Wednesday 8 am, Moshi, Tanzania
A 26-year old man is brought in. He is severely ill and has difficulty breathing. He can’t open his mouth. The man looks frightened. His mother confirms our suspicions. She tells us that a week ago her son hit a rock with his bicycle and fell. One of the old, rusty spokes poked in his leg and inflicted a wound. This wound healed normally but this morning he became severely ill. This man has tetanus.
Tetanus is an infectious disease caused by the bacteria Clostridium tetani that is characterized by muscle spasms. These spasms can get very severe and cause the classic opisthotonus; the body arches backward and the mouth is in lockjaw. It is fatal in 10% of the cases, mostly due to respiratory failure because of the spasms.
Tetanus can be transmitted by animal bites but also by simple rusty accidents. Bicycle, motorbike and car accidents are very common causes of tetanus and this is the reason that you get a vaccine after you had an accident like this. Because yes, you can get vaccinated against these bacteria. The only problem is that the vaccine needs to be updated every 10 years. If your last vaccination is older, you might need a booster dose. But luckily, if you ever had a vaccine the chances of survival are greater than if you never got any vaccinations.
To try to save patients like this, we normally do four things.
- Open the wound from the bicycle accident and surgically remove all possible infected tissue. The bacteria produce toxins that cause the symptoms. So even if the wound looks healed and clean, the toxins still might be present, causing harm. Not easy to convince surgeons to open-up a closed wound but trust me, if you explain the situation, they will help you.
- Give antibiotics that kill the bacteria
- Give immunoglobulins. This is a special type of medicine where you give immune cells against a disease directly to the patient. We have some diseases where this has a very good effect like rabies and tetanus.
- Give him the best supportive care
Wednesday to Friday morning, Moshi, Tanzania
After talking a lot with the surgeons, they opened the wound (step 1: check) and we started the antibiotics (step 2: check).
But now the trouble started. In an earlier post about rabies I mentioned that immunoglobulins are expensive and not always available; Tetanus has the same problem. Unlucky for the man is that we had a similar patient just a few days earlier. We were able to get immunoglobulins from Nairobi, Kenia (close to Moshi) for that patient. It was their last vial. Our 26-old man needed to get his immunoglobulins from Dar-es-Salam. It is in Tanzania, but much further away and thus much more expensive for the family to get it. In other words: they couldn’t get these very important immunoglobulins that might save his life (step 3: no check).
Friday 1.30 pm, Moshi, Tanzania
After two days of supportive therapy (step 4: check) the man is slipping away. We resuscitate for 60 minutes but there is no response. He dies.
It all started with that bicycle. Or did it start much earlier? When he didn’t get the childhood vaccinations? Maybe they were not available, maybe his family never could afford it.
But if you are not yet vaccinated and the vaccinations are available and affordable: get your tetanus shot.
Don’t let a simple bicycle kill you.
Picture: Opisthotonus in a patient suffering from tetanus. Painting by Sir Charles Bell, 1809.