Question

1. (3 points) A 58-year old lawyer presents in the emergency room with headache, irritability, generalized muscle pain and uncontrollable back spasms. He has become very restless and worried because he has had the back spasms all through his court case that afternoon and they became extremely painful. In his history, the lawyer states that he has a very busy practice. He is on medication for high blood pressure (beta blocker) and has mild asthma. He injured himself about 10 days earlier, puncturing his left arm with a nail from an old barn he is in the process of tearing down. The wound has produced moderate quantities of pus, but he has been keeping it clean. When asked, he did not remember having a tetanus shot since he was a kid. The wound was sampled for microscopic examination and culture. The patient’s back appears to have very tight contractions and spasms. He is in obvious agonizing pain. Subsequent microscopic examination has shown a Gram-positive endospore-forming bacillus. The culture would not grow aerobically, but upon culture in a Gaspak anaerobic system bacterial colonies developed.

• What is your diagnosis here?

• What is the proper treatment of this problem?

• How could this have been prevented?

Answer 1

History:

1. Headache, irritability , generalized muscle pain and uncontrollable back spasms

2. Nail injury from old barn.

Inspection:

Patient's back appears to have very tight contractions and spasms

Microscopic examination and culture :

1. Gram positive endospore forming bacillus.

2. Anaerobic.

Based upon the above points my diagnosis is the patient is suffering from tetanus caused by Clostridium tetani.

Tetanus : An acute disease manifested by skeletal muscle spasm and autonomic nervous system disturbance.

Proper treatment:

Passive immunization:

It is the treatment of choice for tetanus. Two preparations are available. They are :

1. HTIG ( Human tetanus immunoglobulin)

2. ATS ( Antitetanus serum , equine derived)

Combined immunization:

In non vaccinated person, it is ideal to immunize with first dose of tetanus toxoid vaccine in one arm along with administration of ATS or HTIG in another arm, followed by a complete course of scheduled vaccine.

Antibiotics:

Antibiotics play only a minor role as they cannot neutralize the toxins which are already released. However, they are useful :

1. In early infection, before expression of the toxin (<6hrs)

2. To prevent further release of toxin.

Prevention:

If he had taken tetanus shot and completed the vaccination schedule, this wouldn't occur.

Active immunization is the effective method of prohylaxis. Tetanus toxoid is commonly used for active immunization.

Prevention of tetanus after injury:

All types of wounds need surgical toilet followed by immunization which depends on the wound type.