about a week after arriving in togo, i examined a six year
old girl who presented with about one week of fever, diarrhea, emesis, and
diffuse abdominal pain. i didn't think much of it, and didn't use gloves,
because they aren't really readily available in the clinic unless you go
looking for them. i have been using them since. we did some blood work, and
admitted her to the hospital. she tested negative for malaria
and typhoid fever, the two most common etiologies of fever here. she also had
significant pancytopenia (low white blood cells, red blood cells, and
platelets), which is strange. we started her on the empiric antibiotic
treatment for typhoid fever, but after two days she continued to have
persistently high fevers, and her three year old sister also started developing
the same symptoms. her sister was found to have the same lab results, and both also
had very high transaminase (liver enzymes) levels as well. all these symptoms
are consistent with viral hemorrhagic fever, specifically a terrible disease called
lassa fever. to top it off, the younger girl started having profuse blood in
her stool.
lassa fever is an arenavirus endemic to certain parts of
west africa, spread by the aerosolized urine of a certain species of rat, which
come into people's homes during the dry seasons. it can also be spread between
people via any body fluids. it was first described in the 1970s, and was named
after a city in northeastern nigeria where there was a major outbreak. it is a
viral hemorrhagic fever similar to ebola and marburg virus, as in addition to
the nonspecific symptoms of fever, abdominal pain, diarrhea, emesis, and throat
pain, etc, it can also cause bleeding from mucosal membranes and hypovolemic
shock and end organ failure. so pretty scary. it has even been cited as a
potential agent for bioterrorism. about 80% of people who get it actually don't
get sick enough to be hospitalized, but the mortality rate is about 50% for
those who need hospitalization. even more scary, well over 50% of nosocomial
infections (person-to-person in a healthcare setting) are fatal.
there had never been a positive case of lassa fever in this
part of togo before, making it less likely. however, antibody studies have been
done suggesting that the majority of togolese have been exposed to the virus at
some point, meaning it exists and just hasn't been isolated, likely simply due
to lack of testing. the first person confirmed to have died from lassa fever in
the recent past who contracted it in togo was an american physician assistant
who was working in a mission hospital in northern togo and fell ill last year.
he continued to deteriorate, and was evacuated to germany, where he sadly died.
they then discovered he had lassa fever. he didn't have any known exposures, so
no one really knows how he contracted it.
after the girls had been sick for a while and after much
discussion among the hospital staff, it was decided to send a blood sample to
the central lab of the government in lome to test for lassa fever. it became
apparent that it is quite the process. the local authorities have to sign off
on the test being done after a meeting, and a medical provider has to escort
the blood sample all the way to lome as it is considered biohazardous. this all
took the better part of a week to arrange. once the blood finally made it there
the confirmatory test by pcr was relatively quick. i read everything on the
internet about lassa fever. interestingly, a number of studies about transmission in exposed, unprotected individuals came out of germany last year after the missionary from togo was evacuated to there with a yet unknown illness. there is an antidote of sorts, but it doesn't really work very well, and isn't exactly available on short notice to a rural hospital in togo.
thankfully, the test came back negative! i must admit
though, in the intervening days i was quite scared that i might get it (and if
i did, more likely than not, die an agonizing death). because the disease
starts with nonspecific symptoms like sore throat, diarrhea and fever, i was
constantly thinking that i might be coming down with it. i prayed more frequently
and fervently than i normally do. it was an important reminder for me of the
fragility of my life, and that they can end before we want them to, a reality
that isn't as apparent in the west as it is in africa. i really needed to trust
in God, and be reminded that my faith in Him is all i really have that matters,
and all i really need. there are so many frivolous concerns in our lives that
just don't really matter when you think you might die soon. thank you to my
amazing wife who comforted me when i was really on edge. we still don't know
what the girls had, but it was almost certainly something viral and nasty.
thankfully they started to do better and we were able to send them home.
