read a paragraph about this disease once, in Robbins Pathologic Basis of Disease. That was during my second year of medical school…almost a decade ago.)
> Cardiac tamponade in a woman with a prior history of tubucular pericardial effusions (and tamponade) who came in with shortness of breath and weakness. It fell to me to do the bedside pericardiocentesis, having neither done one, nor even seen one done, before. (Thankfully, a far more experienced colleague was available that evening to help me out.) Using a portable ultrasound, we found the (not-too-subtle) effusion and drained 1200 mL (more than a liter!) of frankly sanguinous exudate that tested ADA-positive, confirming a recurrent TB effusion.
> Two (unrelated) cases of empyema with pyo-pneumothorax in children. Strangely, both were admitted to the pediatric ward in the same day. Things always seem to happen in two’s and three’s, don’t they?
> Obstetrical complications that include: impending uterine scar rupture in a VBAC; cord prolapse at 20 weeks with IUFD; abruption placentae as the cause of third-trimester vaginal bleeding; and sadly, two babies born with TORCH infections in the same week – likely toxoplasmosis for both.
> A 13-year old boy who presented to the clinic with generalized “failure to thrive” and dyspnea, and was found to have dextrocardia (discovered incidentally on his CXR) along with digital clubbing, a diastolic murmur, and massive polycythemia (his H&H was a whopping 20/62%!)
> My first “mass casualty,” starting at 5 am near the end of a night-call last month. A bus had gone over the edge of a 1200-foot cliff, about an hour’s drive from the hospital. Five of the victims were brought to Tansen, two of them in pretty bad shape. With all the bloody chaos of a trauma-surgery code, I felt way out of my element, not quite sure where to even begin. (A totally different ballgame from the “code-blue-ACLS” emergencies I usually face.) And I’m told that it can get much crazier than that, with 20 or 30 people being brought in at once. I found myself wondering, at that point: “Geez, what am I doing here?!?”
> Tuberculosis – pulmonary and extra-pulmonary alike. (This is almost too common even to mention.)
> A middle-aged gentleman with profound upper extremity weakness (resulting in pseudoataxia), progressive lower extremily weakness, visible fasciculations of his muscles, and atrophic muscle wasting. Although his water-stained CT films looked normal (to me), we rarely have the luxury of a formal report from a radiologist on ANY of our imaging studies, so interpretation falls almost entirely to us. Yet his clinical presentation looked all too much like ALS – a devastating disease.
> Leprosy with a “Lepra Type 2” reaction. (I’d never heard of this before. At least, I don’t recall having ever heard of this.)
> TB meningitis resulting in obstructing hydrocephalus. You could see the patient’s massive ventricles, occupying most of the circular slices on his head CT film, from across the room. Miraculously, with some dexamethasone and anti-tuberculosis treatment, he eventually made a fairly good recovery.
> A severely debilitated, skeleton-thin-cachectic man with a giant TB effusion. I placed my very first chest tube and an enormous amount of vile-smelling, thin greenish liquid came (literally) pouring out from the hole in his chest wall. (Better out than in with that kind of thing, I suppose.)
> Cryptococcal meningitis in a patient newly diagnosed (i.e. on presentation here) with HIV.
> A nearly-unconscious 12-year old girl, transferred from a hospital five hours away (of course, without any records to speak of) and having not shown any improvement while there on ten days of IV antibiotics for bacterial meningitis. On further exam, after waking up a bit, she was found to have a right facial droop with ipsilateral hemiparesis, midraisis, and nystagmus. When we looked over her accompanying head CT films [see radiology note above], it looked like there could be edema and inflammatory changes involving at least the midbrain and temporal lobes. Possibly HSV meningoencephalitis – by then, untreated for more than a week.
> A tension pneumothorax (with huge mediastinal shift), but still virtually asymptomatic, if you can believe it. On history, the man reported a fairly significant fall from a tree six week earlier. Unbelievably, the pneumothorax was thought to have been present since that initial injury.
Well, that’s all for now. Gotta get some sleep now, then back at it with more “rare” cases to see tomorrow… =)