Shibani Mukerji
PGY-3, Partner's Neurology
As in many South American countries, Peru has a wealth of patients with neuroinfectious diseases. In Lima, there appears to be a disproportionate number of neurologists available to help with their diagnosis in comparison to the rest of the country. Peru has 254 neurologists registered with the Peruvian Medical Association (approx. 1 neurologist per 119,980 people) and nearly 73% of them work in Lima.
Navarro-Chumbes et. al, Neurol Int. 2010 June 21; 2(1)
The Instituto Nacional de Ciencias Neurologicas (INCN, http://www.icn.minsa.gob.pe/) is both an inpatient hospital with outpatient clinics that specializes in adult and pediatrics neurology. I spent the majority of the last week in their infectious disease ward. This ward has 28 inpatient beds and will typically be operating at near capacity. In a sampling of 15 patients seen on a single day, 8 patients presented with seizures and headache due to Neurocysticercosis, 1 patient presented with loss of vision, seizure and headache due to a Tuberculosis granuloma, 1 patient presented with decreased consciousness and fever due to TB meningitis, 1 patient developed high grade fevers from presumed bacterial meningitis, 1 patient presented with headache and nausea/vomiting due to cryptococcal meningitis and diagnosed with AIDS, 1 patient with known HIV presented with seizure and diagnosed with presumed toxoplasmosis, 1 patient with headache and hemiparesis with likely glioblastoma multiforme and 1 patient with a multiple sclerosis flare with right arm and leg paresis (the unit cares for several noninfectious related diseases that are not vascular related). The average age of this small cohort was 40 years old.
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| A. Infectious disease ward at INCN. All patients are in one ward separated by men and women. B. Symptomatic patient with Racemose and intraparenchymal neurocysticercosis |
The use of the lumbar puncture is hindered at times as most Peruvians fear invasive testing and need coaxing into performing the procedure. At the INCN, most patients will have LP results but there is limited ability in obtaining gram stains, speciation, HSV PCR or other CSF diagnostic testing. Clinicians rely primarily on the cell count and differential, chloride, lactate, total protein and glucose along with the clinical story to make their diagnosis. They do not obtain opening pressure as they don't typically have manometers. In regards to imaging, the INCN does not have its own MRI at this time, but plans are currently ongoing. Of note, an MRI brain costs ~$250 (US dollars) which has to be paid for entirely by patients.
This past week, I also had the unexpected pleasure to visit Hospital Nacional Dos de Mayo in Lima (hdosdemayo.gob.pe) with a fabulous neurologist, Dr. Fred Raul Jeri. It is a hospital which serves adults and children and has most specialties including neurology. Dr. Jeri initially trained as a psychiatrist and then switched to neurology. He spent a year with the MGH neurology/neuropathology department, training under Dr. EP Richardson and Dr. Ray Adams. His project was to assist in the definition of neuropathological definition of irreversible coma with Dr. Richardson, work later published in 1968. A man in his 80s, he continues to see patients both as an inpatient neurology consultant and in his outpatient clinic, serving primarily HIV patients with neurological and psychiatric conditions. The neurology department has clinical neuropathology rounds every Wednesday morning with interesting cases including last week's case of a woman with HIV who developed progressive weakness of her legs. A chest xray revealed a cavitary lesion in the apex of her left lung which was eventually biopsied and ultimately diagnosed with thoracic actinomycosis which had spread to the vertebra resulting in cord compression.
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| One of the female general wards |
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| Outside Hospital Nacional Dos de Mayo |
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| Dr. Fred Raul Jeri in his clinic |
In this past week, I have learned an extraordinary amount about the clinical presentation of neurological infectious diseases, particularly the art of diagnosing and treating Neurocysticercosis, tuberculosis and HIV-related neurological disease in the setting of limited availability and not always rapid diagnostic testing. On my next blog, I will discuss some ongoing research in Neurocysticercosis.
I am grateful to the Partners Global Health Travel Grant, Partners Neurology Residency Program, Dr. Joseph Zunt and Dr. Hugo Garcia for coordinating and allowing me this amazing opportunity.
