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LETTER TO EDITOR  
Year : 2016  |  Volume : 8  |  Issue : 2  |  Page : 93-94
A case of generalized tetanus from a Nonendemic country


Department of Internal Medicine, General Hospital of Larissa, Larissa, Greece

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Date of Web Publication10-May-2016
 

How to cite this article:
Koufakis T, Gabranis I. A case of generalized tetanus from a Nonendemic country. J Global Infect Dis 2016;8:93-4

How to cite this URL:
Koufakis T, Gabranis I. A case of generalized tetanus from a Nonendemic country. J Global Infect Dis [serial online] 2016 [cited 2020 Feb 18];8:93-4. Available from: http://www.jgid.org/text.asp?2016/8/2/93/182131


Sir,

A 74-year-old female patient presented to the emergency department complaining of dysphagia. She had a history of rheumatoid arthritis under no medication. Physical examination revealed tachycardia, sweating, neck stiffness, and a minor wound on her left shin [Figure 1]. The patient was unable to recall when or how she got injured. In addition, her history of antitetanus vaccination was unclear. The diagnosis of tetanus was clinically established. Her initial treatment included administration of human tetanus immune globulin, metronidazole, and baclofen. 48 h after admission, she presented trismus (lockjaw), risus sardonicus, opisthotonos, and extension of the legs [Figure 2] and respiratory distress. She was then shifted to the Intensive Care Unit (ICU) where she was intubated and received effective supportive care. She was discharged 2 months later after having a complete recovery.
Figure 1: A minor wound on patient's left shin

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Figure 2: Extension of the legs as a result of severe spasticity

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Tetanus is caused by wounds contamination from Clostridium tetani, an anaerobic, Gram-positive bacillus which forms spores and releases toxins: Tetanolysin with no recognized pathologic activity and tetanospasmin, which is responsible for the clinical manifestations of the disease. [1] There are four different clinical types of tetanus such as generalized, localized, cephalic, and neonatal. Opisthotonos or opisthotonus is a Greek word, describing a state of severe hyperextension and spasticity, in which the patient's head, neck, and spinal column come into an arching position. [2] Apart from tetanus, it can be also seen in patients with traumatic brain injury, acute hydrocephalus, or severe cerebral palsy. Risus sardonicus or rictus grin is a characteristic, abnormal, and sustained spasm of the facial muscles that appears to produce grinning. [2] Despite having a characteristic clinical presentation, tetanus should be carefully distinguished from other conditions causing trismus, such as strychnine poisoning, dental infections, intracranial hemorrhage, and epilepsy, among others. Mortality resulting from generalized tetanus has been estimated to be about 30%. [3]

Main principles of treating tetanus are the following: Controlling muscle spasms and autonomic instability, neutralization of tetanus toxin, wound debridement, and administration of antibiotics to prevent bacteria proliferation at the wound site. [4] Early onset of intensive supportive care is extremely important for patient's survival; therefore, ICU admission is, most of the times, a necessity for patients with tetanus.

Interestingly, the severity of the clinical course of tetanus does not seem to be associated with the size of the trauma. As happened to the presented case, even small wounds can lead to the development of generalized tetanus if wound sterilization and patient's immunization are deficient.

Tetanus has been a major problem of public health since ancient times. However, it is nowadays considered as a rare disease, especially in the western world, due to an effective vaccination program. From 2001 to 2008, only 233 cases of tetanus were reported in the United States, meaning a 95% reduction since 1947. [5] Due to its rarity, many diagnostic delays occur as doctors may not consider the diagnosis until the manifestations become apparent. [4] In conclusion, physicians should always include tetanus in their differential diagnosis, when handling patients with compatible clinical presentation, even in nonendemic areas of the world.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Popoff MR. Clostridial pore-forming toxins: Powerful virulence factors. Anaerobe 2014;30:220-38.  Back to cited text no. 1
    
2.
Tapajós R. Trismus, opisthotonus and risus sardonicus: Who remembers this disease? Rev Bras Ter Intensiva 2011;23:383-7.  Back to cited text no. 2
    
3.
Pascual FB, McGinley EL, Zanardi LR, Cortese MM, Murphy TV. Tetanus surveillance - United States, 1998-2000. MMWR Surveill Summ 2003;52:1-8.  Back to cited text no. 3
    
4.
Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: An evidence-based review. Crit Care 2014;18:217.  Back to cited text no. 4
    
5.
Centers for Disease Control and Prevention (CDC). Tetanus surveillance - United States, 2001-2008. MMWR Morb Mortal Wkly Rep 2011;60:365-9.  Back to cited text no. 5
    

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Correspondence Address:
Theocharis Koufakis
Department of Internal Medicine, General Hospital of Larissa, Larissa
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.182131

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2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008