Page 32 - Delaware Medical Journal - May/June 2019
P. 32
A Case of Tetanus in an Unvaccinated Amish Patient
Megan Cohen, MD; Genna Jerrard, MD; Morganne Phillips, MD
Tetanus is a preventable disease
with a significant mortality rate. The incidence of tetanus in the United States has steadily declined since
the addition of tetanus toxoid to routine childhood immunizations. However, there are some populations, specifically the Amish, that are at higher risk due to lower immunization rates. The authors present a case of tetanus in an unvaccinated Amish male after a chainsaw injury.
INTRODUCTION
Tetanus is caused by the exotoxin-producing anaerobe Clostridium tetani and is primarily transmitted through contaminated wounds. Due to immunization, tetanus is rare
in the United States, with an average of
according to the Centers for Disease Control and Prevention (CDC). The most common type of tetanus is generalized tetanus,
which has a mortality rate of up to 20%.1 The following case details the course of an unimmunized Amish male who presented with classic tetanus symptoms after a chainsaw injury.
CASE PRESENTATION
A 69-year-old Amish male with no known medical history presented to the emergency department (ED) with a chief complaint of “lockjaw.” A week prior, he accidentally cut his left foot with a chainsaw. He had been treating the injury with topical honey and burdock leaves. On the evening of moving his jaw and swallowing both
liquids and solids. He also had one episode of non-bloody, nonbilious emesis en route
to the ED. The review of systems was otherwise negative. He does not take any daily medications and has no known medical diagnoses or past surgical history. He has never had any immunizations. Physical exam in the ED demonstrated normal vital signs, no stridor, and normal speech. He had full range of motion of his jaw. His left foot demonstrated a healing laceration to the dorsal aspect of his left great toe, wrapped
in leaves, with no purulent drainage or surrounding cellulitis.
Labs, including a BMP, CBC, and lactate were all within normal limits. The patient He was given empiric IV metronidazole and ceftriaxone, along with a Tdap vaccination. The patient was admitted for tetanus treatment and concern for possible osteomyelitis.
The patient continued to refuse imaging during his hospitalization. Infectious Disease was consulted and recommended tetanus immunoglobulin in addition to continuing with metronidazole and ceftriaxone. Despite these treatments, the patient’s respiratory
status and ability to swallow continued
to worsen. Podiatry was consulted and recommended surgical wound debridement for source control, but the patient refused. The patient continued to deteriorate and eventually the patient and his family decided for comfort measures only. He was transitioned to hospice care and discharged with home hospice care per the patient’s and family’s wishes.
DISCUSSION
Tetanus is a nervous system disorder caused by Clostridium tetani, a spore-forming, exotoxin-producing anaerobe found in soil, manure, and dust. Tetanus occurs when spores gain access to damaged human tissue, typically from a deep, penetrating wound. After inoculation and an incubation period of three to 21 days, the spores germinate
and produce tetanospasmin, also known
as tetanus toxin, which blocks the release
of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter that controls the activity of motor neurons. The resulting loss of inhibitory activity causes muscle spasms and autonomic hyperactivity. Once the toxin binds to a neuron, it cannot be neutralized
128
Del Med J | May/June 2019 | Vol. 91 | No. 3
Abstract
