ISPUB.COM The Internet Journal of Third World Medicine Volume 3 Number 1 1 of 4 A Nigerian Child With Spina Bifida Cystica And A Ruinous Aftermath J Okeniyi, S Oseni, T Ogunlesi, G Oyedeji Citation J Okeniyi, S Oseni, T Ogunlesi, G Oyedeji. A Nigerian Child With Spina Bifida Cystica And A Ruinous Aftermath. The Internet Journal of Third World Medicine. 2004 Volume 3 Number 1. Abstract We report a 3-day old term male Nigerian baby with an uncomplicated unruptured spina bifida cystica who defaulted from neurosurgical care and had incision and drainage done by a quack. He presented 3 months later with hydrocephalus and other neurologic impairments. The socio-economic issues that led to this grave outcome are discussed. INTRODUCTION Spina bifida cystica, a congenital neural tube defect, may be associated with hydrocephalous and recurrent meningitis. 1 It occurs in about 0.1 – 3.5 in 1,000 live births. 2 The aetiology is uncertain although folic acid supplements given to mothers in pregnancy reduce the risks. 1 , 2 Myelomeningocoele and meningocoele are the two common forms of spinal bifida cystica. Meningocoele is less common and less severe being often devoid of neurologic deficits. 2 , 3 , 4 In Nigeria, effective surgical therapy is available 5 but usually fraught with many socio-economic issues some of which are highlighted in this report. CASE REPORT A 3-day-old boy was brought to the Wesley Guild Hospital (WGH), Ilesa, Nigeria on December 27, 2004 because of a cystic lower back swelling noticed at birth. The 28-year-old Para 3 + 1 mother had antenatal care and delivery at a clinic operated by a Community Health extension Worker (CHEW). She refused folate supplements during pregnancy for fear of inducing neonatal jaundice. She had previously experienced a first trimester spontaneous abortion. She earns about Three Thousand Naira (Twenty-two US Dollars) monthly as a seamstress. The 45-year-old father logs timber. Both parents were educated up to the primary level. The siblings, aged 7 and 4 years were apparently well. The term infant weighed 3.0 kg with a normal head circumference (34.0 cm) and full length (46.3 cm). The cystic mid-line swelling at his lower lumbar region measured 2 by 1 cm with normal overlying skin and no discharges. No other abnormality or neurologic deficits were observed. Spina bifida cystica was diagnosed. Following counsel, our offer of investigations and possible neurosurgical intervention was declined. He was re-presented when aged 3 months, with vomiting and fever of 4 days. The very day they declined our medical advice, the lesion was reportedly incised by the same CHEW and thereafter, dressed daily with methylated spirit and given intramuscular Penicillin injections for 5 days. There was an initial clear fluid discharge which later turned purulent and dried up prior to the healing of the overlying skin. The infant weighed 5.0 kg, was severely pale, febrile (38.5 °C) and drowsy. Head circumference was 60.0 cm with cranio-facial disproportion, shiny scalp with distended veins, ‘sun-setting' eyes and cracked-pot sign. Both fontanelles were wide and tense. The upper limbs were spastic with both hands persistent fisted. The left lower limb was flaccid but sensations were preserved. The right lower limb was normal. The fleshy lower lumbar swelling measured 3 by 4 cm with a linear scar about 2.5 cm but no discharge. There were peri- anal excoriations, reduced anal tone, continuous faeco- urinary dribbling. He was in congestive cardiac failure. Diagnoses were iatrogenic ruptured spina bifida cystica with hydrocephalus, anaemic heart failure and probable septicaemia to exclude meningitis. Figure 1 shows the baby and Figure 2, the lumbar lesion.