Case report on tetanus

A 17 year-old came to our hospital complaining of neck stiffness and abdominal pain.

He was semiconscious: still able to be awaken but falling back to sleep immediately after. There was fever of 39⁰C and the patient was sick looking. Malaria slide was positive.

Therefore we have admitted the patient with provisional diagnosis of complicated malaria; rule out meningitis.

At past medical history there was a traditional circumcision at home one week before.

At the observation of the operated site there was some necrosis and swelling.

Considering this history the possibility of tetanus came to our mind, but the fact that the muscles of the abdominal wall were not stiff and the fact that the muscular contractions were not triggered by touch or noise made us delay in the definitive diagnosis.

We have performed a lumbar puncture and the CSF (cerebro-spinal fluid) was negative.

Nevertheless we have covered the patient with iv quinine and iv ceftriaxone.

Few hours later the condition has changed rapidly with muscle rigidity and spasms all over the body, trismus, opistotonus. At this moment we have definitely diagnosed tetanus.

We have isolated the boy in a dark and silent room. We have inserted an NGT for rehydration and nutrition. We have stopped quinine and changed antimalarial treatment into im artemisin, in order to have the iv line free for continuous drip of normal saline with diazepam. We have started with a dose of 40mg diazepan over 24 hours, but we have increased up to 60mg/die because the contractions were not receding.

We have also started im phenobarbitone once daily at the dose of 5 mg/kg/die.

The wound was dressed every day with abundant use of hydrogen peroxide (H₂0₂) in the hope of killing the remaining anaerobic bacteria in it.

We have stopped ceftriaxone and switched to iv benzylpenicilline + iv metronidazole: this is the antibiotic association WHO recommends for this condition in the developing world.

The patient has passed a calm night although we had to follow recurrent episodes of hypoglycaemia, possibly related to the fact that he was not feeding enough. The fevers were reducing slightly with the use of im paracetamol. We have not noticed hypertension or heart arrhythmia, which may be signs of autonomic nervous system disorder in tetanus.

Our hope was to have found a sufficient dose of diazepam and phenobarbitone, in order to prevent muscular tetanic contractions up to when the toxins could be down-regulated by the synapsis.

But at 10.00 am today the patient has developed a continuous state of muscular contractions involving the intercostal muscles and the muscles of the neck. We could not release this state even with the use of iv ketamine, and we were not able to intubate because of laryngeal spasm.

Rapidly the patient died because of respiratory arrest, secondary to intercostals muscle contractions and laryngeal spasm.

LEARNING POINTS

I)        Traditional male circumcision performed by unskilled personnel carries high risks of mortality due to bleeding or infections, including tetanus. It is our duty to discourage traditional male circumcision outside the hospital.

II)        Many young people in our areas are not fully immunized for tetanus and this is a potential risk for the disease in case of non-sterile procedures.

III)      Tetanus is a bacterial disease caused by an anaerobe; therefore all the wounds which are closed, deep, or necrotic pose a high risk of infection

IV)      The incubation period varies according to the site of injury and it is shorter in severe disease with an average incubation of eight days.

V)       The diagnosis is usually made clinically because we have no possibility of culture and sensitivity for Clostridium tetani. The CSF is always negative.

VI)      Unfortunately in Chaaria tetanus immunoglobulins are not available. They would be of much use to prevent further links of the toxins to the neuro-muscular plaque. We normally give a boost of T.Toxoid, but this is of very little use because the antibody production will start after at least three weeks.

VII)   Metronidazole and Benzylpenicilline should be given to prevent further multiplicationof bacteria.

VIII)   External stimulations such as light or noise should be reduced to prevent precipitation of further spasms.

IX)      Valium and phenobarbitone is what we normally have to treat the spasms.

X)       We have no enough expertise to routinely perform intubation or tracheostomy.

XI)      In our environment the mortality of the disease is extremely high.

Dr Bro Giuseppe Gaido

Clinical Officers

Nursing officers

Cottolengo Mission Hospital. Chaaria