Case of the Week - Yaws

This is a picture of a patient’s leg that is suffering from yaws. 

Yaws is a tropical infection of the skin, bones, and joints caused by the Treponema pallidum pertenue (a relative of the spirochete that causes syphilis and pinta).  Yaws can be found in the humid tropical regions of South America, Africa, Asia, and Oceania.  It was introduced to the America’s and Europe through the slave trade with Africa.  A mass treatment campaign in the 1950 eradicated it from many developed countries and greatly reduced the worldwide prevalence, however incomplete eradication led to a resurgence in the 1970’s with the largest number of cases found in Western Africa.  The majority of people affected are children under that age of 15 years of age and it is spread by skin-to skin contact with infective lesions allowing the bacterium to enter through a pre-existing cut, bite, or scratch.  Earlier in the year we had an outbreak of yaws in the school in Nalerigu and the surrounding area.

This infection, like syphilis, has three stages.  The infection starts as a painless but distinctive “mother yaw” lesion.  The infection can continue and have “daughter yaws” appear around the infection site over the course of a few months.  These lesions usually resolve by six months.  Secondary stage yaws can occur months to years later and is characterized by widespread skin lesions of different appearances.  About 10% of people will progress to tertiary yaws where bone, joint and soft tissue destruction is usually seen.  It is seen often as destruction of the bone and cartilage of the nose.

The distinctive "mother yaws" lesion

 

The treatment of the infection is a single injection of penicillin.  However, I have seen the destruction that occurs from the disease is much harder to treat and takes a much longer time to heal.  The skin lesions left behind after infection can take months to heal (some needing skin grafting) especially when the people are malnourished and live in dirty conditions. 

The disease is highly localized which makes case tracing and treatment of potentially infected individuals easy.  For example, when the outbreak occurred in the schools earlier in the year, the public health administrators went to all of the schools and gave the children shots of penicillin.  The cases of yaws we saw in clinic after that dropped dramatically.

This patient is currently admitted to our isolation ward and is undergoing dressing changes to her legs (her other leg not in the picture has similar wounds, as well as her buttocks and left elbow).  Her wounds are nice and clean and we will see if she will start to heal the wounds or if we will have to skin graft some of the bigger wounds.

A Royal Visit

The Nayiri is the man in the red sitting next to me

Yesterday I met the Nayiri.  He is the paramount chief of the Mamprusi empire and his palace is located in Nalerigu.  Each village has a local chief and the Nayiri is the head chief of all of them.  He makes all the major rulings in the area when it comes to law and order, etc.  I was supposed to meet him when I first arrived, but things are been so busy that we finally got around to meeting him now.  He had a large compound in the main part of town.  You are not supposed to walk or drive in front of the palace.  The first month I arrived a volunteer and I drove in front by accident.  These men ran out after us with sticks, but I told her just to gun it and not stop.  I did not really want to be in trouble my first month here.  When I met Nayiri yesterday I did not mention that little infraction of the law.  His palace is a huge compound made of painted white stone and is very distinct from the rest of the structures in Nalerigu.  He was very kind and grateful of all of the work we do at the hospital.  He asked me if I would consider staying another year at the hospital.  I told him my mother and father would miss me too much.  I was not sure culturally how I was supposed to answer that question.  We had to take our shoes off when entering his viewing area and then you need to squat as low as you can and clap when greeting him.  He does not speak English so we had a translator speak for us.  He seemed to have a sense of humor and enjoyed the meeting.  We gave him a gift of a bag of rice and a jug of oil.  In return he gave us a present of a guinea fowl. 

 



With our guinea fowl

I have enjoyed my first week back at the BMC.  There is a large volunteer group here, so I have been able to concentrate on working with and learning from Dr. Andy Norman.  His focus is on female vesicovaginal fistula and rectovaginal fistulas.  These kinds of fistulas are very common in third world countries as complications of pregnancy and prolonged labor.  Over the last few months, I have been collecting cases for Dr. Norman to help me with this week.  We did a number of fistula cases, as well as some other GYN cases.  I learned from him how to do a Le Fort operation for uterine prolapsed, which is an ideal surgery in elderly women instead of putting them through a hysterectomy.  I also started to learn how to do vaginal hysterectomies.  I think I am going to be sticking to abdominal hysterectomies for now, until I can do a few more vaginal cases with someone else because the anatomy to me was all backwards, but it was great to start at learning a procedure.

Back in the Gu!!

After a long trip back to Ghana, I am finally home in Nalerigu.  It is really nice to see everyone here.  All of the staff kept telling me I looked “refreshed.”  I was not sure if that was a compliment . . . I just kept thinking I must have looked really worn out when I left.  I was later informed by a long term missionary that they are actually telling me that I have gained weight and look fatter than when I left, not that I look more well rested.  I guess enjoyed the food back home a little too much!

Case of the Week - Omphalocele

I have had two cases of omphalocele since I have arrived.  One presented around 2 days after birth and the second was born in a very rural village and came about 2 weeks after.  The covering over the defect was necrotic and the child was septic.  I was able to close both defects and the babies went home.  On follow-up a month later, they were both growing and looking healthy.

 

After repair

My favorite part of the this picture is that it shows how we do cardiac monitoring during our surgeries here at BMC.  It is old school with a stethoscope just taped to the patients chest. 
 

Case of The Week - Necrotizing Fasciitis

I could never quite get the whole story about this patient’s medical history from her family.  The stories kept changing.  She is a 70+ year old who showed up in clinic with the abdominal wound for 2 months.  The family said she had a super pubic catheter placed, then removed, and a when I saw her she had a foley catheter in place.  I took her and did a debridement of the wound under ketamine.  We did dressing changes for about three weeks until the wound was clean and then I placed a skin graft.  I just saw her back a week ago and the graft and most taken and she was doing well.  The wound I see here continually surprise me.

On admission



After doing dressing changes for about three weeks.  The abdominal fascia is all gone and those are her abdominal muscles showing.

Placing a skin graft over the wound.

 

Cape Coast

I had a great time with Megan in Nalerigu this past month and she did a wonderful job taking care of the maternity ward.  We were able to operate with each other on a few cases which was a lot of fun.  I am not sure when we will ever have that opportunity again. 

 

We were able to do some traveling in the south of Ghana which was awesome.  We traveled to the Cape Coast and stayed in the town of Elmina at the Elmina Bay Resort, which was a nice little resort tucked away on a very private beach.  If you ever have heard a reference to Africa’s “Gold Coast” that is a reference to this part of Ghana. 


Picture from our balcony.

 

The first day we went into Elmina and took a walking tour of the city and visiting the Castle of St. George.  The town is mostly a fishing village and the first Europeans that settled in the area were Portuguese and later Dutch.  It was the heart of the African gold trade to Europe in the 1400-1600’s.  The city is bustling with activity and was sort of overwhelming.  The fishing vessels, called pirogues, are colorfully painted and decorated with flags.  We had a wonderful morning walking around the city, learning about the history of the area, and then spent a relaxing afternoon poolside.

 Pirogues parked on the beach outside of the castle.

The lagoon where pirogues come and offload their catches of the night.

In the cemetery in Elmina many of first European settlers are buried.  That includes the Brothers and Sisters that came to teach Catholicism .  A group of Irish nuns where some of the first to travel and live in Ghana and their graves are marked with Shamrocks on the headstones.
 

This picture is of the “door of no return.”  The slaves left this door of the castle and where loaded onto the boats that were directly outside.  The majority of would die on those boats before reaching their various destinations. 

In 1482 the Portuguese started to build the Castle of St. George.  It is said to be the oldest European structure in Africa.  It was first build mostly as a trade center to trade arms and ammunition to locals in exchange for gold.  The Portuguese (and later the Dutch when they took over in 1637) started to trade European good for slaves instead of gold.  It remained one of the centers for slave train until it abolishment in 1807.

 

 

 

 

This is a picture of the Castle of St. George from St. Jago Hill where Fort St. Jago was built by the Dutch.  This fort served as protection for the castle.  The watchmen at the fort could look out at the bay and see any ships that might be coming to attack the city.  When the Dutch took over the castle they actually first took this hill and then bombed the heck out of the castle until the Portuguese surrendered.  They later built Fort St. Jago for protection.   

 

The second day we headed on a whirlwind tour of different sites.  We started the day driving north to Kakum National Park.  This is an area of protected rainforest in Ghana about an hour north of the coast.  We enjoyed walking on the hanging bridges and through the forest.  We then stopped at the Monkey Forest Resort where we made friends with some cute baby monkeys.  The resort is a sanctuary for orphaned and injured animals and the home of the most eccentric Dutch couple I have ever met.  We had lunch a restaurant that is built over a lagoon full of crocodiles.  For a small fee the staff will get one out of the water for you to take a picture standing next to.  Megan and I both decided that our parents would not be please if we were eaten by a crocodile in Africa so we stayed put on the deck and just watched other gullible tourists risk their lives.  We ended out tour in Cape Coast the capital city of Ghana’s Central Region. 

 Kakum National Park

Monkey Reserve

 

Cape Coast Castle was built by the British and was one of the largest slave-holding sites in the world during the colonial era.  Unlike the castle in Elmina, it was built specifically for slave trade.  Here slaves that had been traded to the British by the African chiefs for alcohol, guns, and gun powder were held for months while awaiting the arrival of merchant ships that would take them to the west. 

 

 

Case of The Week

People shoot off homemade guns here in Ghana.  They do it for celebrations and funerals.  Earlier in the year they even had a “Fire Festival” for a week and every night they shot off guns and cannons.  The guns are made poorly and end up back firing and blowing off the patient’s left hands.  I have seen too many injuries like this over the last few months.  Most of the time, I just have to amputate just a few fingers or the lucky ones just need some stitching up of the skin.  Below is the worst injury I have seen.  The hand could not be salvaged and I did an amputation at the wrist.

 

His third finger is completely missing and the bones of his wrist are exposed.   

After wrist disarticulation was complete.

Happy Birthday Megan!!!

Megan sporting her new Ghanaian football uniform including Ghana socks.  I had a great time roaming around market looking for gifts for Megan's birthday.  I also tried my hand and baking a home made cake.  I think the only thing that made it edible was the chocolate icing and the M&M's, but it was fun to make.



Bring on the Heat!

We are in the middle of the hot dry season and hot and dry is an understatement.  It is amazing how the campus has transformed since I arrived.  All of the green has disappeared as everything has died.  In the heat of the day it is around 115 degrees and it cools down to the low 90’s at night.  For me the OR is the best place to be because it has air conditioning.  I know that many places in America can boast high temperatures, but not stifling heat day after day, and in America you can go from your air conditioned home, to your car, to air conditioned work, etc, and never really notice the heat.  The worst part of the day for me is trying to sleep.  I received some friendly advice to get all of my clothes wet before I go to sleep.  It is amazing, but with a fan blowing, I actually get a bit chilled and am able to fall asleep.  I usually wake up around three or four in a puddle of sweat and just get up and wet everything down again.   
 

The way campus looked when I first arrived

Dry season on campus . . . looking at this pictures just makes me feel hot! 

The hot dry season comes after the end of the Harmattan here in Ghana.  The Harmattan is a dry dusty trade wind that blows south from the Sahara desert across West Africa into the Gulf of Guinea.  It starts in late November and goes through early March.  On its way over the Sahara it picks up fine dust particles, which it will carry across the land.  The dust was very mild this year, but I am told that sometimes the heavy amount of dust in the air will block out the sun and you will not be able to see a few feet in front of you.  The best part about the Harmattan is that with the wind comes cool temperatures into the 70’s.  On some mornings I would wear long sleeves and at night I would sleep with a blanket, but for the most part the missionaries are finally comfortable.  On the other hand the Ghanaians are bundling up.  They are in long pants, heavy winter coats, hats, gloves, and scarves.  It is quite the sight.  We showed a movie about Jesus out in a village one night and we were all in shorts and tee-shirts and the Ghanaians were huddled up next to each other under blankets for warmth.  I guess it is all what you are used to.

During the Harmattan is the coolest part of the year here in Ghana, but the next coolest is when the rains come after the hot dry season.  And that is what we are all anxiously awaiting now!