On being a doctor in a foreign land

On being a doctor in a foreign land.

One of the DIRA staff came to me with a dilemma. His younger brother, from Idunda, has had recurrent abscesses of the scalp every few months for the past eight years. The older brother has a detailed record of the doctors notes each time this has happened, seven or more times in eight years. Some resolve spontaneously. One was large enough to require wide drainage and packing. Still they recur. They have mostly been on the scalp, but have occurred on the face or temple as well. Some have been incised and drained, the treated with a variety of antibiotics, including erythromycin, metronidazole and ciprofloxacin. Typically, when he gets them, they are accompanied by fever and lymphadenopathy. Sometimes he has delirium, sometimes headache with scintillating scotomata. There have been no neuro defects, rare vomiting. He temporarily loses weight which e regains as these improve. Past skull x-rays have showed no periosteal reaction.

On exam, he is alert and ambulatory but uncomfortable. The mass is warm, not hot, but 10 cm in diameter and moderately tender. It is fluctuant but not pointing. It is in the sagittal line. He has small, tender lymph nodes in the posterior cervical chains bilaterally; none in the anterior chains or angle of the jaw. TMs are clear, throat is clear. Speech is clear. Face is symmetrical; biceps, triceps and grip strength are equal.

My differential is limited: this is an abscess. Why the recurrences? He has had at least the three antibiotic course noted. I do not know if he has been checked for HIV or TB, but these are so common here it is hard to imagine they have not been. Could he have some other immune compromise? Seems like a long indolent course for malignancy.

I spoke with Dr.Saga, the Chief of Staff of Ilula. He appreciated my thoughts and himself thought nutrition might explain the recurrences.

After I&D here in Iringa, he was doing well. The attending has offered a referral to Dar es Salaam. But I think Dr. Saga is correct that it is worth anothe shot with antibiotics first and multivitamins.

Here is a dilemma. He lives in Idunda. He is married, has five children, and like most of the people there, has no job and no money to pay for the referral or even antibiotics. for referral, patients like him require an escort to provide supportive care and talk to the doctors. His brother would have to ask for time off. Essentially, the brother was asking for money. At Ilula, they have a charity fund. To avoid fraud, they check on the finances of the patients who say they cannot pay. Thus, when we get home, I will start a fund for use at the discretion of Bega kwa Bega and consultation by Dr. Saga or other medical staff at Ilula. It is all I can think of to do.

Ken