A 50-year-old male building worker presented with history of an injury to the right arm 10 days before presentation, followed by recent onset of difficulty in opening mouth .Debridement and suturing were performed in the local hospital and tetanus antitoxin immunotherapy was injected 10 days before. A 10 cm longitudinal incision was seen on the palmar side. He represented to our hospital, complaining of painful of the injury site and lockjaw.
After admission, the patient was transfered to SICU single ward immediately to reduce sound and light stimulation. Human tetanus immunoglobulins, 1000 IU IM, were given to the patient to neutralize the circulating toxins. For muscle spasm, diazepam infusion of 1 mg/kg/day was given .Penicillin and metronidazole were given as antibiotic coverage.He developed respiratory failure the following day, the severity of his illness required mechanical ventilation and subsequent tracheostomy. Further surgical debridement was then performed,along with administration of tetanus toxoid (TT)(Fig. 1). Clostridium tetanus was identified in wound secretions by next-generation sequencing(NGS) analysis of etiology(Fig. 2). The wounds were washed with hydrogen peroxide solution every day. Autonomic instability became apparent 7 days after transfer, with rapid and extreme fluctuations in heart rate and blood pressure. We gave him neuroblockers, analgesics and sedatives .His antibiotic regimen altered to intravenous metronidazole and ceftriaxone soon .Because of the use of large doses of sedative and analgesic drugs, the patient's gastrointestinal peristalsis was weakened, and there was a lot of gastric juice every day. Therefore, we gave the patient pyloric feeding later to strengthen nutritional support.
Recognition of the tetanus pathophysiology ,comprehensive treatment in ICU and choice of sedative medications, including dexmedetomidine for its anti-sympathetic effect, led to successful discharge. The patient was discharged after 28 days in SICU and 15 days more in respiratory ward. Except for a little stiffness in the joints, the patient had clear mind, fluent speech and free movement of joints at the time of discharge.
After discharge, the family members complained that the patient had an involuntary shaking of left leg when sleeping at night, and then head MRI showed multiple ischemic lesions in his right frontal lobe and bilateral parietal lobes .Within 3 months after discharge, this kind of left leg involuntary shaking had always existed.
Assent for case presentation were obtained from his wife and daughter, and a study protocol was approved by the Hospital Ethics Committee.