Women´s health and infection control

Yesterday I spent all morning working with the OB/Gyn who works at CFLAG. She does all of the Pap smears for the HIV positive women in the clinic, cares for all HIV positive pregnant patients, and also works for the Hospital San Juan de Dios as an OB/Gyn (separate from the clinic). I really enjoyed working with her. I´ve always liked women´s health, as well as hands-on activities like pelvic exams - so it was a good day. The pathology seen during the pelvic exams consisted of vaginal candidiasis, vulvar/vaginal atrophy, and quite a lot of genital warts. After we finished doing pap smears we went across the hall to watch colposcopies. It was really interesting, since I had never seen colposcopy before. (For my non-medical friends and family, colposcopy is a procedure in which a speculum is introduced into the vagina, just like a regular PAP or pelvic exam, acetic acid is applied to the cervix, and the doctor then looks at the cervix with a microscope, and any part of the cervix that turns white with acetic acid is biopsied. It is a way to look for possible malignancies).

When I first arrived in the clinic for PAPs I was relieved to see that there was paper on the exam table. Finally - a place within the hospital where the bed covering is changed between patients. (In the general HIV clinic the beds are covered with sheets that are not changed in between patients). The PAP exam table had a long strip of brown paper on it, and after we saw the first patient, I reached towards the table to remove the used paper, and was immediately told that the paper is not changed until the end of the day - after all of the pelvic exams are finished. "But these women are sitting on the paper with naked bottoms, dont you think we should change the paper?" I asked. "No. We change it after all the patients are finished. We dont have enough paper to change it after each patient visit," I was told. (Despite the fact that there was a full roll of brown paper under the examination table). And to make matters worse - there was just one cloth gown that all of the women had to change into for their PAP smear!! All of the patients that we saw were HIV positive, many of them with genital warts, many of them with vaginal discharge, and all of them sharing the same brown piece of paper and cloth gown. Also, despite the fact that there was a fully functional sink with a full bottle of soap and a full towel dispenser (a rarity in Hospital General San Juan de Dios), no one used it throughout the day but me. The gynecologist washed her hands at the sink after we had finished seeing all of the patients. This is a trend that I have seen throughout my month here in Guatemala. The majority of practitioners (of course, there are exceptions) wash their hands after having seen all of their patients. It seems that hand washing is perceived more as a means of protecting oneself than of protecting patients.

Anisocoria

Monday I saw a patient who came to the clinic for follow up of a perirectal abscess. He is HIV+ with a past medical history of pulmonary tuberculosis. His current CD4 count is in the 300’s. As it turns out, his abscess had completely resolved, but he was complaining of back pain along his spinal cord that started in his lower back and continued all the way to the back of his head. He said that the pain was so unbearable at times, that he had to lie down. He occasionally felt nauseous, but had not vomited. He feels like he has had fevers in the afternoons, but he does not have a thermometer to measure the temperature (he was afebrile in clinic). He said that all of this started 5 or so days before he went to see the doctor for the abscess, but that it has been getting worse, and the headaches and back pains are progressive.

On physical exam, I first noted his prominent anisocoria. His left pupil was dilated (mydriasis) and his right pupil was constricted (miosis). In addition, it seemed that his left eye tended to abduct (look away from his nose) with forward gaze. His vision was markedly decreased in the left eye. On fundoscopic exam, the margins of the left optic disc were sharp, without any evidence of papilledema, but the retina appeared dark and dusky. I was unable to visualize the right retina, due to miosis. Additionally, bending the patient’s head to his chest caused severe back pain, as well as bending his knees toward his chest while lying on his back – positive meningeal signs. Otherwise, his physical exam was completely normal.

Positive meningeal signs usually merits a lumbar puncture, but since he had focal neurologic deficits, we decided to get a CT scan of his head first. After working with the social worker to find funding for a CT scan, the patient was able to get the scan Monday afternoon. Tuesday the results were back – single hypodensity seen in the right frontal lobe with minimal mass effect. The patient returned to clinic Tuesday for the results, and on further questioning, it was discovered that he has cats in his house.

So what is the differential diagnosis of the mass lesion?

- Primary CNS lymphoma
- Toxoplasmosis encephalitis
- Tuberculous encephalitis (Tuberculoma)
- VZV encephalitis
- Chagoma (Trypanosoma cruzii)
- PML

And he could also have cryptococcal, tuberculous, or fungal meningitis as well.

So what did we do? Well, with the minimal mass effect seen by the CNS lesion, the lumbar puncture was not performed. We ordered a serum cryptococcal antigen test, as a means of looking for cryptococcal meningitis without a lumbar puncture. And we started him on therapeutic dosages of pyrimethamine, sulfadiazine, and leucovorin for toxoplasmosis. The reality is, that there is not an acceptable diagnostic test for toxoplasmosis that is available in Guatemala, so treatment and assessment for improvement or worsening of symptoms with therapy is the way in which it is diagnosed or ruled out. There is not PCR for EBV either, which would be useful in diagnosing Primary CNS lymphoma. The patient has agreed to come to the clinic every day this week for neurological checks, and to assess for change in symptoms. What do you think he has?

Que rapido pasa el tiempo

Three weeks have gone by, and it´s starting to feel like I just got here. I have really enjoyed the past week in the clinic. Similar to my experience during my Internal Medicine rotation third year, I find it much more gratifying to participate in the prevention of disease and the maintenance of health in an outpatient setting, than to drown in the frustration of inpatient medicine with patients who have already passed the threshold of salvaging their quality of life. I like the idea of preventing hospitalizations and enabling patients with chronic disease to live a full and healthy life. And that is certainly what is done in the HIV clinic. With the limited resources available in the hospital and the discrimination against patients with HIV by the inpatient attendings and hospital administration, it is in the patients´ best interest to stay out of the hospital. Over the past week I have seen several patients following up as an outpatient after having been treated in the hospital for diseases such as Toxoplasmosis, PML, Disseminated Histoplasmosis, Cryptococcal meningitis, and of course, TB. I was able to see a patient in follow up that I had cared for during my first week on the hospital floor who had herpes zoster of the first branch of the trigeminal nerve (right forehead and right eye) with bacterial superinfection of the cornea - he looked great, and was only complaining of some itching around the healing skin wounds.

Something that I learned this week that blew my mind was that all admissions to Hospital San Juan de Dios are free. All medications while inpatient are free as well. X-rays are free, food is free. The only thing that requires payment is CT scan, since the CT scanner is not owned by the hospital, but rather by an outside company. After all the complaining that I have done in regards to the quality of care at the hospital, the fact that they are able to provide free care to all patients is pretty amazing.

And for some follow up on the trivia question in a previous post (the man with the rash that itched). A punch biopsy was performed, and it demonstrated lymphocitic and eosinophilic infiltration consistent with insect bites. So, we gave him treatment for scabies, which is most likely the insect causing his rash. Congratulations to Dr. Jen Genuardi from Delaware who emailed me her diagnosis of Norwegian scabies!! She won the trivia question of the day.

Consejería y hongos

I spent the first part of yesterday morning observing the CFLAG counselors. They provide both pre- and post-HIV test counseling to every patient that comes to the clinic for an HIV test. They really do an excellent job of asking patients why they have come to be tested, what they know about HIV, and then providing appropriate information in a very clear and concise fashion. Of note, CFLAG only has funding to provide free HIV tests to pregnant women, so if you are a nonpregnant female or a male, then you have to pay 60 Quetzales ($8) for the test, as well as purchase the needle and syringe for the blood sample (10 Quetzales). If the patient is absolutely unable to pay, then he/she can speak with the social worker about having the fee waived. I asked one of the counselors why the patients had to purchase their own needles and syringes (since they have a decent supply in the clinic), and she said that it was due to funding, as well as the fact that when patients purchase their own needles and syringes, they will be certain that the needle was not contaminated or reused – decreasing the likelihood that someone might blame the HIV+ result on a contaminated needle. Interesante.

After spending some time with the counselors, I headed over to the Tuberculosis and Fungal laboratory to work with the incredible Licenciada Sandra. She is the head of the laboratory, and she spent an hour telling me what they do in the lab, as well as showing me some really neat specimens of fungus and mycobacteria that have been isolated from patients at the hospital. The predominant stains used by the lab are Giemsa, H&E, India Ink, Ziehl Neelson, Kenyan, and occasionally the Gomori methenamine silver stain. By far the most commonly isolated organism in the lab is Mycobacterium. She said that they isolate 150-200 cases per year. The most common fungus is histoplasmosis at 47-50 cases per year. Coccidioidomycosis has a much smaller representation at 4-5 cases per year. When it comes to Mycobacteria, the lab does not currently have the technology necessary to differentiate species of mycobacteria, but are hoping to get the DNA probes within the next month, which will be very exciting for the lab, and beneficial to the patients as well.

Macroconidia of histoplasmosis growing from a bone marrow aspiration

Tinta China (India Ink) positive for crytococcus in CSF

First day in the clinic

Yesterday was my first official day working in the Clinica Familiar Luis Angel Garcia (CFLAG), and it was great. I worked with an incredible doctor, Dr. Herrera, and we saw patients from 7 AM to 2 PM without stopping. We saw a wide variety of patients, from asymptomatic patients with CD4 counts as high as 834 (a normal level for a person without HIV) to very sick, cachectic patients that required admission to the hospital. We admitted 2 patients to the hospital yesterday - one was a man with cough and weight loss for the past three months. He was so weak that he could barely walk. He was seen in the clinic last week, and had taken 3 sputum samples to the lab since then to rule out tuberculosis. All of his sputum samples were negative for tuberculosis, so Dr. Herrera peformed a bone marrow biopsy in the clinic to look for disseminated Histoplasmosis or miliary tuberculosis, then walked him to the Emergency room for admission to the hospital. The second was a woman also with cough and weight loss, as well as headache, neck pain, and dizziness. She previously weighed 125 lbs, but now weighs 80 lbs. She came in asking to be admitted, saying that she could not go on like this. After performing a fundoscopic exam to ensure that she did not have papilledema, I performed a lumbar puncture. Sure enough, the cerebrospinal fluid (CSF) came pulsating out. This makes the diagnosis of cryptococcal meningitis highly likely, since it is known to produce elevated opening pressures. The apparatus needed to measure CSF opening pressure is not available here, so you have to go by the speed and quantity of the fluid. After the lumbar puncture, we walked her to the Emergency room to be admitted as well.

And for the trivia question of the day - this rash belongs to a 62 year old male with AIDS. His CD4 count is less than 200. He has had it for about a month, and it itches like crazy. He scratches it all night long, and pours lemon juice on it during the day to take away the itch. The distribution of the rash includes bilateral lower legs, bilateral forearms, lower back, buttocks, and a few small lesions on the abdomen:

Feliz Día del Cariño

In honor of Valentine’s Day there was an early morning gathering of everyone who works in the clinic. There were biscuits with meat (bolovanes), cakes, cookies, coffee, and some sort of sugar free orange soda. It was a pleasant way to start the morning, and a reminder of how important friendship and camaraderie is here in Guatemala. In a very Guatemalan fashion of doing things, the fiesta started at 7:00 (when clinic usually starts) and lasted until 8:00. Therefore clinic started one hour late, of course. Everyone was very kind to include Tira and me in all of the festivities, giving us hugs, kisses, and valentines.

Dr. Morales and me at the Dia del Cariño fiesta

Things are rather calm for us on the floors of the hospital right now. Most of our patients have tuberculosis and/or histoplasmosis, with a smattering of cryptococcal meningitis and toxoplasmosis. These are all diseases that require a long course of inpatient treatment, so not much new is happening. In the clinic, however, Tira told me that yesterday she helped one of the doctors remove a bullet from a patient (not my idea of typical clinic work!), so I think that she is staying busy. Tira and I will switch positions on Monday – she will start working on the hospital floors, and I will work in the clinic. I look forward to participating in the day to day life of the Clinica Familiar. I think working in a place dedicated to the care of HIV positive patients will be a nice contrast to the often hostile environment of the hospital.

Tira inside CFLAG

Wednesday, February 13, was the opening night of an Orchid Exposition in Guatemala City. The Monja Blanca (a type of orchid) is Guatemala’s national flower, and as one might imagine, many Guatemalans take pride in all types of orchids. The exposition included a competition, and it just so happens that both Dr. Arathoon (clinic director) and Dr. Graybill (former UTHSCSA professor, now living half-time in Guatemala) submitted orchids for the contest and won first prize in their respective categories! The flowers were absolutely beautiful. I have attached a few fotos below.

Some beautiful purple orchids

La monja blanca

Dr arathoon’s prize winning orchids

The man that I spoke about in a previous post, with the hypoxic respiratory failure and presumed Pneumocystis pneumonia, died over the weekend. While it is not surprising, since he was not receiving the treatment that he needed for the majority of his hospital stay, it is quite disheartening. I will never forget his face, or how hard he was working to breath. He was begging us for medicine - something, anything that would help him to breathe - and all that we could do was write suggestions for his primary team to follow. Clearly that was not enough.

Me da pena.

In addition to that man, two more HIV positive patients died over the weekend. Granted, many of the HIV patients in the hospital are new HIV diagnoses, and are presenting with fulminant AIDS and two or more opportunistic infections, putting them at much higher risk of a poor outcome. But I just can’t get this sick feeling out of my stomach that something more should have been done. The patients could have been given the correct medications, started the medications sooner, or gone to the ICU. But not here. Not in the poorest hospital in the poorest country in Central America. There is not enough money to pay for the needs of HIV patients, so we are told.

So here I am, the gringa from San Antonio who came to participate in the service of healthcare to patients with HIV in Guatemala, and I now find myself sad and quite frustrated. This is not a small problem, it is a big one. Systemic change is needed. HIV patients should be cared for by doctors that stay up to date on the newest changes in HIV therapy, not by generalists without the slightest interest in immunocompromised patients. HIV patients should have just as much right to an ICU bed as I do.

A weekend in Antigua

Tira and I were privileged enough to spend our first weekend in Antigua at the Graybill's house. It has been a lovely weekend thus far. Antigua is a beautiful city, full of tourists, with a great deal of history. Yesterday we spent the afternoon hiking up a mountain to see the active Volcano Pacaya. It was quite an adventure - the mountain hike was quite strenuous, and climbing around the cooled lava was often quite precarious. The closer we got to the glowing orange lava, the hotter it became. So hot, in fact, that many of the tourists found lava rocks that had melted into the soles of their rubber shoes! The Graybills have a lovely Guatemalan home, surrounded by gardens on all sides. It seems that Dr. Graybill has an affinity for all things flowering, and his home is surrounded by some of the most beautiful flowers that I have ever seen. He loves orchids and has numerous different species around his home. Today is the first Sunday of Lent, or the "cuaresma," a highly celebrated time in the Catholic church here in Guatemala so we will be heading downtown shortly to see the processions throughout Antigua.

Tira and I on top of the mountain near sunset

“Vivo frustrado todo el dia” – Dr Arathoon

“I live frustrated all day long” said Dr Arathoon, the director of CFLAG after hospital rounds one day. The doctors at CFLAG act as consultants for all of the HIV patients in the hospital, and as consultants they cannot write orders, but only suggestions. It often happens that the suggestions of the CFLAG doctors are not followed by the floor attendings until the suggestions have been made every day for 4-5 days, while the patient continues to deteriorate. For example, there is a man on the floor with presumed Pneumocysits Pneumonia who has been treated with Bactrim for 5 days without improvement. On admission his arterial blood gas demonstrated significant hypoxia, as well as an elevated A-a gradient, both of which are criteria for adding prednisone to the Bactrim regimen, but the prednisone has not been added. When we saw the patient on Thursday with Dr. Arathoon, he was breathing 45-60 times per minute – clinically in severe respiratory distress. I asked why he had not been transferred to the ICU for his respiratory distress and hypoxia, and I was told that HIV patients are not admitted into the ICU because HIV is considered a “poor prognosis.” Poor prognosis?!?! Are you kidding?!?! I was infuriated. In this era of Highly Active Antiretroviral Therapy (HAART), patients with HIV are living decades with their disease. HIV is becoming more and more of a chronic disease like diabetes, that if well controlled does not hinder the life of the patient. To think that a patient with hypoxic respiratory failure would not be allowed in the ICU because he is HIV+ is like saying that your grandmother with Diabetes should not be allowed in the ICU either. Frustrating.

And for another incredibly sad and frustrating story – a young 14 year old girl was admitted to the hospital for 2 years of nausea, vomiting, diarrhea, and weight loss. Her mother brought her to the hospital when she had lost so much weight that she could not walk. During her hospital course she was tested for HIV and found to be HIV+. When asked if she had ever had sex, she denied it. She had no other risk factors for HIV. She continued to deteriorate in the hospital – she stopped talking, she developed nystagmus, and she was barely able to move by the time that I saw her. After 5 days in the hospital without any improvement, the mother wanted to take her daughter back home. Not really understanding the significance of HIV, she felt that her daughter would be better off at home. It just so happened that the day after I saw the young girl in the hospital, her uncle came to the clinic at CFLAG, and was found to be HIV positive. It is most likely in this case that the uncle was one who gave this young girl HIV. The day after her mother found out that her husband’s brother was HIV positive, her daughter died. I arrived at the hospital the next morning only to find the bed empty. “What happened?” I asked. “She died,” I was told. But of what? Why? What happened? No one knew. There was not a doctor on the floor when it happened. She was just found dead by a nurse. There was no effort made to determine the cause of death. The chart was gone, and so was she.

The pinata!
















Sanson, el gran perro
















Cascarones with the grandchildren

This is the waiting room for the Clinica Familiar Luis Angel Garcia, right next door to the hospital entrance.

Fiestas for poodles and bone marrow biopsies

The fiesta for Sansón was quite a success - with cascarones, a piñata, and a delicious cake made by a cousin especially for the occasion. Our house was filled with family - sisters, mothers, grandmothers, cousins, nieces and nephews - there was not a single adult male in the house. It seems the poodle´s birthday was just another occasion to bring all of the young children in the family together and to enjoy each other´s company. It seems that enjoying one another´s company is something quite integral to the Guatemalan life. We spend at least 2 hours eating lunch and dinner, and not because of the quantity of food present!

The hospital is lacking in many of the diagnostic tests that we have at our fingertips every day at University Hospital - particularly laboratory tests for histoplasmosis. So almost every patient with HIV that has lost weight, had fever, developed a pneumonia, or presents with a complaint that is not explained by sputum gram stain and culture, receives a bone marrow biopsy. I watched two biopies yesterday, and I´m told that I will get the chance to do one at some point this month. Blood products are scarce as well - there are several patients on the floor with Hemoglobin as low as 3 and Hematocrits of 11 that are not being urgently transfused. If the patient is clinically stable, they have to ask their friends and family to go the hospital and donate blood so that they can receive a transfusion. Vital signs are taken once daily. Laboratory tests that we consider "daily labs" in the US occur once every 5 or so days here. And the labs that monitor one´s HIV course such as the viral load can take up to 4 months to return, because the lab will not process the request until the government pays for it, and it seems the government doesn´t always pay on time.

Here is el Hospital San Juan de Dios, the general hospital within which resided the Clinica Familiar Luis Angel Garcia. Notice the entrance to the hospital has metal detectors.

el primer lunes

Today was the first day at Hospital General San Luis de Dios and La Clinica Familiar Luis Angel Garcia (CFLAG). Tira, another fourth year med student, and I received an orientation from Dr. Arathoon, the director of the clinic, and a full hospital tour from Dra. Godoy, who is in her final year of medical school in Guatemala City. We visited all of the patients in the hospital with HIV, and saw quite a variety of diagnoses, including histoplasmosis, cryptococcus, PCP, milliary TB, toxoplasmosis, pleural TB, molluscum, and zoster - to name a few. This hospital is the general hospital for the entire country of Guatemala, and is always busy. With the help of the Global Fund, the clinic CFLAG was founded in 1988 to serve Guatemalan patients with HIV, and it serves more than 1000 adults and 300 children. I´ll be working with the HIV patients in the hospital for the first 2 weeks, then in the outpatient clinic for the final two weeks.

Guatemala City is a place of many contrasts. The weather is incredible, cool in the evening and HOT during the day. Our homestay family is a friendly and gregarious group of women - a mother and her two daughters who prepare delicious Guatemalan food, and teach us los modismos guatamaltecos. We share the house with a 10 year old poodle named Sansón, and it just so happens to be his birthday today - so there will be a cake and a piñata - and all of the family is coming over to celebrate this afternoon.