Case Presentation: The patient is a 50 year-old unvaccinated Amish male who presented with progressive jaw pain and tightness after stepping on a nail 9 days prior. Initial management in the emergency department was wound debridement, Tdap vaccination, tetanus immune globulin intravenously (IV) and locally in the wound, as well as IV antibiotics.He was started on hydromorphone and midazolam continuous infusions and intubated due to the severity of muscle spasms. Spasms were difficult to manage despite midazolam as well as propofol. Ultimately, a cisatracurium infusion was required for control of spasms. In an effort to decrease cisatracurium, continuous infusion of magnesium sulfate and trial of bolus intrathecal (IT) baclofen were implemented. In combination, magnesium sulfate and IT baclofen allowed cisatracurium to be weaned. Given the good response, an IT baclofen pump was placed with the basal rate slowly uptitrated to a maximum daily dose of 288.7 mcg. Magnesium sulfate was transitioned to oral magnesium oxide. Sedation was weaned off slowly, and patient was discharged home 1 month after admission. Patient’s course was complicated by autonomic dysfunction including fevers, tachycardia requiring labetalol, and labile blood pressure requiring careful titration between sedation and vasopressors. It was also complicated by respiratory failure secondary to ventilator-associated and aspiration pneumonia, requiring tracheostomy, as well as bilateral deep vein thromboses.

Discussion: Tetanus is caused by the bacterium Clostridium tetani, which produces toxins that block inhibitory neurotransmitter release from the motor and autonomic nervous systems.Muscle spasms can be a significant complication of tetanus infection and difficult to control. Uncontrolled spasms can lead to rhabdomyolysis or even fractures. Benzodiazepines are first line treatment, but in our case, were unable to control spasms. Our patient required continuous infusion of cisatracurium. However, these medications can worsen autonomic dysfunction.IT baclofen has been shown highly effective in controlling spasms in tetanus, due to its agonism at the GABA-B receptor. Oral baclofen has poor penetration across the blood-brain barrier and is ineffective in the setting of tetanus. In our case, IT baclofen promptly controlled spasms and allowed discontinuation of cisatracurium and sedation.Besides spasm-related respiratory failure, which is manageable with mechanical ventilation, the most life-threatening complication of tetanus is autonomic dysfunction. An adjunct therapy that can be used is magnesium sulfate, which has been shown in a randomized controlled trial to decrease the requirement for sedation and neuromuscular blockade. Magnesium has a relaxing effect on muscle, helping with spasms and hypertension, as well as other autonomic effects such as decreasing heart rate and prevention of systemic catecholamine release.

Conclusions: While tetanus is a rare diagnosis due to vaccinations, the disease is a serious and complicated one. Due to the effects of tetanus toxin, the illness can persist for 4-6 weeks. The management of muscle spasms can be difficult and may require unique pharmacological management. The prolonged nature of the illness and need for intensive medical management are accompanied by their own complications. This case reinforces the importance of prevention and recognition of its presentation, which can easily be missed due to its rarity.