Generalized tetanus in a 4-year old boy presenting with dysphagia and trismus: A case report. Cases Journal 2009;:7003

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口腔病理科 On-Line KMU Student Bulletin

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原文題(出處)： Generalized tetanus in a 4-year old boy presenting with dysphagia and trismus: A case report. Cases Journal 2009;:7003

原文作者姓名： Jong PR, Heer-Groen T, Schröder CH, Jansen NJG 通訊作者學校： University Medical Center Utrecht

報告者姓名(組別)：王瓈屏(Intern A 組)

報告日期： 2009/10/12

內文：

Introduction:

1. Tetanus is a neurotoxin-mediated disease characterized by a progressive spastic paralysis of multiple muscle groups.

2. The neurotoxin (tetanospasmin) disrupts neurotransmitter release in inhibitory neurons, leading to peripheral muscle rigidity and spasms.

3. Tetanospasmin is produced by the obligate anaerobic, spore-forming,

Gram-positive species Clostridium tetani, of which it`s spores are ubiquitously distributed in our environment.

4. Muscle rigidity and spasms constitute the typical clinical hallmarks of generalized tetanus e.g. trismus (lockjaw) and opisthotonus

5. The onset of a generalized tetanus infection is not always associated with the clinical signs described above. Tetanus presenting with solely oropharyngeal symptoms can be misdiagnosed as a more common oropharyngeal infection (i.e.

peritonsillar abscess).

Case presentation:

The history revealed that the 4-year-old Caucasian boy had recently injured his left hallux. This had resulted in a small local hematoma and loose toenail. There were no recorded insect or animal bites. Based on religious grounds, the boy had not received immunization according to the Dutch National Immunization Program. The other children, including his identical twin, were healthy.

Hospitalization Day

1~4 general malaise, indolence, mild fever and progressive anorexia.

5 1. refuse all food and fluids

2. progressive dysphagia, sore throat and sialorrhoea 6 1. An otorhinolaryngologist had been consulted

2. Peritonsillar abscess.

3. Examination at that time did not provide any clues for an oropharyngeal infection

7 1. Difficulties with mouth opening 2. Progressive dehydration

3. A pediatrician was consulted Wilhelmina

Children’s Hospital

8 1. no cervical lymphadenopathy

2. ear and nose examination was unremarkable.

Oropharynx was not possible due to trismus.

3. Tendon reflexes: normal 4. No meningeal irritation.

5. The loose toenail did not show clear signs of inflammation.

6. Hart rate was slightly increased Blood pressure was normal

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Farther clinical examination was unremarkable After being asked to walk, he showed muscle spasms of the back and thighs evidently worsening during

examination

Intial differential diagnosis:

i. oropharyngeal infections (e.g. tonsillitis, peritonsillar abscess)

ii. botulism iii. rabies

iv. strychnine poisoning v. hypocalcemia

vi. psychogenic causes vii. tetanus.

Based on normal complete blood cell count and

chemistry profiles, immunization status and the presence of generalized muscle spasms

working diagnosis: generalized tetanus 8 Anti-tetanus immunoglobulins (300 I U. i.m)

Amoxicillin (100 mg /kg i.v.)

Intubated and mechanical ventilation

Transferred to Pediatric intensive care unit (PICU) Metrodazole (30 mg/kg/day i.v. ) for fallowing 10 days 9

Surgical debridement of the left hallux toenail Anti-tetanus immunoglobulins (300 I U. i.m)

13 Blood and wound cultures were negative for C. tetani.

During the entire stay at the PICU repeated cultures of blood, urine and tracheal aspirates remained negative White blood cell counts remained unremarkable

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CRP levels increased to a maximum of 63 mg/L 15 Active immunization DTP was started

Muscle spasms and trismus significantly worsened in frequency and severity

Dosages of midazolam and morphine (i.v.) were increased

Clonidine and lorazepam were added to the regimen 19 creatine kinase levels : 945 U/mL

[reference value: 15–175 U/mL]

22 Haloperidol

Muscle spasms and anxiety decreased Gradual weaning off sedatives was started.

23 Uneventful extubation

Two short periods with increased muscle spasms

occurred thereafter, which were successfully treated with diazepam.

Regional hospital

28 He was transferred back to the referring hospital

Discussion:

1. General tetanus infection is rare in developing countries, because of national immunization programs

2. Patients in developing countries are more likely to present with progressed and unambiguous symptoms i.e. severe spasms of the facial musculature (risus sardonicus) and opisthotonus.

3. Challenge of diagnosing generalized tetanus infection in the mere presence of dysphagia and trismus, which is accompanied by an undiminished risk of rapid clinical deterioration.

General tetanus Cephalic tetanus Tetanus

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neonatorum The most common

form

A variant of localized tetanus

Initial infection of the umbilical stump Character Trismus or lockjaw

Risus sardonicus Opisthotonos

The poorest prognosis of localized tetanus

The mortality in infants exceed 90%

4. Treatment:

(1) Debridement of the primary wound

(2) Metronidazole and penicillin have equivalent activity against C. tetani (3) Passive innunization with human immunoglobulin

(4) Vaccination with tetanus toxoid

5. In fact, the most contributing factor to reduce mortality from generalized tetanus is treatment within modern (pediatric) intensive care units (ICU) with aggressive sedation protocols and advanced ventilatory support

6. Autonomic dysfunction remains the major clinical challenge, as hypotension, arrhythmia and cardiac arrest are important predictors of fatality

Conclusion:

The diagnosis of generalized tetanus in children remains a diagnostic challenge in developed countries, as the classical symptoms may be absent at presentation. Early recognition and immediate initiation of advanced critical care are necessary to prevent rapid clinical deterioration. Therefore, the differential diagnosis of non-immunized children with an acute onset of dysphagia and trismus should always include generalized tetanus

題號題目

1 Which statement about tetanus is right?

(A) The pathogen is an aerobic, spore-forming, Gram-positive rods (B) In-utero infection will not occur

(C) oropharyngeal symptoms is rare in generalized tetanus in developed countries

(D) Culture results are the gold standard for tetanus diagnosis 答案( ) 出處：Medical microbiology 5^th edition P.406~P.409

Murry,Rosenthal, pfaller

題號題目

2 Which statement of treatment of tetanus is right?

(A) Vaccination with tetanus toxoid

(B) Debridement of the primary wound is unnecessary (C) Amoxicillin is the optimal antibiotic for treating tetanus (D) The use of human tetanus immunoglobulin is questionable 答案( ) 出處：Medical microbiology 5^th edition P.408~P.409

Murry,Rosenthal, pfaller