Case report:
A 23-year-old man (wt= 70kg), construction worker from Afghanistan with no notable medical history, was admitted to the emergency department of Sina hospital, affiliated with Tehran University of Medical Sciences. The patient presented lockjaw leading to dysphagia and intermittent intense muscular spasm in the upper and lower limbs. 3 days before admission, a nail stuck into his right sole. The patient was not vaccinated against tetanus. On the admission day, he had stable hemodynamics (BP = 121/79 mmHg, HR = 90 beat/min, RR = 21 breath/min, SPO2=98 %, Temperature = 37.5 °C oral) and normal laboratory results (CBC, ESR, CRP, LFT, Cr, BUN, VBG, and serum electrolytes). He received 1 vial (250 IU) of tetanus immune globulin and the first dose of the Td vaccine intramuscularly before leaving the emergency department with personal consent. Three days later he was readmitted to the emergency department, and presented loss of consciousness (GCS= 10) and generalized severe spasm and rigidity in the lower and upper limbs. Other clinical manifestations included sustained spasms of the facial muscles (Risus sardonicus), severe contractions of masseter muscles (lockjaw), and sweating, and his hemodynamics were unstable (BP = 178/90 mmHg, HR = 180 beat/min, RR = 45 breath/min, SPO2=85 %, Temperature = 38.5 °C). According to the Ablett classification of tetanus severity (9), the patient’s condition was very severe. The patient was intubated in the emergency department and admitted to the ICU. His laboratory results upon admission to the ICU and discharge time are given in Table 1, indicating elevated levels of ESR, CRP, LDH, and CPK, and diminished serum calcium (Ca corrected= 7.6), as well as negative blood and urine culture.
Table 1
In addition to wound cleaning and debridement, the patient received the second dose of tetanus immune globulin (500 IU), diazepam (20 mg), and labetalol 10 mg/hr in the emergency department. The patient was isolated in a dark, quiet room in the ICU because any sensory stimuli—including light, touch, and loud noise—would trigger the spasms. Despite receiving intravenous midazolam 30 mg/hr, morphine 2-3 mg/hr, MgSO4 5 cc/hr, and intravenous metronidazole, the patient experienced severe, painful and refractory spasms permanently. Because of the insufficiency of these medications to manage the spasms, a neuromuscular blocking agent, atracurium 40 mg/hr, was administered as well. The spasm was refractory to all these medications, and we had to start propofol infusion 10cc/hr on the third day of ICU admission for 48 hours. This regimen was followed by intravenous phenobarbital 1 gr as loading dose and 100mg/8hr as maintenance dose. The tracheostomy was performed on the sixth day of ICU admission. The spasm gradually decreased after administering phenobarbital on day 10 of ICU admission; therefore, atracurium and midazolam were gently tapered down to discontinue the medication on day 12 and 25 of ICU admission, respectively. Finally, he was extubated from mechanical ventilation in day 30 of ICU admission. It is worth mentioning that the phenobarbital serum level was at the therapeutic range (between 25-30 mg/L, therapeutic level is 10-40 mg/L in our hospital laboratory) during the survey.
It should be noted that because of MgSO4 infusion and the patient’s low calcium level at baseline, we also administered calcium gluconate supplement intravenously to keep his corrected calcium level above 8.5 mg/dl. Meanwhile, he received pantoprazole and heparin for stress ulcer and DVT prophylaxis from the first day of ICU admission. On the other hand, the patient need high energy due to continuous muscle overactivity and spasms, but he could not tolerate enteral nutrition and had excessive residue volume, so total parenteral nutrition (TPN) started on day 4. The ESR, CRP, LDH, and CPK levels decreased gradually and normalized on day 28. Finally, on day 42 of hospitalization and after receiving the second dose of the Td vaccine, the patient was discharged with no symptom recurrence. A written informed consent was obtained from the patient in order to publish this case report, and it was approved by the Research Ethics Committee of Sina Hospital.