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The Beach

leishmania

Tomorrow was the first day back at school, and Angela Gonzalez could not be more excited. She had not seen her friends since before the spring vacation. She carefully selected, with her mother’s help, her clothes for the first day back.

As a fifth-grader, Angela and most of her friends were in Mrs. Clark’s room. In fact, she had made many new friends since September. Everyone knew Mrs. Clark, because she was usually on the playground at recess. She was strict but fair, and Angela and her friends often depended on her to keep the big kids from taking over the slide and the swing set. Everyone loved Mrs. Clark, even the big kids. This had been a fun year so far, and Angela wanted to see her friends. She decided not to tell her mom about her stomachache. She rarely if ever felt sick and after all, it was just a stomachache. Maybe she ate something she should not have. She walked to the bus stop with her brother Miguel who is in the third grade.

It had been a fun vacation and Angela felt special. She had gone to visit her grandpapa who lived in Texas. She was uncertain exactly where Texas was, but she knew it was a long way from North Carolina. Grandpapa had made her feel very special, and she felt bad that Miguel could not go but, after all, she was the oldest. Over the next few days, Angela’s stomachache came and went. One morning it really hurt badly, and she almost told her mother about it. Then, she would have had to stay home and she would have missed being in school. Saturday evening after church, Angela finally told her mother of her stomachache. Her mother, Catherine Gonzalez, was not immediately worried. Children sometime have stomachaches, although she could not remember a time when Angela had been sick. She decided that the best thing would be for her to take it easy and get rest. She would probably feel better in the morning. When Catherine checked on her daughter that Sunday morning, she was no better, and maybe a little worse. She looked pale, and somewhat sickly Catherine thought to herself. Angela complained that her stomach really hurt badly. Her bed sheets were soaked. Catherine checked the thermostat and found that it was set at 65, and still Angela had kicked the comforter off her bed. She took Angela’s temperature and found she had a fever of 102.

Catherine called the clinic and explained to the nurse on call her daughter’s symptoms. Soon a physician came to the phone and after repeating the information to him, it was decided that Angela had the flu. There was a bug going around, and she had caught it. Angela was to stay in bed, drink plenty of fluids, and rest. Angela missed school on Monday, but by Tuesday, she had begun to feel better. Her fever was gone, but she still complained of a stomachache. Still, she was so determined to go to school that her mother assumed she must be better. While making the bed and her daughter’s room, Catherine noticed something that a several long strands of her daughter’s hair were twisted in the pillowcase. Had Angela decided to cut her hair? She would ask her when she came home. However, she did not have to wait, for the phone rang at noon and Catherine spoke with the school nurse. Angela had doubled over on the playground complaining of a very bad stomachache.

The nurse had given her some water and she had sat in the nurse’s office for some time but she seemed to be getting worse. When Catherine picked up her daughter at school, she was visibly ill. Her normally clear glowing complexion had taken on odd pallor. Catherine asked Angela if she had eaten lunch. Angela explained that she just did not feel hungry lately. Catherine thought for a moment, and asked her daughter she had eaten a meal? The answer came back “a few days I guess”. Catherine wondered how she could have missed this. Angela has always had a healthy appetite. She was busy and active and was constantly on the go.

Since starting her online college courses, Catherine admitted to herself she had not been as attentive as she had been to her children, however, she did not think she had been negligent by any means. Another call to the clinic and more advice that the flu had to run its course. As a single mom, Catherine often had her hands full. Still, Angela and Miguel had been perfect children, seldom demanding and never mean or cruel, to each other or to anyone else. They seldom, if ever complained about anything. So when Angela continued to complain about her stomach ache, Catherine decided that a visit to the clinic was in order.

The wait at the clinic was nearly 2 hours, but eventually Catherine and Angela were seen. At first, the doctor assured her that this was nothing more than the flu. Catherine asked that he at least check for the reason her stomachache, and when the physician attempted to palpitate her abdomen, Angela sat up in excruciating pain. Now she had his undivided attention. Influenza would not cause this level of pain. The physician asked for a list of other things that Catherine had noticed. She told him that her daughter was usually very active and over the past few weeks, she had been much less so. Her healthy appetite had all but disappeared, she seemed always tired, and she complained of her stomachache. The ER physician suspected some sort of an infectious condition, but he was uncertain as to what it might be. He called the nurse and she contacted the phlebotomy office and arranged to have someone come and draw blood.

Catherine and Angela were sent home with assurance that as soon the physician knew something he would call them. The lab at the clinic was very limited, so blood samples would need to be sent for testing. This could take up to two weeks. In the meantime, bed rest, lots of fluids, and try to eat. Angela did not sleep much that night, and her stomachache only grew worse. It was the next day Angela collapsed at the breakfast table and Catherine could not revive her. Catherine placed her daughter in the backseat of her car beside her brother and drove to the clinic. By the time they arrived at the clinic, Angela had regained consciousness, but quickly doubled over in pain. At the ER entrance window, Catherine explained she had been in two days previously and was awaiting blood tests, but that her daughter had collapsed and could hardly stand due to the pain.

A nurse met them in the waiting room and Angela was taken into an exam room where they awaited the physician on call, Dr. Parks. When the Dr. Parks came in, she asked about Angela’s last visit. She asked for a list of symptoms and for about how long this has been going on. She seemed particularly interested in the stomachache. She attempted to palpitate Angela’s abdomen but when she did, Angela shrieked in pain. The physician had no idea what this was, but she knew it was not the flu. A quick history was taken, and apart from spending a few weeks with her grandfather in Texas, nothing out of the ordinary had happened.

The physician then went to the phone and made a call, and after a few minutes, a man knocked on the door. The Dr. Parks introduced him as Dr. Harding. Dr. Harding was an epidemiologist, and he sat down opposite Angela and her mother and began to ask a series of questions. How long had Angela had a stomachache. Did she have a fever? Were there any other observations Catherine had made? After hearing that Angela had a fever but that it had gone, yet the stomachache had gotten worse. Had she noticed any changes in her daughter’s skin color, or any bumps or source? Catherine mentioned that her daughter her daughter’s complexion was not as glowing as it usually was. Dr. Harding asked Catherine if she would describe this as “grayish?” Catherine thought for a moment and then said yes.

Were there any other symptoms? Anything out of the ordinary, that Catherine could remember. At first, she could think of nothing. Then she thought for a moment and commented that Angela had been cutting her hair. She had forgotten all about it until now. Could this be a sign of depression or just a girl trying to change her look? At this point Angela spoke up and said, “I never cut my hair”. Dr. Harding stood up and walked to where Angela was seated. He ran one hand through her thick black hair and several strands came out easily. How long had this been happening? Catherine immediately thought about the hair she had found and her daughter’s bed. Yes, about a week ago I noticed some hair in Angela’s bed, but had assumed that she had just cut it. Now that I think about it, the hair did seem very long to have been cut. Dr. Harding asked Dr. Parks if blood test have been done. A quick look at the chart revealed that they were still waiting for the results. Dr. Harding wondered to himself if Angela would be alive when the results came in.

He thought of the possibilities: a few genetic disorders, one or two cancers, and maybe an infection or two. Dr. Harding asked about vaccinations. “All up to date.” Came Catherine’s reply. A parasite? He wondered to himself. Less likely here in North Carolina. Trying to calm a visibly scared and sick girl and her equally frightened mother, Dr. Harding asked Angela what she liked to do. Where she went, how she spent her time.

Angela remarked that she loves school, that she had many friends, and that she had spent two weeks with her grandpapa. Something in the emotion of her voice when she talked mentioned her grandfather that caught Dr. Hardy’s attention. “Do you see your grandpapa often?” He asked. Catherine explained that since her husband had passed away, her children rarely saw their grand father. Almost as an afterthought, Dr. Hardy stopped, looked at Angela, and asked what she and her grandfather had done when she visited. She remarked that say went for ice cream every day, and went to see a soccer game. After the soccer game, they went for a walk on the beach. At this point, Catherine spoke up and asked what beach, as her father-in-law lived in Houston.

Angela remarked she did not know exactly, only that it was a very long drive to get to the soccer game, but that the beach was near by. She said they drove along the ocean and it was beautiful. She even got to stay at a very nice hotel and she got to watch a movie in the room. They went to the beach in the morning before coming back. Dr. Harding asked Angela if they drove west or south to the soccer game. She really didn’t know, but she did comment that they had to go past some guards who came and asked her grand papa some questions. It was very exciting. Dr. Harding stood for a moment looking out the window. He turned into Catherine and asked “could they have gone to Mexico?”

Catherine did not believe so. Although her father-in-law often accused her of being overprotective, he also knew that she would be quite upset if he had done something like this without first asking. Dr. Harding asked Catherine if she could make a phone call and ask about the beach. Catherine stepped out into the hallway and in a few moments returned, red-faced and visibly angry.

Her father-in-law explained that yes, they had gone to a soccer game in Reynosa, Mexico, so Angela could see her cousins. After, they stayed at a motel, and in the morning, he took Angela to the beach to swim and play before heading back to Texas. He didn’t understand why she was so angry. She never let the children do anything. Dr. Harding then asked the physician if they had done any imaging study on Angela. The answer came back “no”. There was no MRI at the clinic, but they did have an ultrasound, and Angela was taken down to imaging. Dr. Harding asked they specifically focus on the liver and spleen. Especially her spleen. The ultrasound showed Angela’s liver was only slightly swollen, but her spleen was nearly 4 times larger than normal. Dr. Parks looked at Dr. Harding, asking what he was thinking.

To Harding, a specialist in infectious disease, it all fit. The change in complexion, the thinning hair, the stomachache, the fever. All that was missing was the how and where. Now he thought he knew the where. He turned to Dr. Parks, saying, “if I am right, she will be far sicker before the lab results come back. I am not certain we can wait”. Catherine spoke up anxiously, asking what was wrong with her daughter. Dr. Harding told her that in some areas with warm topical climates there are a number of infectious diseases caused by parasites. Mexico is one of these areas, and that if he were correct, Angela had been infected by a parasite called Leishmania. It is spread by the bite of certain flies.

Dr. Parks asked Angela if she had been bitten by a bug while she was with her grandfather. Not that she new of. Almost as a second thought, she did say she had been stung by a bee when she was on the beach, and she rolled up her pant leg to reveal a swollen, open sore on the back of her knee. Angela said she had been rubbing lotion on it to make the itch go away but it was getting worse. Dr. Parks told Catherine that a biopsy would need to be taken before they would know for sure and that may take a few days.

Catherine asked what the treatment would be if Dr. Harding were right, and was told by the physician it was a drug called Amphotericin B. The side effects could be nausea, abdominal pain, and possible vomiting; which Catherine pointed out her daughter had already been suffering with for a week. Were here any other side effects? Can we afford to wait that long asked Catherine? The doctors expressions provided the answer.

Angela was admitted and begun treatment with Miltefosine, and an IV was started for nourishment. She was also given Fosaprepitant by IV for the nausea. For the first few hours, Angela seemed to be getting worse. She vomited and her fever increased. However, by morning, her temperature was nearly normal, and for the first time in many days, she said she was hungry. Catherine asked if there was a need to do a biopsy as Angela had been through so much. Dr. Parks suggested that the treatment had been effective, so whatever the actual cause, Angela was improving. Still, a test should be done. Angela cared little for the long needle Dr. Parks used, but she understood it was necessary, and she felt a bit “creepy” about having a needle “stuck in her bone.”

Angela has since made a remarkable recovery, and was sent home, with bed rest and orders to take it easy, after only a few days. The week after Angela returned to school the phone rang. It was Dr. Parks. The results of the marrow biopsy had come back. As it turned out, the blood test would have told them nothing. Angela’s marrow had tested positive for Visceral Leishmaniasis. There should be no lasting effects, but she could have become much sicker had she not come to the ER. Catherine hung up and immediately dialed her father-in-law’s number. The time had come for a serious discussion.

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