Cephalic Tetanus In An ‘Immunized’ Patient
A case of cephalic tetanus that occurred in a fully immunized patient is described. An 18-year-old man presented with bilateral facial spasms, without trismus or more generalized involvement, followed by facial weakness. The difficulties in clinical diagnosis and the contribution of electrophysiological studies to the management of such patients are highlighted. The variable level of protection that is conferred by immunization is discussed.
Med J Aust. 1986 Aug 4-18;145(3-4):156-7.
Case report of tetanus in an immunized, healthy adult
We report the case of a 58-year-old man born in the United States with a history of complete childhood immunizations who presented to the Emergency Department with trismus. Past medical history was significant only for Elephantiasis. After an exhaustive workup the patient was found to have Tetanus, with no identifiable portal of entry. The patient was successfully treated for Tetanus with complete recovery. Tetanus is caused by the organism Clostridium Tetani, which usually requires an open lesion to cause infection. Our patient was unique in that he was previously immunized with no obvious lesion. Tetanus should be suspected and treated empirically in any patient presenting with typical signs and symptoms even without an apparent entry site.
Nottingham Girl Gets Tetanus Despite Being Vaccinated
Tyla Green of Clifton, Nottingham, had been immunised but doctors believe that she got tetanus when she cut her foot five weeks ago.
After four weeks in the Queen’s Medical Centre, Nottingham, she has returned home and is expected to make a full recovery in six months. Her mother Halima, 34, who has three other daughters aged from 9 to 13, said yesterday: “We are overjoyed to have Tyla home. We have gone to hell and back, but even though she still can’t speak she can laugh and that means the world to us.”
Mrs Green said that Tyla had been sent home from school ill and two days later was found disorientated at home. “When I picked her up she went rigid and started having a sort of a fit.”
Her husband Shane, 39, called an ambulance and Tyla was taken to hospital. Mrs Green said that doctors suspected that Tyla had meningitis, then another brain virus, until she developed a locked jaw, a classic sign of tetanus. “A doctor asked if she had cut herself. At that time, I didn’t think she had, but I learnt later that she had trodden on something which really hurt her foot about a week before she became ill.
“Because it wasn’t pouring blood or needed stitches I dismissed it. Tyla was always running around with nothing on her feet. I would advise all parents to make sure their children have something on their feet whenever they are outside.”
Tetanus is caused by bacteria that attack the central nervous system. It is extremely rare. There were only three cases, all in adults, in England and Wales last year.
Tyla is the first child under 15 to contract the disease since 1989 and hers is thought to be the first child case in Nottingham for more than 20 years.
Her consultant paediatrician, Martin Hewitt, said: “You can easily die from tetanus but this young lady has made a remarkable recovery. She was desperately ill but I expect her to make a full recovery.”
He said it was rare for someone who had been immunised to get the disease but it was possible. “It depends on whether the level of antibodies you have are sufficient to fight the infection,” he said.
Tyla would probably need speech therapy, physiotherapy and occupational therapy in the coming months before making a complete recovery, Mr Hewitt said.
Dr Richard Sack, consultant for communicable diseases at Nottingham Health Authority, said that the chance of anyone developing tetanus from a wound after being vaccinated was extremely low.
The Times 14th August 2000.
Fatal Tetanus in a Vaccinated Drug Abuser with High ‘Protective’ Antibodies
Tetanus is a rare disease in the United States. From 1995-1997, the average annual incidence of tetanus was 0.15/1,000,000 population. Injecting-drug users, particularly those who use heroin, are among the highest risk population for acquiring tetanus. We present a case of an injecting-drug user who was seen in the emergency department with worsening diffuse midthoracic back pain and spasms. He subsequently developed acute respiratory failure and central nervous system hypoxic injury. Serum obtained before administration of tetanus immune globulin showed a tetanus antibody titer greater than 16 times the level considered protective. Because of limited human data on the minimum protective level of neutralizing antibody, as well as reports of tetanus among individuals with “protective” antibody titers, the diagnosis of tetanus should not be excluded solely on the basis of antitetanus titers.
Source: J Emerg Med. 2000 Feb;18(2):189-93.
Elevated Tetanus Antibodies in Vaccinated Man with Generalised Tetanus
This report describes severe, generalized tetanus in a 29-year-old man who had received a primary series as a child and two booster injections. Serum obtained before administration of tetanus immune globulin showed antibody titers to tetanus greater than 100 times the level considered protective. Aggressive supportive care can usually prevent serious consequences. Since most physicians have never seen a case of tetanus, however, the diagnosis can be difficult. Many disorders that exhibit signs and symptoms similar to tetanus must be carefully considered during the evaluation of these patients. Tetanus is a preventable disease. Prevention, however, requires both appropriate immunizations and prompt wound care. While controversy exists regarding the most effective policy to adequately immunize all individuals, this case shows that vaccination alone does not preclude the possibility of tetanus.
Source: J Fam Pract. 1997 Mar;44(3):299-303.
Severe Tetanus in Spite of Tetanus Toxoid
A 66-year-old man sustained an injury to his right foot while gardening. Despite receiving tetanus toxoid one hour later and adequate wound toilet, he developed severe tetanus complicated with autonomic dysfunction six days later. He died 20 days after admission. This case shows that tetanus toxoid alone may not be sufficient to prevent tetanus in wounded patients. Careful consideration must be given to the immune status of the patient and to the nature of the wound sustained.
Source: Med J Malaysia. 1994 Mar;49(1):105-7.
Immunization Does Not Rule out Tetanus
Shimoni et al illustrate a needed caution to clinicians: do not exclude a diagnosis of tetanus in a patient who has been fully immunised.1 Their report adds to the list of rare cases of tetanus that have occurred despite complete immunisation. Although the authors state that all reported cases of tetanus in the United States have occurred in people who have not been immunised, this is not altogether true. A catalogue of the 740 tetanus cases reported by the Centers for Disease Control since 1982 discloses that of the minority whose immunisation status was known, 53 cases had completed a primary series, 22 had received their latest booster between five and nine years before, and two had received a booster within five years.
Source: BMJ. 2000 Feb 5;320(7231):383.
Tetanus in an Immunised Patient
Lesson of the week: Do not rule out a diagnosis of tetanus in a patient who has been immunised fully.
We report a case of severe generalised tetanus in a patient who had been immunised fully.
A previously healthy 34 year old construction worker was admitted to hospital after experiencing what was described as an epileptic fit. Before the fit, the man had had flu-like symptoms for three days. He denied that he had sustained any trauma before the episode, and he had no history of recurrent infections.
BMJ 1999;319:1049-1049 ( 16 October )
16 People Who Had Received 3 Or More Tetanus Vaccines, Still Got Tetanus
Sixteen (13%) of the 122 non-neonatal patients with supplemental data were reported to have received at least a primary series (i.e., three or more doses) of TT before onset of illness (Table_1), including two (40%) of the five non-neonatal patients aged less than 20 years. Three (60%) of the non-neonatal patients aged less than 20 years were unvaccinated because of their parents’ religious objections. The fourth case occurred in a boy aged 14 years who was bitten by a dog and who had received his last dose 2 years previously. This patient did not seek medical care for his injury and was later hospitalized with tetanus for 2 days. He did not require mechanical ventilation and subsequently recovered. The fifth case occurred in a boy aged 15 years who was in a moped crash; the interval since his last dose was 11 years. The patient sought medical attention and received TT within 6 hours of his injury; he was hospitalized 4 days and recovered without sequelae.
Source: MMWR, July 03, 1998 / 47(SS-2);1-13,
Tetanus Surveillance — United States, 1995-1997