An indication for human tetanus immunoglobulin in unimmunized patients.

Sir, I thought your readers may be interested in the management of a recent case of tetanus which occurred at this hospital. A 63-year-old lady presented to the Accident and Emergency Department soon after laceration to her right leg, caused by a sheet of glass taken from a dismantled greenhouse in her garden. A 'V'-shaped flap, 4 cm each limb, an apparently clean and subcutaneous wound, was situated over the right mid-calf area. She had no previous history of tetanus immunization. The clean and superficial nature of the wound led to subjective classification as non-tetanus prone. The wound was fresh with no devitalization and on exploration under local anaesthetic little debridement was necessary. She was given a course of tetanus toxoid but not immunoglobulin. Seven days later she developed tetanus. Ventilation was required for 3 weeks in the Intensive Care Unit before she recovered. Lessons to be learned: * The facts that she was unimmunized and the wound occurred in a garden which had been regularly fertilized by manure put her at great risk of contracting tetanus, regardless of the severity of the wound and degree of devitalization (Atrakchi & Wilson, 1977; Christie, 1980; Department of Health and Social Security, 1984). Therefore, the history alone was an absolute indication for human tetanus immunoglobulin. * Toxoid given to non-immunized people at the time of wounding confers no protection against tetanus infection until some time following the second dose (6 weeks later) (Christie, 1980; Ruben & Fireman, 1983).