A German student contracted a deadly form of tuberculosis in India that was extremely resistant to drugs. The boy was rescued, but doctors are very concerned about such cases, because there are more and more of them every year.
Franz Hagedorn * passed out on the first day of school. It’s fall 2015. He recently returned from India. He spent a year there as part of the Volunteering Social Year (FSJ). He was driven by the desire to experience an extraordinary adventure. In Chennai he taught English, traveled a lot and explored the country in his spare time. Hagedorn is young and athletic. However, that morning the body went on strike and refused to obey. The boy remembers the following days as if in a blur – a doctor, hospital, another hospital. Medical diagnosis: tuberculosis. The adventure of a lifetime turned into a nightmare for a young man.
Tuberculosis is an infectious disease caused by bacteria called mycobacteria. They gradually destroy more parts of the lungs. The sick man is unwell and wasting away in his eyes. Despite the painful and unpleasant symptoms for the eyes, tuberculosis was surrounded by an aura of romance for a long time. It was considered an “occupational disease” of writers, musicians and artists. In fact, tuberculosis has nothing to do with it. No infectious disease takes such a huge deadly toll: it killed 1,8 million people last year, according to the World Health Organization. Mycobacteria of tuberculosis are transmitted by airborne droplets. Most often they get into the lungs and there they dormant for many years or even decades. Under favorable circumstances, they reproduce by division. In the initial stage of the disease, the process is very slow. E.coli strains and other bacteria divide on average every 20 minutes, and Mycoplasma tuberculosis every 17 hours. Methodically destroys the lungs. A painful, slow death awaits the sick person.
Franz Hagedorn did not fall ill with the usual form of tuberculosis. After seeing the test results, the doctors were terrified: the mycobacteria were resistant to the two most effective anti-tuberculosis drugs – rifampicin and isoniazid. Doctors call this type of disease MDR multi-drug resistant tuberculosis. The list of drug resistance is long: rifabutin, ethambutol, moxifloxacin, levofloxacin, ofloxacin, amikacin, capreomycin, kanamycin, prothionamide. Neither of these antibiotics was able to stop the mutant mycobacteria from multiplying in the young man’s lungs. Hagedorn contracted the most dangerous form of tuberculosis with an extreme resistance spectrum: extensively drug resistant, or XDR for short.
In 2015, the World Health Organization recorded more than 10 million new cases of tuberculosis for the first time. Almost half a million are cases of drug-resistant forms of tuberculous bacteria. One tenth of these are extremely drug-resistant XDR. This form of tuberculosis causes many serious problems. Treatment is expensive, takes time, and has a lot of unpleasant side effects. In many countries, there is a lack of adequate anti-tuberculosis drugs which are much more expensive than standard antibiotics. Less than half of the patients recover. – We are aware that this form of tuberculosis will continue to spread – admits Stefan Kaufmann, director of the Max Planck Institute of Infection Biology in Berlin. “We are talking about a disease that is very difficult to treat, and that is a serious cause for concern,” she adds.
About ten cases of the most serious, extremely drug-resistant form of tuberculosis are reported annually in Germany. A journalist collecting material for an article about XDR tuberculosis will sooner or later direct his steps to Borstel, a small settlement in Schleswig-Holstein, with only 131 inhabitants. The Leibniz Institute for Medicine and Experimental Biology is located here. It consists of a complex of red brick buildings. The hospital section has 90 beds at its disposal. The Institute employs over 500 employees. It was established in 1947 as a tuberculosis research center. More than half of the cases of XDR tuberculosis in Germany are treated at Borstel. In 2015, Franz Hagedorn was brought here.
He was in the hospital for many months and was taking a cocktail of dozens of drugs. The normal form of tuberculosis is already a healing marathon. Doctors can inhibit the growth of most mycobacteria within a week using traditional antibiotics. Patients recover after the standard six-month treatment regimen. In the case of extremely drug-resistant tuberculosis, the duration of therapy is extended to 20 months. Patients take thousands of pills, more toxic and more expensive. – The cost of anti-tuberculosis drugs alone is around PLN 100. euro – informs Christoph Lange from the center in Borstel.
Probably Dr. Lange has the most experience in treating XDR tuberculosis in the whole of Germany. At the center in Borstel, the doctor has an unusual laboratory diagnosis: he sequences the genome of the bacterial strain in each patient. Based on small anomalies in the genome of 4,5 million pairs and time-consuming laboratory tests, scientists are able to determine effective antibiotics and the appropriate, individual doses of drugs for each patient. “This means that once we are diagnosed with TB, we are able to develop a personalized treatment very quickly,” explains Christoph Lange. Doctors also check the levels of the drugs in the patient’s blood to make sure they are strong enough to kill Mycobacterium tuberculosis. “Our therapy is probably the only one and unique in the world,” says Dr. Lange.
Hagedorn’s organism responded very well to the therapy, the number of mycobacteria was significantly reduced. “The prognosis is very optimistic,” admits Dr. Lange. It is likely that partial lung resection will be avoided. Even so, treatment will be painful and take a long time.
As Hagedorn began to recover from boredom, he trained to climb the old tower at the resort. “I felt boredom the most,” he admits. Will stay in Borstel until Easter. He will come home for Christmas. At first, it seems that the history of his illness has found an optimistic ending, but we will have to wait for a happy ending.
– I am going home, but I will have a long treatment. It will not be possible to return to normal life yet, says Hagedorn.
For a long time, scientists have believed that mycobacterium tuberculosis develops drug resistance when treating the standard form of tuberculosis, when patients are not taking regular medications or are inadequately treated. Mycobacterial tuberculosis strains acquire drug resistance very quickly. In 2011, the first two new anti-tuberculosis drugs in decades were launched. Already at the end of 2013, there were reports of patients whose body became resistant to new drugs. Carriers of drug-resistant tuberculosis strains can infect others, which is happening more and more often. In January, scientists published the results of a study of four hundred people in South Africa suffering from tuberculosis type XDR in the New England Journal of Medicine. More than half of them contracted the deadly form of tuberculosis through contact with a mycobacterium person.
This scenario is very likely in the case of Hagedorn. It is no coincidence that the infection happened in India. 60 thousand annual incidence of tuberculosis type XDR annually places India in the forefront of tuberculosis countries extremely resistant to the available antibiotics. “This is a warning signal for now, but it must be taken with the utmost seriousness,” says Christoph Lange. People returning from these countries with complaints about any symptoms should be screened for drug-resistant tuberculosis.
Hagedorn intends to take up his interrupted studies at the faculty of mechatronics. He always carries his medications with him. The most important of these, meropenen, is only valid for four days. Every three days, the pharmacy sends you a carton of pills, syringes and antibiotics in liquid form in rubber bags. Doctors implanted Hagedorn with a vascular port with a catheter leading directly into the ventricle.
In the morning, at noon and in the evening, he thoroughly rinses the port with a saline solution and connects a rubber pouch with the drug gradually released into the heart chamber to the port. He also takes many pills. Due to the risk of infection, swimming in a pool or lake is strictly forbidden. Doctors also forbade him to engage in contact sports. If he leaves home for a few days, he has to inform the pharmacy about it, so that it can send him medications. Traveling abroad is not an option at all.
Hagedorn’s treatment will probably end in May. Then he will be able to swim, play any sport and travel. Doctor Chrisoph Lange believes that the young man was extremely lucky. “It is very likely that if he had stayed in India, he would not have been alive,” the doctor says. Meanwhile, Hagedorn is maturing for a new expedition and another adventure. This time, his choice fell on Indonesia. Not afraid of bringing a new disease? “Not at all,” he replies lightly.
* The name of the hero has been changed.