A couple cases...and a monkey

I wanted to write about a case or two that I have seen here this week.
First, a child I saw on the Wards.
This was a 4 year old boy who came in due to a 4 day history of very high fever as well as a peculiar papular rash (which means you can feel it when you run your hand over the skin ...aka it sticks up) that started on the head and spread to the trunk as well as the palms of the hands and soles of the feet. Rashes usually do not appear on the palms and soles and there are only a few infections/reasons for such. The rash almost looked like a rash you seen in measles. Small lumps all over his face and body that were slightly red. He also did not look too ill-appearing, although he was very warm to touch.
One of these rashes that are on the soles and palms is Rocky Mountain Spotted Fever. Well here in India there are no Rocky Mountains, which is spread via tick bites kind of like Lyme disease and caused by a bacteria -Rickettsia. Not until this past summer was it found that rickettsia was also a problem here in India -- and there was quite an outbreak with many cases. The Peds program is currently doing research on this and testing children with fever and a rash for rickettsia to assess how prevalent this diagnosis is. Here in India they have a different species of Rickettsia which is called Scrub typhus ... something I have never seen in the states. So the treatment -- doxycycline. Now even patients they are not sure if they have it or not will treat with doxy and if the fever diminishes within 72 hours it is diagnosed as Scrub Typhus. Actually today, I saw another woman who actually had an eshar from where the tick had bitten here and was treated with doxy for presumed Rickettsial infection.
I asked the resident today about these ticks and he described them more as chigger. Scrub typhus is not transmitted via ticks but via chiggers or mites described in articles on it. It will be interesting to see how their study here finds.
A second case...
there are so many patients we see everyday so I will try to share ones that are unique to this country.
In clinic on Friday we had a 10 year old child come in who looked about 5 years old. He was very underweight, malnourished, and very short. He came in just a year prior to be treated due to his poor growth. He was diagnosed with Rickets at that time, or Vitamin D deficiency. This is a pretty common thing they see here. One, because of malnutrition, also due to their dark skin ( one way Vit D is created is vie sunlight in the skin) and the cultural practices of wearing veils and swaddling babies or not allowing much sunlight to reach the skin. I was also reading that many here may not be totally Vit D Deficient but with lower daily intake of Calcium here causes a increased need for Vitamin D to absorb the Calcium -- and causes those with low Vitamin D to become deficient due to increased need by the body.
This child (I will add a picture of him later) has bow legs pretty severely due to this. He also has what is called rachitic rosary, which is where the ribs have bony knobs where the ribs join the sternum. His knees were also very enlarged - this is called walking Rickets. This bone deposition increases at pressure points, so in children that can walk this is at the knees - called walking rickets. And in children that crawl, this is at the wrists and called crawling rickets. Rickets is a disease of children and causes poor bone formation at the growth plates. In adults, after the growth plates are closed, Vit D Deficiency results in osteomalacia ( soft bone).
They were treating the child with Calcium and Vit D, but due to the late period of arrival the doctors did not feel he would be able to catch up on his growth.