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A6861 - Cephalic Tetanus in an Elderly Woman: A Case Report
Author Block: F. Penaranda1, R. S. Reodica2, R. M. Llorin3; 1Department of Internal Medicine, St. Luke's Medical Center - Global City, Taguig, Philippines, 2Institute of Pulmonary Medicine, St. Luke's Medical Center - Global City, Taguig, Philippines, 3Infectious Disease Services, St. Luke's Medical Center - Global City, Taguig, Philippines.
Introduction Tetanus is an acute, often fatal neuromuscular disorder caused by tetanospasmin, a neurotoxin produced by Clostridium tetani. Since the introduction of primary vaccination, its incidence in the developed world has diminished significantly but still remains a burden in underdeveloped countries.
Case Report A 78-year old Filipino female, known hypertensive presented to the ED with 6 days history of throat pain and neck stiffening. She has no other co-morbidities, no history of trauma or recent surgery, with unknown vaccination history. Six days prior, she developed throat pain and difficulty swallowing. She was diagnosed with tonsillopharyngitis and started on antibiotics. Four days after, she noted progressive dysphagia, new-onset fever, neck stiffening and jaw rigidity. Tetanus infection was entertained. She was given Anti-Tetanus Serum, Tetanus Toxoid and Tetanus Immunoglobulin. Metronidazole, Penicillin G and Cefuroxime were started. While attempting nasogastric tube insertion, patient developed seizure-like posture, neck rigidity, upward rolling of eyeballs, bronchospasm and eventually went into respiratory failure. Airway was secured, then patient was transferred to our institution. On admission, received a GCS 11 (E4V1M6) patient with stable vital signs. Upon examination, noted marked nuchal rigidity, trismus and reflex spasms. No open wounds were noted. Complete neurologic exam was unremarkable at that time. Diagnostics revealed only mild electrolyte abnormalities. CT scan of the neck ruled out abscess formation. She was admitted to the Medical ICU managed as Cephalic Tetanus and was started on Midazolam infusion. However due to persistence of spasms, antispastic agent Baclofen was added. Empiric antibiotic was started. Nutrition support was given via nasogastric feeding. Prophylaxis for deep vein thrombosis was started. Early tracheostomy was performed on the 5th ICU day. On the 10th ICU day, noted restlessness, desaturation, tachyarrhythmias and blood pressure lability. Muscle paralysis was deemed inadequate hence Atracurium, a neuromuscular blocker was started while maintained on controlled ventilation. On the 24th ICU day, sedation was successfully tapered and ventilator weaned off. Rehabilitation then initiated. She was transferred out after 33 ICU days and eventually discharged improved after 46 in-hospital days.
Discussion Cephalic tetanus can progress to generalized tetanus and if left untreated, can lead to death. Early recognition of signs allows for prompt management. We present here a rare case of cephalic tetanus with no apparent infection site who recovered completely after 6 weeks of intensive care. Crucial aspect of therapy is to eliminate ongoing toxin production, neutralize unbound toxin, immunization, airway protection and aggressive supportive care.