Tetanus Diagnosis Sometimes Elusive

Nurse Practitioner, Nov 2003 by Quackenbush, Priscilla, Tuorinsky, Shirley, Rabb, Rebecca

Tetanus is an acute, often fatal infectious disease caused by an exotoxin produced by Clostridium tetani, a spore-forming bacteria. Classic symptoms include generalized rigidity and convulsive spasms of the skeletal muscles. The muscle stiffness commonly involves the jaw and neck, and then becomes widespread. C. tetani usually enters the body through a puncture wound. The spores germinate in the anaerobic conditions, and toxins, including tetanospasmin, are produced. The toxins travel through the body via the blood and lymphatics, and act at several central nervous system sites including peripheral motor end plates, spinal cord, brain, and sympathetic nervous system. Tetanus toxin interferes with neurotransmitter release, blocking inhibitor impulses and resulting in unopposed muscle contraction and spasm. Seizures can occur as well.1 Diagnosing tetanus in modern medicine is particularly challenging because it mimics other infectious disease processes and is considered preventable in today's world.

Case History

L. L., a 44-year-old female in otherwise good health, was cleaning debris from a creek on her land. The shallow and muddy creek water was drainage from the surrounding land and nearby road, and most likely contained animal feces. The patient was removing rocks from the creek bed when she accidentally grasped a piece of barbed wire concealed by the murky water. This led to four cuts to the palmer surface of four fingers on her right hand. She cleaned the injury with an antibacterial soap and immediately continued working in the creek, submerging her hand in the dirty water.

Twenty-seven days later, L.L. awoke with a severe headache. Although she has a history of migraine headaches, this had never happened. Her bilateral temporal pain, however, was usual for her episodes of migraine headaches. By mid-morning, her headache was so severe that she presented to the emergency room (ER). She received one Demerol injection and was released. Approximately 6 hours later, her headache worsened and the left side of her jaw became painful and slightly swollen. She returned to the ER. She received another Demerol injection for pain and Augmentin for jaw swelling, and was released.

After 7 hours at home, she awoke with severe left jaw swelling, inability to open her mouth, and difficulty breathing. She returned to the ER for the third time. At this visit, she received facial radiographs and a computerized tomography (CT) scan, which showed soft tissue swelling. She was given Versed for the CT scan. The patient was admitted to the intensive care unit with a diagnosis of obstructed airway. Consults to pulmonology, ear, nose, and throat (ENT), and infectious disease departments revealed no specific etiology. Treatment included pain medication, steroids, and ice to her jaw. Oral surgery was also consulted because a tooth abscess could possibly cause jaw swelling and difficulty opening the mouth. The patient was discharged with oral pain medication, antibiotics and a follow-up appointment with the ENT physician 10 days later.

At home, L.L. began to experience muscle spasms, twitching, headache, low-grade fever, fatigue, and general aching. She described her fingers on both hands contracting in a "claw-like" position. She attempted to contact the ENT provider, but was unsuccessful. Four days later, when she did see the ENT provider, no change in the treatment plan was made.

A nurse practitioner (NP) saw her the following day for a refill of Fioricet. L.L. relayed her recent medical situation and stated she was still not feeling well. After performing a thorough medical history and listening to the patient's description of the events, the NP suspected tetanus. She ordered tetanus diphtheria booster and referred the patient to another ENT physician for a definitive plan of care. The next day, the patient saw the ENT provider who, based on her history, diagnosed her with tetanus. No further treatment was indicated.

Over the next 4 months, the patient continued to experience jaw swelling, neck stiffness, and muscle tightness, particularly in her arms, legs, fingers, toes, and occasionally in her face. During this time, she was treated with Cipro and Levaquin for the tetanus infection, and Robaxin for muscle spasms. She also noted a painful lump in the left side of her neck, which reached the size of a lemon. It was diagnosed as an infected parotid gland, without a specific etiology. The salivary glands also showed chronic inflammation. The patient was given the option to have it surgically removed, which she declined at that time. Six months later, she had the mass removed, with no tetanus on biopsy. After another 5 months, the mass returned, and she decided to once again have it surgically removed.

* Past Medical History

L L. had a history of tension/migraine headaches that began in 1987 following an episode of viral meningitis. Treatment included opioids and muscle relaxants. She had a 24-year half a pack per day smoking history. Past medical history was not significant for tetanus. Her last tetanus booster was in 1986, and before that, in 1965.