Each day I've been trying to write down some of the more interesting diseases and conditions we see (though I have not been as good about it lately). Overall, probably 98% of our patients are HIV positive (the clinic offers screening & they will follow a HIV negative patient until any other acute issues present at screening are resolved....often this involves malnutrition and/or TB), so pretty much all of the disease we see is automatically in the setting of HIV & some degree of immunosuppression). That said, the following are among the things we see in a "typical" day over the last 2 weeks: tuberculosis (and more tuberculosis - both pulmonary and extrapulmonary), pneumonia, diarrhea, malnutrition, measles, STIs, rashes. It seems that almost everyday there are also one or two patients with extremely unique diagnoses as well. I have seen two patients (both girls in their early teens) with Kaposi's sarcoma, a form of cancer that is seen most often (in this era of medicine) in HIV/AIDS patients though endemic forms do exist in Africa. (Both girls are improving on chemotherapy regimens currently.)
Yesterday we had a man who has not only HIV and TB but also leprosy. Leprosy is a pretty uncommon diagnosis in Swaziland, from what I understand; however, the patient lives near the Swazi-Mozambique border, and there is apparently a reasonable amount of leprosy still in Mozambique. His leprosy lesions are on both hands such that it almost seems as if he's had amputations of each & every finger (as the fingertips are somewhat squared off). The peripheral nerves are damaged in leprosy which can lead to contractures (shortening) of the joints as well as increased susceptibility to infections...any combination of these things may have led to our patients fingers changing the way they have. Here is a picture from the web that is somewhat similar to the patient I saw (especially the hand on the left side of the picture) though these fingers are more shortened.
We have also seen children who are very sick (or recovering from having been so). One of the patient's who is still something of a mystery to the doctors here is a 13 year-old who was recently in the hospital with severe dehydration (secondary to diarrhea and vomiting). While in the hospital, they discovered that her kidney was acutely failing (for an unknown reason) in addition to a few other seemingly unrelated problems. In medicine everything ties together somehow though the missing link in her case remains to be found....in medical school we joke about unknown diagnoses being autoimmune disease, cancer, syphilis, or tuberculosis (as they can all present in a huge variety of ways). In her case, though, those have all been checked and are so far negative (which is good for her). The best hope (because it is an answer) is that her kidneys were strained with her recent illness and are failing because of underlying kidney disease secondary to her HIV infection. (one more little mystery, for the medical folk reading this, is that despite having a CD4 count qualifying for ARVs - around 200, I believe - and potentially HIV nephropathy, she is still producing enough white cells to get a WBC count of 17)
Not all of the patients are sad stories or mysteries, however. For instance, today we had a 7 month old baby girl who is robust & happy. Although her HIV results are still pending, all clinical signs point towards her being uninfected. Even many of the children we do see, who are HIV positive, are happy and healthy - eager to play outside, go to school, & do all the same things other kids do. It's nice to see the positive patients to help balance out both the more trying cases (for instance, how to handle patients who just aren't taking their ARVs as they need to and are getting sick because of it) as well as the "fact of life" parts of the high HIV prevalence in Swaziland (like the multiple billboards for funeral homes and funeral packages or all of the young faces that peer out from the obituary sections of the papers).
In any case, I will leave those thoughts short & simple so as not to make the great wildlife photos too bittersweet (so many different realities here in Africa). We are still enjoying our time here & learning a lot. This week has flown by - it's hard to believe we have just 7 more days of clinic work remaining (and we'll be starting our second massive travel day in just two weeks).
I hope everyone had a lovely Easter and is having a smooth and easy week.
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