Kernicterus and opisthotonus (#2)

Was in a district hospital today and rounded in the peds ward. Now, as a doc, there exists a side of me that has a "life list" of pathology as it were. I see people with diagnoses that would rarely be seen in the US and "collect" them on my list. I know, sick and wrong. But there you have it, all in the name of transparency. So today we were in peds and the pathology was waist deep.

There were two kids with malnutrition and other co-existing diseases. Often they have been admitted many times with the same co-morbid diagnoses and nobody asks why. I may have mentioned that the kids here are compared to growth curves that are weight and height for age, not weight for length. So they can be happily tracking along at a low percentile, not raising suspicions and still be quite malnourished by w/l measurements. We saw both of the major kinds of malnutrition and had a long discussion about what the nutritional requirements are in theses variants of disease and why they are somewhat altogether different, not unlike diabetes type 1 and 2. Both are wasting illnesses with different manifestations and nutritional therapies.

Then we saw a child with a constellation of symptoms that medical types in the States spend a lot of time worrying about but rarely if ever see. This child was admitted with "pneumonia", an all too common diagnosis, one I/we frequently "undiagnose". In the process of discussing the situation, the mother volunteered that she had taken the child to an ophthalmologist for an eye exam and had been told the eyes "were just OK". As we looked at the child I noticed some slow grimacing and posturing called choreo-athetoid movements. His eyes were averse to upward gaze to the extent that he looked so far downward his pupils were buried in the lower lids. And his mother reported that it seemed as though he couldn't hear. She then volunteered that he was admitted with a post birth bilirubin that was 36 times normal. He had all the cardinal signs of kernicterus. This is also a true bastard; his fate is sealed. In the States there is a lot of preoccupation about this very rare ( in the Western World) complication of bilirubin metabolism. But this is the first case I have seen.

Then it was opithotonus, again. A child that was in the ward a week ago with this was now on ATT but was still in great pain and distress. I asked to take a picture as this was on the list but I now have seen enough that the novelty has worn off.

Then a young boy with monstrous neck nodes that, I think, were misdiagnosed as extra pulmonary Tb. We wanted to take him to the OR ("theatre") but the anesthetist was resistant. There was a bit of gesticulating and animated conversation following and she called PMH (now called the "Hospital of Death" in the local media, well deserved in my opinion) and they accepted the child in transfer to undergo anesthesia by an anesthesiologist. The nodes should explode and reduce in size significantly. I'll really be surprised of this is Tb.

More for the list.