Download Tetanus in an unvaccinated child in the United Kingdom: case report

Journal of Public Health
doi:10.1093/pubmed/fdh198
VoI. 27, No. 1, pp. 118–119
Advance Access Publication 25 November 2004
Tetanus in an unvaccinated child in the
United Kingdom: case report
B. Padmakumar and Anjali R. Date
Summary
Tetanus is a serious infectious disease that is associated with
high morbidity and mortality. It is uncommon in developed
countries like the United Kingdom due to widespread immunization. However, cases are still being reported in children
who are not immunized. We report a case of an 8-year-old
Asian boy who had missed his childhood vaccinations but
had been living in the United Kingdom for 3 years. He presented with trismus and muscle spasms needing ventilation
in Paediatric Intensive Care for 3 weeks. The case highlights
the importance of vaccinating newly arrived children
Introduction
Tetanus is a vaccine preventable disease and is more common in
developing countries. Despite widespread availability of safe
and effective vaccine against tetanus, a total of 175 cases have
been reported in England and Wales during the period 1984–
2000 and 11 per cent of these were in people eligible for routine
childhood vaccination. It is very important that vaccination
strategies are effectively implemented for eradication of this
serious disease.
Case Report
An 8-year-old Asian boy presented to us with a 12 h history of
fever, neck pain and difficulty in opening his mouth, which was
getting progressively worse. He could not speak or swallow and
could not move his neck due to pain. There was no history of
recent trauma or open wounds. He did not have headache or
photophobia.
He was born in Bangladesh. His family had moved to the
United Kingdom 3 years previously. He had his first lot of
immunization (diphtheria, tetanus, oral polio and Haemophilus
influenzae B) 2 days prior to presentation along with his siblings
aged 7 and 12. All of them had missed their childhood immunisations. The other siblings remained well. None of the other
children immunized with the same batch of vaccine from that
GP practice had shown any adverse affects.
On examination he was afebrile, alert and cooperative. He
was lying very still with his neck retracted in an opisthotonic
posture. He had severe trismus and could not speak or swallow.
Any attempts to look inside the mouth increased the trismus.
He developed generalized muscle spasms with any movement.
He could not sit up or walk. The rest of the examination was
unremarkable.
His initial investigations revealed a normal full blood count,
urea and electrolytes, calcium and magnesium. His C-reactive
protein was <5 mg/l. A diagnosis of tetanus was made based on
the clinical features in a child who was unprotected by immunizations. He was treated with tetanus immunoglobulin and
intravenous antibiotics and transferred to a high-dependency
unit in the nearby tertiary centre. In the high-dependency unit
he was commenced on intravenous diazepam and muscle relaxants. He continued to have severe spasms and opisthotonic
posturing in spite of increasing the strength of the diazepam
infusion. He had a lumbar puncture, which ruled out meningoencephalitis. A cranial CT scan ruled out intracranial lesions.
Three days later he had a respiratory arrest following prolonged spasms and was intubated and ventilated. He was ventilated for 3 weeks. Following extubation he needed intensive
rehabilitation in the neurology ward. His medication was
switched over to oral diazepam and baclofen, which was gradually weaned off over the next few weeks. He has made an
uneventful recovery apart from developing subglottic stenosis
secondary to prolonged intubation.
Discussion
Tetanus can be acquired at any point in an unprotected child’s
life and is associated with a high likelihood of mortality. It is
caused by Clostridium tetani, a spore-forming anaerobic Grampositive organism.1
Diagnosis is based on history and clinical features. The clinical presentation of non-neonatal tetanus includes trismus, risus
sardonicus, neck retraction, difficulty in swallowing, dysphasia,
spasms, hyper salivation and muscle rigidity.1–3 Our patient
had most of these clinical features. The differential diagnosis
The Royal Oldham Hospital, Oldham OL1 2JH
B. Padmakumar, Consultant Paediatrician
South Manchester University Hospital NHS Trust
Anjali R. Date, Specialist Registrar in Paediatrics
Address correspondence to Dr B. Padmakumar.
E-mail: [email protected]
© The Author 2005, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.
TETANUS IN AN UNVACCINATED CHILD IN THE UK
includes drug reactions (phenothiazines), poisoning with strychnine, hypocalcaemic tetany and rarely hysteria.1–5 There was no
evidence of any of these in our case. His clinical course progressed
to a full blown clinical presentation of tetanus needing ventilation
for 3 weeks. This ruled out the possibility of a reaction to tetanus
toxoid. CSF analysis and cranial CT scan ruled out meningoencephalitis and space-occupying intracranial lesions.
Tetanus is recognized as a serious public health problem
because of the high mortality associated with it and yet it can be
totally prevented by immunization. Tetanus is comparatively a
rare disease in England and Wales. A total of 175 cases of tetanus
have been reported in England and Wales during the period 1984–
2000.6 However 20 (11 per cent) of these were in people eligible for
routine childhood vaccination.6 In areas like Greater Manchester
where there is a large immigrant population, it is particularly
important for general practitioners to be vigilant and ensure that
all children registered in their practice are fully immunized.
Tetanus will continue to be a paediatric problem until vaccination strategies are effectively implemented and surveillance
119
systems are improved. As the disease becomes rare more rigorous tetanus case surveillance is essential.
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