Case Presentation: A 33 year old female with a past medical history of hypertension, anxiety & depression, hepatitis C and history of opiate/benzodiazepine abuse presented to the hospital with progressively worsening painful body spams associated with abdominal cramping, nausea, vomiting, diarrhea, eye twitching, difficulty swallowing and pain/difficulty opening her mouth. On presentation the patient was noted to be in severe distress from pain associated with generalized muscle spasm. She was hypertensive and tachycardic with significant flushing of her face. There was evidence of trismus with only 1.5 – 2cm mouth opening, neck stiffness, a tight abdomen, and stiffness of the upper and lower extremities. No respiratory compromise was noted. On Further questioning the patient reported no tetanus vaccine in over 10 years, and a recent puncture wound to her right foot from “an old piece of metal in the floor” about 1 week prior to presentation. Given her history and clinical presentation a clinical diagnosis of tetanus was made. Her foot wound was imaged for retained foreign body, which was negative. Relevant laboratory analysis was unremarkable. She was treated with 3000 units of tetanus immune globulin to eliminate ongoing toxin production, in addition to diazepam, metronidazole, and IV magnesium sulfate followed by labetalol for autonomic dysfunction. She was discharged to follow up with her primary care provider and Infectious Disease specialist with improvement of symptoms on oral benzodiazepines.
Discussion: Tetanus is a vaccine preventable, neurologic illness mediated by toxins produced by the anaerobic bacterium, clostridium tetani. Incidence is noted to be highest in developing countries, largely due to low rates of vaccination. Illness typically manifests as one of four clinical syndromes including: generalized tetanus which is marked by diffuse muscle spasms and rigidity, localized tetanus with pain and muscle spasm at site of bacterial inoculation, neonatal tetanus occurring in neonates born to mothers who lack immunity and cephalic tetanus which is rare.
Symptoms generally arise about 7-10 days after exposure, but incubation ranges from 3-21 days. Severity of clinical features can vary depending on the amount tetanus toxin that reaches the central nervous system. Mortality ranges from 25%-70%.
Diagnosis can be considered in patients with no or unknown history of vaccination who present with trismus, risus sardonicus, and generalized muscle spasms. Diagnosis is based on clinical and historical findings in the setting of recent wound contamination, particularly with soil, or skin infections complicated by IV drug use or chronic disease states such as Diabetes Mellitus.
Management consists of aggressive supportive care measures with admission for close hemodynamic monitoring and possible airway management. Wound care or debridement may be necessary to reduce toxin burden from necrotic tissue with anti-tetanus immunoglobulin to neutralize circulating tetanus, benzodiazepines for control of muscle spasms, magnesium sulfate and/or beta blockers for autonomic dysfunction control, and consideration of antibiotics to include metronidazole or penicillin. The usual duration of clinical tetanus is 4-6 weeks.
Conclusions: Although rare in the US secondary to wide spread vaccination, tetanus is a potentially fatal condition that needs to be considered in anyone who presents with focal or generalized muscle spasms and a history of skin brake on the setting of unknown or no history of vaccination.