Generalized tetanus: a pediatric case report and literature review

Deniz, Melis; Erat, Tugba

doi:10.1590/S1678-9946202365040

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REVIEW • Rev. Inst. Med. trop. S. Paulo 65 • 2023 • https://doi.org/10.1590/S1678-9946202365040 copy

Generalized tetanus: a pediatric case report and literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Pediatric tetanus is a rare and forgotten disease in countries with high childhood tetanus toxoid vaccination rates. Therefore, the clinical manifestations, treatment and management of this potentially life-threatening disease are not well known. With a literature review and discussion of tetanus management in pediatric patients, we describe a clinical course of a rare and fatal but vaccine-preventable disease, the generalized tetanus, in an adolescent who was successfully treated.

Tetanus; Children; Vaccine

Articles	Number of patients	Age	Inoculation site	Presenting symptoms	Vaccination history	Treatment	Outcome
Bagcı⁶6. Bağcı Z. Cephalic tetanus: a rare case report. J Trop Pediatr. 2020;66:549-52.	1 patient	16 months	Mucosal erosion in right cheek	Rigidity of jaw, face and neck, salivation	Unvaccinated	HTIG, penicillin, metronidazole, midazolam, tetanus toxoid vaccine	Survived
Ahmed et al.⁷7. Ahmed BS, Beck MJ, Williamson G, Ericson JE, Kumar P. Pediatric tetanus in Central Pennsylvania. J Pediatric Infect Dis Soc. 2019;8:358-60.	5 patients	3 years	Foot laceration	Fever, abdominal distention, and back pain	Unvaccinated	Exploratory laparotomy, HTIG tetanus toxoid vaccine metronidazole.	Survived
		7 years	Hand laceration	Trismus, jaw pain, and neck, back, and leg stiffness	Unvaccinated	HTIG, tetanus toxoid vaccine, penicillin	Survived
		11 years	Knee laceration	Trismus, pain, and discharge from wound	Unvaccinated	HTIG, tetanus toxoid vaccine, metronidazole cefazolin	Survived
		9 years	Foot splinter	Trismus and dysphagia	Unvaccinated	HTIG tetanus toxoid vaccine. metronidazole	Survived
		7 years	Foot laceration	Trismus, sore throat, and body stiffness	Unvaccinated	Magnesium sulfate, HTIG tetanus toxoid vaccine, metronidazole	Survived
Bagcı⁸8. Bağcı Z. Truncal tetanus: a case report. J Trop Pediatr. 2021;67:fmaa129.	1 patient	9 years	Trunk injury	Chest, abdomen, back muscle stiffness	Unvaccinated	HTIG, tetanus toxoid vaccine. metronidazole, baclofen, midazolam, penicillin G	Survived
Cejudo-García de Alba et al.⁹9. Cejudo-García de Alba MP, Valle-Leal JG, Sánchez Beltrán JG, Vázquez-Amparano AJ. Tetanus, a current disease in pediatric population: case report. Rev Chil Pediatr. 2017;88:507-10.	1 patient	6 years	Right arm splinter	Abdominal muscle stiffness, trismus difficulty walking	Incomplete immunization	Metronidazole, penicillin, wound debrided, HTIG tetanus toxoid vaccine	Survived
Asín et al.¹⁰10. Pérez-Jacoiste Asín MA, Langbazounga M. Neonatal tetanus in an African newborn. Int J Infect Dis. 2018;67:1-2.	1 patient	7-day-old newborn	Umbilical cord	Muscular spasms, Trismus rigidity	Unvaccinated	HTIG, metronidazole diazepam, ampicillin gentamicin	Survived
Sesama et al.¹¹11. Sesama M, Gomber S, Yadav M. Cephalic tetanus presenting as ptosis. Indian Pediatr. 2020;57:72-3.	1 patient	7 years	Left ear discharge	Reflex spasm of masseters, left eye ptosis	Unvaccinated	Diazepam, ceftriaxone, metronidazole, supportive management, HTIG, diazepam	Survived
Akane et al.¹²12. Akane Y, Tsugawa T, Hori T, Togashi A, Yoto Y, Inazawa N, et al. Tetanus in a partially immunized child. J Infect Chemother. 2018;24:980-2.	1 patient	13 years	Fracture of right distal radius	Trismus, muscle rigidity, excessive diaphoresis, risus sardonicus	Partially immunized	HTIG, tetanus toxoid, metronidazole, diazepam, penicillin G	Survived
Douvoyiannis et al.¹³13. Douvoyiannis M, Belamarich PF, Goldman DL. Tetanus after vaccine refusal and an opportunity for the pediatric infectious diseases specialist. Clin Pediatr (Phila). 2015;54:513-6.	1 patient	9 years	Nail	Painful neck stiffness, lockjaw	Unvaccinated	HTIG, tetanus toxoid, midazolam	Survived
Homola et al.¹⁴14. Homola L, Klučka J, Helešic J, Jirsenská Z, Kratochvíl M, Dominik P, et al. Unvaccinated child tetanus from nasal toy battery. Cent Eur J Public Health. 2021;29:322-4.	1 patient	2 and a half years	Deep erosion in the nasal mucosa, nasal toy	Difficulty swallowing trismus	Unvaccinated	Clindamycin, metronidazole, HTIG, tetanus toxoid	Survived
Condé et al.¹⁵15. Condé I, Cherif MS, Dahal P, Hyjazi ME, Camara F, Diaby M, et al. Neonatal and postneonatal tetanus at a referral hospital in Kamsar, Guinea: a retrospective audit of paediatric records (2014-2018). Int Health. 2022;14:468-74.	39 patients	13 days (median age)	Post-circumcision: 2 Umbilical cord: 20 Wound: 12 Limb fracture: 1	Fever, generalized muscle spasm, trismus	Unvaccinated: 17 Received 1 dose: 19 Received 2 doses: 3	NR	Died (n=20) Survived (n=19)
Maharaj et al.¹⁶16. Maharaj M, Dungwa N. Neonatal tetanus associated with skin infection. S Afr Med J. 2016;106:888-90.	1 patient	1 week	Lower abdominal skin infection	NR	Unvaccinated	Sedatives, muscle relaxants, antibiotics, intrathecal / intramuscular immunoglobulin, wound treatment	Survived
Nakubulwa et al.¹⁷17. Nakubulwa C, Opio E, Alekat GS, Kibetenga M, Alaroker FO. Neonatal tetanus with good outcomes at a regional referral hospital in Eastern Uganda: a case report. J Med Case Rep. 2022;16:54.	1 patient	9 days	None	Labile heart rate, tachypnea, hyperpyrexia, abdominal muscle rigidity, generalized spasms	Maternal partially immunized	Cefotaxime, gentamicin, metronidazole, diazepam, magnesium sulfate, equine tetanus antitoxin	Survived
Okidi et al.¹⁸18. Okidi R, Sambo VD, Eyul J. Neonatal tetanus in St. Mary’s Hospital Lacor: a case report. Clin Case Rep. 2020;8:2234-6.	1 patient	5-day-old neonate	NR	Fever, refusal to breastfeed, excessive crying, difficulty in breathing	Unvaccinated	Diazepam, metronidazole, phenobarbital	Died
Tadele et al.¹⁹19. Tadele H. Clinical profile and outcome of pediatrics tetanus: the experience of a tertiary hospital in Ethiopia. Ethiop J Health Sci. 2017;27:559-64.	24 patients	8 years (median age)	Trauma Tungiasis	Generalized tetanus symptoms	Maternal partially immunized	Diazepam, chlorpromazine, debridement, penicillin G, metronidazole, tetanus toxoid	Survived (n=17) Died (n=7)
Ogunkeyede et al.²⁰20. Ogunkeyede SA, Daniel A, Ogundoyin O. Paediatric otogenic tetanus: an evidence of poor immunization in Nigeria. Pan Afr Med J. 2017;26:177.	23 patients	3.4 years	Otogenic tetanus	Ear discharge, trismus and spasms	Complete tetanus immunization (12), unvaccinated (6), partial tetanus immunized (5)	Topical antibiotic ear dressing, tetanus toxoid, HTIG, antibiotic therapy, sedatives	Died (n=3) Survived (n=20)
Barlas et al.²¹21. Barlas ÜK, Kıhtır HS, Yeşilbaş O, Petmezci MT, Akçay N, Petmezci E, et al. Tetanus, a forgotten infection disease: a report of two cases. Turk J Pediatr. 2020;62:274-9.	2 patients	12 years	Puncture on right foot	Lock-jaw, facial, abdominal muscle rigidity	Unvaccinated	HTIG, tetanus toxoid, metronidazole, diazepam, vancomycin, ceftazidime, rocuronium, baclofen, fentanyl	Survived
		6 years	Puncture on left foot	Back pain, difficulty in opening the mouth and swallowing	Unvaccinated	ampicillin-sulbactam, metronidazole, HTIG, tetanus toxoid, fentanyl, baclofen, midazolam	Survived
Aqeel et al.²²22. Aqeel AY, Arishi HM, Ageel HI, Arishi NH. Epidemiological and clinical aspects of neonatal tetanus from a tertiary care hospital. Int J Pediatr Adolesc Med. 2017;4:71-4.	30 patients	Neonate	Unhealthy umbilical stump	Muscle spasm, refusal to eat, abnormal posture	Maternal unvaccinated: 27 Maternal partially immunized: 3	HTIG, penicillin G, gentamicin, muscle relaxant pavulon	Died (n=6) Survived (n=24)
Irie et al.²³23. Irie BG, Asse KV, Kadiane NJ, Kofi N, Nda-Koffi C, Ogondon B, et al. Tetanus after application of traditional topical treatment to a severe burn. Med Sante Trop. 2018;28:446-7.	1 patient	2 years	Severe thermal burn	Fever, refusal to eat, trismus, generalized contractures	Unvaccinated	HTIG, amoxicillin clavulanic acid, benzodiazepine	Died
Neal et al.²⁴24. Neal M, Culbertson MC 3rd, Mendiratta S, Smith BC 3rd, Whittle JS. Boy with muscle spasms. Ann Emerg Med. 2017;70:432-40.	1 patient	10 years	Foot puncture	Muscle spasms, trismus, fever, risus sardonicus, opisthotonus	Unvaccinated	Diazepam, metronidazole, HTIG, tetanus toxoid, surgical debridement	Survived
Şık et al.²⁵25. Şık G, Aydoseli A, Çıtak A. Intrathecal baclofen use in the management of tetanus related spasm: a case report. Turk J Pediatr. 2019;61:126-9.	1 patient	12 years	Right foot laceration	Spasms of the right foot, back, tachycardia hypertension, rigidity	Unvaccinated	Diazepam, morphine, vecuronium, magnesium sulfate, crystalline penicillin, HTIG, tetanus toxoid, intrathecal baclofen	Survived
Felter et al.²⁶26. Felter RA, Zinns LE. Cephalic tetanus in an immunized teenager: an unusual case report. Pediatr Emerg Care. 2015;31:511-3.	1 patient	14 years	Right foot laceration	Speaking with difficulty, bilateral ptosis, pain, swelling, sternal chest pain with palpitations	Unvaccinated	Diazepam, lorazepam, HTIG, tetanus toxoid, metronidazole ciprofloxacin	Survived
Gowda et al.²⁷27. Gowda VK, Veerappa BG, Handral A, Benakappa A. Re-emergence of tetanus: epidemiological features, clinical profile and outcome from South India. Indian J Pediatr. 2016;83:1015-7.	8 patients	Range: 2–11 years	Right foot laceration, left finger	Lock jaw, difficulty in walking	Unvaccinated: 6 Vaccinated: 2	Tetanus toxoid, crystalline penicillin, wound management care, HTIG	Survived (n= 5) Died (n= 3)

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[1] Correspondence to: Melis Deniz Sanlıurfa Training and Research Hospital, Department of Pediatric Infectious Diseases, Sanlıurfa Egitim ve Araştırma Hastanesi, Eyyubiye, Sanlıurfa, Turkey E-mail:mlsdnz@gmail.com