Lo gboto - asala lango mbrambra (He's had seizures for a week).

Please forgive excessive medical jargon and stories.  If you are not medical, feel free but not obliged to move on.

     Well nourished previously healthy infant is transferred from an outlying health post with persistent seizures, fever, encephalopathy despite one week artesunate and ceftriaxone.  On arrival here he is started on the protocol - artesunate and ceftriaxone. (and diazepam).  In absence of skin lesions next step in protocol is add gentamicin.  I order, throw in levetiracetam.  I find out, we have gram and giemsa staining in the lab (for now, anyway).  Kid deserves LP, though no micro.  Maybe lympho predominant will buy TB tx, or eos I can do albendazole for Strongyloides (I saw CNS S. stercoralis in Boston once upon a time).  No India Ink.  LP uncomplicated, CSF clear, glucometer cannot read.  Gram stain neg, 10 reds (no one to champagne me anyway) WBC 5 (no diff.)  So not much help.  One day (well 8d) into ceftriaxone w 1 day genta/Keppra seems to be defervescing, a little more awake, no seizures.  What am I treating?  I'll take yes for an answer.  We'll think about HIV (since we just met, not quite ready.  So far I've come up neg every time I order) sooner rather than later if fails to improve.

     A different puzzle:  Girl readmitted 10 days after discharge for meningitis (no micro, no LP).  Did well for a week, returned with empyema.  Chest tube drainage is super nasty, gram stain loaded with polys and yes I must agree those are cocci in chains!  So, that makes sense, S pneumo meningitis with missed/inadequately treated lung focus, drain, abx, we should be good, yes?  No TPA, and the funkiest chest tube drainage system ever (please squeeze the green-rim valve-tube when you walk by to generate negative pressure), seems to be clogged.  Surgeon agrees to chest tube washout - post lavage fluid is clear. . . then what up with that, looks like milk? From the chest tube? And only after she drinks milk?  OK, fistula would be weird not impossible.  Thoracic duct lesion seems less likely.  Surgeon wisely advises we give her "Jamaica" (that's Spanish for hibiscus tea, known as karakandji in Sango, beautiful red color) p.o. to see if it comes out the chest tube.  Will let you know what happens tomorrow after NPO except karakandji.


    

Here's the hibiscus tea (honey sweetened) bright red:



 and the subsequent chest tube drainage - still cottage cheese.  Not red.

No fistula by the karakandji test.  Repeat washout via chest tube scheduled for early next week.  Kid looks ok (a little marasmic).









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