Patients with seizures can be like buses; there are none for ages, then two appear within minutes of each other.
This morning, Loveness, a 10-year-old girl, limped into the clinic with her granny. I was surprised to see that Loveness had a left-sided hemiplegia. Her granny told us that she had had a stroke following a bout of severe (“cerebral”) malaria when she was two. She had recently moved with her mum to live at her granny’s house, which was in our catchment area.
It was difficult taking a history because of the stigma of seizures. Local people think that a seizure is a sign someone is bewitched and that the evil spirit inside the sufferer might escape and enter anyone who tries to help. Granny gave very guarded answers to our questions.
A detailed history is absolutely essential, with a reliable witness able to describe exactly what happens during a seizure. It is important not to ask leading questions, as patients often want to “please” the doctor by answering in the affirmative.
Loveness started having seizures spontaneously in January 2020. She had an aura, a sensation which precedes an attack; she felt someone was pushing her. She would fall down, unconscious and rigid, following which her whole body would shake for a few minutes. She had occasionally bitten her tongue and wet herself during a fit. She had been having about three convulsions per week since January, but recently she had experienced three in one day. The seizures were becoming more prolonged. Her granny sought help at the health centre because of this deterioration.
Zambian children in the health centre are often very subdued. Some are frightened of a muzungu (white) doctor, but they usually refuse to answer questions, preferring their carer to give the history. I needed to examine Loveness’ central nervous system, and this gave me an opportunity to engage with her. I like to squat or kneel, so I am at eye level with the child. I even take my mask off so that they can see my facial expression. If I can make the child relax and smile while I am gathering information, that’s a bonus. We played games while testing her cranial nerves, screwing up her eyes, blowing out her cheeks, showing me her teeth, watching my finger moving in all sorts of weird directions. She had lost the use of her left arm and her left leg was stiff (hypertonic), with limited movement.
I came to the conclusion that the cause of her seizures was organic brain damage/scarring caused by cerebral malaria; she has epilepsy. In the UK, she would have seen a paediatric neurologist, had multiple scans and electroencephalograms, perhaps even being considered for brain surgery. Here in rural Zambia, we have two drugs to treat epilepsy – phenobarbitone and carbamazepine. The latter has fewer side effects but works best in temporal lobe epilepsy. We decided to try it and I will see her in the village next month during the community child health clinic.
I have some diazepam for rectal administration, to halt continuous epileptic convulsions, an emergency. (The drug is extremely effective but out of date and I can’t bring myself to throw it out because I cannot get any more.)
Just as we finished explaining the management plan to granny, the registrar told me that a baby was having convulsions now in the waiting room.
Agness was just four months old, but her disabled mother felt that breast milk was not providing her with enough nourishment, so today, for the first time, she fed her some pap – a thin, maize meal porridge, with cooking oil, sugar and salt. She didn’t use a spoon, but cupped the pap in her hand and poured it into Agness’ mouth. Health educators advise against this traditional feeding technique when giving educational talks in the villages. I don’t know why she didn’t use a spoon. Perhaps she was too poor to afford one.
Agness stopped breathing as she inhaled the pap into her lungs. She had a seizure, probably caused by lack of oxygen reaching the brain. The mother said that she had convulsed for an hour, but I didn’t consider that was reliable information, as she had no means of telling the time. The baby had regurgitated some of the pap.
The baby was extremely distressed, breathing rapidly at 76 breaths per minute, with inspiratory wheeze (stridor). I couldn’t hear any sign of any pap still in the lungs. She was not cyanosed. I don’t have a paediatric pulse oximeter to measure the saturation of oxygen in her blood. We calmed the mother and grandmother down, and Agness was able to breast feed intermittently. It seemed to give her some comfort.
Aspiration pneumonia is very tricky to treat. There had been some cooking oil in the pap, and this could cause lipoid pneumonia. Although initially, children may appear to be recovering, their condition can deteriorate a day or so later. We don’t have oxygen at the health centre. Intravenous antibiotics would normally be withheld for 24 hours to see if the baby is going to recover spontaneously.
The baby was now breathing at 60 breaths per minute and looked more comfortable. I thought we might be exiting the woods, but on reviewing the child after lunch, it was clear the child needed oxygen and more care than we could provide. I organised a transfer to the local hospital (I have since learned that the baby has made a full recovery after a week’s admission).
In this blog, I write about and post photographs of the wonderful variety of animals and birds in South Luangwa. I don’t want to give the impression that I am just having a fabulous time on safari for three months so I include pieces about my work and clinical problems I am trying to manage. WordPress statistics tells me that clinical pieces are popular, too.
But it’s probably obvious to some of my readers that my writing about these tragic cases helps me to cope with my own feelings and emotions. Extracting and transforming my sadness, frustration and helplessness into words on a laptop screen is cathartic. And in the words of the BT advert, it’s good to talk.