Day 13: Lupus, Leprosy and Kaposi’s Sarcoma [NSFW]

Dermatology in Africa differs from the US or Canada in one big way – there isn’t much skin cancer. Darker people with more melanin in their skin aren’t as susceptible to it. But they do have more infectious diseases with some interesting presentations.

For the second day in a row, I saw patients with Dr. Joshua in the dermatology clinic at Amana Hospital. Dr. Joshua is the only dermatologist in the Ilala District, one of three districts of Dar Es Salaam, with a population over 900,000 as of 2012. Due to the paucity of dermatologists in Tanzania, and the lack of dermatology training in Tanzanian medical schools, many patients show up at Dr. Joshua’s clinic after trying several treatments from multiple general practitioners.

I was under the impression yesterday that all patients at the dermatology clinic had national health insurance coverage, but it turns out that’s not true, as almost all patients today paid a 10,000 shilling (~US$4.50) consultation fee to be there.

We saw some “garden variety” dermatologic problems that are easy to treat – dermatitis, prurigo nodularis (itchy purple nodules that Dr. Joshua believes are caused by reactions to mosquito bites), and several cases of jock itch in young men.

One man came in deeply distressed by penile papules that erupted over the last two months. We reassured him that this was a normal anatomical variation – the only treatment option is laser surgery or “electrocautery” surgery. The man didn’t seem convinced that his penis wasn’t diseased. I imagine he’ll either learn to live with the papules or return for a surgery consult.

Penile Papules

Penile Papules, courtesy of Wikipedia

A Rare Diagnosis

Another man came in complaining of purple lesions on his shins and inner leg, all the way up to his groin. Dr. Joshua let us mull on what the diagnosis could be, but none of us could figure it out. It was unlike anything we’d ever seen. Making a diagnosis in dermatology is largely about recognizing lesions, and this is one we’d never seen before.

“My diagnosis is… Kaposi’s sarcoma,” Dr. Joshua declared.

Kaposi's Sarcoma Lesions

Kaposi’s Sarcoma Lesions, courtesy of Wikipedia

Kaposi’s sarcoma is a form of skin cancer caused by a herpes virus – HHV8 – not the same one that causes genital herpes. It’s very rare except in immune-compromised people. This patient, Dr. Joshua explained, was HIV-positive and has been taking HIV drugs (which are free in Tanzania) regularly since 2014.

In the early days of the AIDS epidemic in western countries, many gay men discovered they had AIDS when the characteristic lesions of Kaposi’s sarcoma appeared. The lesions usually shrink or go away in people on HIV treatment, but our patient could have a resistant strain of HIV that isn’t responding to first-line treatment. He also had fungal infections in his toenails, another sign of a suppressed immune system.

As Kaposi’s sarcoma is more common in gay men versus heterosexual men, even among those with HIV (at least in the US and Canada), I asked Dr. Joshua if he planned to take a sexual history. “No,” he said. “If a patient has sex with the same sex, there’s so much stigma that they wouldn’t be willing to tell me.”

Dr. Joshua sent the patient for blood tests, including a CD4 count to monitor the progress of his AIDS. The patient will then be sent to the HIV care and treatment center and switch to a second-line therapy if needed.

Lupus – the disease you’ll never forget

Today I saw a malar rash in person for the first time. Malar rashes are a butterfly-shaped and spread from one side of the face to the other, over the nose. It’s the defining feature of lupus. The patient also had discoid rashes on her neck and arms, another characteristic feature.

Malar Rash

Malar Rash, courtesy of Wikipedia

Discoid Rash

Discoid Rash, courtesy of Thomas Ray, University of Iowa

Lupus is an autoimmune disease that can attack almost any part of the body – skin, joints, lungs, kidneys, heart, etc. Patients often die from complications of the disease. Our patient today was treated with prednisone, a steroid that suppresses the immune system. Another drug that can be used is methotrexate, which also used to treat rheumatoid arthritis and other autoimmune diseases. Dr. Joshua opted not to use methotrexate because of its toxicity, and because the patient was improving on prednisone.

Keloid Scars

We saw a woman with large skin lesions called keloid scars. People with these scars usually have keloid disorder, which causes excessive amounts of collagen or glycoprotein to be deposited when skin heals. Every time a patient with keloid disorders is injured – even if it’s just a tiny scratch, the area of skin could develop a keloid scar. In simple terms, the mechanism in the body responsible for creating scar tissue is out of control. The disorder is largely genetic and much more common in Africans than Europeans.

Keloid Scars

A woman with keloid scars in the Dermatology Clinic, Amana Hospital

Dr. Joshua scheduled the woman for liquid nitrogen treatment. The scars will be frozen with the liquid nitrogen, killing the cells in them, which will then fall off. Her treatment will be done gradually in stages. Unfortunately there’s no permanent solution – as her skin is scratched or cut in the future, she’ll develop more keloid scars.

Leprosy

A man came in with flat pink lesions on the dark skin of his face and thighs. At first we thought these might be a case of vitiligo, where the skin mysteriously loses pigment in some patches. But vitiligo usually results in pale white lesions, not pink ones.

“This is a case of leprosy,” announced Dr. Joshua.

One way to tell whether the lesions might be caused by leprosy is to test the patient’s sense of touch in the affected area. Dr. Joshua discovered that the patient lacked sensation in his lesions.

Dr. Joshua tests a patient's lesions for sensation

Dr. Joshua tests a patient’s lesions for the sensation of touch with a folded piece of paper

Leprosy is something we haven’t learned about yet in medical school, although I’ve read about it in historical novels. People with leprosy were branded as “lepers” and often shunned because the disease is contagious. It’s caused by the same family of bacteria as tuberculosis, and as such the treatment is a combination of antibiotics.

Because leprosy damages the nerves, skin, lungs and eyes, infected people lose sensation in their extremities and often end up with infections that cause them to lose fingers and toes. The disease can be spread through droplets coughed up by infected people.

Lidia and Dane wondered whether we should be wearing our N95 masks. I felt it was unnecessary because the patient wasn’t coughing. Leprosy also isn’t as easily spread as tuberculosis – for this reason, it’s a much rarer disease.

I’ve really happy to have spent two days in the dermatology clinic. We don’t get much dermatology treatment in medical school, so this exposure was extremely valuable. Hopefully I’ll be able to recognize some of these diseases if I see them in my patients in the future.

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