Case Series and Case Reports Recurrent generalized tetanus: a case report M A Alhaji MBBS FWACP M G Mustapha MBBS FWACP G M Ashir MBBS FWACP R T Akuhwa MBBS FWACP M A Bello MBBS FMCP A G Farouk MBBS Department of Paediatrics, University of Maiduguri Teaching Hospital, PMB 1414, Maiduguri, Borno State, Nigeria Correspondence to: Dr M A Alhaji, Department of Paediatrics, University of Maiduguri Teaching Hospital, PMB 1414, Maiduguri, Borno State, Nigeria Email: m_alhaji@hotmail.com TROPICAL DOCTOR 2011; 41: 127–128 DOI: 10.1258/td.2010.100338 SUMMARY We describe recurrent generalized tetanus in a four-year-old unimmunized boy following recurrent suppurative otitis media (SOM) within an 11-month period. There are not many published reports on recurrent tetanus.We highlight the importance of both primary immunizations and the need for active immunization before discharge as the infection does not confer a lifelong immunity.The usefulness of booster doses of tetanus toxoid and missed opportunities for immunization are emphasized. Introduction Tetanus is an important disease, particularly in the develop- ing countries where it causes high morbidity and mortality despite the availability of an effective vaccine. 1,2 Tetanus is caused by the systemic effect of an exotoxin of Clostridium tetani and is characterized by rigidity and spasms, sometimes with autonomic dysfunctions. There are four clinical types of tetanus. The generalized form is the most common type of tetanus; other types include local, cephalic and neonatal tetanus. Diagnosis is usually clinical. The principle of the management of tetanus generally includes: eradicating the organism by wound debridement and effective antibiotics; neutralizing unbound toxin with anti-tetanus serum (ATS); sedation; control of spasms with combination drug therapy such as diazepam, phenobarbitone and chlorpromazine; and skilled nursing care. Residual muscle rigidity is managed with physiotherapy. Tetanus toxoid (TT) is given either at discharge after the successful management of tetanus, as the infection does not confer lifelong immunity, or on admission in order to avoid missing the opportunity for immunization. This case report underlines the importance of primary immu- nization for tetanus, booster doses of TT as well as missed opportunities for immunization in developing countries. Case history A four-year-old boy was brought to the emergency paediatric unit (EPU) of the University of Maiduguri Teaching Hospital (UMTH) with a one-week history of purulent discharge from the left ear, an inability to open his mouth and generalized body stiffness and painful spasms of five and four days, respectively, prior to presentation. There was also a three-day history of fever and cough. He had been admitted to the same unit for post-neonatal tetanus 11 months earlier with similar stiffness and painful spasms following left suppurative otitis media (SOM). He had not received primary immunization for tetanus. He was managed with ATS, diazepam, phenobarbi- tone and antibiotics. The otorrhoea ceased, clinical improve- ment was steadily sustained and he was discharged home after three weeks. However, active immunization with TT was inadvertently missed before discharge. He was seen on follow-up visits and had recovered and remained well until 31 July 2010, when he presented with the above symptoms and signs. Examination revealed a conscious but apprehensive child, afebrile, not dehydrated, with trismus and in an opisthotonic posture with provocative spasms. Ear, nose and throat examination showed purulent otorrhoea with per- foration of the left tympanic membrane. Other systemic examinations were unremarkable except that he was dys- pnoeic and tachypnoiec with widespread coarse crepitations on auscultation. An assessment of recurrent generalized tetanus following recurrent SOM with bronchopneumonia was made. An ear swab culture yielded profuse growth of Staphylococcus aureus. Both haematological and electrolytes profiles were within normal limits. He was initially started on combination drug therapy with intravenous diazepam 2 mg/kg/dose, intramuscular pheno- barbitone 3 mg/kg/dose and intravenous chlorpromazine 2 mg/kg/dose 6-hourly in order to achieve sedation and control of the spasms. Subsequently, the parenteral drugs were changed to oral after inserting a nasogastric tube for feeding and medication. Other medications given included: intramuscular procaine penicillin 25-iu/kg/day for 10 days; intravenous cefuroxime 100 mg/kg/day in three divided doses for five days; ATS 5000 IU each by intramuscular and intravenous after a negative test dose; and TT 0.5mL intramuscular at different sites. The ear was kept dry with regular aural toileting. He was nursed in a quiet side room of the unit in order to avoid any unnecessary stimuli. There was considerable control of spasms until on the 11th day of admission he died following aspiration of feeds. All resuscitative efforts were abortive. 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