Chest
Volume 122, Issue 4, October 2002, Pages 1488-1492
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Selected Reports
Respiratory Failure in Tetanus: Case Report and Review of a 25-Year Experience

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The objectives of the study were to describe a novel presentation of tetanus and to review the course of the respiratory component and the treatment and management of the disease. A case report is presented with a review of a 25-year experience at Mayo Clinic. We describe the case of a 65-year-old woman who presented with persistent hiccups, dyspnea, and pleurisy of 3 days duration that was caused by tetanus from inadequate secondary immunity. She required intubation for progressive trismus and laryngospasm-associated respiratory failure. Infusion of lorazepam did not control her spasms. Refractory spasms and hiccups resolved with fentanyl and cisatracurium therapy. After 3 weeks, the patient was weaned from the ventilator with complete recovery. In the past 25 years, nine additional patients have presented to Mayo Clinic with acute tetanus. Respiratory failure requiring intubation developed in seven patients, and six of the seven intubated patients survived with minimal deficits. The prognosis of tetanus is favorable if it is diagnosed promptly and if treatment and supportive measures are begun. To our knowledge, this is the first report of a patient with acute tetanus presenting with hiccups. This report also confirms the results of previous studies that suggested a need for improved immunity in the elderly population.

Section snippets

Case Report

A 65-year-old woman presented to the emergency department with hiccups, dyspnea, pleurisy, jaw stiffness, and epigastric pain of 3 days’ duration. She had been seen 1 week earlier for a traumatic knee laceration, which was irrigated and sutured. She was given a tetanus toxoid vaccination as part of her care. Four days after the initial injury, she underwent wound incision and drainage and began therapy with cephalexin.

Evaluation results at the local hospital included a normal ECG and normal

Mayo Clinic Experience

In the past 25 years, nine additional patients have presented to the Mayo Clinic with acute tetanus (Table 1). The majority of the patients were elderly (average age, 68 years) and had received childhood vaccinations only or did not know their vaccination status. Most patients presented with mild early trismus (78%), which led to generalized tetanus. The treatment of these patients is described in Table 2. Respiratory failure requiring intubation developed in seven of these patients (78%). Six

Significant Findings

A novel finding in this case report is the presenting symptom of hiccups. In addition, this report confirms previous reports that elderly patients may not have adequate immunity to prevent the illness. Finally, this case and the Mayo Clinic experience demonstrate the need for prompt diagnosis and treatment because of the risk of respiratory failure.

General Description

Tetanus is caused by a toxin secreted by Clostridium tetani, a Gram-positive, obligate anaerobic bacillus that forms a stable terminal spore. C

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