CPJXXX10.1177/0009922814533411Clinical PediatricsDouvoyiannis et al


Tetanus After Vaccine Refusal and an Opportunity for the Pediatric Infectious Diseases Specialist

Clinical Pediatrics 2015, Vol. 54(6) 513­–516 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814533411 cpj.sagepub.com

Miltiadis Douvoyiannis, MD1, Peter F. Belamarich, MD2, and David L Goldman, MD2

Introduction In the era of increasing vaccine refusal, the reemergence of “almost forgotten diseases” presents a challenge to timely diagnosis and therapy. A child who was completely unvaccinated and suffered tetanus was recently reported.1 Here, we describe in more detail his clinical presentation and course as we admitted and followed (MD) the child. The issue of vaccine refusal in the United States is briefly reviewed, and a suggestion for a more active role of the pediatric infectious diseases specialist is made.

Case Description A 9-year-old boy was transferred to the Children’s Hospital at Saint Francis in Tulsa, Oklahoma, from a local hospital with complaints of painful neck stiffness and difficulty opening his mouth since that evening. On physical examination, the boy was alert, afebrile, and sitting on his bed. He couldn’t touch his chest with his chin, open his jaw more than 2 to 3 cm, or stick his tongue out. There was no erythema, edema, or tenderness of the jaw or the mastoid areas. His abdomen was tender and rigid. He had increased muscle tone with hyperactive deep tendon reflexes. No ataxia, cog-wheel rigidity, Babinski sign, or clonus was noted. He had full range of motion of all 4 extremities. A puncture wound with a 0.5 cm surrounding mild swelling was noted on the left sole, without erythema or drainage. Minimal stimulation such as administration of oral diphenydramine, attempt to place a tourniquet around his arm, and even laughing induced in him extreme irritability manifest by painful contraction of facial muscles—resembling ironic smiling (risus sardonicus), painful swallowing, drooling, trismus, hand clenching, and back arching (opisthotonus), which lasted for almost a minute each time. He lived with his parents and 8 siblings on their farm. He had contact with various animals including dogs, cats, and cows. No animal or tick bites were reported. He did not drink unpasteurized milk, and he had no

recent travel. He had stepped on a nail 4 days ago, and his mother cleaned the wound with hydrogen peroxide. The boy and his siblings had never received any vaccinations because of parental preference.

Hospital Course The child’s initial symptoms were thought to be the extrapyramidal manifestations of a drug ingestion or due to hysteria. As the clinical picture became clearer, a diagnosis of tetanus was made. After oral midazolam was given, human tetanus immune globulin (HTIG) 500 IU was administered intramuscularly. The child was transferred to the pediatric intensive care unit where he was mechanically ventilated for 12 days and remained for 16 days. Autonomic instability characterized by hypertension (up to 175/134 mm Hg) and hypotension and fever occurred. HTIG 4500 IU intramuscularly and metronidazole for 10 days were administered. In addition, 250 IU of HTIG were infused intrathecally. The mother initially refused all vaccinations, but finally gave consent to administer Tdap. The child remained hospitalized for 23 days, and on discharge, he was able to feed himself but had moderate expressive language deficits and spasticity of the legs, necessitating support and physical therapy.

Discussion Tetanus is a life-threatening disease characterized by hypertonia, contractions of the muscles of the jaw and neck, and severe generalized muscle spasms accompanied by autonomic instability. It is caused by tetanospasmin, released by the germinating spores of the anaerobe 1

Altru Health System, Grand Forks, ND, USA Albert Einstein College of Medicine, Bronx, NY, USA


Corresponding Author: Miltiadis Douvoyiannis, Department of Pediatrics and Pediatric Infectious Diseases, Altru Health System, Main Clinic 1000 S. Columbia Road, Grand Forks, ND 58201, USA. Email: [email protected]

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Clinical Pediatrics 54(6)

Clostridium tetani that have contaminated wounds. C tetani is ubiquitous in the environment, including the human gut flora. No specific test offers confirmation of the disease, and the diagnosis is based on the clinical presentation. In contrast to other vaccine-preventable diseases, protection by herd immunity does not apply in tetanus. The reported number of tetanus cases has declined more than 95% since 1947 with the introduction of tetanus toxoid–containing vaccines, the tetanus immune globulin, and improved wound care.2 From 2001 to 2008, 233 cases of tetanus were reported from 45 states with a case fatality of 13%. Although the majority of patients (72%) had suffered acute wounds, only one third of them sought medical care. More important, of those who did, 96% did not receive appropriate tetanus immunization and immunoglobulin prophylaxis when indicated. Twenty-two of the cases were children 5 to 19 years old. Sixteen (73%) of them had received no (46%) or only 1 (27%) dose of tetanus vaccine. No children died.2 Recent data highlight the increasing problem of decreased vaccination rates across the nation. Among children entering kindergarten, from 2012 to 2013 and in 48 states, including the District of Columbia, the median vaccination coverage was 95.1% for diphtheria, tetanus toxoid, and acellular pertussis; 94.5% for measles, mumps, rubella; and 93.8% for varicella immunizations. The median percentage of the children that were exempted was estimated at 1.8%. Regarding 3 or more doses of DTaP/DT, the states with the lowest vaccination coverage (

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