MALAWI UPDATE

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I am at the Loma Linda Hospital in Malawi for a couple of weeks substituting for the regular internist and family medicine physicians who are on vacation in Southern California. So this is my yearly Malawi update.

IMPROVEMENTS
We still run out of basic medications and lack certain machines–see below. The staff seems better trained and experienced. Instead of one nurse for ~60 beds, there is also a nurse for the High Dependency Unit ( our highest care unit which is lower than an ICU).

HEART FAILURE
Many do not get their blood pressure treated or run out of medications. This sounds like some with HIV in Southern California. Like with HIV here or there, hypertension cannot be ignored; a price must be paid–small prices early (taking medication, going to clinic) or a large price later (heart failure, heart attack or stroke).
We have a gentelman in the ICU who was swollen in his legs, arms, face, and torso. The Xray showed fluid in his lungs and the echocardiogram (what a helpful machine here!) showed a very weak and stretched out heart with some fluid around it. We could barely feel a pulse and he had low blood pressure since his heart was failing. He didn’t respond to a medication to make him urinate so we doubled the dose. I and two Loma Linda medical students and a Clinical Officer (from here, like a physician’s assistant) worked hard on him like a committee. We also had to get his blood pressure up by making many calculations and mixing some medication to drip slowly into his vein. This worked very well and he urinated about a gallon in 36 hours and his blood pressure came up. He was still quite swollen but not dizzy when he stood. Now his face looks normal and he doesn’t need oxygen or the low blood pressure med.
When we make person urinate so much, they can lose potassium in the urine so we started a slowly acting medication to hold onto potassium. There were no potassium pills in the pharmacy. Lack of potassium can stop the heart; so can too much (some give high doses of potassium as part of the cocktail to execute prisoners after, hopefully, deeply sedating them).
When he gets over this, he will be on many medications and be quite weak.

RAIN REFRESHES, GROWS CROPS, AND………..MOSQITOES
The rainy season is in their summer, January and February, but it is Autumn here and we have some rain. The mosquitoes are out and we admit about 4 adults and 4 children with malaria per day. I have treated about 1 malaria case a day who are not ill enough to be admitted to the hospital. The symptoms are weakness, fevers, chills, sweats, headache, abdominal pain and much more.
To prevent malaria, pesticide treated bed nets are given out and this has made a big difference in the number of cases. I sleep under a net and so far, have no bites. The other way to prevent is to take a medication before you come, during your stay, and some days after since the parasite hides and comes out on a cycle like HIV does. This is impractical for the people living here. It is kind of like Truvada® for PrEP (pre-exposure prophylaxis for HIV).
There is a little boy with malaria causing a coma in the pediatric ICU. He was completely limp and now moves and has muscle tone, but can’t focus or talk yet. I hope he recovers.
In the world there are a few types of malaria parasites. The most common one here is plasmodium falciparum which will usually register positive on a fingerstick test here. There was a lady with multiple negative fingerstick tests, but when the lab looked at her blood smear they found the other parasite, plasmodium ovale. Over the years malaria becomes resistant to the medications, just like in HIV, so the medications must be switched if they are invented in time. Due to resistance, combinations of medications are used in the treatment of malaria, HIV, and TB.

TB
Tuberculosis is quite common here. We have a lady with fluid on her lungs and scarred lungs from tuberculosis. A man has cryptococcus of the brain and TB of the lungs along with HIV. He kept having seizures, so we drained out some of his spinal fluid to decrease the pressure. When he had seizures and not extra fluid to drain, we started him on an anti-seizure medication, valproic acid (like Depakote® or Depakene®). There are some drug interactions with the HIV medications, but they are minor if we choose the right medications among those available–the choices are limited.

DIARRHEA
I had a patient in Riverside with severe diarrhea who didn’t respond to our usual stepped plan so he had a colonoscopy which showed a virus (CMV) in his colon. Hopefully he is improving on the new medication. He deteriorated to this low immunity level from not taking his medication daily and not being serious about “owning” his status of being HIV positive.
I have a lady here with severe diarrhea and nausea and vomiting but the upper and lower scopings showed nothing. So we need to change her antivirals. The choices are limited. Her kidneys are hurt probably from the tenofovir in her regimen, which is quite similar to Atripla®. So we had to stop that.
Her scoping of the esophagus and stomach, and later the colon showed no major infections. She needs effective HIV medication badly. She, like the Riverside patient, wasn’t serious about her HIV and her immunity deteriorated, letting the HIV take over her body.
The HIV Clinical Officer specialist here who follows the great Malawi HIV guidelines, wants her off the antivirals till we try to fix her kidneys by treating the diarrhea. Since the scopings are negative, the HIV is probably causing the diarrhea. This is a Catch-22=damned if you don’t, damned if you do. Add some uncertainty to this: sometimes the tests for parasites and toxic bacteria are inaccurate.
I will treat her with antibiotics, anti-parasitics, and anti-diarrheals, following the Malawi guidelines.

COOKING FIRES ARE LIKE SMOKING CIGARETTES
Families cook on these little stoves made from car wheel rims. The charcoal has much smoke and if the fire is in the house on the floor then the house has much smoke. Children and adults are then exposed to the smoke for years causing emphysema and chronic bronchitis, just as if they were smoking for many years. They end up with failing hearts and lungs. I saw a poster saying, don’t sleep near a cooking fire. Imagine breathing in smoke all night, not to mention the carbon monoxide danger.

TYPHOID FEVER
I had a young man and a boy with negative malaria tests who had fevers and abdominal pain. We switched over from malaria treatment to treating for typhoid fever in these cases and they improved after a couple of days and were discharged. The tests for this sometimes come out falsely negative.

TRANSFUSION REACTION
In the USA a transfusion reaction is very rare since the matching of the blood is so intense and detailed. We had a baby who got a transfusion and had a fever. That is also commmon in the USA since the foreign cells can’t be completely matched. But this babby had blood in his urine showing that his antibodies were attacking the new red blood cells. We stopped the transusion. If the reaction is severe or if we hadn’t stopped the blood, many red blood cells would be attacked and explode, releasing their hemoglobin which can clog the kidneys. This can also cause a reaction in the lungs causing shortness of breath. The baby was fine the next morning.

TREATING BASED ON EVIDENCE VS. EXPERIENCE
Of course we all should handle life’s questions based on evidence and experience. E.g. if I don’t pay attention to my gas gauge (evidence) then I might have a repeat of the painful experience of running out of gas.
In some cases we must make a decision based on experience if there is no evidence readily available since there is a time crunch. We do this in medicine; we act based on experience since the tests sometimes come back a day or a week later and sometimes they are not accurate. You know from experience that the weather might change from the morning prediction so you plan accordingly. Using evidence and experience is a good way to make decisions.
In Malawi, there is much less evidence (lab tests, scans, etc) for the health care provider than in the USA. Protocols based on experience are written in Malawi, and other countries, based on the wisdom and experience of experts. This increases the chances of a successful outcome.

ATTITUDE ABOUT HIV
I haven’t met anyone this trip who doesn’t know their HIV status or doesn’t want testing. In some ways, this is more modern than the attitude in the USA.

Be Safe! Wear protection. Get tested. Keep those questions coming.

Daniel Pearce, D.O., FACOI, AAHIVS
Clinical Associate Professor of Medicine, Loma Linda University School of Medicine
Adjunct Professor of Internal Medicine and HIV, Touro University California College of Osteopathic Medicine and Midwestern University Arizona College of Osteopathic Medicine
HIV Specialist, Assistant TB Physician, Riverside County Public Health Department
Member, Coachella Valley Clinical Research Initiative

REFERENCES: Medscape®

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