Case report on tetanus

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

He was semiconscious. 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 part 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 was negative.

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

Few hours later the condition has changed rapidly with muscle rigidity 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 over 24 hours, but we have increased up to 60mg/die because the contractions were not receding.

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

The wound was dressed daily with abundant use of hydrogen peroxide in the hope of killing the remaining anaerobic bacteria in it.

We have stopped rocephin and switched to iv Pen G and 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.

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 organism.

But at 10.00am 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 muscle contractions around the lungs and laryngeal spasm.

LEARNING POINTS.

I) Traditional circumcision performed by unskilled personnel carries high risks of mortality due to bleeding, infections including tetanus.

II) Many young people in our areas are not fully immunized for tetanus and this is a potential risk for tetanus 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 usually negative

VI) Unfortunately in Chaaria tetanus immunoglobulins are not available.

VII) 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.

VIII) Metronidazole and pen G should be given to prevent further multiplication of bacteria.

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

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

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

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

The photo is an icon given to us as a gift by the Contemplative Cottolengo Sisters of Tuuru. It represent to "Good Samaritan": the sisters wanted to express their appreciation for our continuous dedication to the service of the people in need.

It has been a very nice gift

Bro Beppe Gaido