Case Presentation: Tetanus, a life threatening neurological disorder involving muscle spasms caused by Clostridium tetani, is now a rare disease, with an annual incidence of 0.10 cases/million population. We present a case of fulminant tetanus requiring ventilatory support in an unimmunized patient.A 20-year-old unvaccinated female with active intravenous drug use presented with difficulty swallowing, inability to open her mouth, and progressive, diffuse muscular spasms for 3 days. She had sustained a laceration on her wrist 3 weeks prior and had not undergone medical evaluation. Physical examination revealed trismus, clenched jaw, opisthotonus with the head turned to the right, and diffuse muscular rigidity. Laboratory work-up was notable for leukocytosis and elevated creatine kinase. A diagnosis of generalized tetanus was made, prompting the administration of human tetanus immunoglobulin, tetanus toxoid, and metronidazole. She was placed in a room with minimal auditory and visual stimuli. Diazepam, baclofen, fentanyl, and magnesium were initiated for control of muscle spasms. Given progressive trismus and airway compromise, nasotracheal intubation was performed, and mechanical ventilation was initiated. Given her history of polysubstance abuse and high tolerance to sedatives, she required high dose propofol, fentanyl, and midazolam infusions. Percutaneous tracheostomy was performed in anticipation of prolonged ventilation. Her clinical course was complicated by fluctuating blood pressure and bradycardia, attributed to autonomic dysfunction due to tetanus. She was successfully weaned off ventilatory support and discharged after 26 days following decannulation of tracheostomy.
Discussion: Tetanus is caused by the inhibition of GABAergic and glycinergic neurons by tetanospasmin, a toxin released by C. tetani, with consequent increased muscle tone and autonomic instability. The incidence of tetanus remains low, with 23 cases reported in the USA in 2018. (1) However, only 83.4% of children aged 19 – 35 months received the full course of the tetanus vaccine in 2017 (2), and dropping immunization rates poses a risk of resurgence of this life threatening disease. The rarity of tetanus made its management in our community based setting challenging. Our patient had a history of polysubstance abuse, which made control of sedation and muscle spasms difficult; high doses of propofol and midazolam were required for symptom control. Heroin abuse can be a risk factor for tetanus; quinine, which is used to dilute heroin, can support the growth of C. tetani. (3) Tetanus is a rare but severe illness that most practitioners in the USA are not familiar with, but is something healthcare providers should be vigilant for, given the prevalent era of vaccine skepticism. Treatment involves neutralization of the offending toxin with immunoglobulin, and antibiotics.
Conclusions: We describe the diagnosis and management of case of fulminant generalized tetanus with respiratory failure and autonomic adverse effects. Hospitalists should be familiar with the manifestations and management of tetanus, given the increasing rate of vaccine skepticism.