Page 33 - Delaware Medical Journal - May/June 2019
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CASE REPORT
by antibodies or immunoglobulins.2
The clinical forms of tetanus include generalized, local, neonatal, and cephalic. Approximately 80% of tetanus cases
are the generalized form, which usually presents with trismus (lockjaw), as was the case with our patient. Other symptoms of tetanus include muscle spasms, rigidity, dysphagia, upper airway obstruction due to laryngospasm, and autonomic overactivity.2
The goals of treatment include source control to stop toxin production, neutralizing circulating toxin, and supportive care. In cases of severe tetanus, supportive care often includes sedation, paralysis, and mechanical ventilation in an intensive care unit. Human tetanus immunoglobulin should be administered both intramuscularly neutralize unbound toxin. Patients should also receive immunization with tetanus toxoid since recovery from tetanus disease does not confer immunity. Wound care, including debridement if indicated, is essential for source control. Metronidazole is the preferred antimicrobial treatment,
but penicillin G can also be used. Drugs used to control muscle spasms include benzodiazepines, neuromuscular blocking agents, and baclofen. Magnesium may be used to treat both spasms and autonomic overactivity. Other drugs used to control autonomic overactivity include labetalol, clonidine, and epidural bupivacaine.
Approximately 10-20% of patients with generalized tetanus will die despite intensive mortality rate, the overall incidence of tetanus is rare in resource-rich countries
like the United States due to childhood immunization. The CDC reports an average of these cases occurring in individuals who have never been vaccinated or have not had a booster in the preceding 10 years.4 Our patient was not vaccinated as the result of his Amish heritage and eventually refused
additional imaging or treatment aimed at source control once the infection had been diagnosed. These interventions had the potential to be lifesaving, but were refused based on cultural beliefs. Such case studies have been seen numerous times in the context of preventable diseases and beg analysis of patient demographics involved.
Delaware is home to a growing community of Old Order Amish and neighboring Pennsylvania is home to Amish and Mennonite communities with a combined population of greater than 90,000 people. to have lower immunization rates than
the rest of the population, making them susceptible to occasional outbreaks of vaccine-preventable diseases such as measles, varicella, pertussis, and tetanus. after an outbreak in an under-immunized Amish community in Ohio. This happened after measles was declared to have been eliminated from the United States in 2000, but was unknowingly reintroduced by two unvaccinated aid workers returning from the Philippines.5 Although tetanus does not carry the same high communicability as measles, it is still a deadly disease. It is also highly preventable. Several studies
at Hershey Medical Center, which serves a similar unimmunized population as Delaware, have shown that most, if not all, tetanus cases occurred in unvaccinated patients.5
The cost of treating vaccine preventable diseases is high for both hospitals and under- immunized communities, especially since many members of this community pay out of pocket.
There have been many successful examples of outreach and education programs at the population level to bridge the gap between the Amish and preventative health care. Following a case of obstetric tetanus in an unvaccinated woman after home delivery, an Advisory Committee on Immunization
Practices (ACIP) was created in Kentucky
as part of a 2016 community outreach campaign to identify risk factors and provide recommendations.6 It is well known that and while there is great potential for health nonimmunized populations, it is crucial to maintain trust between communities. Only with culturally sensitive education can we hope to improve health-related behaviors and outcomes among these populations.
CONTRIBUTING AUTHOR
■ MEGAN COHEN, MD is a third-year emergency medicine resident at Christiana Care Health System.
■ GENNA JERRARD, MD is a third-year emergency medicine resident at Christiana Care Health System.
■ MORGANNEPHILLIPS,MDisemergency medicine faculty at Christiana Care Health System as part of the Doctors for Emergency Services physician group.
REFERENCES
1. Centers for Disease Control and Prevention. (2017). Tetanus. Retrieved from www.cdc.gov/ tetanus/index.html
2. Sexton, D. (2018). Tetanus. In J. G. Bartlett and A. Bloom (Ed.), UpToDate. Retrieved June 1, 2018, from www.uptodate.com/contents/ tetanus
3. Edlich, R. F. (2003). Management and prevention of tetanus. Journal of Long-Term Effects of Medical Implants, 13(3), 139-54.
4. Williamson, Gregory (2016). Description
of Children Hospitalized with Vaccine Preventable Diseases in Central Pennsylvania. Open Forum Infectious Diseases 3(1) 767.
5. Ahmed, Bilaal M.P.H. et al. (2017). Mapping Pediatric Tetanus Cases in Central Pennsylvania and Analyzing Hospital Costs Associated with Treatment. Open Forum Infect Dis. Retrieved from www.ncbi.nlm.nih.gov/ pmc/articles/PMC5632055/
6. Yaffee, Anna Q. et al. Notes from the Field: Obstetric Tetanus in an Unvaccinated Woman After a Home Birth Delivery - Kentucky, 2016. CDC Morbidity and Mortality Weekly Report 66(11); 307-308.
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