Sam was having a bad day. He became irritable, and so in turn did I. His maths went backwards and the lesson became a battle. What was going on? I started to become concerned.
‘I am sick.’
Maybe he was. He had had a bad cold a week or so earlier, but he now seemed to be much worse than usual: irritable, poor concentration, stuffy nose and residual cough. Perhaps another virus?
I went on a 90-minute trip to get some cash out of an ATM. On my return, he was burning up. Oh, oh, oh, f**k, please don’t be malaria.
Sam was high risk; of that there was no doubt. His long-sleeves phobia had previously put him at higher risk than others, although not so much in Uganda where it was too hot to wear long sleeves anyway. Mosquito nets were the problem. Despite best efforts, he would inevitably end up twisted in knots, like a shark caught in a net, often with limbs poking out, unprotected. Occasionally the whole net would be pulled off the frame or ceiling.
I whisked Sam into a cab and we headed through traffic to a surgery recommended by the Red Chilli staff, where an expat British doctor worked. Sam lay on the back seat, listless and lethargic. In the consultation room of the smart looking medical practice, the doctor, who had worked in Kenya and Uganda for decades, got a debrief from me on our situation.
‘Blimey! Just the two of you, eh?’
He was clearly very knowledgeable on tropical medicine, and not overly concerned about malaria. He did have some concerns about the possibility of Katayama fever, which occurs in response to a schistosomiasis infection. Schistosomiasis (also known as bilharzia) is a parasite that can penetrate human skin of an individual after swimming in fresh water in sub-Saharan Africa and other parts of the developing world. Lake Malawi, where we’d gone swimming a month earlier, has been described as schistosomiasis central.
While not life threatening, schistosomiasis can make you weak, tired and irritable. Long term complications can occur if it remains untreated. The Katayama fever is an immune response to an early phase in the disease where schistosome eggs are first deposited into the body’s tissues. If Sam had that, or just a viral illness, that was better than malaria; schistosomiasis is usually easily treated.
The doctor felt further tests weren’t necessary at that stage but advised us to return if Sam’s fever continued. I remained anxious. The fever persisted through the night, but Sam didn’t look dramatically unwell; lethargic and quiet but alert and walking around in the morning.
Still, I decided I wanted more reassurance and obtained a malaria testing kit from a pharmacy. It required three or four drops of blood to perform the test, hard to obtain from a finger prick test. I attempted a venesection which proved to be very difficult with Sam freaking out.
‘NO! I don’t want this!’
‘Sam, we need to do the test to make sure you don’t have malaria.’
‘I don’t want this, I don’t want malaria. Malaria SUCKS!’
‘Yes, malaria does suck, and we need to know if you have it. Malaria is very serious, Sam.’
‘Malaria is more common in Malawi. They should call it Malawia.’
I eventually won him over and got the blood test done, despite the plastic syringe plunger breaking half-way through. In a hostel room, using a pillow case as the tourniquet and slightly dodgy equipment on an uncooperative patient, it was not my most professional venesection. But the test was negative, yay!
I breathed a sigh of relief and let his anxious mother know on Skype. It wasn’t certain we were out of the malaria woods, but it was a reassuring indicator.
In the afternoon, Sam deteriorated again. Temperature soaring again, eyes blood shot, he looked worse than ever.
‘I haven’t got malaria.’
‘I certainly hope so.’
‘It’s all right Dad. Don’t worry.’
I was. His skin was goose bumping, but he didn’t have rigors (involuntary shakes). I checked for unusual rashes; none present. There were other worrying conditions besides malaria that can cause a persisting fever without an obvious focus of infection. Should I take him to the hospital? I decided to see what he looked like after a dose of paracetamol kicked in.
An hour later, it did, and Sam improved, even wanting something to eat. I remained unconvinced. The last fever had shaken my confidence; he had been febrile for more than 24 hours, with high fevers too.
Most of the time in my job, in general practice, you are telling people not to worry, that everything is OK and nothing needs to be done. Most of the time you are hitting the brake. Very occasionally it is the opposite,the time to do something, to investigate, to refer, to hit the accelerator.
I hit the accelerator, and ordered a cab to the International Hospital, Kampala.
The hospital was significantly more down at heel than the private clinic, but moved efficiently enough. Everything was paid for in advance, cheap by western standards but expensive by Ugandan, hence we encountered an empty waiting room and went straight in to see the doctor. I was disturbed at the lack of physical examination, but the main game was to get a blood film done to look for malarial parasites as well as a blood count.
Sam tolerated his second venesection of the day better than the first; maybe knowing what was involved reduced his anxiety. The film was clear, and we were processed door-to-door in under two hours.
As soon as I had made the decision to go to the hospital, Sam became progressively more congested. By the time we left the hospital he was coughing, sniffling and sneezing. We finally had a ‘focus’ – doctor speak for an explanation for the fever. The blood count also revealed a profile consistent with a viral infection and unlikely to be acute schistosomiasis. Phew.
The next day Sam’s fever settled. The crisis had passed.