Recurrent tetanus

Abstract

A 64-year-old woman presented to the emergency department with a stiff painful jaw. She had grazed her forearm whilst gardening 48 h earlier. Within a few hours she developed trismus, risus sardonicus (figure) and painful muscle spasms. We made a clinical diagnosis of tetanus, and started high dose intravenous tetanus immunoglobulin and metronidazole. The wound was debrided and anaerobic cultures of wound swabs grew Clostridium tetani. After 7 h, the patient's spasms became uncontrollable, so we sedated, paralysed, and intubated her. She was mechnically ventilated for 17 days, developing ventilator-associated pneumonia and autonomic instability requiring inotropes to maintain her blood pressure. We started a magnesium infusion to maintain ionised magnesium levels of 1·5–2·0 mmol/L, as muscle spasms were consistently worse once the serum magnesium fell below 1·5 mmol/L. Painful muscular spasms continued for weeks after extubation and were controlled by supranormal magnesium levels for a further 9 days and subsequently baclofen.