Tetanus and Occam’s Razor: Almost Forgotten but Not Gone: A Case Report

Abstract

Tetanus is a rare disease in industrialized countries, largely due to the highly protective effect of immunization. We present a case of tetanus in a formerly preterm infant with myelomeningocele repaired in utero, who presented at 44 days of age with poor feeding, lethargy, and increased tone. His symptoms progressed despite a course of antibiotics for presumed meningitis. At 73 days of age (on 29th day of hospitalization), a clinical diagnosis of tetanus was made based on the presence of risus sardonicus, trismus, and generalized hypertonicity. Consequently, tetanus immune globulin, muscle relaxants, and metronidazole were administered. Five months later, the infant has had complete resolution of the hypertonicity, has regained normal jaw movement and swallowing, and is regaining oral feeding skills. This case involved a delay in diagnosis despite clinical symptoms and signs classic, in retrospect, for tetanus, highlighting the importance of recognizing the constellation of symptoms that should lead us to consider this rare diagnosis.

Pediatric Tetanus in Central Pennsylvania

“…Tetanus should be considered as a cause of muscle spasm and dysphagia in patients who live in an underimmunized community. Delays in diagnosis can increase morbidity and associated costs [6]. In some cases, a missing patient history and the absence of typical examination findings can contribute to a delay in diagnosis.…”

Return of the old guard: a case of tetanus in an unvaccinated patient

“…The Incubation period of tetanus is typically 3–21 days but may be longer 8. The classic presentation of tetanus infectious consists of trismus (Lock Jaw) due to masseter spasm, which is the presenting complaint in 75% of cases 1.…”

Laporan Kasus: Tetanus Tipe General pada Usia Tua Tanpa Vaksinasi

“…3 Masa inkubasi dari tetanus umumnya sekitar 3 sampai 21 hari, namun dapat lebih. [13][14][15] Semakin pendek masa inkubasi pasien, semakin buruk prognosanya yang berhubungan dengan resiko kematian. 9 Pada kasus didapatkan adanya keluhan mulut terasa kaku sehingga sulit untuk dibuka disertai dengan nyeri dan kaku pada seluruh badan dengan disfagia sejak 1 hari SMRS.…”

“…Setelah berada di sistem saraf pusat, toksin akan berikatan dengan inhibitor GABA atau saraf glisinergik sehingga toksin tetanus dapat memotong VAMP dan menghambat pelepasan GABA dan glisin sehingga menyebabkan manifestasi patognomonik berupa kontraksi, rigiditas otot dan spasme dari otot yang hiperaktif dan nyeri. [3][4][5][6][7]9,10,14,12 Gejala yang kurang spesifik seperti irritable, susah menelan, kaku pada leher, rigiditas pada otot abdomen dan thoraks. 14 Toksin akan berikatan secara ireversibel sehingga setelah toksin berikatan, toksin tidak akan dapat dinetralisir oleh tetanus immunoglobulin (TIG).…”

“…[3][4][5][6][7]9,10,14,12 Gejala yang kurang spesifik seperti irritable, susah menelan, kaku pada leher, rigiditas pada otot abdomen dan thoraks. 14 Toksin akan berikatan secara ireversibel sehingga setelah toksin berikatan, toksin tidak akan dapat dinetralisir oleh tetanus immunoglobulin (TIG). 8 Ketika toksin sampai di sistem saraf pusat dan menimbulkan gangguan neurologi, diperlukan tatalaksana medik yang cepat dan tepat.…”