Acute Muscle Rigidity Secondary to Tetanus: A Toxicology Simulation Case for Fourth-Year Medical Students.

Introduction: Tetanus is uncommon in the United States secondary to vaccination. However, vaccination hesitancy is increasing. This case challenges medical students to consider tetanus in the differential and understand its complications. Methods: Fourth-year medical students took a pretest on the neurotransmitter glycine and associated disease states. They received two 10-minute lectures on glycine and acid-base abnormalities. Students then participated in a simulation featuring a 27-year-old man bitten by a dog, resulting in tetanus. Required equipment included a mannequin with monitor, a defibrillator, and personal protective equipment. Critical actions consisted of learners dividing up roles amongst each other, using closed-loop communication, placing the patient on a cardiac monitor, choosing to establish IV access and intubate the patient, starting IV fluids, and administering tetanus immunoglobulin. The case ended after 20 minutes. Outcome measurements encompassed performance on a posttest and critical actions. Results: Twenty students participated. Mean pretest and posttest scores were 69.5 and 92.5, respectively (p < .001). All groups completed the items on the critical actions checklist within a 20-minute time frame. Discussion: Rising vaccine hesitancy may increase the likelihood of physicians encountering new cases of tetanus and require them to perform lifesaving management of a patient presenting with muscle rigidity. This simulation provides learners with hands-on experience caring for a patient with tetanus and muscle rigidity. It can improve their knowledge of recognition, assessment, and decision-making toward lifesaving management of tetanus by allowing them to practice their skills in a safe environment.

Clinical profile and outcomes of tetanus patients in a tertiary hospital in the Philippines: a ten-year retrospective study.

BACKGROUND: Tetanus is a life-threatening but preventable neurologic disorder characterized by trismus and muscle spasms. Despite its decreasing global incidence, it remains to be endemic in resource-limited settings such as the Philippines. This study aimed to determine the incidence, demographic characteristics, risk factors, clinical presentation, management, complications, and outcomes of non-neonatal tetanus cases in a tertiary hospital in the Philippines. It also aimed to compare the clinical profile and outcomes between the adult and pediatric subgroups. METHODS: This study used a retrospective cross-sectional design including all adult and pediatric non-neonatal tetanus patients admitted at the University of the Philippines - Philippine General Hospital from January 2012 to June 2023. Data was extracted from department censuses and inpatient charts. RESULTS: One hundred thirty-eight cases were included. The incidence rate was 0.03%, while mortality rate was 29%. Majority of patients were males presenting with trismus and spasms after sustaining a puncture wound. Chronic hypertension was associated with an increased hazard of death by 4.5 times (p = 0.004), while treatment with magnesium sulfate was associated with a decreased hazard of death by 35 times (p = 0.005). The mode of infection and the medications administered differed between the adult and pediatric subgroups. CONCLUSIONS: Although the total number of cases has decreased over the past decade, tetanus remains to have a high incidence and mortality rate in the Philippines. Increasing vaccination coverage, improving public awareness, and educating health professionals can help reduce morbidity and mortality from this disease.

Case Report: A Challenging Case of Tetanus Presenting with Headache.

Tetanus is a life-threatening infectious neurological condition that has become uncommon due to large-scale immunization campaigns. We describe a rare instance of generalized tetanus presenting with a headache on a tropical island in Malaysia. A 43-year-old woman presenting with headaches and generalized body weakness, which progressed into trismus and neck stiffness. Her medical history indicated a wound on the sole of her foot caused by shattered glass in an unhygienic area, but no tetanus prophylaxis had been administered. The patient was subsequently given immunoglobulin, tetanus toxoid, metronidazole, and sedatives in the recommended dosages. Her neurological condition improved remarkably, but she suffered blood pressure fluctuations due to dysautonomia. She was successfully discharged with complete recovery after 6 months of follow-up. The case demonstrates the significance of appropriate identification and care of tetanus, as well as the lethal effects of untreated wounds in vulnerable patients.

Progressive encephalomyelitis with rigidity and myoclonus (PERM) associated with anti-glycine receptor antibodies and urothelial carcinoma: a case report.

BACKGROUND: Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare neurological condition with paraneoplastic etiology in about 20% of cases, usually presenting before or shortly after the oncological diagnosis is established. PERM associated with anti-glycine receptor antibodies is not previously reported in a patient with bladder cancer. CASE PRESENTATION: A 72-years-old Caucasian male was admitted with acute onset of dysarthria, dysphagia and trismus three years after initial surgical treatment for bladder cancer. The condition was initially diagnosed as tetanus and treated accordingly, but the diagnosis was reconsidered because of progression despite adequate treatment. Diagnostic workup on readmission revealed lung and paraaortal metastases from bladder cancer and anti-glycine receptor (anti-GlyR) antibodies both in the cerebrospinal fluid and in serum, which supplemented with the clinical presentation led to the diagnosis of PERM, presumably related to bladder cancer. The patient showed improvement and stabilization after treatment with intravenous immunoglobulin and chemotherapy against metastatic bladder cancer. CONCLUSION: To the best of our knowledge, this is the first reported case of anti-GlyR antibody positive PERM related to urothelial carcinoma. The symptoms mimicked tetanus, and responded to chemotherapy and immunotherapy.

Vaccination efficacy in patients with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is a disorder of mature malignant B cells with multiple elements of immune dysfunction. Infections are common in CLL patients due to complex immunodeficiency. Vaccines are used as preventative measures for common diseases including influenza, pneumococcus, tetanus/diphtheria and shingles in the general population. Vaccines are utilized to mitigate this risk, although there have been some concerns regarding the efficacy of vaccines in the CLL population due to the inherent complex immune dysfunction associated with the disease. In this review, we describe the clinical and laboratory indicators for efficacy of the vaccines in the CLL population (including COVID-19, influenza, pneumonia, herpes zoster, and tetanus) and discuss immunization recommendations for patients with CLL.

Suspected Generalized Neonatal Tetanus in a Litter of Puppies.

Tetanus, caused by Clostridium tetani neurotoxin, is extensively described in adult dogs and is frequently associated with a recent history of wounds. Although this condition is reported in 2-3 mo old puppies, tetanus has not been described in neonates. Herein, we report the clinical signs of 3-5 day old American Bully puppies from the same litter, presenting with an acute onset of marked generalized stiffness of the extensor muscles, trismus, and an inability to suckle. Three puppies died because of tetanus: one died during consultation, one was euthanized owing to respiratory distress, and the third died 1 mo after initial presentation following deterioration. All three of these puppies were clinically affected by omphalitis. Complete bloodwork, toxicological screening (including strychnine assay), serology, and polymerase chain reaction tests for selected infectious diseases were unremarkable. Necropsy of the euthanized puppy confirmed suppurative omphalitis, which may have contributed to C. tetani infection. These are the first cases of suspected neonatal tetanus in puppies, which is a frequent condition in newborn humans and is associated with omphalitis as the route of infection.

Electroencephalography of rapid eye movement sleep behavior disorder in a dog with generalized tetanus.

CASE SUMMARY: A 3-month-old Airedale dog with clinically diagnosed generalized tetanus was investigated for the occurrence of excessive paddling and chewing movements when sleeping. Electroencephalogram (EEG) with time-locked video over 31 hours determined occurrence of the abnormal movements to be within 20 to 180 seconds of the onset of rapid eye movement (REM) sleep, but not at any other stage of wakefulness or sleep. No epileptiform activity was noted. Clinical signs of generalized tetanus resolved over 8 weeks with antimicrobial and symptomatic treatment, and sleep-associated movements resolved 6 weeks after presentation. CLINICAL RELEVANCE: Rapid eye movement sleep behavior disorder (RBD) has been suspected in dogs with generalized tetanus but not confirmed by correlation of repeated episodes of vocalization or motor behaviors or both with REM sleep defined by an EEG. The case further defines RBD in dogs with tetanus, and highlights the value of EEG to differentiate among different parasomnias and epileptiform activity.

Application of noninvasive positive pressure ventilation to respiratory complications of severe tetanus: a case report.

Respiratory failure because of muscle spasms is a major sequela of tetanus. Spasms can be controlled with sedation and adjunctive treatment, albeit at the expense of respiratory drive and weakness. Invasive ventilation under deep sedation with intensive care unit admission is the best practice. Where invasive ventilation is unavailable and when patients decline intubation, the management of muscle spasms and respiratory failure is extremely limited, with low survival rates. Herein, we present a case of severe tetanus in a 90-year-old female farmer who declined intubation and whose respiratory failure was managed with noninvasive positive pressure ventilation (NPPV) with a moderate dose of continuous benzodiazepine infusion to treat spasms. Compared with invasive ventilation, NPPV reduces the duration of ventilatory support and the risk of nosocomial pneumonia. Because spontaneous respiratory drive of the patient was maintained to trigger ventilation, pressure control ventilation was initiated. In previous references to tetanus management, the application of NPPV has not been mentioned. NPPV is a treatment option for patients with tetanus who are not intubated owing to limited medical resources or do-not-intubate orders for older patients.

The Role of Surgical Debridement in the Treatment of Systemic Tetanus: A Case Report.

CASE: Tetanus is a potentially life-threatening infection of Clostridium tetani characterized by painful muscular spasms and hypertonia. Surgical debridement of infected tissue is intended to reduce the number of spores and limit the extent of the disease. We report a case of an unvaccinated 13-year-old adolescent boy who presented with systemic tetanus after stepping on a nail, and we describe the role that surgical debridement of infected tissue plays in optimizing outcomes. CONCLUSION: Orthopaedic surgeons must remain aware of the role of surgical debridement of wounds potentially infected with C. tetani because it is an important component of proper management.

Cephalic tetanus manifesting as isolated facial nerve palsy- a case report from rural Armenia.

Cephalic tetanus is a rare clinical form of tetanus, clinically characterized by trismus and cranial nerve palsy involving one or more cranial nerves, facial nerve being the most common. We report a case of cephalic tetanus with left-sided lower motor facial nerve palsy in a 66-year-old non-immunized patient after an untreated laceration injury. The patient had dysphagia, spasm of the muscles of mastication, asymmetry of the left side of the face, cough, shortness of breath, and stiffness of neck muscles. The presentation was unique given that the facial nerve palsy appeared prior to the occurrence of trismus, which misled the initial diagnosis towards Bell's palsy. He was successfully treated with tetanus antitoxin without any adverse events. Although widespread use of tetanus vaccine has led to a dramatic decline in this fatal disease, sporadic disease occurrence is still possible, particularly in individuals without up-to-date vaccinations. In this case report we illustrate the importance of early recognition of cephalic tetanus prior to the development of the full clinical picture. The early initiation of therapy is the key to recovery from this deadly disease. Physicians are encouraged to include cephalic tetanus as a cause of facial nerve palsy in their differential. In particular, paying attention to cases manifesting early after head or neck injury.

Respiratory complications in dogs with tetanus: A retrospective study of 53 cases.

Tetanus can lead to respiratory complications, and the outcome of dogs affected by this disease is still largely unknown. This retrospective study aimed to evaluate the frequency and outcome of 53 dogs with tetanus and respiratory complications between February 2006 and January 2019. Medical records from dogs diagnosed with tetanus admitted to a referral teaching hospital were reviewed. Fifty-three dogs were diagnosed with tetanus and respiratory complications were observed in 26.4% (14/53) of dogs; 8 developed aspiration pneumonia (AP), 5 developed upper airway obstruction (UAO) and 1 dog developed both. A total of 5 AP dogs were mechanically ventilated. Three dogs with UAO had tracheostomy tubes placed. Dogs with respiratory complications had a poorer outcome, with only 14.3% (2/14) surviving to discharge, compared to 94.8% (37/39) for dogs with no respiratory complications. Respiratory complications such as AP and UAO were common in dogs with tetanus, and this was associated with a poorer outcome.

Complications respiratoires chez des chiens affectés par le tétanos : une étude rétrospective de 53 cas. Le tétanos peut entrainer des complications respiratoires et les conséquences de celles-ci sur le pronostic vital du patient sont souvent inconnues. Cette étude rétrospective d'observation a pour but d'évaluer l'incidence et les conséquences de complications respiratoires chez 53 chiens affectés par le tétanos entre février 2006 et janvier 2019.Les dossiers médicaux de chiens ayant le tétanos et admis dans un hôpital de référence furent analysés. Cinquantetrois chiens furent diagnostiqués du tétanos et des complications respiratoires ont été observé dans 26,4 % (14/53) des cas; huit développèrent une pneumonie par aspiration (AP), 5 développèrent une obstruction des voies aériennes supérieures (UAO), un patient eut les deux. Trois patients avec une UAO reçurent une trachéostomie. Les patients avec des complications respiratoires avaient une évolution plus néfaste, avec seulement 14,3 % (2/14) qui survécurent jusqu'à la sortie de l'hôpital, comparativement à 94,8 % (37/39) pour les patients sans complications respiratoires. Les complications respiratoires chez les chiens souffrant du tétanos sont courantes et ces patients ont un pronostic vital plus mitigé.(Traduit par les auteurs).

Clinical outcomes and healthcare costs of inpatients with tetanus in Korea, 2011-2019.

BACKGROUND: Tetanus is a rare, vaccine-preventable but extremely serious disease. We investigated the recent trend of the clinical outcomes and medical costs for inpatients with tetanus in South Korea over 10 years. METHODS: We conducted a retrospective review to determine the clinical factors and medical costs associated with tetanus at two national university hospitals in South Korea between January 2011 and October 2019. RESULTS: Forty-nine patients were admitted for tetanus (mean age, 67.0 years [range, 53.0-80.0 years]; 32 women [57.1%]). All the patients had generalized tetanus, and 5 (10.2%) died during hospitalization. The median duration from symptom onset to hospital admission was 4 days. Trismus (85.7%) was the most common symptom, and the median hospital stay was 39 days. Thirty-two patients (65.3%) required mechanical ventilation, and 20 (40.8%) developed aspiration pneumonia. The median total healthcare cost per patient was US $18,011. After discharge, 35 patients (71.4%) recovered sufficiently to walk without disability. CONCLUSIONS: Tetanus requires long hospital stays and high medical expenditures in South Korea; however, the vaccination completion rate is low. Medical staff should therefore promote medical advice and policies on the management of tetanus to the general South Korean population.

MANAGEMENT OF MEDICAL COMPLICATIONS ASSOCIATED WITH A PRESUMED TETANUS INFECTION IN A NORTHWEST BORNEAN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS).

An 18-yr-old female orangutan (Pongo pygmaeus pygmaeus) developed opisthotonus after sustaining conspecific bite wounds 3 wk earlier. The orangutan developed progressive tetraparesis and dysphagia, despite normal mentation, suggestive of tetanus. A tetanus vaccine had been administered at 2 yr of age, but none since. Brain magnetic resonance imaging, computed tomography, cerebral spinal fluid tap, and bloodwork were unremarkable. Viral, Baylisascaris, and tetanus toxin testing were negative. A femoral central venous catheter (CVC) was placed to provide medications, fluids, and parenteral nutrition. The orangutan received human tetanus immunoglobulin, tetanus toxoid, penicillin, methocarbamol, and analgesia. After 1 wk, the catheterized limb became edematous; a deep vein thrombosis (DVT) was diagnosed ultrasonographically. A cephalic CVC was placed, the limb casted, intravenous therapy reinitiated, and enoxaparin started. The orangutan became mobile days later, and progressively improved. Despite no compliance with enoxaparin, the DVT resolved without residual signs. This is the first reported case of presumptive tetanus and DVT in a great ape.

[Localised tetanus with no obvious entry site: about a case in Bamako (Mali)]. / Tétanos localisé sans porte d´entrée apparente: à propos d´un cas à Bamako (Mali).

Tetanus is a major public health problem in sub-Saharan Africa. Localised tetanus is rare, unlike generalized tetanus which has been sufficiently described in the literature. We report a case of localised tetanus with no obvious entry site managed in the Department of Infectious Diseases in Bamako. The study involved a retired nurse aged 59 years who had not undergone tetanus booster immunisation within the last 10 years, corresponding to the date of her last delivery. She was referred to our Hospital with dysphagia associated with inability to open the buccal cavity. Patient's history was characterized by long-term therapy associated with many specialized consultations without any improvement. The diagnosis of localised tetanus with no obvious entry site was retained after having excluded any other local disorder. Outcome was favorable ten days after adequate management. Underdiagnosed or unknown to health-care providers, localised tetanus may mimic other diseases delaying diagnosis and management. Targeted campaign to build awareness should be implemented in order to improve adherence with immunization schedules.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy.

BACKGROUND: The specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents. CASE PRESENTATION: A 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions. CONCLUSION: This is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Demography and Symptom Profile of Tetanus: A Cross-sectional Observation in an Infectious Disease Hospital of Bangladesh.

Tetanus is a potentially preventable neurological infectious disorder with paucity of literature in Bangladesh. We aimed to see the demography and symptom profile of tetanus cases managed at the Infectious disease Hospital Sylhet. This hospital based cross-sectional descriptive study was conducted within the time period of January to December 2012 among 50 consecutive admitted patients in the Infectious Disease Hospital, Sylhet, Bangladesh who were diagnosed as a case of tetanus and fulfilling the inclusion criteria and exclusion criteria. Neonatal tetanus was considered as exclusion criteria and clinical diagnosis of tetanus was considered as the tetanus. Data were collected purposively with pretested predesigned questionnaire. Data were processed manually and analyzed with the help of SPSS Version 16.0. The mean±SD age was 33.00±16.8 years, ranging from 10 to 70 years. Among the 50 respondents, 72.0% were male, 50% from lower class, 34% were students and 30.0% had their educational status of primary level, 60.0% from rural social background. Trismus was found in 98.0% of the cases, rigidity in 96.0% cases, body ache in 94.0% cases, dysphagia in 92.0% cases, neck pain in 78.0% cases, dysarthria in 92.0% cases, reflex spasm in 66.0% cases, opisthotonus in 46.0% cases and urinary retention in 26.0% cases. In this study rural male people with lower socioeconomic status individuals were mostly affected with trismus, rigidity, body ache and dysphagia symptoms.