Cristina – Peru

The name of the child in this story has been changed to protect confidentiality.

Baby Cristina’s first birthday should have been a happy occasion. However, instead of eating cake and receiving presents, Cristina spent most of the day in the back of an old ambulance that carried her the six hours from a local hospital in central Peru to a referral hospital in Lima. By the time she arrived in the emergency department, Cristina was barely responsive to stimuli, and her left pupil was fixed and dilated—a sign of impending death from brain swelling.

Cristina lived with her family in the jungle district of Junín, one of the poorest regions in the country. Several months after Cristina was born her mother became ill, and was symptomatic for months before being diagnosed with TB.

Two weeks before her first birthday Cristina began experiencing fevers and a cough. Her parents gave her a fever-reducing medicine, but her symptoms became more severe. Five days later Cristina’s parents took her to the local health center, where she was diagnosed with a cold and sent home. Two days later, Cristina had a seizure. Returning to the local hospital, she was again given medicines for her cough and fever, but was not evaluated further and was discharged after a day of observation. However, Cristina became increasingly drowsy over the next several days, so her parents again returned with her to the hospital. Her clinical status quickly worsening, the staff decided to transfer her to Lima. Her father accompanied her while her mother, undergoing treatment for her own TB, stayed in Junín.

At the hospital in Lima, neurosurgeons performed an emergency operation to save Cristina’s life. Her doctors determined that she had already suffered permanent brain damage, and most likely had both pulmonary TB and TB meningitis. The physicians believed that she had most likely caught TB from her mother, but, despite their many efforts, were unable to obtain any specific information about her mother’s illness or treatment course from Junín to know if she had a drug-resistant strain. As a result, Cristina began the standard treatment for drug-sensitive TB while her diagnostic tests were pending.

After a month of treatment, Cristina’s clinical status still had not improved, and her medical team began to suspect DR-TB. Her laboratory tests soon confirmed that she had multidrug-resistant TB (MDR-TB). The pulmonologists immediately altered the drug regimen. In the meantime, she underwent another surgical procedure and received several medicines to prevent further brain swelling and seizures.

Unfortunately, despite aggressive treatment, Cristina’s clinical course slowly progressed, and, four months later, she died of progressive brain swelling. The doctors who cared for her expressed hope that a lesson could emerge from this tragedy: that providers at every level of the health system should consider and evaluate for TB, particularly when a member of the household also has active TB. Baby Cristina presented to care multiple times before she finally received appropriate diagnostic studies and treatment. If Cristina had been diagnosed earlier, she might have survived.

Story Collected by: Hernán del Castillo (National Institute of Child Health [Instituto Nacional de Salud del Niño]), Silvia Chiang (Children’s Hospital Boston and Partners In Health), and Leonid Lecca (Partners In Health)