Acute Muscle Rigidity Secondary to Tetanus: A Toxicology Simulation Case for Fourth-Year Medical Students

Introduction

Tetanus is uncommon in the United States secondary to vaccination. However, vaccination hesitancy is increasing. This case challenges medical students to consider tetanus in the differential and understand its complications.

Methods

Fourth-year medical students took a pretest on the neurotransmitter glycine and associated disease states. They received two 10-minute lectures on glycine and acid-base abnormalities. Students then participated in a simulation featuring a 27-year-old man bitten by a dog, resulting in tetanus. Required equipment included a mannequin with monitor, a defibrillator, and personal protective equipment. Critical actions consisted of learners dividing up roles amongst each other, using closed-loop communication, placing the patient on a cardiac monitor, choosing to establish IV access and intubate the patient, starting IV fluids, and administering tetanus immunoglobulin. The case ended after 20 minutes. Outcome measurements encompassed performance on a posttest and critical actions.

Results

Twenty students participated. Mean pretest and posttest scores were 69.5 and 92.5, respectively (p < .001). All groups completed the items on the critical actions checklist within a 20-minute time frame.

Discussion

Rising vaccine hesitancy may increase the likelihood of physicians encountering new cases of tetanus and require them to perform lifesaving management of a patient presenting with muscle rigidity. This simulation provides learners with hands-on experience caring for a patient with tetanus and muscle rigidity. It can improve their knowledge of recognition, assessment, and decision-making toward lifesaving management of tetanus by allowing them to practice their skills in a safe environment.

Clinical profile and outcomes of tetanus patients in a tertiary hospital in the Philippines: a ten-year retrospective study

BACKGROUND

Tetanus is a life-threatening but preventable neurologic disorder characterized by trismus and muscle spasms. Despite its decreasing global incidence, it remains to be endemic in resource-limited settings such as the Philippines. This study aimed to determine the incidence, demographic characteristics, risk factors, clinical presentation, management, complications, and outcomes of non-neonatal tetanus cases in a tertiary hospital in the Philippines. It also aimed to compare the clinical profile and outcomes between the adult and pediatric subgroups.

METHODS

This study used a retrospective cross-sectional design including all adult and pediatric non-neonatal tetanus patients admitted at the University of the Philippines - Philippine General Hospital from January 2012 to June 2023. Data was extracted from department censuses and inpatient charts.

RESULTS

One hundred thirty-eight cases were included. The incidence rate was 0.03%, while mortality rate was 29%. Majority of patients were males presenting with trismus and spasms after sustaining a puncture wound. Chronic hypertension was associated with an increased hazard of death by 4.5 times (p = 0.004), while treatment with magnesium sulfate was associated with a decreased hazard of death by 35 times (p = 0.005). The mode of infection and the medications administered differed between the adult and pediatric subgroups.

CONCLUSIONS

Although the total number of cases has decreased over the past decade, tetanus remains to have a high incidence and mortality rate in the Philippines. Increasing vaccination coverage, improving public awareness, and educating health professionals can help reduce morbidity and mortality from this disease.

Case Report: A Challenging Case of Tetanus Presenting with Headache

Tetanus is a life-threatening infectious neurological condition that has become uncommon due to large-scale immunization campaigns. We describe a rare instance of generalized tetanus presenting with a headache on a tropical island in Malaysia. A 43-year-old woman presenting with headaches and generalized body weakness, which progressed into trismus and neck stiffness. Her medical history indicated a wound on the sole of her foot caused by shattered glass in an unhygienic area, but no tetanus prophylaxis had been administered. The patient was subsequently given immunoglobulin, tetanus toxoid, metronidazole, and sedatives in the recommended dosages. Her neurological condition improved remarkably, but she suffered blood pressure fluctuations due to dysautonomia. She was successfully discharged with complete recovery after 6 months of follow-up. The case demonstrates the significance of appropriate identification and care of tetanus, as well as the lethal effects of untreated wounds in vulnerable patients.

Progressive encephalomyelitis with rigidity and myoclonus (PERM) associated with anti-glycine receptor antibodies and urothelial carcinoma: a case report

BACKGROUND

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare neurological condition with paraneoplastic etiology in about 20% of cases, usually presenting before or shortly after the oncological diagnosis is established. PERM associated with anti-glycine receptor antibodies is not previously reported in a patient with bladder cancer.

CASE PRESENTATION

A 72-years-old Caucasian male was admitted with acute onset of dysarthria, dysphagia and trismus three years after initial surgical treatment for bladder cancer. The condition was initially diagnosed as tetanus and treated accordingly, but the diagnosis was reconsidered because of progression despite adequate treatment. Diagnostic workup on readmission revealed lung and paraaortal metastases from bladder cancer and anti-glycine receptor (anti-GlyR) antibodies both in the cerebrospinal fluid and in serum, which supplemented with the clinical presentation led to the diagnosis of PERM, presumably related to bladder cancer. The patient showed improvement and stabilization after treatment with intravenous immunoglobulin and chemotherapy against metastatic bladder cancer.

CONCLUSION

To the best of our knowledge, this is the first reported case of anti-GlyR antibody positive PERM related to urothelial carcinoma. The symptoms mimicked tetanus, and responded to chemotherapy and immunotherapy.

Respiratory complications in dogs with tetanus: A retrospective study of 53 cases

Tetanus can lead to respiratory complications, and the outcome of dogs affected by this disease is still largely unknown. This retrospective study aimed to evaluate the frequency and outcome of 53 dogs with tetanus and respiratory complications between February 2006 and January 2019. Medical records from dogs diagnosed with tetanus admitted to a referral teaching hospital were reviewed. Fifty-three dogs were diagnosed with tetanus and respiratory complications were observed in 26.4% (14/53) of dogs; 8 developed aspiration pneumonia (AP), 5 developed upper airway obstruction (UAO) and 1 dog developed both. A total of 5 AP dogs were mechanically ventilated. Three dogs with UAO had tracheostomy tubes placed. Dogs with respiratory complications had a poorer outcome, with only 14.3% (2/14) surviving to discharge, compared to 94.8% (37/39) for dogs with no respiratory complications. Respiratory complications such as AP and UAO were common in dogs with tetanus, and this was associated with a poorer outcome.

[Localised tetanus with no obvious entry site: about a case in Bamako (Mali)]

Tetanus is a major public health problem in sub-Saharan Africa. Localised tetanus is rare, unlike generalized tetanus which has been sufficiently described in the literature. We report a case of localised tetanus with no obvious entry site managed in the Department of Infectious Diseases in Bamako. The study involved a retired nurse aged 59 years who had not undergone tetanus booster immunisation within the last 10 years, corresponding to the date of her last delivery. She was referred to our Hospital with dysphagia associated with inability to open the buccal cavity. Patient's history was characterized by long-term therapy associated with many specialized consultations without any improvement. The diagnosis of localised tetanus with no obvious entry site was retained after having excluded any other local disorder. Outcome was favorable ten days after adequate management. Underdiagnosed or unknown to health-care providers, localised tetanus may mimic other diseases delaying diagnosis and management. Targeted campaign to build awareness should be implemented in order to improve adherence with immunization schedules.

Demography and Symptom Profile of Tetanus: A Cross-sectional Observation in an Infectious Disease Hospital of Bangladesh

Tetanus is a potentially preventable neurological infectious disorder with paucity of literature in Bangladesh. We aimed to see the demography and symptom profile of tetanus cases managed at the Infectious disease Hospital Sylhet. This hospital based cross-sectional descriptive study was conducted within the time period of January to December 2012 among 50 consecutive admitted patients in the Infectious Disease Hospital, Sylhet, Bangladesh who were diagnosed as a case of tetanus and fulfilling the inclusion criteria and exclusion criteria. Neonatal tetanus was considered as exclusion criteria and clinical diagnosis of tetanus was considered as the tetanus. Data were collected purposively with pretested predesigned questionnaire. Data were processed manually and analyzed with the help of SPSS Version 16.0. The mean±SD age was 33.00±16.8 years, ranging from 10 to 70 years. Among the 50 respondents, 72.0% were male, 50% from lower class, 34% were students and 30.0% had their educational status of primary level, 60.0% from rural social background. Trismus was found in 98.0% of the cases, rigidity in 96.0% cases, body ache in 94.0% cases, dysphagia in 92.0% cases, neck pain in 78.0% cases, dysarthria in 92.0% cases, reflex spasm in 66.0% cases, opisthotonus in 46.0% cases and urinary retention in 26.0% cases. In this study rural male people with lower socioeconomic status individuals were mostly affected with trismus, rigidity, body ache and dysphagia symptoms.

A case report of generalized tetanus in a 42-year-old man with dental infection

Background In the post-vaccination era, as it is today, generalized tetanus is a rare diagnosis, although mortality and morbidity continue to increase significantly throughout the world. Infection occurs when the Clostridium tetani spores are introduced into wounds, skin lesions and infections. The symptoms often begin with stiffness or spasms in the jaw muscles; they are called trismus or "lockjaw" and/or then spread to the neck and abdominal muscles. Case presentation This is a report of a 42-year-old man who was referred to the hospital with dysphagia, rigidity and trismus. He was diagnosed with generalized tetanus with a Philips score of 15. The patient was admitted to the isolation unit, received treatment that included procaine penicillin, metronidazole, diazepam, human tetanus immunoglobulin (TIG) and anti-tetanus serum (ATS). Treatment was considered according to the guidelines of the World Health Organization, and also, the drug dose has no adverse event reaction during the treatment. Conclusion The therapeutic response is related to the identification and appropriate treatment, especially in hospitalized patients with inadequate immunization so that patients recover soon.

Functional outcome and muscle wasting in adults with tetanus

BACKGROUND

In many countries, in-hospital survival from tetanus is increasing, but long-term outcome is unknown. In high-income settings, critical illness is associated with muscle wasting and poor functional outcome, but there are few data from resource-limited settings. In this study we aimed to assess muscle wasting and long-term functional outcome in adults with tetanus.

METHODS

In a prospective observational study involving 80 adults with tetanus, sequential rectus femoris ultrasound measurements were made at admission, 7 days, 14 days and hospital discharge. Functional outcome was assessed at hospital discharge using the Timed Up and Go test, Clinical Frailty Score, Barthel Index and RAND 36-item Short Form Health Survey (SF-36) and 3 and 6 months after discharge using the SF-36 and Barthel Index.

RESULTS

Significant muscle wasting occurred between hospital admission and discharge (p<0.01), particularly in severe disease, where a median 23.49% (interquartile range 10.01-26.07) reduction in rectus femoris cross-sectional area occurred in those with severe (Ablett grades 3 and 4) disease. Muscle mass at discharge was related to objective and subjective measures of physical and emotional function at discharge and 3 and 6 months after discharge. In patients >70 y of age, functional recovery at 6 months was reduced compared with younger patients. Hospital-acquired infection and age were risk factors for muscle wasting.

CONCLUSIONS

Significant muscle wasting during hospitalization occurred in patients with tetanus, the extent of which correlates with functional outcome.

Severe Tetanus Complicated by Takotsubo Cardiomyopathy

A 70-year-old woman was admitted to our hospital due to difficulty in moving her limbs. She had trismus and a necrotic and contaminated wound in her left lower leg. A diagnosis of tetanus was confirmed and intensive care was started. On the second day, her blood pressure fell and a ST segment elevation on electrocardiography (ECG) was detected. She was diagnosed with takotsubo cardiomyopathy by echocardiogram and improved undergoing conservative therapy.

Phrenic Nerve Palsy in Severe Tetanus

Unilateral or bilateral raised hemidiaphragms were observed on chest X-ray in three patients with severe tetanus. Diaphragmatic movement was absent on ultrasonography and fluoroscopy. Nerve conduction study confirmed phrenic nerve palsy. Bilateral involvement caused delayed weaning from the ventilator, whereas unilateral involvement was asymptomatic. There was complete recovery from phrenic nerve palsy in all patients.

Association between clinically probable REM sleep behavior disorder and tetanus in dogs

BACKGROUND

Abnormal sleep behavior has been reported in 5 dogs during recovery from tetanus.

HYPOTHESIS

REM sleep behavior disorder (RBD) is a more common consequence of tetanus than previously reported in veterinary literature and easily confused for epileptic seizures.

ANIMALS

Sixty-one client-owned dogs diagnosed with tetanus at 2 UK referral centers.

METHODS

A retrospective review of medical records was combined with a questionnaire sent to owners of surviving dogs, to identify cases that developed clinically probable RBD and determine its clinical progression and effect on quality of life of affected dogs and their owners. Descriptive statistical evaluation was performed.

RESULTS

Eleven dogs (18%) died or were euthanized before discharge. At least 46% surviving dogs developed abnormal "dream enactment" clinically consistent with RBD. Twitching, running, and vocalization were new sleep behaviors in 53, 80, and 60% of affected dogs. Clinically probable RBD was described as violent or "nightmare"-like in 36% affected dogs, and like an epileptic seizure in 40% affected dogs. When trialed, antiepileptic medications were ineffective. Onset occurred before discharge in 25% cases. For dogs that developed clinically probable RBD postdischarge, onset occurred within 2 weeks of discharge in 77% dogs. Clinically probable RBD did not worsen in severity or frequency in any dog, and spontaneously resolved within 6 months in 43% cases.

CONCLUSIONS AND CLINICAL IMPORTANCE

Clinically probable RBD is a common sequel to canine tetanus with many clinical similarities to epileptic seizure activity. Owners should be made aware of its potential development and care taken to avoid misdiagnosis with epileptic seizure activity.

Cephalic tetanus: about two cases

Tetanus is still a common problem in developing countries. Localized tetanus remains a rare clinical presentation dominated by cephalic localization. Head, neck or ear infection strongly guide the diagnosis. A trismus and one or several cranial nerve impairment are the major symptoms. We report two cases of cephalic tetanus associating a trismus with involvement of the cranial nerves. Diagnosis was difficult because the neurological damage preceded the trismus.

Long-term outcome in survivors of neonatal tetanus following specialist intensive care in Vietnam

BACKGROUND

Neonatal tetanus continues to occur in many resource-limited settings but there are few data regarding long-term neurological outcome from the disease, especially in settings with critical care facilities.

METHODS

We assessed long-term outcome following neonatal tetanus in infants treated in a pediatric intensive care unit in southern Vietnam. Neurological and neurodevelopmental testing was performed in 17 survivors of neonatal tetanus and 18 control children from the same communities using tools previously validated in Vietnamese children.

RESULTS

The median age of children assessed was 36 months. Eight neonatal tetanus survivors and 9 community control cases aged < 42 months were tested using the Bayley III Scales of Infant and Toddler Development (Bayley III-VN) and 8 neonatal tetanus survivors and 9 community controls aged ≥42 months were tested using the Movement Assessment Battery for Children. No significant reductions in growth indices or neurodevelopmental scores were shown in survivors of neonatal tetanus compared to controls although there was a trend towards lower scores in neonatal tetanus survivors. Neurological examination was normal in all children except for two neonatal tetanus survivors with perceptive deafness and one child with mild gross motor abnormality. Neonatal tetanus survivors who had expienced severe disease (Ablett grade ≥ 3) had lower total Bayley III-VN scores than those with mild disease (15 (IQR 14-18) vs 24 (IQR 19-27), p = 0.05) with a significantly lower cognitive domain score (3 (IQR 2-6) severe disease vs 7 (IQR 7-8) mild disease, p = 0.02).

CONCLUSIONS

Neonatal tetanus is associated with long-term sequelae in those with severe disease. In view of these findings, prevention of neonatal tetanus should remain a priority.

Trismus as a Clinical Manifestation of Tetanus: A Case Report

Although the incidence of tetanus disease has radically declined in developed countries, both dental practitioners and oral and maxillofacial surgeons should be knowledgeable about its diagnosis since initial manifestations of the disease, such as trismus and dysphagia, are observed in the orofacial region. This study reports on a case of generalized tetanus diagnosed in a middle-aged man. Before the tetanus diagnosis, the patient had sought medical advice from seven different health care professionals, including a dentist and an oral and maxillofacial surgeon. The patient reported trismus and dysphagia as his main complaints. The suspicion of tetanus emerged from the patient's manifestations in conjunction with his history of trauma and his agricultural occupation. The patient underwent successful treatment including administration of muscle relaxants, antibiotics, and booster vaccination doses of tetanus toxoid as well as a tracheostomy and aided mechanical ventilation. This case report highlights the significance of taking a meticulous medical history, thoroughly performing a physical examination, and systematically assessing orofacial signs and symptoms.

[Tetanus, an almost forgotten but serious disease]

Tetanus, an almost forgotten but serious disease Tetanus is the systemic consequence of a local infection with Clostridium tetani, that produces toxin which spreads in the systemic circulation. In developed countries, it is extremely rare. Women born before 1950 are a group at risk due to lower prevalence of immunisation. This report describes a case of tetanus. The patient is a previously healthy 82-year-old woman. She presented to primary care with a complaint of stiffness in the neck and jaw. A physical exam and basic laboratory tests were normal apart from a slightly increased blood pressure. Later the same day she was admitted to the intensive care unit for suspected tetanus. During the night she deteriorated with marked stiffness in her thorax and, as a result of this, severe respiratory distress. After induction of anesthesia she was ventilated and intubated without problem. The treatment for tetanus, an antibody, was given 5 hours later after urgent delivery from the national supply. The patient was successfully weaned from the ventilator after 37 days. During intensive care she had fluctuating stiffness and autonomic instability, both commonly described in patients with tetanus.

Tetanus: An Analysis of the Prognosticating Factors of Cases Seen in a Tertiary Hospital in a Developing African Country between 1990 and 2000

This is an analysis of the effects of prognosticating factors on the outcome of a case series of 66 patients with tetanus, presenting between 1990 and 2000. The mortality rate was 26.2% with a fatality rate of 16.2% for those under 40 years of age. This increased to 75% for those patients above 70 years of age. The socio-economic status, immunization status, the incubation period, and age of the patient together with the severity of the spasms, duration of hospital stay, type of treatment received and time of onset were found to affect the outcome of the patients.

[Tetanus can still be found in Denmark]

Tetanus (lockjaw) is caused by toxins produced by Clostridium tetani, usually transmitted through contaminated wounds. We describe a case of tetanus in an unvaccinated, previously healthy 78-year-old woman. Twelve days after minor trauma to the right palm, initially treated with tetanus vaccination without immunoglobulins, she developed hoarseness, dyspnoea and difficulties swallowing and opening her mouth. She got severe, painful muscle cramps of especially the truncal muscles requiring large doses of sedatives and complicating respiratory insufficiency. She was treated in intensive care for 33 days, but recovered completely.

Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

INTRODUCTION

Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms.

METHODS

Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h(-1)) than group 2 (n=5) (1.5 to 2 g.h(-1)).

RESULTS

The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d(-1)) than group 2 (n=3) (106±9 mg.d(-1)) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO(4) for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d(-1)) of infusion in group 2 (n=4) but not in group 1 patients (n=4).

CONCLUSIONS

The larger dose of MgSO(4) infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.

New trends in the management of tetanus

The prevalence of tetanus reflects a failure of immunization. Prompt diagnosis and prediction of severity are crucial for the prevention of early life threatening complications and the institution of appropriate management. The current symptomatic treatment of heavy sedation, paralysis and artificial ventilation for 3-5 weeks for moderate and severe tetanus, is, even in the best centers, still associated with unacceptably high mortality, due to the disease and complications of the therapy itself. It is especially inappropriate for the developing world where intensive care resources are minimal. New options reported to avoid artificial ventilation and sedation are dantrolene (Dantrium, Procter and Gamble Pharmaceuticals), baclofen (Lioresal, Novartis) and magnesium. Magnesium therapy has the advantages of controlling spasms and sympathetic over activity without sedation. This simplifies nursing care and minimizes the need for ventilatory support except in the very severe disease and the elderly. Magnesium is recommended as the first-line therapy in tetanus.

Tetanus--a case report with severe autonomic instability and: a review of the literature

BACKGROUND

Tetanus is an infection that can be associated with a high mortality especially in developing countries. Critical care which may include artificial control of respiration is crucial in survival, but cardiovascular complications from autonomic instability remains an important cause of death. The objective of this report is to highlight this important cause of mortality despite artificial control of ventilation to prevent respiratory arrest.

METHOD

The medical record of the patient and relevant literature were reviewed.

RESULT

A 29-year old male following a wound on the lower limb presented with clinical features suggestive of tetanus. Incubation period was short and immunization history was uncertain. Basic treatment directed at removing source of infection and neutralisation of unbound toxin was however commenced. Following signs of imminent respiratory failure due to severe uncontrollable spasms, controlled mechanical ventilation was instituted in the critical care unit (CCU). However, the patient succumbed to cardiac arrest as a result of severe autonomic instability, despite aggressive cardiopulmonary resuscitation.

CONCLUSION

Cardiovascular arrest from severe autonomic instability remains an important cause of mortality in tetanus despite artificial ventilation. Early management with appropriate therapy is advisable to prevent its occurrence.

Tetanus is still present in the 21st century: case report and review of literature

Tetanus is a very serious disease that can be fatal. Its incidence in the developed world has diminished considerably since the introduction of tetanus toxoid. More importantly, tetanus is one of the few infectious diseases that can be prevented. The recommendations for immunization are clear and readily available. In spite of the progress, we still see cases of tetanus in which the prognosis is poor. We present the case of a 67 year-old man that was admitted to our hospital with one of the most common manifestations of tetanus: trismus. Even though his treatment was established immediately, the hospital stay was long and made him susceptible to various medical complications and nosocomial infections. The incidence of tetanus in Puerto Rico is low but the mortality rate continues to be elevated in the high-risk group: patients older than 60 years of age. This is the reason for which we present this case. Our goal is to provide information with regards to epidemiology, pathogenesis, clinical manifestations, diagnosis and management of tetanus. In addition, it is equally essential to remind our colleagues the significance of adequate prevention of this potentially mortal and disabling disease.

[Prognostic value of allergic reaction indicators in the vaccination of children with chronic diseases]

To define the likelihood of development of adverse reactions and complications due to vaccination, the authors conducted clinical and laboratory studies of 115 children aged 1 to 15 years with chronic pathology (allergic diseases, pyelonephritis, immunodeficiency states), vaccinated with diphtheria and tetanus toxoids and pertussis vaccine and diphtheria and tetanus-M anatoxin and revaccinated with diphtheria and tetanus-M anatoxin. The results of the study suggested the prognostic value of allergic reaction indicators (total IgE, DA- and CA-specific IgE, vaccine sensitization detected by the basophil degranulation test) against adverse events and complications of immunization. Vaccination in children with chronic pathology in the presence of higher parameters of allergic reactions, by using hyposensitization therapy, was followed by to the formation of tense antidiphtheria and antitetanus immunity. The given data support the immunological efficiency and safety of immunization of children with chronic diseases against diphtheria and tetanus provided that hyposensitization therapy is performed, by keeping in mind the results of prior clinical and laboratory studies.

Neonatal tetanus: a study of five cases in Sandakan, Sabah

This study aims to study the demographics, clinical presentation, treatment and outcome of neonatal tetanus patients managed at Hospital Duchess of Kent from January 1st 2006 to December 31st 2006. Five neonates were studied. All presented with fever, poor sucking and limb stiffness, with a history of unsterile delivery and uncertain maternal tetanus immunity status. All were nursed in a minimal-stimuli environment and were given IV penicillin G, IM tetanus immunoglobulin and sedatives to control spasms. Nutrition and chest physiotherapy were rendered. Three patients required artificial ventilation. Duration of treatment ranged from 25 to 44 days. All survived. Inadequate maternal immunization, unsterile delivery and inappropriate umbilical cord care are major contributing factors of neonatal tetanus in our study. Supportive measures are the mainstay of treatment in our setting with very limited resources.

An unusual case of chronic relapsing tetanus associated with mandibular osteomyelitis

A 55-year-old man underwent radiation therapy due to malignant lymphoma of the neck. Eight years after the therapy he developed tetanus. It appears that the radiation therapy resulted in mandibular necrosis, and that this lesion may have been the infectious focus of tetanus. Treatment with penicillin G was very effective in the acute stage, and chronic administration of metronidazole prevented relapse of the disease. However in spite of injections of tetanus toxoid, symptoms of tetanus returned when the administration of metronidazole was discontinued because the infectious focus could not be completely removed. This is the first report of chronic relapsing tetanus associated with radiation-induced mandibular osteomyelitis, and demonstrates that tetanus can occur due to mandibular focus but the chronic administration of metronidazole can prevent relapse.

Pediatric and neonatal tetanus: a hospital based study at eastern Nepal

A prospective hospital based study of childhood (<15 yrs) and neonatal tetanus cases from July 2004 - May 2006 was done to study the demography, clinical features and outcome of pediatric and neonatal tetanus cases at BPKIHS. During the study, 24 cases of tetanus were admitted from 9 districts including 5 neonatal tetanus. Among children with tetanus, 31.5% received 3 doses of DPT and 10.5% received TT vaccine as tetanus prophylaxis. In 16.0% children there was no recognizable injury preceding the disease. Otitis media preceded tetanus in 16.0%. All neonatal tetanus cases occurred following umbilical sepsis. Despite their mothers receiving 2 doses of TT during pregnancy, 2 neonates developed tetanus. A neonate delivered in hospital also developed neonatal tetanus. Average incubation period was 7.7 days and average onset time was 16.9 hours. Short onset time predicted the favorable outcome (p=0.005). Generalized tetanus cases were 75.0%, neonatal tetanus 21.0% and cephalic tetanus 4.0%. Generalized spasm was present in all cases. Common autonomic dysfunctions were fever, tachycardia and hypotension. Respiratory failure, aspiration pneumonia, rhabdomyolysis and seizure were common complications. Only one case received Intensive Care Unit (ICU) care. Survival rate was 21.1% for childhood tetanus and 40.0% for neonatal tetanus. Respiratory failure was the cause of death in majority. Study finds tetanus as an important disease in eastern Nepal, with substantial morbidity and mortality, primarily affecting the unvaccinated and inadequately vaccinated individuals. Despite lack of adequate resources, we can still manage tetanus cases with comparable outcome to other case series reported in the literatures.

Pattern and outcome of adult tetanus in Ile-Ife, Nigeria

OBJECTIVE

This is a retrospective study of all adult patients with tetanus managed at the Obafemi Awolowo University Teaching Hospitals Complex from 1995-2004. The aim was to study the pattern of adult tetanus in Ile-Ife, Nigeria, and see what improvements could be made in the future in particular with regard to decreasing the prevalence in our environment.

METHOD

Data was obtained from the hospital records of all the patients, the admission and discharge registers of the medical wards of the hospital.

RESULT

79 adult patients with tetanus were managed during the study period and they accounted for 44% of neurological admissions. There were 56 males and 23 females giving a M:F ratio of 2.4 to 1. 45 (57%) of the patients were under 30 yrs of age and two-thirds (67%) had puncture wounds in the lower limbs. 20 patients (25%) had mild tetanus, 16 (20%) had moderate disease and 43 (55%) had severe tetanus. The patients were treated with tetanus antitoxin, antibiotics and sedatives. The mortality rate was 45% and laryngeal spasm was the most common cause of death. None of the patients was managed in the intensive care unit (ICU).

CONCLUSION

Tetanus remains a major public health problem in Nigeria. It is commonly associated with high mortality due to late presentation. Health education should be promoted to reduce the unacceptable prevalence in our practice setting.

Autonomic dysfunction in tetanus - what lessons can be learnt with specific reference to alpha-2 agonists?

Severe tetanus is seen infrequently in the developed world, but often requires intensive care support. Mechanical ventilation with neuromuscular blockade and heavy sedation, good wound care and prompt administration of antitoxin are important. The management of autonomic dysfunction remains challenging. We measured serum catecholamine levels in a patient with severe tetanus in whom autonomic crises were a major and persistent feature, and investigated the impact of sedatives plus alpha(2)-agonists on these levels. Serum adrenaline levels were elevated up to 100-fold with clinically observed crises, although noradrenaline levels were much more difficult to interpret. There was no appreciable difference in catecholamine levels following administration of alpha(2)-agonists in the doses we used, although clonidine did allow easier control of crises with other agents. This case highlights some important lessons in the management of severe tetanus.

A 12-year review of cases of adult tetanus managed at the University College Hospital, Ibadan, Nigeria

In this review, hospital case records of 202 adult tetanus managed between January 1990 and December 2001 in a tertiary institution in Southwestern Nigeria were reviewed. The mean age of the patients was 36.1+/-17.8 years with male:female ratio of 2.2:1 and an overall mortality rate of 64%. Patients with unfavourable outcomes spent 4.5+/-0.41 days compared with 16.6+/-1.2 days by those who survived. Factors associated with poor prognosis are age >60 years (P=0.029), incubation period <7 days (P=0.007), period of onset <48 h (P=0.0001), tachycardia with pulse rate >120/min (P=0.001) and spasm (P=0.002). Gender (P=0.11), post-injury vaccination (P=0.48) and types of antibiotics administered (P=0.49) were not significantly associated with increased mortality. The three most common complications were aspiration pneumonitis, sepsis and urinary bladder obstruction while complications with highest mortality (100%) were sepsis and cardiac arrest.

Tetanus-induced acute kidney injury in a renal transplant recipient

A 48-year-old renal transplant recipient who developed tetanus 6 years after transplantation is described. His immunosuppressive protocol was mofetil mycophenolate, sirolimus, and prednisone. The patient presented symptoms of severe tetanus with autonomic dysfunction, requiring ICU care and mechanical ventilation. His clinical course was marked by development of tetanus-induced acute kidney injury and sepsis. He was discharged after 37 days of hospitalization with recovered renal function. Tetanus is a preventable disease associated with a high fatality rate. Its treatment is difficult and requires specialized and intensive care. This case highlights the crucial importance of following adequate immunization guidelines in transplant recipients.

Maternal HIV infection and placental malaria reduce transplacental antibody transfer and tetanus antibody levels in newborns in Kenya

BACKGROUND

In clinical trials, maternal tetanus toxoid (TT) vaccination is effective in protecting newborns against tetanus infection, but inadequate placental transfer of tetanus antibodies may contribute to lower-than-expected rates of protection in routine practice. We studied the effect of placental malaria and maternal human immunodeficiency virus (HIV) infection on placental transfer of antibodies to tetanus.

METHODS

A total of 704 maternal-cord paired serum samples were tested by ELISA for antibodies to tetanus. The HIV status of all women was determined by an immunoglobulin G antibody-capture particle-adherence test, and placental malaria was determined by placental biopsy. Maternal history of TT vaccination was recorded.

RESULTS

Tetanus antibody levels were reduced by 52% (95% confidence interval [CI], 30%-67%) in newborns of HIV-infected women and by 48% (95% CI, 26%-62%) in newborns whose mothers had active-chronic or past placental malaria. Thirty-seven mothers (5.3%) and 55 newborns (7.8%) had tetanus antibody levels <0.1 IU/mL (i.e., were seronegative). Mothers' self-reported history of lack of tetanus immunization was the strongest predictor of seronegativity and of tetanus antibody levels in maternal and cord serum.

CONCLUSION

Malarial and HIV infections may hinder efforts to eliminate maternal and neonatal tetanus, making implementation of the current policy for mass vaccination of women of childbearing age an urgent priority.

[Diagnostic image (320). A new mother with opisthotonus and extensor spasms]

A 21-year-old woman was admitted to a rural hospital in Tanzania after a home delivery one week before. She had signs of general body rigidity due to maternal tetanus.

Enteral baclofen in the management of tetanus-related spasms: case report and review of literature

We report here the successful use of baclofen administered by nasogastric route in a 3.5-year-old child with tetanus, whose spasms were not controlled even with high dose of midazolam infusion.

Back pain as the presenting symptom of generalised tetanus

Back pain is a common presenting symptom in emergency departments and primary care across the UK. The extensive differential diagnosis includes mechanical, infective, thoracic, abdominal and vascular causes. This case report describes a patient who presented with lower back pain with a rare diagnosis, which is becoming more common in certain population groups, and emphasises the importance of clinical skills and insuring adequate tetanus prophylaxis.

Sympathetic overactivity and arrhythmias in tetanus: electrocardiographic analysis

As a result of the advances in the control of pulmonary insufficiency in tetanus, the cardiovascular system has increasingly been shown to be a determining factor in morbidity and mortality but detailed knowledge of the cardiovascular complications in tetanus is scanty. The 24h-Holter was carried out in order to detect arrhythmias and sympathetic overactivity in 38 tetanus patients admitted to an ICU. The SDNN Index (standard deviation from the normal R-to-R intervals), was useful in detecting adrenergic tonus, and ranged from 64.1 ± 27 in the more severe forms of tetanus to 125 ± 69 in the milder ones. Sympathetic overactivity occurred in 86.2% of the more severe forms of the disease, but was also detected in 33% of the milder forms. Half the patients had their sympathetic overactivity detected only by the Holter. The most frequent arrhythmias were isolated supraventricular (55.2%) and ventricular (39.4%) extrasystoles. There was no association of the arrhythmias with the clinical form of tetanus or with the presence of sympathetic overactivity. The present study demonstrated that major cardiovascular dysfunction, particularly sympathetic overactivity, occurs in all forms of tetanus, even in the milder ones. This has not been effectively detected with traditional monitoring in ICU and may not be properly treated.

Tetanus prophylaxis for diabetic foot ulcers

The infected or ulcerated diabetic foot is a suitable environment for Clostridium tetani. Tetanus intoxication as a result of foot ulcer has been described in the literature. Immunopathy, vasculopathy, and ulceration place the diabetic patient at risk for developing tetanus. Of diabetic patients who contract generalized tetanus in the United States, foot ulcer or gangrene are responsible for 25% of cases. Patients who have diabetic wounds should receive tetanus prophylaxis. The prophylaxis should follow the "tetanus-prone" wound recommendations as set by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.

[Tetanus following an abrasion injury]

HISTORY AND CLINICAL FINDINGS

A 80 year-old woman contracted an abrasion of her right forearm while gardening. 5 days later, dysphagia, trismus and a cramp of the right hand developed. On admission (8 days after the injury) cramps of the platysma and pharyngeal muscles were observed. A tetanus vaccination had not been carried out for years.

INVESTIGATIONS

Electrophysiologically a pathological masseter inhibitory reflex with a missing "silent period" was observed. The level of serum anti-tetanus-toxoid IgG antibodies was 0.03 IU/ml (definitively protective above 0.1 IU/ml). Free tetanus toxin was not detectable in the serum upon mouse challenge. The diagnosis of tetanus was made based on the typical symptoms and the serological susceptibility.

TREATMENT AND COURSE

On admission the wound was antiseptically cleaned and a bandage was applied. On the next day a debridement was performed. After taking a serum sample the patient was immunized against tetanus (active and passive). On the following two days the patient received a further dose of tetanus-antitoxin. The patient was treated with metronidazole for 8 and with penicillin G for 10 days. Within the first days after hospital admission laryngospasms, tachycardia and tachypnoe occurred. From the 7 (th) day in hospital the trismus and the cramp of the hand improved. 4 weeks after admission the patient was discharged; the trismus had completely disappeared, but a slight cramp of the hand was still present.

CONCLUSION

Minor superficial injuries can lead to acute tetanus, if the level of anti-tetanus toxin-antibodies is non-protective and a disinfective wound cleaning and a postexpositional vaccination are not performed.

Tetanus: the ’forgotten disease’. A rare cause of dysphagia and trismus

Tetanus kills approximately 500 000 people worldwide each year. Widespread immunization has ensured that it is rarely encountered in the United Kingdom. An increase in global travel may increase the likelihood of such encounters in the developed world in the future.

In the non-immunized patient, death from tetanus can be avoided by early recognition and timely intervention. The potential need for airway support and sedation should not be underestimated.

The authors’ case report should increase the awareness of the otolaryngologist when confronted with atypical cases of dysphagia and trismus and provides details of the recommended treatment regime.