(592) Escaping From the (Lock)Jaws of Death: A Tetanus Case Report

Introduction: In the United States, Tetanus has become an extremely rare illness thanks to widespread vaccination against the causative toxin. In this age of vaccine hesitancy, misinformation and poor health literacy, diseases that had previously been all but eradicated have been reemerging.

Description: A 69-year-old female with a past medical history of hypertension, Insulin dependent Type 2 Diabetes Mellitus, hyperlipidemia and asthma, presented to the emergency department complaining of jaw and neck stiffness and difficulty swallowing for 3 days. Her family were unaware of her immunization status. A few days prior to admission, the patient had a nasal polyp resected, otherwise no trauma was reported, and no visible signs of trauma were present on full body examination. She was evaluated by speech pathology and neurology and was initially managed for angioedema. Her symptoms intermittently improved but returned worse with each recurrence. Rapid responses were called 3 times for symptom recurrence. Symptoms self resolved spontaneously the first 2 times. The third time, a code blue was called and ROSC was achieved. Patient was intubated and admitted to the ICU where increasing doses of midazolam and fentanyl infusions were given to manage her worsening muscle spasms and dysautonomia. She additionally was given pushes of rocuronium for paralysis. She received anti tetanus immunoglobulin and tdap vaccine. Flagyl was started for tetanus coverage. The patients anti tetanus immunoglobulins were negative. She was placed in a dark quiet room to avoid any external stimulation. The patient began to show signs of improvement by day 13 of hospital stay, tracheostomy and percutaneous gastrostomy tube were placed on day 15, sedation was weaned off by day 20, and patient no longer required ventilatory support by day 28. A second dose of Tdap was given on day 32 and the patient was discharged to a rehabilitation facility on day 46 .

Discussion: Tetanus remains a preventable illness with vaccination. Our patients anti tetanus immunoglobulin titers were below the range for immunity and the family was unsure of her last vaccine dose. In this age of vaccine hesitancy, education of the importance of keeping up with tetanus boosters, is imperative in keeping this rare but fatal infection from becoming commonplace.