Delayed presentation and management approach of autonomic dysfunction associated with severe tetanus

Introduction: In 2019, there were over 73 000 estimated tetanus cases globally, including more than 27 000 cases of neonatal tetanus, and the worldwide deaths caused by tetanus were almost 34 684. The mortality rate of tetanus is greater than 50% in countries without ICUs and 10% in developed countries, mostly attributed to autonomic dysfunction. Countries with the greatest rates of post-neonatal tetanus mortality (greater than five fatalities per 100 000 people) were Somalia, South Sudan, and Kenya. Case presentation: A 66-year-old unvaccinated male patient came to our hospital emergency department with generalized rigidity, neck stiffness, lockjaw, and an altered level of consciousness for 5 days. His symptoms started with stiffness in his neck and back 4 days before. The patient was diagnosed with tetanus, as he was unimmunized, had a recent injury, and presented clinical findings. The authors started treatment by administering intramuscular human tetanus immunoglobulin and metronidazole. He was admitted to the ICU and placed in an isolation room with minimal auditory and visual stimuli. Following 2 weeks after admission his blood pressure began to fall, and his pulse rate started to fluctuate with alternating tachycardia and bradycardia. After 1 month in the ICU, he was discharged from the ICU and transferred to the ward. A catch-up immunization regimen was established. Clinical discussion: Tetanus is a rare condition in the Western world, primarily due to widespread vaccination programs from infancy to adulthood. There are crucial barriers that still exist to overcoming this disease in our country, including a lack of reliable immunization programs. In tetanus, the increase in survival is associated with the use of intensive care facilities for the management of tetanus, besides expanding the knowledge of the disease, which is a challenge for developing countries. Conclusion: It is essential to have enough immunization at an early stage of trauma since severe autonomic dysfunction linked to tetanus might be lethal.