Rebekah's Cough

Walking through the Webuye clinic, where people of all ages sat on the benches lining the hallway and looked up expectantly at the doctor in the white coat, the first thing I noticed was how terribly one little girl was coughing. Despite the towering stack of patient charts on my desk, I made sure this little girl in a pink dress was the first patient I saw for the day.

Her grandmother told us the story as the little girl sat shyly on her lap, coughing occasionally and smiling at me through shy fingers covering her face:

This five-year-old girl, who I will call Rebekah, spent most of the last week in the district hospital with a bad pneumonia.  Her mother died two years ago, and her grandmother has been taking care of her ever since. The whereabouts of Rebekah's father are not known, and the grandmother is not sure if he is still alive or not. She has heard rumors that he is dead too.  Rebekah has been sick off and on for the last year, and she ended up in the hospital because she had a high fever and was not eating.  They thought she had malaria, but (oh, by the way), she had also had a bad cough for "weeks and weeks".  The hospital team treated Rebekah with antibiotics for pneumonia, and she seemed to get a bit better. And, towards the end of her time in the hospital, Rebekah's grandmother gathered up her courage and had the clinicians test her granddaughter for HIV.  Rebekah's test came back positive.  And so, here they are, in the HIV clinic in Webuye, where they happened to have the luck of coming on a day when a pediatrician was around.

My immediate suspicion was that young Rebekah had, not only HIV, but also TB. The disease that we keep talking about this week after World TB Day. While Rebekah's HIV may be the reason that she is small and skinny, that her body is covered with swollen lymph nodes, and that she keeps getting sick, TB also may have something to do with this.  And, TB is almost certainly the reason she has been coughing for weeks and that the x-ray of her lungs showed all sorts of nasty infiltrates and fluid making it hard for her to breathe. But because Rebekah is a child, it's hard to know for certain if she has TB. The usual, inexpensive tests for TB don't work as well in kids, and we don't have the most expensive test options.

To make matters even more messy, it's complicated when you have both HIV and TB at the same time. Not only does it make it harder to tell what is making you sick and not only do you have 2 terrible diseases as once, but the medicines for the 2 diseases cause problems for each other.  We generally have to delay starting the HIV medicines, so we can use the TB medicines by themselves for a few months, and then we add in a special set of HIV medicines after the first phase of TB treatment is done. Complicated.

Rebekah stuck in my mind because we have been finishing up a research project tackling just these problems: How do we best diagnose TB in children who have HIV or who are very likely to have HIV? And, how do we decide what TB and HIV treatments to give these children - especially if we are not completely sure that they have TB? Ultimately, we hope to give some suggestions for how to answer these questions here in Kenya and how to answer these questions in other resource-limited settings.  I think it's important work, and I certainly would appreciate having more guidance about how to best take care of the Rebekahs of Kenya.

Posted at 15:01

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