Encounter with Death in a Foreign Land
Joann Mead, MA is a researcher and author of biocrime fiction.
Consulted with Dr Celina Pereira
Celina Pereira, MD, FAAP is an Adolescent Medicine physician with special interests in Mind Body Spirit connection, International Travel and Cross Cultural Communication.
It was supposed to be a dream vacation to India, but it turned out to be a nightmare. On my return to the USA, I consulted with my friend, Dr Celina Pereira who is of Indian origin.
In the central highlands of India, I wore sandals on an unplanned walk in our safari lodge in the tiger reserve’s “buffer zone”. As we approached a small dwelling where tribal people lived, a wild boar darted across our path. He was so close he kicked up dust and worried the lodge manager who accompanied us. “Don’t get close, they can be quite dangerous.” Nearby, Langur monkeys eyed us suspiciously; deer could be seen in the distance. I suggested we turn back and return to our bungalow. I changed into socks and walking shoes for the scheduled game drive that afternoon.
We never did see the elusive tigers during our safaris. Despite seeing their paw marks and hearing them snore (they slept all day in the dense bamboo forests), the abundance of wildlife and the rare spotting of a leopard kept me from focusing on the tick I found on my right leg.
In the north of India, we seldom stayed longer than two or three nights in one place. On the 8th day of our journey, I dismissed a bout of diarrhea as “Delhi Belly”. On the days that followed, a persistent “watery” left eye I blamed on the smoky funeral pyres at Varanasi. The swollen knees I attributed to climbing the “ghats” (steep steps) along the Ganges River. In Agra at the Taj Mahal, the swelling and fatigue made climbing stairs a painful burden. By the time we got to our Jaipur hotel, a diffuse rash broke out all over my body. A doctor was called to the hotel. Doctor #1 lifted only my sleeve to view the rash. The doctor took my word that that the rash covered most of my body. It spared my face. Noting my recent diarrhea, he left me with a probiotic, Vitamin B and an antihistamine.
The next day, frightening nightmares were followed by bizarre but somewhat pleasant hallucinations. Ordinary objects in the hotel room became animated, the most notable being a mohawk-haired wild boar with flashing electric-illuminated eyes. A second doctor was called. When Doctor #2 arrived, he told us he was “President Bill Clinton’s doctor on call during his visit to India”. More thorough in his exam he asked that I remove my clothes. He ordered a CBC. He later returned and injected my buttocks with what I presumed to be an antibiotic. Writing Urticaria and URI as the diagnosis, he prescribed erythromycin, prednisolone, antihistamine, antacid and a cough medicine for my dry cough.
Unable to eat, my GI symptoms worsened, arthralgia increased as did the malaise and delirium. If I had a fever, I was unaware of it. The vicious cycle of symptoms worsened in Udaipur, our final destination in India, before returning to London via Mumbai. The prescribed course of medication was almost over but the rash thickened into a deeper shade of red and purple. At this point I seldom left my hotel room. Malaise was constant, my knees, feet and ankles ballooned, GI disturbances were unbearable, my cough worsened, my eyes were now painful and extremely photosensitive.
I knew I needed the expertise of a hospital with a tropical and infectious disease unit. On-line, I found Massachusetts General Hospital (MGH) in Boston, our final destination. The next day, my left eye turned a zombie shade of purple-red. I thought I would go blind. I was finally convinced to take an earlier flight to Boston.
On the flight, the GI distress was intensely painful. Unable to urinate, I thought my kidneys were shutting down. I worried that I would soon go blind in my left eye.
Heading straight to MGH, I was admitted through the ER. I was shuttled next door where my eyes were examined in the Mass Eye and Ear Hospital ER. The Ophthalmologist diagnosed Uveitis and suspected Rickettsia. He prescribed Prednisolone drops for my left eye. At MGH, I was isolated until contagious diseases could be ruled out.
It was Day 28 since the start of my journey. My rash spots became massive, black and purple in color. The soles of my feet were spotted with an underlying deep purple; walking was unbearable. My eyes were so light sensitive I asked to have the blinds closed and lights out. Even breathing was labored. I was sure I was dying and requested DNR and “no tubes please”. I did not mention my respiratory distress out of fear they would intubate me.
Two days of IV and 12 days of oral Doxycycline (100 mg twice daily) resolved the worst of the symptoms. My response to the IV Doxycycline was rapid. It became easier to breathe, to urinate, to walk on the soles of my feet. The massive rash spots reduced in size, the knee and ankle swellings subsided. Some photosensitivity and “spider-web” eye floaters remain as does the rash; both appear to be lessening over time.
My diagnosis at MGH with Rickettsia conorii (strain Indian Tick Typhus) was based on travel to an endemic area. The Rickettsia diagnosis was later confirmed by Spotted Fever IgG and IgM titers.
What would have led to an earlier diagnosis and treatment? The cultural differences in India were immense, compounded by the fact that my condition was worsening. I suspected that I was being given less than optimum care. Faced with a progressive illness, it might have been judicious to take the first flight back to the US and go to a hospital with an Infectious Disease unit. I later realized that the best care in India might have been obtained at the nearest teaching institution with a medical school or I could have sought the recommendation of an American Embassy or Consulate regarding the choice of a hospital or an allopathic practitioner.
I missed the instant emotional connection with my physician at home and my familiarity and confidence in the US healthcare system. I realized how important prevention of tick, mosquito and animal bites is.(1–2) Rickettsial diseases are reportedly difficult to diagnose and untreated cases can have fatality rates as high as 30%–35%.(3)
References:
2 https://www.cdc.gov/mmwr/volumes/65/rr/rr6502a1.htm
3 Manjunath Hulmani, P Alekya, and V Jagannath Kumar. Indian Tick Typhus Presenting as Purpura Fulminans with Review on Rickettsial Infections. Indian J Dermatol. 2017 Jan-Feb; 62(1): 1–6