Imagine: You are the single provider manning a rural clinic in Northern Tanzania along the shore of Lake Victoria. You are one of only a handful of physicians in the entire region and you have minimal access to diagnostics or therapeutics. Your clinic does not have any power. Your diagnostics include: urinalysis, urine pregnancy, CBC and rapid tests for HIV, syphilis, and malaria. You have 2 nurses, one of whom acts as a translator (from Swahili to English). You are armed primarily with your intellect, knowledge of local disease processes, and your keen sense of intuition.
Case # 8
52 yo F p/w lesions of bilateral breasts & neck x several months, now worsening. Reports discomfort but no overt pain. No fevers, chills, nausea, vomiting. Husband now deceased with a prior history of skin lesions and deformity. Rapid tests for HIV and syphilis negative.
PE: 37C, HR-82, RR-16, BP-128/76
Gen: Appears anxious but in no acute distress
HEENT: PERRL, EOMI. Oral thrush noted.
C/V: S1S2 present, RRR, no m/r/g
Resp: CTAB, no crackles/wheezes
Abd: soft, nt/nd no rebound/guarding
Skin: Diffuse regularly bordered, excoriated ulcerative lesions extending from the anterior chest, between the breasts, outwards. Non-tender to palpation. Minimal erythema. No active bleeding or drainage. Dry, leathery skin of the chest and axillae. Similar lesions to the anterior neck as well as R lateral neck. These lesions are moist with minimal bleeding and friable borders, again non-tender to palpation. In addition, there are numerous small, raised rounded lesions on bilateral arms and legs. They are rubbery and the skin is darkened. Non-tender to palpation. Pictures below.
What is the presumed diagnosis? What else is in your differential?
Case #8: Diagnosis = Leprosy
Ddx includes: Leprosy, Cutaneous Leishmaniasis, Cutaneous Tuberculosis, Necrotizing fasciitis, Malignancy, etc.
Leprosy (aka Hansen’s disease) is a chronic infection caused by Mycobacterium leprae and Mycobacterium lepromatosis. Initial infections may be asymptomatic for as many as 5-20 years. Infection with M. leprae leads to chronic granulomatous inflammation in skin and peripheral nerves. Patients with lepromatous leprosy are anergic towards M. leprae and have multiple lesions with mycobacteria present. Nerve involvement typically leads to the lack of ability to feel pain at lesion sites. This often leads to repeated injuries of extremities with potential for loss and significant disability.
Leprosy has been present throughout history and has been documented for several thousand years. While the prevalence has fallen strikingly over the past 50 years, new case detection rate for leprosy remains high, with about 250,000 new cases per year. Cases have been reported primarily in 17 countries with more than half of new cases in India alone.
Treatment for paucibacillary leprosy is dapsone and rifampicin for 6 months. For multibacillary leprosy treatment includes dapsone and rifampicin along with clofazimine for 12 months. Nerve damage and disability can progress despite treatment. Historically, leprosy has been associated with a very high degree of social stigma. The mode of transmission is still not conclusively proven, although person-to-person spread via nasal droplets is believed to be the main route.
Leprosy jumped to the top of my differential after I discovered that the patient’s husband had been diagnosed with leprosy many years before and suffered significant lesions and disability, being committed to a leprosy ward. Her lesions were also non-tender and she was HIV & syphilis negative. There was still a leprosy ward in Shirati, Tanzania, however there were only about 10 remaining patients with “burned out” cases. In fact, this was potentially the first known new case of leprosy in several years in the district.
Case # 9
65 yo M PMH CHF & PUD p/w pitting edema to thighs, diffuse crackles bilaterally. Previously treated with hydrochlorothiazide, digoxin, and furosemide but lives in extreme poverty with inability to afford meds and has poor access to health care as he lives several hours away from the nearest clinic. Still has some furosemide remaining but no digoxin or hydrochlorothiazide.
PE: 37C HR-120s RR-20 BP-200/100
Gen: Appears uncomfortable and short of breath.
HEENT: PERRL, EOMI, +conjunctival pallor
C/V: S1S2 present. Tachycardic to 120s. Normal rhythm. III-IV/VI holosystolic murmur loudest at the LUSB
Resp: Diffuse crackles bilaterally; decreased air movement
Abd: Epigastric tenderness. Mild abdominal fullness. No rebound. Mild voluntary guarding. +Fluid wave.
Ext: Diffuse 3+ pitting edema to bilateral thighs
Ethical Dilemma: This patient would clearly benefit from admission to a hospital with aggressive management for decompensated heart failure. However, in rural Tanzania most care is fee for service and this patient is unable to afford admission to the local hospital. In fact, he is unable to afford observation overnight at your clinic or even HIV/syphilis tests. The total cost for overnight observation and IV medications and tests would amount to less than $10.
What do you do?
This patient presented on one of the days I was running the rural stand-alone clinic by myself. This is a common example of an ethical dilemma that may arise during a global health elective. Diagnostics and therapeutics in this patient would normally be straightforward however the waters are muddied when resources are limited. Issues raised in this case include resource allocation, poverty, and access to care. Since it would cost just a few dollars to get medications, tests, and an admission the thought of pulling out a few dollars from one’s pocket immediately comes to mind. We are fierce patient advocates but must be cognizant of the downstream effects of our actions. How do you decide whom to help and whom not to help? Will treating this man for one day change the course of his disease? There are no right or wrong answers but each case is worth analyzing closely.
In our case, the man was able to afford several vials of IV Lasix (80 mg), which I administered to him prior to his discharge. I was also able to increase his oral Lasix dose and restart his digoxin and hydrochlorothiazide. The patient promised to return for admission the following week after he returned to his village and gathered more funds.
- WHO. Leprosy--the disease. 2015. Accessible at: http://www.who.int/lep/leprosy/en/
- CDC. Hansen’s disease (Leprosy. 2013. Accessible at: http://www.cdc.gov/leprosy/
- Selvam A. The Other Side of the Looking Glass: Ethical Dilemmas During the Global Health Elective. EM Resident. 2015. Accessible at: http://www.emresident.org/ethical-dilemmas-during-the-global-health-elective/
- Pinto AD, Upshur REG. Global Health Ethics for Students. Dev World Bioeth. 2009;9(1):1-10.