Case of the Week: 19th Nov

November 20, 2018

Our case of the week is from Dr Anna at Makunduchi and deals with a severely sick and malnourished infant admitted to the ward.

The mother brought her 5 month old boy to the hospital in seriously sick and unstable condition. The baby weighed only 3.6 kg at 5 months of age, though had a normal birth weight of 3.7kg. For 2 days he had diarrhoea and was coughing severely. Examination of the baby showed a very weak and septic (severely unwell with infection) infant with significant dehydration. Furthermore he had a massive fungal infection of his mouth and inner eye angles.

 

The baby was immediately taken to the emergency room, given oxygen and and IV line was inserted. The boy was started on intravenous antibiotic treatment for sepsis, as well as a treatment for the fungal infection. Thus after a while we were able to stabilise the boy a bit.

 

As the mother was not breastfeeding sufficiently, the baby was given Infant formula by spoon or cup feeding. But since the small one had a massive oral fungal infection, feeding was very complicated. Therefore we decided to place an nasogastric tube (from the nose into the stomach) to ensure correct feeding amounts.

 

Talking to the mother, we finally found out that she was diagnosed HIV positive long term ago and was not on any medication. Initially she did not admit to be HIV positive. We therefore concluded that the baby was HIV positive as well and thus presented with a clinical stage 4 disease. Testing for infants is not available in Zanzibar, so the sample was send to Dar es Salaam (on the mainland of Tanzania) for further investigation.

 

We consulted with the ministry guidelines and started the baby here on antibiotic prophylaxis (to prevent HIV-related infections) as well as on anti-TB treatment. We planned to start anti-retroviral therapy (to treat HIV) after 14 days.

 

During the following days the baby stabilised further and the oxygen therapy could be stopped. While feeding by NG-tube, he started to gain some weight slowly.

Unfortunately the family decided to leave the hospital as soon as the infant was a bit more stable. They did not finish the antibiotic treatment nor did they come back to the clinic for follow up. We tried to contact them, but they were not reachable anymore.

 

Malnutrition is a significant problem in Zanzibar, particularly for children under 5. We are continuing the work of previous HIPZ volunteers at Kivunge and Makunduchi to improve the management of malnutrition, both on inpatient and outpatient basis. This case illustrates the need to look for underlying causes for malnutrition - in this case untreated HIV - alongside stabilising the patient and carefully controlling the feeding.

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