Opisthotonus and ANUG

The week began in Lobatse where I saw a child, one of several times in the peds ward, that had been horribly attacked by HIV and Tb. She had Tb meningitis and had an opisthotonic posture; back arched in a painful ark and unable to easily breathe or eat. She was not yet on anti-AIDS medication (HAART) as, while she was born here, her mother was from SA and therefore needed documentation that her daughter was born in Botswana, and therefore eligible. Never mind that she was born at that same hospital and this was one of many admissions. She was mal/undernourished and couldn't swallow, so afflicted was her brain and musculature by the combination of these two diseases. I placed an NG tube to start feeds while we waited for documentation that she could get HAART. I know, I didn't understand it either. And in the long run it wouldn't have made a difference.

That afternoon her father showed up to see her. The same that had dropped her off at the police station so THEY could take to the hospital. We informed him of her condition and his ambivalence was deafening. I had to leave. She died that night. Shit.

Acute Necrotizing Ulcerative Gingivostomatitis, a name that sounds as ugly as the disease. Factor in HIV and it is a true bastard. I was in Kanye yesterday and a 2y/o child was presented at morning report. We usually try to attend this before we give our presentation for the week at each outlying hospital. During the report a child was presented that had "an abscess" of the right cheek and was HIV unknown. His mother however was "late" (dead) most probably due to HIV. He, the patient, had been tested for HIV and was found to be "positive" only to have it whited out in his chart, or "card" (who the hell has white out around here other than Lynne?). In its place was "negative". Right....

In any case he looked like he was one year old, malnourished, and deathly ill. He had a right cheek that was immensely swollen and he appeared toxic as could be imagined. The culprit? Looking in his mouth I recognized the cardinal signs of ANUG; erythematous and exudative gingivae, blunting of the papillae, necrotic matter on the margin of the teeth (picture a kid who has just eaten pancakes and hasn't brushed his teeth), and teeth that are carioius to a fair-thee-well. Oh, and an odor of sewage.

I have yet to find a disease that isn't made worse by HIV and this unfortunately was no exception. I gloved up and palpated his right maxillary teeth only to have one float off in my finger. God I almost lost it. My voice cracked and I found myself tearing up as a wave of dismay, empathy, revulsion, and rage washed over me. I palpated his cheek and was greeted by the "ulcerative" component of the name, and things just got worse. He had eroded into his maxillary sinus and was a tissue paper thin bone away from his brain. All of his deciduous teeth on that side were loose, eroded or gone and I could see bone under them.

I have seen much worse but, perhaps to my credit, the immensity of that situation, now years ago, has dimmed and I wasn't prepared for how much I was affected by this child. By that morning he had been tested for HIV and to no one's surprise he was indeed positive. He was on the appropriate antibiotics and needed some x-rays to investigate whether he had infection of the bones of his face (an easy call) and how long to give him IV antibiotics (months). Not a good Friday.

And today I find myself a touch the worse for wear. So how did I handle it? I went to the pool (weird how it feels to say that we have one here), warmed up and swam a 400IM. Now I'm so baked that all I need is fork to finish me. Off for a big fat nap.