A lethal case of generalized tetanus.

sented to an emergency department in Hamilton, Ontario, on Sept. 28 with a two-day history of dysphagia. On Sept. 3, the patient had undergone a dental procedure to remove a plate from her mouth. She had been well until Sept. 17, when she had fallen on her driveway and suffered an abrasion to her right forearm, which had been managed at home by her daughter with local wound care. She had then presented to the emergency department on Sept. 19 with pain and swelling in her right arm. A diagnosis of a possible scaphoid fracture had been made and her wrist splinted. She had also been given an injection of tetanus toxoid, 0.5 mL intramuscularly, because she had received her last tetanus booster more than 10 years previously. On Sept. 24, she had returned to the dentist to have a cavity filled. She subsequently presented to the emergency department on Sept. 28 with a two-day history of dysphagia, drooling, difficulty opening her mouth, and face and neck pain. Her medical history included a right middle cerebral artery territory stroke six years earlier with residual left-sided weakness, type 2 diabetes mellitus, hypertension, dyslipidemia, osteoporosis, cat a racts, glaucoma and amputation of the right first toe for diabetic foot infection. She lived independently and had no recent history of travel. On physical examination, she had a temperature of 37.8°C and was hemodynamically stable. She had a markedly abnormal posture with arched back and hyperextended neck, consistent with opisthotonos, as well as trismus and neck stiffness. The remainder of her neurologic examination showed deficits related to her previous stroke. Cardiovascular, respiratory and abdomin al examinations were noncontributory. The right wrist was splinted; there was no abrasion visible on her right forearm and no other areas of skin breakdown. Results of blood tests showed a leukocyte count of 21.9 (normal 4.0–11.0) × 10/L with 20.4 (normal 2.0–7.5) × 10/L neutrophils. The patient’s blood glucose level was 6.4 mmol/L. A lumbar puncture was performed, and the cerebrospinal fluid showed a leukocyte count of 3 (normal 0–5) × 10/L, a protein concentration of 0.36 (normal < 0.45) g/L and a glucose concentration of 8.6 (normal 2.2–3.9) mmol/L. Computed tomography of the head and neck did not show a retropharyngeal abscess or an intracranial space-occupying lesion. A clinical diagnosis of generalized tetanus was made. Metronidazole was started at a dose of 500 mg intravenously every eight hours and continued for seven days. The patient received 6000 U of tetanus immune globulin (TIG) intramuscularly, although not at the site of the earlier abrasion because it was no longer visible. She was admitted to the intensive care unit, where she required intubation and mechanical ventilation. Midazolam and morphine infusions were started for treatment of severe muscle spasms. She had frequent fluctuations in her blood pressure related to autonomic instability and required tracheotomy on Oct. 13. Intractable spasms continued and an infusion of the neuromuscular blocker cisatracurium was started on Oct. 28. On Nov. 28, she received a second dose of tetanus toxoid, and on Dec. 1, she began a five-day trial of magnesium sulfate infusion, with no substantial change in her clinical status. She also re ceived treatment for multiple nosocomial complications throughout her stay in the intensive care unit, including two episodes of central line– associated bloodstream infection and an upper extremity deep vein thrombosis. On Dec. 8, after discussion with the patient’s family, active life Cases