The little girl looked very poorly. She was semi-conscious, draped across her mother’s arms, with a fever of 39C. Mother showed me a bag of tablets and capsules. With a bit of detective work, I reckoned she had been taking some ampicillin and a selection of vitamins. It must have been difficult getting a child under three years of age to take these, I thought.
“Where did you get these?” I asked. With some reluctance she told me that “someone in the village” had given her the medication. She would not tell me if this was a private doctor or just someone working freelance.
“Has she taken anything else?” I enquired. Mother brought out another plastic bag containing used ampoules of gentamicin (a potent antibiotic) and diclofenac (a non-steroid anti-inflammatory drug, sometimes used as a painkiller). I had no idea how much of each ampoule had been injected into the child. Mum said she had received the drugs intravenously. Injectable diclofenac should not be administered to children at all. And if she had received the whole ampoule, it would have been an adult dose.
Mother told me that it was three days since the injections and her daughter was getting worse, so she had come for help at the clinic. I examined the child carefully and was convinced that she had meningism, the clinical signs of meningitis. Her neck was stiff, Kernig’s sign positive, Brudzinski negative. I really thought this little girl had half-treated meningitis.
She was moaning and clearly distressed. The medic had taken blood for routine “fever tests”, but I had to decide on whether to submit the child to a lumbar puncture. Because she had already had antibiotics, it would be unlikely for us to find the germ causing her illness, so I decided to just give the most powerful broad spectrum antibiotic we have. It’s a bit like Domestos – “kills 99% of all household germs” – as the advertising copy states. And hope for the best.
The following day it was still touch and go. With typical doctor cunning, I tried to get her to bend her neck to suck on a straw in a pack of orange juice. But she wasn’t able to. Her temperature was still high and mum had sent for her father to come.
After three days of intravenous ceftriaxone, her fever settled and she was able to move her neck. I was mightily relieved. Then we received the results of her initial fever tests. They showed she had dengue fever.
Dengue is a viral infection transmitted by mosquitoes in warm climates. The main symptoms are fever, headache and generalised muscular pain. It can rarely cause inflammation of the linings of the brain, resulting in meningism. Usually there is a rash, but she didn’t have one. Most people recover in a week or so, and the mortality rate is low.
The word dengue is Spanish for fastidious, or careful. This reflects the way that people with dengue walked, slowly and gently because of their excruciating muscle and joint pains. In the West Indies, slaves with dengue were said to walk like a dandy – an aristocratic fop – leading to the term “dandy fever”. My favourite term is breakbone fever, coined by Dr Benjamin Rush, one of the US Founding Fathers.
The only treatment is supportive. My intravenous antibiotics were useless. I kick myself (metaphorically of course) for missing the diagnosis at first. Perhaps a more experienced physician would have recognised that this was dengue and not started antibiotics. But doctors play dice, we weigh up the odds while simultaneously working out what is the worst that could happen if we make the wrong decision. We call this safety netting. And we try not to practise “just in case” medicine to cover every eventuality, however rare it might be.