Tetanus as a cause of acute renal failure: possible role of rhabdomyolysis

Rocuronium as Neuromuscular Blockade in Tetanus Patients With Methamphetamine Use Disorder: A Case Report

BACKGROUND

Spasm control is essential in the management of tetanus. Benzodiazepines are administered as initial treatment of tetanic spasms; however, sedation may be difficult to attain among patients with methamphetamine use disorder. Neuromuscular blocking agents, which act on an entire different mechanism, can be given to induce paralysis.

METHODS

We describe 2 cases of patients with methamphetamine use disorder who were diagnosed with severe tetanus and our experience in the use of rocuronium to control their spasms. We performed a systematic review of the SCOPUS and PubMed databases for case reports and case series describing the use of rocuronium in tetanus patients who also have methamphetamine use disorder. We discussed the clinical features and treatment outcomes.

RESULTS

A total of 4 cases of patients with substance abuse disorder who had severe tetanus were reported in the literature, including the current cases. The mean age was 28.8 years; all of them male. Trismus, generalized limb and abdominal rigidity were the most common presentation. Three patients underwent emergency tracheostomy. Rocuronium was given as 0.008mg/kg bolus in 1 patient; 2 patients received an intravenous bolus dose of 0.6mg/kg. Infusion dose ranged from 5 to 10 mcg/kg/min. Spasms were controlled within 24-48 hours after giving rocuronium in 3 out of 4 patients. One patient died from complications of dysautonomia and immobility.

CONCLUSION

Rocuronium demonstrates a potential role as neuromuscular blocking agent of choice for patients with chronic methamphetamine use disorder and severe tetanus. Management challenges and complications of severe tetanus were also highlighted in this study.

A Man With Intractable Convulsion

Tetanus is a rare disease in the United States. Fewer than 40 cases are reported annually because of the high incidence of vaccination. Recognition of the clinical presentations is important because laboratory recovery of pathogen is only 30%, and toxin detection is rare because of consumption at motor neurons. We report a case of tetanus in an elderly man who had a reaction to tetanus vaccination as a child and was nonvaccinated through adult life.

Incidence of and risk factors for nosocomial pneumonia in patients with tetanus

From June 1998 through July 2000, 28 patients with tetanus admitted to the Intensive Care Unit for Tetanus and Infectious Diseases at the Hospital das Clínicas of University of Medicine at São Paulo, Brazil, were evaluated to establish what the incidence of nosocomial pneumonia was and what their risk factors were. The degree of severity of tetanus was assessed in all patients by means of APACHE II scores. The mortality rate was 3.6%. There were 63 hospital infections in 20 patients; among these, there were 10 cases of nosocomial pneumonia in 8 patients. Nosocomial pneumonia was associated in univariate analysis with the degree of severity of tetanus, dysautonomy, use of neuromuscular blockers, use of higher doses of diazepam, and lower arterial oxygen and oxygen fractions. In the multiple logistical regression, significance was found for dysautonomy (relative risk, 31.67; 95% confidence interval, 2.68-373.74; P=.006). Dysautonomy was an independent risk factor for pneumonia in patients with tetanus.