TONNY

Probably about 1.5 weeks into my time at Kapsowar a 10 year old boy Tonny was admitted for low back pain. The Kenyan physician who admitted him was concerned for Pott’s disease (TB infection in the spine). The xrays were negative, he had no sign of infection (no elevated white count or fever). He lay in his bed and moaned. I was worry so Aaron and I ordered the test for Bruceolosis, which came back border line positive. He’d definitely been exposed to it and may or may not be having an active bout of the infection. About 20-30% of the time patients with bruceolosis developed low back pain and require up to 3 months of antibiotics instead of the normal 6 weeks. He was improving so we discharged him home on Doxycycline and Rifampin. Maybe a week later when I was on call, I was called in during the evening to evaluate a new admission…Tonny. According to his father the back pain hadn’t improved and starting that morning he had been confused, not knowing who his parents where and not about to answer questions or follow commands. On exam he was moaning in severe pain and his neck was so stiff that I wasn’t able to bend it forward. He also screamed out in pain with flexion of his hip. I became very worried for meningitis. I called Aaron, who was on call with me, to come in as well to evaluate Tonny and do the Lumbar puncture (LP the test were we stick a needle into the back between the vertebrae in to the spinal column and collect some cerebral spinal fluid [CSF] to send for studies to see if WBC’s, RBCs, bacteria or fungus is present) with me. Aaron agreed with my concern and we waited for the nurses to set up the LP. They were unable to find a LP tube (evidently the hospital was out and they were waiting for the newly ordered tubes to arrive). So Aaron and I went up to the lab to look for a LP tube. He found only one (usually you collect fluid in 3-4 vials in the USA so that you can do various studies and decrease the chance of contaminating the fluid with blood from the skin as you inserted the needle). We made it work. We called the lab in and waited as they ran all the studies on the CSF. Protein was high, glucose was normal, WBC was very high, bacteria was numerous. They did a Gram stain on the bacteria and it came back Gram positive cocci single and in pairs. They didn’t have the ability to culture the CSF. So we had to guess based on the Gram stain that he had Strep Pneumonia Bacterial Meningitis, so started him on Ceftriaxone. (There’s no Vancomycin here). The next morning he was very little better (sometimes knowing who people were) if at all. His dad was concerned and wanted him transferred 2 hours away to Eldoret where they could do a CT scan. We had discussed it before the LP results, but now we knew the diagnosis and could give the appropriate treatment at Kapsowar, and he wasn’t stable to transfer. Aaron helped me consol the boy’s father, and he agreed to wait another day. The next day the boy knew who he was, where he was, the month, the year, and why he was there. But he still had neck pain which was worse with eating, drinking and any movement. Because he wasn’t drinking or moving his family felt he was the same. Again Aaron and I talked with his father, saying they could transfer if they wanted, but he was improving. Personally I was still concerned that he was still too unstable to transfer. Aaron explained that the improvement from meningitis was very slow, and was the same no matter if he was at Kapsowar, Eldoret, Nairobi or in the USA. Aaron told the father that the boy was improving impart due to the antibiotics, but mostly due to God and his response to our daily supplications. His father agreed to stay. The next morning we found out the boy had eaten some the day before, and I found him sitting up with his legs hanging off the side of the bed as his father fed him. Finally he was stable enough for transfer if they wanted. The father wanted to think about it, but we had community clinic so we discussed the case with the Kenyan doctor who was covering the hospital while we were out. He’d arrange physician to physician transfer to a neurologist in Eldoret if the family decided. The next morning I started rounds not sure if Tonny would still be there…. He was. He continued to improve day by day. Yesterday was my last day and he was eating, up in a wheelchair, and laying out in the grass on his side during the day. Today is day 8 out of 14 days of IV antibiotics. His father’s smile testifies that he had seen the glory of God.