Saturday, May 4, 2013

Practicing Neurology in Tumbes, Peru

Shibani Mukerji, MD/PhD
Neurology Resident, PGY3
Travel Grant:  Infectious and Cardiovascular diseases in Peru

Greetings from Tumbes, Peru!

Colored by child with schizencephaly 
Tumbes is a small city that sits near the border of Peru and Ecuador.  It is a town of approximately 200,000 people with three hospitals and a satellite site for the Center of Global Health for the Universidad Peruana 
Cayetano Heredia in Lima, Peru.  It was started as a Neurocysticercosis (NCC)  elimination center where the focus was on decreasing the incidence of taeniasis and cysticercosis through
Study pigs at the Center for Global Health
active treatment campaigns of both humans and pigs and education.  In the past decade, they have effectively decreased the rates of cysticercosis in Tumbes and now will begin survelleince and treatment programs in the neighboring community of 

NCC is one of the most common parasitic infections of the human CNS and a frequent cause of epilepsy worldwide. Neurocysticercosis  is caused by an infection of the human central nervous system (CNS) by the larval stage of the pork tapeworm Taenia solium.
Understanding the life cycle of taeniasis and cysticercosis 
The Center of Global Health Clinic-Tumbes is now conducting studies in the epidemiology of epilepsy in this region.  Here they see and treat patients with epilepsy.  In their cohort of over 1000 patients,  approximately 40% have epilepsy due to NCC.  Other main causes are CNS malformations, neonatal hypoxia, tumors and other CNS infections.  The neurological care in this area is severely limited by several key issues: 1) there is only one neurologist in this city who is able to see patients in the Center of Global Health Clinic once per month; 2)  Tumbes has one CT scanner located at the clinic and is used by all three hospitals.  The hours of use by the scanner are 1-6pm and a technologist can be called in for emergencies.  A MRI is located 3-4 hours drive in the neighboring town of Piura; 3) There are no EEGs available and so diagnosis and treatment of epilepsy is performed solely through clinical history.  Like most developing countries, there is a limitation with the types of antiepileptic agents that can be used due to availability and cost.  Typical agents used are Carbamazapine, Dilantin and Phenobarbital.  Keppra and Depakote are available but expensive. 

Donated EEG machine that sadly does not work

The diagnosis and treatment of epilepsy is through a group of highly intelligent and dedicated internists led by Dr. Luz Maria Moyano.  Dr. Moyano has taken it upon herself to learn about epilepsy and fundamentals of neurology through reading and telemedicine with neurologists in Lima.  In the past several months, they were able to diagnose a family from the highlands with spinocerebellar ataxia type 10 with the help of neurologists at the National Institute of Neurological Sciences, and a young boy with Poland Syndrome and AVMs.   
From right to left: Dr. Moyano, Dr. Azabache, Lily, Vilma and myself

On this trip to Tumbes, Dr. Moyano and I went to one of the local hospitals for consultation rounds where three Global Health clinic patients were admitted.  One patient with well controlled seizures was recovering from Dengue.  One patient with idiopathic epilepsy was admitted after a seizure of unknown etiology.  Another patient recently started on Dilantin developed a allergic reaction but did not realize it and continued to take the medication despite developing oral mucosal breakdown. We were able to develop a plan for all these patients with a few limitations given that we don't have EEG machines, and antiepileptic levels are not typically gathered in real time.  Given the limited access to neurologists, and no pediatric neurologists,  Dr. Moyano and I plan to use Skype in the future to discuss interesting and complex cases with residents in the Partners neurology program.  It is my hope that we can get more Partners neurology residents to this site for education and our own understanding of diseases here.  

It is hard to believe that my time in Peru is coming to an end.  This visit has provided me with an incredible insight into the fundamental understanding of the epidemiology and neurological manifestations of diseases endemic to Peru.  There is an amazing network of physicians 
and projects here for research.  I am incredibly grateful to Dr. Joseph Zunt and Silvia Montano for helping me arrange this visit and Dr. Hugo Garcia, his lab, Dr. Moyano and the people in the Global Health Center who welcomed me to both Lima and Tumbes and allowing me to participate in the care of their patients. 

My sincerest thanks again to the  Partners Global Health Travel Grant and Partners Neurology Residency, especially Vanya Sagar and Silvya Eaton and Drs.  Tracey Milligan and Tracey Cho who actively encourage residents to seek out these opportunities and expand our focus globally.