On August 21, 2005, an adult in his 60s developed jaw and neck muscle tightness and spasms, dysphagia, and difficulty speaking. On August 22, he presented to a local emergency department and was diagnosed with probable tetanus. Tetanus toxoid, tetanus immune globulin, and metronidazole were administered, and he was admitted to the intensive care unit. The symptoms progressed, with severe and frequent spasms including arching of the back, which required mechanical ventilation and induced paralysis. Subsequently, a tracheotomy was necessary. An estimated hospital stay of 1 to 2 months is expected. Although this case was not reported to Public Heath (!), it was detected through our emergency department syndromic surveillance system, allowing us to investigate and document the case.

The patient had two possible exposures in the three to twenty-one days (the incubation period for tetanus) preceding symptom onset. [Note: depending on the character, location, and extent of the wound, tetanus incubation can range from one day to several months.] Two to three weeks prior to onset he cut his hand with a knife while fishing. Though he cleaned the wound, bandaged it, and kept it covered with a glove during the day, he did not seek medical attention for the wound and at the time of hospitalization the wound was healed.  Four days prior to onset, the man got a splinter under his fingernail while gardening. The splinter was still under his finger and was removed during his hospitalization.

It is unknown whether or not this patient received a primary series of tetanus vaccine as a child, however, family members thought any booster dose of tetanus vaccine would have been given at least twenty years prior to illness onset.

Tetanus is a serious and sometimes fatal disease of the central nervous system. Clostridium tetani (the organism that causes tetanus) is ubiquitous in soil and in the environment, typically entering the body through a wound. This case is a good reminder that the entry wound does not need to be a serious wound, and that the risk for tetanus infection is not confined to “classic” tetanus-prone wounds, such as “stepping on a dirty nail.”

Because most people do not seek medical care for uncomplicated, seemingly minor (yet potentially contaminated) wounds, routinely monitoring your patients’ vaccination status, and keeping tetanus immunizations up to date is the key to  prevention of this severe and potentially fatal disease.  

Almost all tetanus cases occur in persons who were either never immunized, or who received a primary series, but had not received a booster dose in at least ten years. Assessment and immunization of adults is particularly important; between 1980 and 2000, 70% of tetanus cases were among persons 40 years of age or older.  

Assessment of tetanus vaccine history is also important during wound management. Tetanus wound management depends on both vaccine history and the condition of the wound (clean and minor; all other wounds) to determine whether vaccine and/or tetanus immune globulin (TIG) are indicated. If this patient had sought medical care for his wound, both TIG and Td would have been recommended because of the lack of evidence of adequate immunization, and because of the potential contamination of these wounds with soil.