An Unexpected Case of Generalized Tetanus

Tetanus is a disease of the nervous system caused by a toxin produced by Clostridium tetani, an anaerobe found in high concentrations in the soil. The occurrence of tetanus is related to contaminated traumatic wounds, and most patients have had some failure in their immunization. However, there are rare case reports of generalized tetanus in patients with proper vaccination schemes who failed to receive appropriate prophylaxis after high-risk exposure. A 79-year-old woman presented to the emergency room (ER) with a large wound on her leg caused by an iron pipe during agricultural work. Tetanus immunization status was confirmed (the last booster received seven years prior to the injury), the wound was debrided and sutured, and she was discharged. Four days later, she returned to the ER due to high fever, neck pain, and inability to completely open her mouth. Hypertension, cervical stiffness, and sardonic smile were observed and soon evolved into severe dysautonomia, which required prolonged sedation and analgesia. Since there was a strong suspicion of tetanus, tetanus immunoglobulin (TIG) and tetanus vaccine (TTV) were administered, new surgical wound debridement was performed, and intravenous antibiotic therapy with metronidazole and ceftriaxone was initiated. She would later be discharged to a continued care facility where, despite a slow recovery, she progressed favorably. Tetanus is a disease that can present with different clinical forms and severity, but it is relatively easy to prevent when appropriate pre- and/or post-exposure prophylaxis is carried out. It is of utmost importance that physicians remain up to date in the latest scientific knowledge and guidelines surrounding tetanus, so as to avoid lapses in the administration of TTV when indicated. Such was the case with our patient: given that her last tetanus TTV booster was administered more than five years prior to the high-risk injury she sustained, prophylaxis with TTV should have been promptly administered during the initial ER episode. The rarity of tetanus in developed countries should not overshadow the gravity of the disease and the potential for severe outcomes if left untreated.