Tb or not Tb?

Sorry for the bad pun, but I just thought I'd write a bit about the challenges of working without being able to do many investigations. There aren't many tests available here- we can check the blood count and do tests for malaria and HIV and sickle cell etc but when it comes to other diseases we get a bit stuck. TB is a good example of a condition that can be very hard to diagnose as it has similar symptoms to lots of other conditions. There are more and more fancy investigations available but unfortunately we don't have them here. In adults the definitive test is to look at the patient's sputum for the distinctive bacteria but kids don't cough anything up! To complicate things further, the treatment is a minimum of 6 months long with patients needing to take 4 drugs for the first 2 months and then 2 for the rest of the time. If they miss doses they risk creating a drug-resistant strain, which is obviously bad news. So basically we rely on the history, examination and then look for patterns on their blood count and chest X-ray which make TB more likely.

Another difficult problem is the very anaemic children. We have had a few quite old children come in with really severe anaemia that stays low even after a number of blood transfusions. This is often triggered by malaria but it's important to know whether they might have an underlying abnormality, such as sickle cell disease, which makes them more likely to get severely anaemic. The problem is that by the time we see them they've often already had a blood transfusion, at which point any blood tests we do will be analysing the donor's blood instead! The soultion is to get them to come back in 3 months when all the donated blood cells have gone but many don't come back, or alternatively get ill during those 3 months and have more transfusions.

We very rarely find out for sure what our patients have, except when it's clear cut malaria. It can be frustrating as it's always nice to get an answer and be confident that you are giving people the right treatment. The good news is that most of the children get better anyway!