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LOCALISED TETANUS: RARE PRESENTATION OF A ‘FORGOTTEN’ DISEASE

2011; Wiley; Volume: 47; Issue: 3 Linguagem: Inglês

10.1111/j.1440-1754.2011.02007.x

1440-1754

Vineeta Gupta, Shashikant Dewangan, Bal Dev Bhatia,

Orthopedic Infections and Treatments

Dear Editor, Tetanus is a vaccine-preventable disease but continues to be endemic in many developing countries due to lack of adequate immunisation coverage. The commonest form is neonatal tetanus occurring in newborns of unimmunised mothers. It is responsible for a large number of infant deaths each year, majority of which occur in Asian and African countries. Non-neonatal cases of tetanus are associated with traumatic injury inflicted by an unclean object. We report a rare case of localised tetanus in an unimmunised child following incision of a gluteal abscess and discuss clinical forms and therapeutic intervention. A 12-year-old girl presented with a painful spasm of the right lower limb for the last 6 days. On examination, the right lower limb was being held in extension with markedly increased tone. No flexion was possible in any of the joints. The limb could be moved only as a single rigid extremity. Any attempts to examine the limb exaggerated the spasm. Other limbs were normal. There was no trismus or any symptoms related to the head and neck. There was no sphincteric involvement and she was afebrile. The child was fully conscious. Ten days prior to the onset of present complaints, the child had developed an abscess over the right gluteal region following an intramuscular injection for which incision and drainage was done in her native village. She had not received any immunisations at all. Investigations revealed a normal haemoglobin, total and differential count. The erythrocyte sedimentation rate (ESR) was 22 mm in the first hour. C-reactive protein and creatine phosphokinase levels were normal. Antitetanus antibodies could not be measured as the facilities were not available. X-ray and ultrasonographic examination of the hip joint, knee joint and iliopsoas region were normal. In view of the history and examination findings, a diagnosis of localised tetanus was made. The child was given intravenous benzyl penicillin (100 000 U/kg/day) for 10 days along with 1000 IU of tetanus immunoglobulin intramuscularly. As the child had severe spasm of the limb she was started on diazepam infusion in a dose of 1 mg/kg/day. Since there was no improvement in the spasm, the dose was increased to 2 mg/kg/day. The spasm improved in the next 2 weeks and she was switched to oral diazepam. The child was immunised against tetanus before discharge. Tetanus is an acute, spastic paralytic illness caused by the neurotoxin produced by Clostridium tetani. Generalised is more common or localised. Localised tetanus causes painful spasm of muscles adjacent to the wound site and may precede generalised tetanus. Cephalic tetanus is a rare form of localised tetanus which involves bulbar musculature, and the patient may present with dysphagia, trismus, retracted eyelids, deviated gaze and risus sardonicus.1 It may follow wounds or foreign body in the mouth, nose and face.2 Localised tetanus involving other group of muscles is even rarer, with only occasional case reports in the literature.3 In the present case, the site of entry was gluteal abscess which was followed by spasm of the right lower limb. Diagnosis is mainly clinical which may not be very difficult in generalised tetanus. But localised tetanus presents diagnostic dilemma and may be confused with joint disease, dystonia or even hysteria, as what happened in this child. A possibility of joint disease was considered in this child at the time of admission. The clinical course was similar to a case of localised tetanus reported previously.4 Investigations are not very helpful in making a diagnosis. Routine laboratory studies including cerebrospinal fluid examination are normal. Peripheral leucocytosis may be seen in the presence of secondary bacterial infection. No characteristic pattern is seen on electroencephalogram or electromyogram. Treatment is directed towards eradication of the organism by giving intravenous penicillin G, neutralisation of tetanus toxin by administration of tetanus-immune globulin and control of spasms by diazepam infusion.5 An episode of tetanus does not result in the production of toxin-neutralising antibodies; therefore, active immunisation with tetanus toxoid is mandatory before discharge. Prognosis is favourable in those with long incubation period, absence of fever and localised disease. In the present case, the child had a favourable outcome as she had a localised disease without fever. The case is being presented to highlight the importance of routine immunisation, failure of which can lead to the reappearance of a forgotten disease.