Karen* sat on her bed lost in thought. I said hello as I set down her bulky file on the foot of the bed, but she did not even acknowledge my presence.
The year was 2007 and I was a bright-eyed energetic medical intern excited to be rotating in the acute gynaecology ward. The patients in my cubicle lingered on for various reasons, allowing me to bond with each of them.
There was Lucy* in the corner bed. She had refused to accept her HIV diagnosis. There was Anyango*, the cubicle prefect, brought in bound by ropes due to a violent post-partum psychosis episode.
It was in the midst of all this that Karen found herself. She was yet to get accustomed to the drama all around her after nine years of self-isolation. Karen was once a housewife, a mother to two young men and an adorable nine-year-old. Her troubles began with the birth of her daughter. The delivery was hellish. It left her with a fistula, leaking urine for all these years.
In those days, fistula surgeons were few and the stigma associated with it was enormous. Karen was home-bound, unaware that she could get help. She survived all those years because of the love and care of her mother-in-law.
Her husband, on the other hand, was a different kettle of fish. He destroyed Karen emotionally, psychologically and eventually physically. He treated her with disdain because of her condition. He forced himself on her several times.
It took a lot of courage for Karen to come to hospital when she heard about our annual fistula camp on her small radio. It was the first time she had left the house in nine years. Her courage had saved her life. During screening, the doctor noted that Karen was developing deep vein thrombosis of her left leg, probably as a result of her immobility. She was admitted for emergency treatment.
After weeks of observing Lucy’s experience, Karen had adamantly refused to get tested for HIV.
A month down the line, instead of Karen heading to the operating room to repair her fistula, new problems were cropping up. She developed unexplained abdominal swelling with pain, especially in the lower abdomen. She began to lose weight and would be sweating profusely in the night even in the freezing cold July weather. We were constantly medicating her for constipation.
She underwent tests which were all negative. Her ultrasound scans did not tell us much and the review by the general surgeons did not shed any light. Karen was worried sick. So were we. We took a leap of faith to open her up and see what was causing her symptoms.
We were unprepared for what we found. Karen’s intestines were all matted together by abdominal tuberculosis. The tubercles were all over the peritoneum (the serous membrane lining the cavity of the abdomen and covering the abdominal organs), turning it into a hard cake. The lymph nodes in the abdomen were visibly enlarged.
The surgery was quickly brought to a close. We took biopsy samples for the lab and closed her up. It is all she needed. Testing Karen for HIV was no longer optional. It took a lot of explaining for Karen to understand what abdominal TB was. Like most people, she only knew that TB affects the lungs.
TB affects every single organ in the body, save for hair, teeth and nails. Abdominal TB is difficult to diagnose due to the non-specific symptoms, but it is good to know that with advances in imaging technology, we can diagnose it earlier and avoid unnecessary surgery.
Further, it was paramount that we ascertain Karen’s HIV status, seeing that TB is one of the Aids-defining illnesses . Her fears were confirmed by the lab as she tested positive. Karen was in need of comprehensive care including eight months of TB medication, lifelong anti-retroviral drugs for TB, continued treatment for deep vein thrombosis and the pending surgery to repair her fistula.
The tears poured in torrents. Tears of knowing that her fistula and its attendant complications had led to the rejection by her husband. That in his quest to satisfy himself out there, he had contracted HIV and passed it on to her.
Out of sight, I cried for Karen. Not for her medical jigsaw puzzle, as this was manageable and mostly curable, but for the indignity she had suffered. Physically she would heal, but emotionally and psychologically, she was scarred for life. It was a long walk back to health for Karen, but there was hope.