I had one of those days today for which words just can't do justice. I'm going to try, though, because it was such an incredible twenty minutes that I really need to share. It started as a pretty normal day. Rounds in the maternity ward, rounds in the peds ward, and then we started consultations. Nothing too exciting at first - lots of cough, fever, UTIs, malaria, etc. Then the arrival of a six year old girl and her father. They were from Equatorial Guinea, and had lived in Gabon for a year or so, so the father spoke a bit of French. The chief complaint was cough and fever for a week. Pretty standard. After doing a history of present illness, I asked the father about the bandage I noticed on her left hand. "It's nothing," he told me. "It's healing."
The child undressed and climbed up on the examining table, and we unwrapped the hand. Both Dr. Bonito and I gasped in horror -- the wound in the photo was what we found, but filthy - covered with dirt and some sort of traditional healing "pommade" that smelled like rot. (The photo here is after the nurses cleaned the wound.) Upon further questioning we learned that the wound has been present for over a month. It wasn't a difficult diagnosis - a Buruli ulcer, which is fairly common in this area (we're in an endemic region), but the infection is so advanced that she will probably lose the finger.
I continued the physical exam as I do for any child with a cough and fever. Nothing of note on her lung exam, no heart murmurs, no lymphadenopathy... everything seemed normal until I looked in her throat. She was sitting up on the table, and tilted her head back for me. I asked her to stick out her tongue and say "ahhh" but she only opened her mouth slightly. I asked again, and her father said "she can't!" She continued to try to open her mouth for me, and as I maneuvered the tongue depressor into her mouth and her father continued to say "she can't!" the child's jaw clenched shut. Her head arched back, every muscle in her body stiff as a board, and her upper body plummeted towards the table as Dr Bonito and I reached quickly to catch her shoulders and set her down on the examining table.
My heart skipped a beat. TRISMUS?!? The thoughts that raced through my head over the next few seconds went something like this.... "could this be a case of tetanus?!? No way. I'm doing the med student thing, jumping to the worst possible conclusion." Despite my doubts, I looked at the father and asked if the child had been vaccinated. No vaccines at all. Bonito clapped me on the back. "You're thinking what I'm thinking," he said gravely.
So much for the fever and cough. After some further, more probing questions, we learned that the poor kiddo had experienced brief "crises" of stiffening for the past four days. No vaccine, clear "porte d'entree" (entry point - the Buruli ulcer) - it was a definite case of tetanus. Textbook. Trismus and everything. I couldn't believe it.
We gave her anti-tetanos serum, a tetanus vaccine, cleaned her finger wound, hit her with some heavy antibiotics, and put her in isolation, and now it's just a waiting game. We're hoping that we've caught it early enough to avoid progression to respiratory compromise, because there are no respirators here in Lambarene. Terrifying.
