It was 17th November, and I got a What’s App message from a lady. It appeared she had a serious liver problem and had got my number from another doctor. The young lady was from Kenya, had come to Dubai for her first job at a hotel one year ago. About 6 months ago, she had been detected to have abnormal liver tests but could not undergo further evaluation due to her busy work schedule. Around mid-October she started noticing progressive yellowness of her eyes (jaundice) and developed leg swelling. She saw a doctor and was diagnosed to have acute hepatitis. Usual causes like drugs, alcohol and viruses were excluded. One of the liver autoimmune markers was positive. She needed a liver biopsy to confirm the diagnosis of autoimmune hepatitis and therefore she contacted me. I glanced through her test results. Serum bilirubin was 30 mg/dL and INR was 3.0. Her ultrasound scan showed a scarred (cirrhotic) liver with lot of fluid in the belly (ascites). These values represent advanced liver dysfunction. The situation looked scary, and my instincts told me that this was a likely a flare of autoimmune hepatitis leading to liver failure. Nothing short of a liver transplant can salvage these patients.
I asked her to come and meet me the next day. Upon further conversation with her, she was alone in Dubai with limited resources and had a very basic medical insurance plan. I told her that she most likely had severe autoimmune hepatitis for which steroids are the treatment of choice. But her condition was far too advanced, we still did not have a confirmed diagnosis, and there was no time or resources to do further tests or a liver biopsy. Giving steroids in such a situation runs a very high risk of complications and infections. She got overwhelmed when I told her to prepare for liver transplantation. The very same evening, she had a vomiting with a large amount of blood and collapsed in her room. Thankfully she landed up at another hospital where a colleague did an urgent endoscopy and controlled bleeding from large esophageal varices. Her clinical condition worsened due to the bleeding, and it appeared that we would lose her. After a few days, she messaged me that she had been referred to a hospital for a liver transplant who quoted close to a million dirhams for the transplant and her insurance would not cover this amount. I told her that I could help her get a transplant in India at a much reasonable price, but she still needed a close family member or friend who could donate part of their liver. This was obviously a huge challenge for her.
About three weeks passed and there were no further messages from her. A few days into the new year, I got some blood test results from her. I saw them and asked her to meet me the same day. To my extreme surprise she had miraculously improved. Her jaundice had reduced to a bilirubin of 5 mg/dL and her swelling in the legs and belly was completely gone. Interestingly she had remembered the steroids that I had given her and had continued to take them. It looked like her autoimmune hepatitis seemed to be responding. The smile on her face, the sparkle of life and hope was distinctly evident. It looked like that she may survive without a liver transplant. She still has a long way to go before she recovers completely, and I sincerely hope and pray that she continues to do well.
