Categories
Bangladesh Medical

Noma or Not?

WARNING – CONTAINS A GRAPHIC IMAGE WHICH MAY BE UPSETTING

October 2017, Kutupalong refugee camp, Bangladesh.

It began with a misunderstanding. I asked the Rohingya mother how her baby had developed an evil-looking purple swelling on the side of its nose. I thought the nurse translating said that it had been caused by boiling water. It seemed to make sense – fragile newborn skin being splashed with hot water during cooking, perhaps in a dark, plastic-covered hovel in the migrant settlement area. It looked superficial, it should have healed swiftly.

I misheard. The nurse translating the mother’s response actually said that it started with a boil on the face, a small spot, a furuncle. Over the next few days, the skin changed from the colour of a bruise to a dark patch of necrotic (dead) skin. Another dull red patch developed on the baby’s ear. The neonate had already been started on antibiotics but without much obvious benefit. The lesion started to ulcerate. We added another antibiotic specifically for staphylococci and yet another for fusobacteria. We even added an antifungal drug, in case the baby’s immune system was so compromised that this was an opportunistic infection.

 

P1310606
I have crudely blacked out the baby’s eyes to preserve confidentiality.

 

There is a great online tool for doctors working in remote settings called Telemed, which allows us to seek the opinions of a group of specialists from all over the world. With the mother’s permission, I posted a photograph of the baby on the Telemed website and waited for paediatric dermatologists to give their opinions.

The infection got worse. We asked for help from the Memorial Christian Hospital, who thought that the baby had Noma, otherwise known as oro-facial gangrene (cancrum oris). This normally affects older children and is incredibly rare in the neonatal period. The hospital doctors thought the baby might benefit from a special antibiotic only used to kill multi-drug resistant bacteria. The ambulance was ready to take them for therapy, but the mother refused. She needed permission from her husband to leave Kutupalong.

Did he have a cell phone? No.

Was he going to visit her soon? No, he was looking after the four other children.

A nurse suggested sending the police out to find him and bring him to the hospital to get his permission. We dismissed this as too heavy-handed.

The mother said that she wanted to leave the ward, against our medical advice. She said she needed to discuss with her husband and that she would return if he agreed.

A day after she left, the Telemed paediatric dermatologists came up with another possible solution – a strawberry birthmark (capillary haemangioma) which had ulcerated and become infected. There is a cure for the birthmark, propranolol, though we would struggle to find it in Bangladesh. We’d probably have to improvise and use a different drug, which is not licensed for this condition. The baby would still need treatment for the flesh-eating bacteria, however.

The mother never brought the child back to the ward. I still think about this child. How could we have handled this better? Tragic cases, like this one, occurred every day in Kutupalong.

By Dr Alfred Prunesquallor

Maverick doctor with 40 years experience, I reduced my NHS commitment in 2013. I am now enjoying being free lance, working where I am needed overseas. Now I am working in the UK helping with the current coronavirus pandemic.

3 replies on “Noma or Not?”

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s