Tetanus in a child – case report

A 6-year-old female patient with a low socioeconomic status, with an incomplete immunization schedule according to her age (only one dose of pentavalent vaccine and rotavirus had been applied). She began her clinical
presentation 11 days prior to hospital admission, after having a sharp slice of wood on her right arm.

Figure 1.
Position of oppistottons, characteristic of generalized tetanus.

She went to the emergency department, where she was washed with antiseptic. Doctors gave the indication of domiciliary treatment based on dicloxacillin and paracetamol. Pain persisted in the place of injury, and after 10 days, she started a fever, abdominal muscle stiffness, trismus (sardonic laughter) and difficulty walking, because of her complete limitation to bend her both legs, thus, she went to the emergency epartment again. The picture shows the progress during the following hours, with the appearance of opisthotonos (figure 1), initially without alteration of the vital signs nor the state of consciousness. Laboratory tests, cranial computed tomography (CT) and lumbar puncture were performed, all of them with normal results:
Hemoglobin 11.8 mg/dl Hematocrit 37.1% Leucocytes 7230, Neutrophils 4490, Lymphocytes 1730,Platelets 173000, Glucose 100 mg/dl, Urea 23 mg/dl, Creatinine 0.2 mg/dl, ALT 10 U/L AST 44 U/L, Calcium 9.8 mmol/L, Sodium 136 mmol/L, Potassium 4.1 mmol/L.
She was hospitalized in the Pediatric Intensive Care Unit (PICU) for neurological deterioration, being treated with ventilatory support, sedation, muscle relaxation, and with the administration of antibiotics metronidazole and Penicillin). In the PICU, a wound was debrided in order to remove a 3cm long wood splint from the previous injury. Due to the clinical picture and her incomplete immunization schedule, generalized tetanus was suspected and a high dose of human immunoglobulin was intramuscular administered (500 IU), as well as one dose of tetanus toxoid.
The patient’s evolution was torpid as she developed several complications, including: left pneumothorax, Acinetobacter iwwofi nosocomial pneumonia, leftt atrial endocarditis, and complex partial convulsive seizures.

Electroencephalogram reported right temporal paroxysmal discharge, and a new report of CT showed a subcortical cortical atrophy of frontal predominance. After the recovery of the infectious process, the patient was discharged with some neuromuscular compromise. The monitoring was carried out by 2 years in external consultation with pediatrics, with medication and physical rehabilitation. After this period, the patient is asymptomatic and without evidence of neuromuscular sequelae, totally integrated to her school and social environment.