In Greek mythology, the Hydra had the body of a serpent and many heads, one of which could never be harmed by any weapon. If any of the other heads were severed another would grow in its place, and the stench from the Hydra’s breath was enough to kill man or beast. When it emerged from the swamp it would attack herds of cattle and local villagers, devouring them with its numerous heads.
– Encylopedia Mythica
14 years after finishing medical school, you’d think I should know something about most things to do with sick children. But the human body is a complex beast, and its enemies just keep attacking in sometimes-bizarre ways. So this post is devoted to tuberculosis (TB) – my own personal many-headed hydra. Subtle, innocuous and deadly.
Victor came to us last week with a history of his eyes gradually bulging, veins starting to stand out of his head. He came to the neurosurgical clinic because any time a child has a big head, for whatever reason, most people assume it’s hydrocephalus and all of Kenya knows that this is the place for treatment.
Susan, our neurosurgeon’s wife who also happens to be the most outstanding nurse practitioner I’ve had the pleasure of working with, took one look at him and knew that not only did he have a big head with protruding eyes – he was sick. Pale and weak, she had already sent his blood for testing before we, as non-surgeons, arrived to help figure out what was going on. He was dangerously anaemic, but apart from that we couldn’t easily figure out what his problem was.
So we sent him for a CT scan in Nairobi – which didn’t show anything specific at all except for swelling of the lining of the brain. Leland (probably the hardest working and busiest pediatric neurosurgeon the continent, volunteering to train local doctors in neurosurgery here during his retirement) took him to the operating theatre and took samples – his skull bone was replaced with something that looked like tumour, and the lining of his brain looked similar. His suspicion: cancer that had spread from another site. The final pathologist report: tuberculosis. The strangest presentation any of us has ever seen.
Moses came to us from the northern part of the country with a strange story – 6 months ago, after falling out of a tree, his right thigh slowly, gradually started to swell. His family had tried traditional healing by burning the skin, but there had been no improvment so they had come to us. He was a puzzle – his right thigh was 5 times the size of his wasted left thigh, with strange lumpy areas that felt like a tumour. A superficial biopsy showed nothing specific, and an MRI scan, done in Nairobi at horrendous expense, shows… a mass. Nothing specific – not part of the muscle, not part of the bone. Just a lumpy… thing. Looking at the rest of him, he is wasted, skeletal. We know he is HIV negative, which narrows things down – but in this country, when you are wasting away and nothing else shows up, it’s TB until proven otherwise. The surgeons are going to do deeper biopsies to see if we can catch TB bugs under the microscope, but in the meantime we’ve started a 6-month treatment course.
And last, gorgeous little John. Pudgy and sweet, he came to us at 2 months of age with fevers, having already received a week’s worth of antibiotics for presumed meningitis – the other hospital had not tested his spinal fluid. When he arrived, we looked at his spinal fluid and found cells suspicious for an infection that hadn’t quite cleared, so we treated him for another 14 days. At which point we found – more cells in his spinal fluid. Although clinically he was doing brilliantly – chubby, gaining weight, no fever, happy – the microscope was telling us that we were on the wrong track. We stopped his antibiotics and retested the fluid 3 days later – MORE cells. This is TB meningitis until proven otherwise. He too has just started 6 months of daily medication.
We have no idea who infected these kids – their families don’t know of any friends or family who have TB. Which means each of them was infected by a probably undiagnosed adult who is spreading the disease to others around them. Kenya ranks 13th out of the UN World Health Organization’s 22 “high TB burden countries” and has the fifth-highest in Africa. There are an estimated 12,000 TB-infected children younger than 14, representing 11 percent of all infections.
Bulging eyes. Ever-increasing thigh lumps with the rest of the body wasting away. An silent, progressive brain infection that isn’t found until you search for it. TB, my many-headed nemesis – we will continue to fight you, and to win.
Update Oct 4 – Victor had a repeat lymph node biopsy that showed us he, in fact, does have metastatic cancer (neuroblastoma). Prayers appreciated for him and his family as they contemplate expensive chemotherapy at another hospital, with little chance of success, or letting the disease take its course.