It was Friday, and as usual, we were having our grand rounds in the inpatient department. The patient from bed number 6 was a 9 year-old female child who had presented to the emergency department (ED) yesterday with fever for 4 weeks (recorded up to 104 degrees Fahrenheit in the ED), which was associated with chills and rigors. She had not traveled anywhere recently; the fevers all occurred while she was in our district of Achham. Her fever has spiked again this morning, and she was admitted with a diagnosis of fever under evaluation. She was given injectable antibiotics, fluids, and some antipyretics to soothe her fever discomfort.
Taraman dai, one of our Health Assistants, went up to examine her. On examination we found her to be jaundiced (showing signs of liver inflammation) with an enlarged spleen. She weighed 17 kgs. No edema (swelling of the tissues due to water) was found on evaluation. She did not complain of any pain with urination.
Her lab tests showed pancytocytopenia (low numbers of different types of blood cells) and negative exams for malarial parasites. We suspected her of visceral leishmaniasis (Kala-azar) and sent for an RK 39 test, which is a rapid test for antibodies to the Kala-azar infection. It was around 11 a.m. when our lab technician came up to me and showed me that the RK 39 test was positive, effectively diagnosing her with Kala-azar (although occasionally there can be “false positives,” or tests that incorrectly indicate that the diagnosis is positive). Also, the HIV test was found to be non-reactive, or negative. Here, we had a case of visceral leishmaniasis at Bayalpata Hospital (BH). This was the third time we had recorded any cases of Kala-azar at BH. The previous two cases were diagnosed at BH and referred to higher centers, but both patients expired despite consistent efforts. These cases are very concerning because Kala-azar is a disease that is transmitted by a particular type of insect, which is supposedly not endemic to our region. Thus, we were seeing a series of Kala-azar cases in a non-endemic region.
In the past, one of our leishmaniasis patients had died, despite our best efforts. We had to save our patient with leishmaniasis this time. “How can we help this patient?” was the question on my mind. Firstly, the idea of referring the patient to a larger hospital with specialty services (in another area of the country, over a day’s travel away) came to my mind, as we had neither Miltefosine nor Amphotericin B (the drugs for treating Kala-azar) available at BH. Also, the ongoing bandh (political strike) in Nepal was a major obstacle in our referral because the roads were blocked and people were not able to move around the country freely. Even ambulances were vandalized at many places and referral seemed impossible. Dr. Payel Gupta (our Director of Clinical Operations) was in Kathmandu those days for some official meetings. I called her up and informed her about the case. She assured me that she would bring the anti-leishmanial medications back to BH from Kathmandu when she returned in one week’s time.
Meanwhile, on the third day of admission, along with the daily spikes of fever (>101 F), the patient started to have a few episodes of epistaxis (bleeding from the nose). We controlled the bleeding with anterior nasal packing and also sent for her lab studies for complete blood counts and other hematological tests. Her lab reports showed profound anemia, with a hemoglobin concentration of 5.2% and platelet count decreased to 40,000/mm3; this nearly shook me up.
The patient needed an immediate transfusion of platelet rich products, which was only available in Kathmandu. There was also a possibility of recruiting donors from the community in the district capital, who might be able to provide fresh blood to her. This was in Mangalsen, which was a 1 hour bus-ride from BH. We had to prevent any hemorrhagic manifestations and buy some more time until Dr. Payel could come from Kathmandu with the Amphotericin B. We called the district hospital in Mangalsen and arranged for blood donors from the community, and then the patient was sent on our ambulance for blood transfusion. This was a challenge for us, but we decided to take it.
The Kala-azar patient returned back to BH after successfully receiving two pints of blood transfusion over a period of two days in Mangalsen Hospital. In Mangalsen, she had continuous fever despite regular antipyretics and had vomited some blood in the morning. My hopes were still high that we could save our leishmaniasis patient this time. Several days later, Dr. Payel returned from Kathmandu with our wonder drug, Amphotericin B, amidst the bandh (strike). This added fuel to our hopes. We taught our nurses how to monitor for the side effects commonly associated with Amphotericin B administration, and get ready with hydrocortisone, chlorpheniramine and paracetamol injections for combating the “ampho-terrible” side effects that the patient would experience.
We took her baseline complete blood count, renal parameters, and electrolyte parameters before starting the drug to monitor its side effects. Every day, we paid special attention to her in the morning rounds and also tried to explain to her father each day about the disease and treatment. The emotional toil of caring for patients suffering from rare and unnecessary illness is not easy, as I learned with this patient. On day 7 of treatment, the size of her spleen had regressed (improved). She had re-gained her appetite. The child had no spikes of fever for 24 hours, and no signs of heart symptoms. Lab reports suggested that her bone marrow was recovering slowly. We also had added some fortified feeds to her diet, hoping that it could help her to gain some weight. Dr. Payel and I were both excited and crossed our fingers that she could recover completely.
Her kidney function lab tests were within normal limits but her electrolyte reports showed decreasing potassium levels and ensuing hypokalaemia which somewhat worried us. We tried to look for any bananas from the surrounding villages, but could not obtain any because of the growing season. Nor could the patient’s father from home. So, we had to start a potassium intravenous infusion along with the regular Amphotericin B until the electrolyte parameters could be maintained within range. We monitored the electrolytes daily to look for the progress, and finally we had it within range. There was more hope.
On day 14 of the Amphotericin B treatment, she had had no fever for the past few days. Her spleen size had regressed to normal on clinical examinations and she had gained her appetite. The bone marrow had recovered. The patient was better, and every one of us was satisfied; a sigh of relief was seen in the eyes of our whole team. Finally we were able to discharge our leishmaniasis patient from the hospital. It was with great pride and satisfaction that we assured the child’s father that the disease has been cured and she would be safe now. We asked him to be in constant follow up at the hospital to look for recurrence.
A rare case, with local unavailability of medicine, regular transport strikes, and difficult-to-access blood transfusion facilities – but as the old adage says, “if the god persists, all of us will be blessed.” It was made possible at Bayalpata Hospital. The whole Nyaya team did a great job to make this difficult treatment accessible to the patient and family. I feel immense satisfaction when we are able to treat our patients at BH.
Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is currently the Medical Director for Nyaya Health.