Question

A 58 year old lawyer presents in the emergency room with headache, irritability, generalized muscle pain and uncontrollable back spasms. He has become very restless and worried because he has had the back spasms all through his court case that afternoon and they became extremely painful. In his history, the lawyer states that he has a very busy practice. He is on medication for high blood pressure (beta blocker) and has mild asthma. He injured himself about 10 days earlier, puncturing his left arm with a nail from an old barn he is in the process of tearing down. The wound has produced moderate quantities of pus, but he has been keeping it clean. When asked, he did not remember having a tetanus shot shinc he was a kid. The wound was sampled for microscopic examination and culture. The patient's back appears to have very tight contrations and spasms. He is in obvious agonizing pain. Subsequent microscopic examination has shown a Gram-positive endospore-forming bacillus. The culture would not grow aerobically, but upon culture in a Gaspak anaerobic syste bacterial colonies developed.

A. What is your diagnosis here?
B. What is the proper treatment of this problem?
C. How could this have been prevented?

Answer 1

A. What is your diagnosis here?

As per symptoms and incident of puncturing left arm with nail from an old barn indicates it can be infection of Clostridium tetani causing disease tetanus.

When such kinds of wound occurs, there should be injection of tetanus immunoglobulin (TIG) immediately. This injection contains antibodies against Clostridium tetani which can kill the microorganism. It should be injected as soon as possible. But this is short term immediate medication.

B. What is the proper treatment of this problem?

For the treatment antibiotic penicillin, metronidazole or tetracycline can be given, it prevents multiplication of bacteria and production of neurotoxin from bacteria. these neurotoxins are responsible for muscular spasms. Along with antibiotic some anticonvasculants, muscle relaxants can be given to reduce spasms, anxiety.

C. How could this have been prevented?

This infection can be prevented by giving its vaccine in childhood itself. Vaccine is given in the form of DTaP vaccine (diptheria, tetanus toxoid, acellular pertusis). It is given in 5 shots. It is given in the arm or thigh when child is at 2 month age, 4 month age, 6 month age, 15 to 18 month age, 4- 6 years of age.

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