Could We Be Doing More?

The following was written by DeAnna Friedman, third-year pediatrics resident

Last week was definitely a week of presumed clinical diagnoses and unanswered questions. As I have said in previous posts, much of the testing we have here centers around a CBC with diff, a CMP, and cultures. There are a few other tests here and there, but on the whole, we often must make presumptive clinical diagnoses without having the tests to prove us right or wrong.

There was a child who died at the end of last week due to fulminant hepatic failure leading to bleeding complications and brain death. His hepatitis B and C tests were negative, so everyone presumed that hepatitis A had been the cause of his liver failure. However, his AST never rose above 780. He had a high bilirubin and a very high INR (>6), and then developed a high PTT, followed by kidney failure, then possible intracranial hemorrhage and brain death. Drug levels, a liver biopsy, more FFP, more options for helping his hyperammonemia (which I'm sure he had, even though we weren't able to test for it), may have helped us to save this child. But I really can't be sure. A liver transplant may have been his only hope, and there is no transplantation in Cambodia.

Another child I cared for was brought in with a knee abscess and fever. He also had thrombocytopenia. Given how well he appeared and his lack of schistocytes on blood smear (and the sheer number of dengue cases we've been seeing), it was presumed that he had a knee abscess with concurrent dengue hemorrhagic fever, as opposed to DIC. However, he also had Trisomy 21, and when I saw him the next morning, I was concerned that he may have ALL. Luckily, there's a hematology-oncology specialist here from New York right now who was kind enough to take the time to look with me for blasts on the smear. We found one, which could be a sign of early ALL, could be transient myeloproliferative syndrome, or could be normal. I hope for his sake that it's one of the last two, as AHC will not have chemo up and running until later this year. It will be hard to follow him closely, as many of the patients don't have the means to come to AHC on a regular basis.

I also saw at least 3 children between last week and today who had a congenital cardiac lesion (PDA, PS, or VSD) and congenital cataracts. Given the immunizations that are provided for the patients and that only a portion of the children receive them, I suspect that they are likely congenital rubella syndrome. I think they are being selected for as there was a PDA surgery day this past week and there is a team of cardiothoracic surgeons coming next week to do open heart surgeries. But, it is alarming to me that I saw 3 in the span of a week. These children could have been otherwise completely healthy if their mothers had received the MMR vaccine when they were younger. However, now they are likely going to be blind, possibly deaf, and may have problems with heart failure if they don't get fixed when the heart surgery team is here (who is only about to do about 15 cases per trip).

Some of these problems are easily fixable; MMR vaccine is not so expensive, and the freeze-dried version doesn't even require a cold chain (it only has to be refrigerated after reconstitution). With a little funding, it would be easy to have a nationwide campaign for catchup and education. Some problems are not as fixable. AHC is working on opening clinics in more provinces so that children can get care closer to home, but this requires doctors who are willing to live in these provinces and money to set up the clinics and their infrastructure. A liver transplantation program for Cambodia is something that, at the moment, seems nearly impossible--given the infrastructure that would be required--and very impractical, given how many other inexpensive interventions are still needed here. I can't help but wonder at times if we could be doing more for these patients...

DeAnna