Localized Tetanus in an Adult Patient: Case Report

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What to Learn from this Article?

This case report signifies the existence of a rare form of an infectious disease, i.e.,, localized tetanus and emphasizes the importance of early recognition and prompt management to prevent life-threatening complications.


Case Report | Volume 6 | Issue 4 | JOCR September-October 2016 | Page 100-102 | Mohamed Amirali Gulamhussein, Yueyang Li, Abhijit Guha. DOI: 10.13107/jocr.2250-0685.592


Authors: Mohamed Amirali Gulamhussein[1], Yueyang Li[2], Abhijit Guha[1]

[1]Department of Orthopaedics, Worcestershire Acute NHS Trust UK, B98 7UB, Redditch, UK, 2Department of Orthopaedics, Mid Essex Hospitals
NHS Trust UK, Broomfield, Chelmsford, CM1 7ET, UK.

Address of Correspondence
Dr. Mohamed Amirali Gulamhussein,
Worcestershire Acute NHS Trust UK, B98 7UB, Redditch, UK.
E‑mail: m.amiraligh@gmail.com


Abstract

Introduction: Tetanus is a severe and potentially fatal infection caused by the bacterium Clostridium tetani. Of all the cases described in literature, generalized tetanus is by far the most common presentation, but it may also present as neonatal tetanus, cephalic tetanus, and localized tetanus, the latter two being much rarer. In this case report, we present the rare form of this disease, i.e., localized tetanus in an adult male with a history of minimal trauma as well as a late, unusual mode of presentation.
Case Report: A 35-year-old Caucasian male presented with an acutely painful, swollen right thumb associated with a smallsuperficial collection on the dorsal aspect of the base of the thumb. A formal wound exploration and washout were carried out in theater, however, at the time of tourniquet inflation, the right hand went into a carpopedal spasm and remained in that position until an infusion of a muscle relaxant was given. The findings were consistent with a case of localized tetanus. The patient was treated with human immunoglobulin and tetanus toxoid and safely discharged home 48 h later without any complications.
Conclusion: This case report emphasizes the importance of the recognition of a rare form of this fatal infectious disease, which may present with prodromal symptoms before the generalized form shows its clinical effects. Moreover, the astute clinician should be aware of the variable presentations of this infectious disease, with early identification greatly reducing the associated risks of morbidity and mortality.
Keywords: Localized tetanus, carpopedal spasm, wound exploration.


Introduction
Tetanus is a serious and a life threatening infectious disease with a grave outcome if not detected and treated at an early stage. An infection found more frequently in Tropical climates, it accounted for 58,900 deaths worldwide in 2013 [1]. In the UK however tetanus is rare, with only 6 reported cases in England and Wales in 2013 [2].
Majority of the cases described in clinical practice involve the classical generalized form of the disease with disabling and fatal sequel, mandating ventilator support. However, the atypical forms of this entity i.e. neonatal, cephalic and even rarer subtype; localized tetanus is seldom reported. The unfamiliarity surrounding this subtype of tetanus further strengthens the necessity of reporting this case which highlights the unusual manner of clinical presentation as in our case which would have otherwise gone unnoticed, had the patient not have had the wound explored following the admission.

Case presentation
A 35-year-old right handed male presented to the emergency department at our hospital with a twenty-four history of a painful swollen right thumb with surrounding cellulitis. The patient worked at a metal fabrication factory, dealing with cutting and welding of various metals from international suppliers. Other than a lumbar decompression a few years ago, he had no previous medical history of note. As a child, the patient had received a full immunization program, but had no further boosters. There was no history of acute trauma and he was systemically well. He was sent home with oral flucloxacillin and advised to return if symptoms worsened.
A few hours later he developed a high temperature with chills and returned to the emergency department where he was referred to the on-call orthopaedic team. On further questioning, the episode had started with pain and swelling in the distal phalanx of the thumb the previous day. Whilst at dinner, he experienced an episode lasting 30-60 seconds, when his thumb had become rigid and he was unable to use cutlery, but this resolved spontaneously.
On examination, his right thumb and thenar eminence were grossly swollen, erythematous and exquisitely tender to palpation. He held the thumb in flexion, with the interphalangeal and metacarpophalangeal joint movements very limited and painful. There was a small superficial collection dorsally on the radial aspect of the proximal phalanx base. Ascending lymphangitis was present extending into the axilla but without palpable lymph nodes. Also noted was a small, nearly completely healed puncture wound at the fingertip. He recalled that 2 weeks ago he had been injured with a metal splinter that he was able to extract it using a needle, however the wound became infected. It discharged pus for a few days, and then seemingly resolved of its own accord so he did not seek help.
The patient was then admitted for intravenous antibiotics and strict elevation. Blood tests showed mild neutrophilia (8.8) and elevated CRP (114). Calcium, magnesium, liver function and thyroid function tests were all within range. All investigations carried out on admission are summarized in [Table 1].
The patient was taken to theatre the next morning for a formal wound exploration and washout. At the time of tourniquet inflation, his right hand went into a carpopedal spasm, with full flexion of the metacarpophalangeal joints and wrist joint of the right hand with extension of the interpahalangeal joints. His hand would remain in this position until an infusion of a muscle relaxant was given to allow surgery to proceed. At surgery, there was only a superficial collection with no tendon sheath involvement.
The unusual intra-operative events were discussed with a consultant Microbiologist, who agreed that the signs would be consistent with a case of localised tetanus. Metronidazole was added to the antibiotic regimen, and a single infusion of human immunoglobulin (10,000 units) was given, as no tetanus immunoglobulin was available within the trust.
A single dose of tetanus toxoid was also given as a booster and the patient was then sent home after forty-eight hours of monitoring. Wound swab taken intra-operatively did not grow any organisms.

Discussion
Clostridium tetani is an anaerobic bacterium found commonly in soil in spore form or in the gastrointestinal tracts of mammals and produces a potent neurotoxin, tetanospasmin. Incubation period ranges from 3-21 days, with most average incubation period being 10 days. Tetanospasmin causes violent spastic paralysis by blocking the release of γ-aminobutyric acid (GABA), an inhibitory neurotransmitter acting on motor neurones.
Generalized tetanus is far more common than the localized form, which involves painful spams of the muscle adjacent to the wound site, and this eventually leads to the former variety. Cephalic tetanus is a rarer subtype of localized tetanus, which presents as dysphagia, trismus, retracted eyelids, deviated gaze and risus sardonicus; all primarily involving bulbar musculature [3]. Localized tetanus involving other groups of muscles is even rarer with limited evidence of similar cases in published literature, often masquerading as alternative pathologies [4].
In 2001, a retrospective analysis by Kakou et al examined similar cases over 22 years 38 % of the cases contracted the infection via limb wounds and only 2 % cases through abdominal wounds. Furthermore, 37 patients (82 %) were cured with 5 cases (11 %) having sequelae and a total of 7 deaths were observed (16 %). All patients included in this series lacked adequate immunoprophylaxis and the major risk factor was secondary generalization of tetanus [5].
There is no doubt that national immunization programmes have indeed abolished almost all cases of tetanus in developed countries. However, there are still a small number of cases, which present with ambiguous or non-specific symptoms such as dysphagia, neck stiffness and other oropharyngeal symptoms portraying a prodromal state of the illness, which could eventually lead to full blown generalized tetanus. Once developed or allowed to progress, it ultimately leads to respiratory or autonomic dysfunction necessitating long-term intensive care or even death in more severe
Cases [6].
Another diagnostic challenge lies in the distinction between localized and other forms of this disease. The former involves muscle spasms limited to specific body areas with generally good outcomes, but rare cases go on to involving vital structures such as the cranial nerves leading to cephalic tetanus and increasing the risk of developing generalized tetanus with high mortality rates [7].
Moreover there have been reports of similar cases in the past whereby partially or completely immunized individuals have been misdiagnosed as suffering from illnesses other than tetanus and physicians have taken their immunization status for granted [8]. This highlights an important aspect of diagnosing this rare infection, considering some cases may even present without an acute wound as evident in our case and in another case series [9].
Treatment of tetanus involves wound debridement, antibiotics to decrease bacterial load and supportive care. Some studies have shown metronidazole to be more effacious when compared to penicillin, as penicillin is thought to enhance inhibitory effects on neuromuscular junctions aggravating the disease further [10].
The second step and the most vital aspect in managing this disease is the administration of tetanus immunoglobulin, which greatly reduces the mortality from generalized tetanus. It is generally recommended that the tetanus accelerated immunization course should include immunization when the patient presents or is at high risk, at discharge and four weeks later to confer concrete immunity and greatly reduce further risks.

Conclusion
Localized tetanus is indeed a rare form of tetanus, which may present with variable symptoms before a full blown generalized state occurs. The inconstant presentation of this infectious disease still exists in the developed world and can equally occur in previously immunized individuals. Early diagnosis and management greatly reduces the risk of respiratory arrest and ultimately death. Furthermore, this case report also signifies the fact that all open wounds including minor puncture wounds should be routinely screened for tetanus and early prophylaxis should be given if required. Lastly, whilst taking a history, particular attention needs to be paid to points such as handling of goods from international suppliers as they could be a potential source of many infectious organisms.

Clinical message
This case demonstrates the importance of keeping an open mind when treating patients in our increasingly globalized world. Taking a thorough history including occupation, recent travel and contact with non-indigenous people or materials will yield valuable clues when making a diagnosis, where signs or symptoms are unexpected.
It would also be prudent to consider educating people who work with many international suppliers about the dangers of imported pathogens and the importance of keeping up to date with vaccinations.

References
1. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Jan 10; 385(9963): 117-171
2. PHE (2014) Tetanus (England and Wales): 2013. HPR 8(12): immunization.
3. Gupta V, Dewangan S, Bhatia B. Localised tetanus; a rare form of a ‘forgotten’ disease. J Paediatr Child Health 2011 March; 47(3): 152
4. Dutta TK, Padmanabhan S, Hamide A, Ramesh J. Tetanus mimicking incomplete transverse myelitis. Lancet 1994; 343: 983-4
5. Kakou AR, Eholie S, Ehui E, Ble O. Localized tetanus in Abidjan: clinical and prognostic features (1976 – 1997). Bull Soc Pathol Exot 2001 Nov; 94(4): 308-11
6. Jong P, Heer-Groen T, Schroder C. Generalised Tetanus in a 4 year old boy presenting with dysphagia and trismus: a case report. Cases J 2009 April; 29(2): 7003
7. Cook TM, Protheroe RT, Handel JM. Tetanus: a review of the literature. Br J Anaesth 2001, 87:477-487.
8. Fiorillo L, Robinson JL. Localised Tetanus in a child. Ann Emerg Med 1999 April; 33(4): 460-3
9. Zurieta HS, Sutter RW, Strekel DM, et al: Tetanus surveillance-United States, 1991-1994. MMWR Morb Mortal Wkly Rep 1997;(SS-2) 46:15-25
10. Ahmadsyah I, Salim A: Treatment of tetanus: An open study to compare the efficacy of procaine penicillin and metronidazole. BMJ 1985; 291:648-651


How to Cite This Article: Gulamhussein MA, Li Y, Guha A. Localized Tetanus in an Adult Patient: Case Report. Journal of Orthopaedic Case Reports 2016 Sep-Oct;6(4): 100- 102. Available from: http://test.jocr.co.in/2016/10/10/2250-0685-592-fulltext/ 


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