When 15-month-old Noy* arrived at LFHC, doctors thought she was another case of sepsis, a bacterial infection that overwhelms the body. Sepsis is a potentially dangerous condition, killing an estimated 2.9 million children under five years of age globally in 2017 alone1.
Our doctors are able to recognize and treat sepsis promptly, relying on basic blood tests in the absence of more expensive microbiology tests which doctors in well-resourced settings use to identify bacteria. Most sepsis patients start to recover within a couple of days.
However Noy did not get better. The doctors changed her antibiotics and looked for more unusual infections, all to no avail. And her case had some unusual features that had troubled doctors from the outset. Her blood cell counts were low, her liver and spleen were enlarged, and a few days into the admission she developed a rash which rapidly spread over her face and body. A blood triglyceride test raised doctors’ suspicions that perhaps she didn’t have an infection at all, but a life-threatening hematological disease called hemophagocytic lymphohistiocytosis (HLH).
To confirm the diagnosis, a sample of her bone marrow was needed. In the past, this had been a procedure referred to Children’s Hospital, Vientiane, which is the only facility offering chemotherapy (the treatment for HLH) in Laos. However, on the verge of a national lockdown and fear of COVID-19, travel to Vientiane was already extremely difficult.
Dr. Dorkeo Boupao had returned to LFHC recently having completed her pediatric residency in Vientiane, where she learned to perform bone marrow aspirations. After discussions with the parents, who are always an integral part of the patient care team at LFHC, the team decided to do the bone marrow aspiration here at LFHC.
This case is truly a story of Lao leadership and teamwork. Dr. Dorkeo and Laboratory Leader Anousine Phonedala worked together to plan and prepare for the procedure. Dr. Dorkeo obtained the samples and Anousine and his team prepared the slides. Our doctors examined the slides and found the typical appearance of HLH.
The nurses assisted with the sedation for the procedure, and helped support and advocate for the parents throughout the child’s nine-day hospitalization. The parents were amazingly patient and brave as they maintained a vigil by her bedside, helping to care for her as they watched their usually beautiful child become almost unrecognizable as the rash crept over her face and body.
With the diagnosis confirmed, it was much easier for the parents to commit to spending the time and money needed for treatment in Vientiane. The Children’s Hospital, Vientiane used LFHC’s slides so that she was able to start treatment without delay after arriving in Vientiane. She still has a long road ahead of her, but days after starting chemotherapy, she was rash- and fever-free.
Although LFHC cannot yet treat such cases, being able to perform the diagnostic procedure at LFHC makes a huge difference for patients and their families. Sending patients to Vientiane for this procedure incurs great cost for the family and there’s no guarantee that the subsequent treatment will cure the patient. In this case, the family was given accurate information about prognosis and treatment cost to aid their decision-making and give them peace of mind that the expensive treatment was justified. The journey is long and arduous, especially with a sick child, and in the future, we hope that we can save some children and their parents from going through this unnecessarily.
We are extremely proud of our Lao team, who didn’t stop thinking and caring about their patient, and displayed an ability to learn, innovate and develop their service, even in the midst of a historic pandemic and its attendant restrictions. They were excited to learn about this rare condition and to see that the quality of care that they provide to their patients continues to improve. In the future, we hope to have more LFHC doctors trained in the procedure and in reading the slides so that we can expand the repertoire of diseases that we can diagnose locally.
* The name of the patient has been changed to protect confidentiality.
- Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Rudd K.E. et al. Lancet 2020; 395: 200-11