What's the rub?

8 July 2010

Tuberculosis has re-emerged as a major cause of death in sub-Saharan Africa over the past 20 years. After decades of declining death rates from TB in much of the world, TB has come back to life through those who carry the HIV virus. The immune compromised state of HIV patients provides the perfect host for tuberculosis to thrive in (and spread to both HIV positive and HIV negative people in the same community). We now have 3 patients who we have placed on TB treatment due to the high probability of co-infection in the cases that we have. That is 30% of our team’s medical patients. Right now we have several consults we are doing for surgical patients but these patients weren’t admitted for their medical problem, just the surgical one and we are diagnosing and/or treating their hypertension or diabetes to improve their postoperative care and prep them to go home. The “sick” side of the service is dominated by HIV and TB (and a case of cryptococcal meningitis to boot).

Oh yeah, the man with the large pelvic mass – before he went to ultrasound, a catheter was placed just to see if it could be his bladder. FIVE liters later, his bladder was drained. Never thought you could store 5 liters of urine in a human bladder but he did it. Wonders never cease.

9 July 2010

What’s the rub?

It has been quite cool the last 24 hours here on the equator – low clouds hang over the Rift Valley and the sun has been blocked out for the most of the last several days. This afternoon, it is finally breaking through and warming up the air here at 7200 ft.

Our service continues to grow ahead of our discharges. Remarkably, no one has died yet and in fact we have some surprising turnarounds. Two of our AIDS patients have improved greatly – one is going home today on TB treatment before he starts on AIDS medications, and the other one with cryptococcal meningitis has woken up and is clear and conversant. Charles has had two women with the same diagnosis die in the last two days, reminding us of the true mortality that exists with these patients with advanced stages of immunosuppression.

After rounds yesterday, I was reviewing one of our new HIV patient’s XR and noted that though the miliary TB was noted by my intern and resident, the enlarged heart was not. Frederick, our clinical officer, and I pulled out his old X-rays and saw that his heart shadow was indeed enlarged. So on rounds this AM I asked what that meant. Then we did a careful cardiac exam, which when he was laying on his back was remarkable only for his fast rate. Then I sat him up and listening for a few seconds at the base of his heart you could clearly hear a pericardial friction rub. I had the whole team listen to hear it since it can easily be overlooked if you don’t know what you are listening for. It has the characteristic sound of squeaking new leather shoes. This explained his X-ray findings and also changed our treatment for his TB (adding steroids) so that we can calm the effusion before it compresses his heart and leads to cardiovascular collapse. So much to learn about TB and also the value of a careful and thoughtful physical exam.

Peg and the rest of our entourage are out at Siyapei clinic now for the week – it sounds pretty austere – not the high flying lifestyle we are used to at Kijabe. Her blog has all of the gnarly details:

http://dispatchesea.blogspot.com/

Tomorrow should be a short day - round in the AM, then out for a hike up Kijabe Hill if the weather permits. Charles Nelson, one of my senior residents, will be joining me on the hike after we are both done at the hospital and will get a chance to get out to see a bit of rural Kenya.