Trismus: The Phantom Menace

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97761

Case Presentation:

A 73–year–old man presented with symptom of locked jaw for one day. On further enquiry, he reported that he suffered an injury to the right leg after stepping on a rusty steel object one week ago. Even though he was seen at a nearby health facility for the wound, no tetanus shot was administered. His last tetanus vaccination was several years ago. On examination, he had neck stiffness, and a 10 x 10 cm erythematous and edematous open wound at his right lower extremity which was draining serous fluid and had black pigmentation of skin around the opening. The remainder of the examination was normal. Patient was diagnosed with Tetanus and was started on Tetanus Immunoglobulin, tetanus toxoid–containing vaccine and metronidazole. Wound debridement was done. Next day, patient condition deteriorated and was to be cyanotic, and bradycardic. After receiving atropine, he developed asytole, followed by successful resuscitation and intubation. During the stay in ICU, the patient developed generalized muscle spasm, fluctuating blood pressure, hypothermia and rhabdomyolysis with renal failure. Midazolam, diazepam, fentanyl and vecuronium were given for muscle relaxation and sedation. Morphine, magnesium sulfate, and labetalol were administered for control of autonomic instability. He was discharged with improvement in clinical conditions after 49 days of hospitalization.

Discussion:

Tetanus is a very rare potentially fatal disease, caused by a tetanospasmin released from wounds infected with Clostridium tetani, an anaerobic gram–positive bacillus transmitted as spores distributing in soil. The annual incidence in the United States is about of 0.10 cases/million population. As tetanus become less common, cases are likely to be misdiagnosed or go unrecognized. Tetanus is defined by trismus or risus sardonicus or painful contraction with a history of wound infection. The diagnosis is based entirely on clinical presentation. Generalized, localized and cephalic types are 3 clinical manifestations of tetanus in adults. Most patients (78%) presents with mild early trismus. In this case, trismus and infected wound were key clinical features leading the clinician to prompt diagnosis and emergent treatments, including TIG, tetanus toxoid–containing vaccine, metronidazole and wound debridement. The patient eventually progressed to severe generalized tetanus with autonomic instability as TIG does not neutralize toxin that has already bound to nerve endings. At this stage, the main treatment is supportive care; early protection of the upper airway, adequate ventilation, control of muscle spasms, and limiting the consequences of autonomic dysfunction which is the most common cause of death in ventilated patients with severe tetanus. Magnesium sulfate is drug of choice to control cardiovascular instability.

Conclusions:

Since tetanus is a very rare case, physician education is vital in detecting tetanus at very early stage, so further lifesaving interventions can be done.

To cite this abstract:

Anuwatworn A, Limann B, Shingala H, Cirilo I, Cheriyath P. Trismus: The Phantom Menace. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97761. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/trismus-the-phantom-menace/. Accessed September 18, 2019.

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