Manish Goes to the Hospital…

…On August 6, 2010, Manish Pasman was born at home in a tiny village in rural Bihar, one of the poorest states in India. He had a small “chickpea-sized” growth on the right side of his nose. Only days after his birth, Manish and his family moved to Faridabad as his parents searched for higher wages and a better lifestyle in the slums of Sector 4, right where I found him.

When I first saw Manish, he was being held by his mother on the side of a road in the slum. When I stopped, she scurried off down an alley with Manish in her arms. When I asked Mithlesh about the little boy with a growth on his face, he did not know whom I was talking about. Although Mithlesh knows almost everyone in the slum, he had never seen or heard of Manish before. Luckily, Manish had been out of the house just as I walked by. When I returned with Mithlesh to translate for me, Manish’s family was pleased to learn that I wanted to help.

–Manish on February 10, 2012–

At two months old, Manish’s defect had grown slightly. His parents took him by bus to the All India Institute of Medical Sciences in Delhi, the best public hospital in India. The doctors told him to come back in four months. When they returned, the growth had spread across Manish’s cheek. The doctors scheduled an MRI, for which Manish and his family had to wait four more months. Now ten months old, Manish’s condition had proliferated substantially. The mass on his cheek and nose seemed to be growing out of control. Even after the MRI, doctors seemed torn as to what the condition really was. Favoring a conservative treatment, the physicians placed Manish on standard corticosteroid medication for the next 100 months (8.3 years!).

Since then, over the past nine months, Manish’s condition has stretched and swollen even faster than before. There is even noticeable difference between when I first saw Manish on February 10 and now. Obviously touched by Manish and in disbelief that more could not be done, I set out to help him as if he were my own son. I made calls to numerous locals and was put in contact with Dr. Amitabh Singh, the leading plastic surgeon at one of the best private hospitals in town. Dr. Amitabh was enthusiastic to help. He said, “Bring him to me at 11am tomorrow.”

Fewer than 18 hours later, I was sitting in Fortis Escorts hospital with Manish, his mother Dolly, Dolly’s father’s friend Vikram, and Mithlesh. Dr. Amitabh’s first reaction was one of slight surprise. I don’t think he anticipated the case being so advanced. However, his warm personality and extensive knowledge were immediately apparent. I felt confident in Dr. Amitabh’s ability to provide the best possible care to Manish.

Dr. Amitabh explained in great detail what the condition could be both in English (for me) and Hindi (for the others). His clinical impression, given the compressibility, rigidity, appearance, and temperature of the growth is that it is a vascular malformation, more specifically a venous malformation. However, we needed more evidence. Since Manish’s last MRI was nine months ago, unavailable, and difficult to obtain, we opted to undergo a new battery of tests.

Furthermore, Dr. Amitabh wanted to specifically find the answers to multiple questions. He wanted to know if the vascular structure is being fed or drained by vessels to or from the eyes or brain. He also wanted to ensure that other vascular malformations are not present in Manish’s other organs, especially his brain or liver.

Dr. Amitabh personally escorted us to the radiology department. On the way, I was introduced to the chief of the hospital. Sixty seconds later, Dr. Amitabh and I were standing with the chief radiologist, Dr. Nirmesh, in his control room. After a run-down of our challenge, Dr. Nirmesh asked, “Is he ready today?” After fasting for a few hours, Manish was prepped for his MRI. He was given a dose of chloral hydrate syrup as a mild sedative and an IV line was started for the contrast agent.

Everywhere we walked, Manish was the center of attention. Even surgeons came out from their other work to see him and investigate his condition. Slowly, the sedative set in and we were ready to begin the MRI.

Manish was positioned and aligned as Vikram stood watch. Vikram had removed the metal from his clothes and pockets in order to stay by Manish’s side. With all systems ready, Manish was slid into the tube.

At my request, I was generously given permission to join the radiologists and technicians in the control room. For the first 20 minutes, everything went perfectly. Hundreds of cross sections were taken of Manish’s head to search for feeder vessels, vascular structure, and any potential vascular malformations within his brain.

Manish then began to show his tremendous vitality. With only ten minutes and the contrast scans remaining, Manish awoke. The test was shut down.

Manish was given one more dose of syrup and his IV line was cleared with saline while we waited to see if he would sleep once more.

After one pleasant nap and unexpectedly waking up inside of a loud claustrophobic tube, Manish showed no signs that he was going to fall asleep again. Now late in the afternoon, we were sent home and scheduled to continue the tests at 9am the next morning. Via a tuk-tuk, we returned to the slum.

The next morning, we returned to complete the contrast MRI. After 30 minutes, Manish was out cold again. However, he woke up just before the scans commenced. He fell asleep 30 minutes later, and then woke up again as he was rolled into the tube. The next time, he woke up while he was being covered with a blanket on the MRI table. After two days and five attempts at an MRI, Manish finally cooperated and slept peacefully through his contrast MRI. Noticing conflicting potential diagnoses between the contrast and standard MRI’s, Dr. Nirmesh freed up the CT scan for a third evaluation.

Dolly stood watch over Manish with a lead apron as the CT scan was completed. Next, we took Manish to a high resolution ultrasound to search for any vascular malformations in his other organs, notably his liver, kidneys, gall bladder, intestines, and urinary bladder. I am happy to report that, other than his face, Manish is perfectly healthy.

However, his face seems to be discouragingly difficult to properly understand. Although the growth clinically presents as and is supported by standard MRI to be a venous malformation, the contrast MRI patterns suggest structures more typical of a proliferating hemangioma with some features of involution.

If the growth were strictly a venous malformation without any feeders to or from the eyes or brain, clotting agents could be injected to collapse the vasculature from the inside out. If the growth were strictly a hemangioma, multiple paths could be taken but most likely nothing surgical or invasive. Surprisingly, an infantile hemangioma even of this size will eventually enter a stage of involution in which it slowly collapses on itself. However, Manish would be left with permanent scaring and excess skin not to mention the social and emotional burdens of looking like this for the next 8 years!

Dr. Amitabh had departed the hospital by the time our scans were complete. On Monday, we will return to see Dr. Amitabh, determine the complete diagnosis, and discuss treatment options. I look forward to learning how we can help this precious and unfortunate young trooper. I am happy to learn that Manish is otherwise healthy but wary that our options may indeed be limited. Rest assured, we will do everything we can do for Manish. As you saw today, we’re not holding anything back to care for him. He is already a celebrity at the hospital and is receiving red carpet treatment from all of the physicians. Even if we have to let nature run its course, that course will be heavily monitored. Stay tuned as we learn more!

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