Blessings had been sick on and off for a few days now. Although it seemed usual for the 12 year old boy to be down with something every month, this time what had started off as a single febrile episode progressed into something more severe.
He developed a throaty productive cough and was breathless with exertion. Although he usually stayed away from strenuous sporting activities because of tiring easy, this time he was always exhausted even without having done anything.
A wiry lad for his age, Blessings was enrolled in a private Christian boarding school – a privilege that most sub-Saharan African children cannot enjoy. In a continent where a handful of school-aged children finish primary school, to be able to afford to go to a private Christian boarding school meant his family had much more means than the average.
Etta an American missionary and registered nurse working for the American Church that manages the school took notice and brought Blessings to the school clinic where she worked as the in house school nurse.
A rapid malaria antigen test turned up positive and she started him on standard artemether combination therapy (ACT) using Lumefantrine + Artemether and paracetamol/acetaminophen to control the fever. Etta phoned up Blessings’ mother who at that time was in Johannesburg for a few weeks of work and informed her that Blessings was with malaria and on treatment promising to phone for updates.
Initially the three-day treatment seemed to work and the boy was symptom free for most of the week. Then during the second weekend, he started having the symptoms all over again. It was then when Etta and the school matron took him to a private hospital.
As Blessings was ushered into the doctor’s office, he had a fever of 40.5 C (102 F) and was weak and pale. A quick but concise examination suggested an infectious etiology and Initial blood workup showed that he had malaria with an estimated parasite load of 20,000 parasites per uL of blood (about +3 on a malaria thick smear). He also had mild to moderate anemia with a hemoglobin count of 9.5g/dL.
Since he had just finished ACT and the parasite load was substantially high, the doctor decided to start him on a Quinine drip. For a boy his age, the doctor thought he was a bit smaller than the average and quite frail looking. A further investigation into the boy’s health history and that of his family was inconclusive.
There was nothing to point towards a genetic disorder that would cause this particular child to be sickly and all other laboratory tests came back satisfactory. The blood glucose levels were normal as were the liver and kidney functions. Even the chest x-ray was not suggestive of active, latent or childhood TB.
A urine and stool test was done to screen for parasites and there was note of hookworm ova in the stools. Likewise a Bilharzia/Schistosomiasis serologic test was done which showed a previous but not an acute infection. Because of the supposed intestinal parasitemia, Blessings was also started on the anti-parasitic agent Mebendazole and was given hematinic supplements for the anemia.
As soon as he got admitted, Etta phoned Blessings’ mother to inform her of the boy’s hospital admission and if she could please come. As the mother was a few countries away, it would take a few days for her to arrive. In the meantime she had asked Etta to please watch over her son until she came.
Blessings was an ideal patient. He took his medications on time and ate proper food. When the infusions of Quinine were due every eight hours, he sat quietly and patiently, oftentimes sleeping off the nausea and vertigo the medication caused. Although he seemed to be improving with treatment, the doctor noted that Blessings was taking longer to respond.
In what usually cleared within three or four days of quinine now stretched to five. The parasite load that had gone down to about 100 parasites per uL of blood (about +1 on a malaria thick smear) on the third day jumped back up to 1,000 parasites per uL of blood (about +2 on a malaria thick smear) on the fourth day when it would have been expected to become zero.
Then the parasite count rose further on the fifth day to about 8,000 parasites per uL of blood (about +3 on a malaria thick smear) quite close to his parasite burden when he first presented at the clinic.
Although he was reportedly feeling much better than before, the laboratory tests said otherwise and he still had to stay confined to the hospital to continue the qunine treatment. It was then when Etta thought there could be something else behind the boy’s illness.
A nurse for most of her life, Etta had enough exposure to know something about HIV in the pediatric population. She had suspected something even months before when Blessings had come repetitively to the clinic for some kind of complaint.
She however, dismissed the notion of Blessings having HIV considering that he should definitely be worse off now with opportunistic infections if he had HIV since birth. Also, if he was indeed with the HIV, shouldn’t his parents be also sickly or on treatment? It seemed unlikely for Blessings’ parents to be seropositive as they both looked very well nourished.
Also, both parents were alive and well and though lived half the time in Johannesburg – several countries away, took very good care of Blessings as he was their only child.
In any case, Etta told the doctor of her suspicions to which the doctor asked her if she knew if the boy had a history of blood transfusions.
Although initial blood tests did not show Blessings had a blood disorder, or the medical history revealed no surgical procedure performed on him, it remains a fact that 1 in 2,135,000 cases of HIV contract the disease from transfusions with poorly screened donor blood or inappropriately unsterile aseptic technique.
This ratio has decreased in the past two decades thanks to improvements in donor screening protocols and hygiene and sterilization techniques.
Since Blessings’ mother was still a day away, Etta knew that it was legally impossible for her to ask the hospital to perform such a test as she was not the parent or the designated legal guardian.
to be continued…
– Dr. Luc Victor, Medical Observer