Rigor from the Rubble in Haiti

Abstract

INTRODUCTION: The average annual incidence of tetanus in the USA is 0.16 cases/million population. During 1998-2000, an average of 43 cases of tetanus was reported annually. The reported incidence of tetanus morbidity and mortality in the United States has declined substantially since the mid-1940s, when tetanus toxoid became universally available. In developing countries of Africa, Asia, and South America, tetanus is far more common. The annual worldwide incidence is between 500,000-1 million cases. We present a patient with classic signs of tetanus and discuss the treatment and management. CASE PRESENTATION: Rescue workers in Haiti found an 18 year old male two days after the earthquake under a collapsed building. At that time, his foot was crushed, he had trismus, sustained orbicularis oris muscle contraction (risus sardonicus) and generalized tetanus seizures with flexion and abduction of the arms, extension of the lower limbs and arching of back (opisthotonus seizures). They intubated him, performed a below-the-knee amputation and infused equine tetanus immune globulin. The US Navy airlifted him from Haiti while he was experiencing persistent tetani. Upon arrival to Atlanta, we gave him human tetanus immune globulin, and tetanus toxoid. We continued therapy with vecuronium, versed, morphine, metronidazole and magnesium. He developed autonomic dysfunction requiring intravenous labetalol. As his spasms ceased, we discontinued the paralytic. Although his Tobin index was normal, he was unsuccessfully extubated due to respiratory muscle spasms and chest wall pain. We then performed a tracheostomy and titrated the benzodiazepine, morphine and beta-blockers to control his muscle spasms and autonomic dysfunction. After a fifteen day intensive care unit stay, he was transferred to a long term acute care facility for ongoing rehabilitation. Upon discharge, he was awake, interactive and communicative. DISCUSSIONS: This common disease seen worldwide is very infrequent in the states. Although the patient's presentation was classic for tetanus, treatment and management was a challenge for all specialists involved. Many experienced clinicians admitted that they had never treated a tetanus patient. The most common presentation of tetanus is from acute puncture injury but can also present in patients with abscess, ulcers or gangrene. Mainstay of treatment is to eliminate the source of toxin, control muscle spasms, monitor respiratory status, and control autonomic dysfunction. Human tetanus immune globulin 3000-6000 units IM should be given promptly to neutralize circulating toxins. Already bound neural tissue is unaffected. Equine tetanus antitoxin has a shorter half-life and is cheaper but is not available in the US. It commonly elicits a hypersensitivity reaction and serum sickness. Metronidazole is administered to eradicate Clostridium Tetani, which creates the toxins. To control muscle spasms, multi-drug combination of benzodiazepines, nondepolarizing neuromuscular blockers, and magnesium sulfate are used. Magnesium sulfate drip reduces the amount of benzodiazepine and neuromuscular blockade needed. However, electrolytes must be frequently monitored. If spasms are still persistent, intrathecal baclofen can be initiated. Most patients require intubation due to laryngospasm or ventilatory muscle contraction. Labetolol or esmolol may be used to control autonomic dysfunction. All patients should be immunized, because immunity is not induced by the small amount of toxin that causes the disease. The course of tetanus can last for 4-6 weeks. CONCLUSION: Tetanus typically occurs from penetrating trauma and presents with diffuse muscle spasms, respiratory compromise and autonomic dysfunction. Prompt recognition and initiation of human tetanus immune globulin, metronidazole, benzodiazepine, nondepolarizing neuromuscular blockade, magnesium sulfate, labetolol and tetanus vaccine are life saving.