Page 25 - Delaware Medical Journal - April 2018

CASE REPORT
and CPR. Wound cultures suggested a polymicrobial infection and he remained on vancomycin, ceftriaxone, and metronidazole. He developed worsening muscle spasms
and autonomic instability requiring frequent doses of intravenous benzodiazepines (Figure 1). Due to lack of source control
he continued to have episodes of intense spasms that eventually led to respiratory arrest and brief asystole. He had a return
of spontaneous circulation but went into a narrow complex tachycardia shortly after.
It is interesting to note that supraventricular tachycardias are indeed the most common form of arrhythmias noted in Clostridium tetani infections. A trial of intravenous magnesium was suggested to improve spasticity, but the family was hesitant to continue further therapy. Due to ongoing decline in respiratory and cardiac status, the patient was transitioned to hospice care.
DISCUSSION
Treatment involves intravenous

along with tetanus immunoglobulin and vaccination. Because tetanus toxin binds irreversibly with tissue, immunoglobulin is important to bind any unbound toxin. Surgical intervention is essential for source control, because any surviving bacteria will continue producing the toxin. Intravenous magnesium has shown to reduce the requirement for benzodiazepines and neuromuscular blocking agents used to control spasms and tachycardia. Other options, including baclofen, labetalol, clonidine, and bupivacaine, have all been reported to alleviate autonomic instability. Morphine had also been studied for this use and interestingly, when the patient was initiated on intravenous morphine for comfort care, his rigidity and tachycardia improved noticeably. The case-fatality
FIGURE 1
Vital sign trend through hospital stay. Increase in autonomic activity noted between days 2-3. Abrupt cessation and improvement in heart rate and blood pressure coincide with intravenous morphine administration.
rate of tetanus is approximately 13% in the USA, with autonomic instability and respiratory compromise being the leading causes of death. Given the relatively high mortality rate, addressing these issues is an integral part of management.
CONTRIBUTING AUTHORS
■ FAZAL ALI, DO is an Internal Medicine Resident at Christiana Care Hospital finishing his final year of training, after which he will be pursuing a fellowship in Cardiology.
REFERENCES
■ SANJANA BHATIA-PATEL, DO Is a third year Internal Medicine Resident at Christiana Hospital in Newark, DE. She completed her medical training at Lake Erie College of Osteopathic Medicine in Erie, PA. She will continue her training as a cardiology fellow at Christiana Hospital.
■ KATHLEEN ELDRIDGE, MD is the Medical Director for Christiana Care Hospitalist Partners and serves as a faculty member of Christiana Care and the Sidney Kimmel Medical College.
1. Henriques Filho GT et al. Sympathetic overactivity and arrhythmias in tetanus: electrocardiographic analysis. Revista do Instituto de Medicina Tropical de Sao Paulo. 2007;49:1(17-22).
2. Thwaites CL, Farrar JJ. Preventing and treating tetanus. BMJ. 2003;326:117.
3. Santos Sde S et al. Lethality and osteomuscular and cardiovascular complications in tetanus.
Revista Brasileira de Terapia Intensiva. 2011;29(1).
4. Pascual FB, McGinley EL, Zanardi LR, Cortese MM, Murphy TV. Tetanus surveillance — United States, 1998--2000. Center for Disease Control (CDC), MMWR 2003;52(No. SS03);1-8.
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