A rare manifestation of burns after lightning strike in rural Ghana: a case report

A 10-year-old Ghanaian girl presented to a hospital with burns on her right arm, abdomen and both thighs after she was struck by lightning during a downpour. She was struck by lightning when she opened her bedroom door to walk out. On general examination, she weighed 25 kg and was febrile with a temperature of 38.0 °C, not pale, not dehydrated, and not jaundiced. Her blood pressure (100/70 mmHg), pulse (80 beats per minute) and respiratory rates (16 cycles per minute) were normal. She sustained second-degree burns on the posterior part of her right arm, abdomen, anterolateral part of her right thigh and the anteromedial part of her left thigh as shown in Fig. 1. Using the “rule of nines” for estimating the total body surface area for burns of persons at least 10 years old [14], the estimated burnt surface area was 9%. The affected areas of the burns were erythematous with blisters. However, examinations of her gastrointestinal, cardiovascular, and neurological systems were all normal.

Our patient was admitted to the children’s ward and initial laboratory results showed leukocytosis of 15 × 10^9/L with neutrophilia of 80%. Serum urea (4 mmol/L), creatinine (80 μmol/L), sodium (138 mmol/L), and potassium (4.1 mmol/L) levels were normal. A routine urine test was normal. However, the hospital lacked the capacity to carry out wound swabs and blood tests for culture and sensitivity. She was put on an intravenous broad-spectrum antibiotic (ceftriaxone 1 g daily) for 7 days and oral paracetamol 500 mg every 8 hours for 5 days. She was also given 25 mg diclofenac every 8 hours for 5 days to relieve pain. A urethral catheter was inserted to monitor her urine output while she was given 900 mL of Ringer’s lactate intravenously for the first 24 hours to ensure that she remained hemodynamically stable. Half of the volume of fluid (450 mL) was administered in the first 8 hours and the remainder was given in the next 16 hours. The burns were dressed daily with sterile gauze impregnated with Vaseline (petroleum jelly) and silver sulfadiazine. In addition, our patient was covered with a blanket to prevent hypothermia. Our patient had physiotherapy daily to prevent contractures of her affected limbs.

After 48 hours of treatment, her temperature became normal. Treatment was continued and her vital signs were checked regularly and remained normal. On the 16^th day of treatment in the ward, the burns had almost completely healed and there were no contractures as shown in Fig. 2. The full blood count was repeated and it was found to be normal. Our patient was discharged from the ward and put on oral amoxicillin 500 mg every 8 hours for 5 days. She and her guardian were asked to return to the hospital daily for dressing as their residence was close to the hospital. On the 21^st day of treatment, the burns were completely healed and treatment was discontinued.

This case report is unusual as the incidence of burns as a result of lightning strike is rare in Ghana. Most cases of burns reported are mainly due to fires, chemicals, electricity, and hot liquids [15, 16]. In many sub-Saharan African countries, including Ghana, lightning injuries have largely been blamed on various misconceptions including religious beliefs and superstitions, and afflicted individuals may face social stigma [4, 17, 18]. However, this is misleading as lightning injuries have been well documented scientifically [1].

The lightning injury in this study occurred when our patient tried to step out of her bedroom. This finding is contrary to many studies that reported lightning strikes during outdoor activities [1, 10, 19, 20]. However, our finding was consistent with studies by Mistovich et al., who reported lightning strikes that occurred indoors [9]. Opening of doors when indoors has been found to be a risk factor for lightning injuries [9], this might have accounted for the lightning strike in this study.

The fever, high white blood cell count, and leukocytosis from the initial laboratory results were suggestive of a bacterial infection. However, the hospital lacked the capacity to carry out wound swabs and blood tests for culture and sensitivity, which might have informed clinicians of the focus of infection and the type of bacterial organism involved. The lack of diagnostic logistics and equipment reemphasizes the challenges clinicians encounter in providing primary healthcare in poorly resourced settings [21]. In spite of the challenges encountered by the clinicians, the parenteral administration of ceftriaxone as well as the gauze dressing impregnated with Vaseline and silver sulfadiazine seems to have brought the fever, high white blood cell, and leukocytosis under control to normal levels. The use of sterile gauze dressing impregnated with Vaseline and silver sulfadiazine was successful in treating the burns. Similar studies have found silver sulfadiazine to be effective in the treatment of burns [22]. On the contrary, some studies have reported hypersensitivity reactions, wound contracture, and scar formation associated with the usage of silver sulfadiazine in the treatment of burns [14, 23]. This was not found in our study and might probably be due to the addition of Vaseline to silver sulfadiazine during the gauze dressings.

This report has provided evidence of a case of a patient with burns resulting from lightning strike, despite its rare occurrence. This also serves as evidence for those in doubt, particularly in communities where lightning injuries are associated with widespread superstition. The case report also revealed how challenging providing primary care in poorly resourced settings can be amid lack of basic diagnostic equipment and logistics. However, we recommend that in resource-limited settings, Vaseline (petroleum jelly) and silver sulfadiazine can be used in the treatment of burns.