The patient is a 45‐year‐old Mexican‐American from South Texas. He is a construction worker who fell from a ladder lacerating his left ankle on a jagged brick. He was initially treated at home with ibuprofen, topical ointments, and some dressings applied by a relative. The next day he presented to the ED with fever, increased swelling, and ankle pain. Physical exam revealed a patient who was slightly disheveled. His vital signs were normal except for temperature of 99.4°F and a heart rate of 115 bpm. He had an 8‐cm laceration at the level of the left medial malleolus. This was packed with cobwebs. There was marked swelling, erythema around the left ankle over the dorsum of the foot. An X‐ray of the left ankle revealed a comminuted calcaneal fracture. The patient received a Td booster and was started on broad‐spectrum antibiotics. He was admitted to the orthopedic service and twice underwent debridement to the infected wound and open left ankle fracture. On the second hospital day the patient started complaining of severe chest, back, and neck pain, along with difficulty breathing and diaphoresis. His oxygen saturation was in the low 80s, he was diaphoretic., using accessory respiratory muscles, with trismus, neck rigidit.y and opisthotonus. The hospitalist group was consulted, and the diagnosis of tetanus was made; the patient was transferred to the MICU, where he received tetanus immunoglobulin, penicillin and supportive care for his respiratory distress and muscle spasms. He required long period of mechanical ventilation and was finally discharged after a prolong hospitalization
Tetanus is caused by the Clostridium tetani exotoxin. Worldwide tetanus remains a major health concern, with as many as 800,000 cases per year. However, in those countries with mandatory immunization it is a rare entity, with fewer than 30 cases in the United States in the year 2002. Therefore, tetanus is very uncommon to be addressed as an inpatient problem. It is standard of practice to address tetanus status in all patients presenting with any skin breakdown with a high risk of anaerobic infections. The patient had a tetanus‐prone wound, and packing with foreign contaminated material (cobwebs) may have increased the risk of infection in this case.
This case illustrates several important points: First, in the United States there are groups, including some immigrant groups and elderly individuals, that may not have received a primary course of immunization. Second, emphasize the awareness of potential tetanus in Mexican border regions, where more transit of immigrants can be seen. Third, in a high‐risk group, with a high‐risk wound, one is obligated to use tetanus immunoglobulin. Finally, with early recognition and appropriate supportive care, there is a good chance for recovery.
P. Abanto, none; L. Garcia, none; R. Hernandez, none; F. Meza, none.