Case Report Tetanus following human bite G. I. Muguti and M. S. Dixon Departments of Surgery and Medicine, Mpilo Central Hospital, Bulawayo, Zimbabwe SUMMARY. We present an unusual case of tetanus which followed a human bite. The patient, a 43-year-old woman, developed tetanus within 4 days of sustaining a human bite. She died 6 days after admission despite aggressive management in the intensive care unit.
6 days later after a fluctuating clinical course. Uostridium tetani was not actually isolated from the wound microbiologically.
Tomasetti et al. (1979) have defined a human bite as “ . . . one inflicted on a person by another person”. Most human bites occur during quarrels but they have also been reported to occur during the course of sexual activity (Losken and Auchincloss, 1984; Al Fallouji, 1990). These injuries should always be treated as serious because of their potential for causing disfigurement, disability and in some cases severe wound infection. The present case is interesting in that it is probably the first documented case of tetanus following a human bite.
Discussion The virulent nature of human bites stems from the fact that the oral cavity harbours a wide range of bacterial flora with ct-haemolytic streptococci and bacteroides
Case report A 43-year-old Zimbabwean female was admitted to Mpilo Central Hospital with a presumptive diagnosis of tetanus. Four days prior to admission the patient had been involved in a domestic dispute with another woman. A struggle had taken place during which the patient was bitten on the anterior skin fold of the left axilla. The patient had remained at home for the next 2 days with no ill effects. No treatment was applied to the wound although it had been covered with a clean cloth. One day prior to admission the patient presented to the casualty department as the wound was becoming septic. The casualty oEicer who saw her documented a “slightly septic wound in the left pectoral region, 4 cm in diameter”. The patient was apparently otherwise well. The wound was cleaned and dressed with Betadine, anti-tetanus toxoid was administered and amoxycillin and metronidazole were prescribed orally. The following day the patient re-presented to casualty complaining of “a stiff neck and an inability to open her mouth” for 12 h. On examination the patient was apyrexial but had obvious trismus and stimulation would provoke opisthotonos. The blood pressure was labile (being 190/ 120 in casualty and 90/50 1 h later on the ward). Inspection of the left axilla revealed a mildly septic wound. There was no other sign of injury anywhere else. The wound was excised under local anaesthetic in casualty (Fig. 1); human tetanus immunoglobulin (20000 iu), intravenous metronidazole and intramuscular chlorpromazine were administered. The patient was transferred to intensive care, paralysed with alcuronium and ventilated. Intravenous morphine was administered via an infusion. The patient died
Fig. 1 Figure l-Patient wound excision.
614
on the ventilator
in 1CU. Site of human
bite after
615
Tetanus Following Human Bite species being the most frequent isolates (Goldstein et al., 1978). Curtin and Greeley (1961) reported that the crushing and de-vitalisation of the tissues, as well as the depth and extent of the wound, contribute to bacteria being deeply seeded thus promoting anaerobic infection. Indeed death has been reported due to septicaemia following a pyogenic arthritis caused by a clenched-fist injury (Mann, 198 1). Some unusual infections are known to have been transmitted by human bites. An outbreak of hepatitis B caused by a “ biting inmate” of an institution for the mentally retarded (Cancio-Bello et al., 1982) and a case of primary syphilis following human bite (Fiumara and Exnor, 1981) have been reported. The advent of the Human Immunodeficiency Virus epidemic has raised the possibility of transmission through human bite. The possibility of transmitting tetanus through human bite has so far received little attention in the literature. Indeed some authors make no mention of tetanus in their discussion of the management of human bite injuries (Tomasetti et al., 1979; Losken and Auchincloss. 1984). Both Lowry (1936) and Curtin and Greeley (1961) stated that cfostridium tetani never appear in the mouth or in human bite wounds and felt that anti-tetanus therapy was unnecessary in such cases. In an earlier study involving 64 patients with human bite injuries treated at Mpilo Central Hospital no cases of tetanus were encountered (Muguti et al., 1991). At this hospital anti-tetanus toxoid is routinely administered to all patients with human bite injuries. The case presented lends support to this policy. The current practice of thorough wound toilet, wound excision and administration of appropriate antibiotics goes a long way in preventing tetanus and other serious wound infection. Jn those patients who present within 24 h of the injury this may well be all that is needed. Tomasetti et al. (1979) reported no infections in human bite injuries when treatment was begun within 24 h. In the case presented it is debatable whether tetanus could have been prevented if the casualty officer at the first presentation (1 day prior to admission) had carried out wound excision in addition to the measures
that were instituted: wound toilet, betadine dressing, anti-tetanus toxoid, amoxycillin and metronidazole. This report highlights the potential danger of tetanus transmission through human bite. The current practice of thorough wound toilet, wound excision and appropriate antibiotics minimises the danger of both sepsis and tetanus from human bites. Antitetanus therapy should probably be considered for all victims of human bites and especially for those who present later than 24 h.
References Al Fallouji, M. (1990). Traumatic love bites. British.lourd of Surgery, 77, 100. Cancio-BeUo, T. P., de Medina, M., Shorey, J., Valledor, V. D. and S&i& E. R. (1982). An institutional outbreak of Hepatitis B related
to a human
biting carrier.
Journal of‘Infech~~
Dkax.~.
146.652. Curtin, J. W. and Greeley, P. W. (1961). Human
bites of the face. Plastic and Reconstructive Surgery, 28, 394. Fiumara, N. J. and Exnor, J. H. (1981). Primary syphilis following a human bite. Journal of Sexually Transmitled Diseases. 8. 2 1. Goldstein, E. J. C., Citron, D. M. and Wield, B. (1978).Bacteriology of human and animal bite wounds. Journal of Clinicul Mic,robiology, 8, 667. Losken, H. W. and Auchincloss, J. A. (1984). Human bites of the lip. Clinics in Plastic Surgery, Il. 773, Lowry, T. M. (1936). The surgical treatment of human bites. ,4nnu/.s of Surgery. 104, 1103. Mann, R. J. (1981). Rapid therapy of human bites. American Familv Physician, 23. 110. Muguti, G. I., Zvomuya, M. and Bvuma, E. T. ( 1991). Experience with human bites in Zimbabwe. Cenrral .$/KwI Journal of’ Medicine, 37. 294.
Tomasetti,B. J., WaIker, L., Gromley, M. B., Berger, R. and Gold, B. D. (1979). Human bites of the face. Journal of&al Surgery, 37. 565.
The Authors G. I. Muguti, FRCS(Ed), Head,
Department
of Surgery
M. S. Dixon, MRCP(UK), Physician, Department of Medicine Mpilo Central Hospital, PO Box 2096. Bulawayo. Zimbabwe Requests for reprints
to Mr G. I. Muguti.
Paper received 18 March Accepted 3 April 1992.
1992.
6 days later after a fluctuating clinical course. Uostridium tetani was not actually isolated from the wound microbiologically.
Tomasetti et al. (1979) have defined a human bite as “ . . . one inflicted on a person by another person”. Most human bites occur during quarrels but they have also been reported to occur during the course of sexual activity (Losken and Auchincloss, 1984; Al Fallouji, 1990). These injuries should always be treated as serious because of their potential for causing disfigurement, disability and in some cases severe wound infection. The present case is interesting in that it is probably the first documented case of tetanus following a human bite.
Discussion The virulent nature of human bites stems from the fact that the oral cavity harbours a wide range of bacterial flora with ct-haemolytic streptococci and bacteroides
Case report A 43-year-old Zimbabwean female was admitted to Mpilo Central Hospital with a presumptive diagnosis of tetanus. Four days prior to admission the patient had been involved in a domestic dispute with another woman. A struggle had taken place during which the patient was bitten on the anterior skin fold of the left axilla. The patient had remained at home for the next 2 days with no ill effects. No treatment was applied to the wound although it had been covered with a clean cloth. One day prior to admission the patient presented to the casualty department as the wound was becoming septic. The casualty oEicer who saw her documented a “slightly septic wound in the left pectoral region, 4 cm in diameter”. The patient was apparently otherwise well. The wound was cleaned and dressed with Betadine, anti-tetanus toxoid was administered and amoxycillin and metronidazole were prescribed orally. The following day the patient re-presented to casualty complaining of “a stiff neck and an inability to open her mouth” for 12 h. On examination the patient was apyrexial but had obvious trismus and stimulation would provoke opisthotonos. The blood pressure was labile (being 190/ 120 in casualty and 90/50 1 h later on the ward). Inspection of the left axilla revealed a mildly septic wound. There was no other sign of injury anywhere else. The wound was excised under local anaesthetic in casualty (Fig. 1); human tetanus immunoglobulin (20000 iu), intravenous metronidazole and intramuscular chlorpromazine were administered. The patient was transferred to intensive care, paralysed with alcuronium and ventilated. Intravenous morphine was administered via an infusion. The patient died
Fig. 1 Figure l-Patient wound excision.
614
on the ventilator
in 1CU. Site of human
bite after
615
Tetanus Following Human Bite species being the most frequent isolates (Goldstein et al., 1978). Curtin and Greeley (1961) reported that the crushing and de-vitalisation of the tissues, as well as the depth and extent of the wound, contribute to bacteria being deeply seeded thus promoting anaerobic infection. Indeed death has been reported due to septicaemia following a pyogenic arthritis caused by a clenched-fist injury (Mann, 198 1). Some unusual infections are known to have been transmitted by human bites. An outbreak of hepatitis B caused by a “ biting inmate” of an institution for the mentally retarded (Cancio-Bello et al., 1982) and a case of primary syphilis following human bite (Fiumara and Exnor, 1981) have been reported. The advent of the Human Immunodeficiency Virus epidemic has raised the possibility of transmission through human bite. The possibility of transmitting tetanus through human bite has so far received little attention in the literature. Indeed some authors make no mention of tetanus in their discussion of the management of human bite injuries (Tomasetti et al., 1979; Losken and Auchincloss. 1984). Both Lowry (1936) and Curtin and Greeley (1961) stated that cfostridium tetani never appear in the mouth or in human bite wounds and felt that anti-tetanus therapy was unnecessary in such cases. In an earlier study involving 64 patients with human bite injuries treated at Mpilo Central Hospital no cases of tetanus were encountered (Muguti et al., 1991). At this hospital anti-tetanus toxoid is routinely administered to all patients with human bite injuries. The case presented lends support to this policy. The current practice of thorough wound toilet, wound excision and administration of appropriate antibiotics goes a long way in preventing tetanus and other serious wound infection. Jn those patients who present within 24 h of the injury this may well be all that is needed. Tomasetti et al. (1979) reported no infections in human bite injuries when treatment was begun within 24 h. In the case presented it is debatable whether tetanus could have been prevented if the casualty officer at the first presentation (1 day prior to admission) had carried out wound excision in addition to the measures
that were instituted: wound toilet, betadine dressing, anti-tetanus toxoid, amoxycillin and metronidazole. This report highlights the potential danger of tetanus transmission through human bite. The current practice of thorough wound toilet, wound excision and appropriate antibiotics minimises the danger of both sepsis and tetanus from human bites. Antitetanus therapy should probably be considered for all victims of human bites and especially for those who present later than 24 h.
References Al Fallouji, M. (1990). Traumatic love bites. British.lourd of Surgery, 77, 100. Cancio-BeUo, T. P., de Medina, M., Shorey, J., Valledor, V. D. and S&i& E. R. (1982). An institutional outbreak of Hepatitis B related
to a human
biting carrier.
Journal of‘Infech~~
Dkax.~.
146.652. Curtin, J. W. and Greeley, P. W. (1961). Human
bites of the face. Plastic and Reconstructive Surgery, 28, 394. Fiumara, N. J. and Exnor, J. H. (1981). Primary syphilis following a human bite. Journal of Sexually Transmitled Diseases. 8. 2 1. Goldstein, E. J. C., Citron, D. M. and Wield, B. (1978).Bacteriology of human and animal bite wounds. Journal of Clinicul Mic,robiology, 8, 667. Losken, H. W. and Auchincloss, J. A. (1984). Human bites of the lip. Clinics in Plastic Surgery, Il. 773, Lowry, T. M. (1936). The surgical treatment of human bites. ,4nnu/.s of Surgery. 104, 1103. Mann, R. J. (1981). Rapid therapy of human bites. American Familv Physician, 23. 110. Muguti, G. I., Zvomuya, M. and Bvuma, E. T. ( 1991). Experience with human bites in Zimbabwe. Cenrral .$/KwI Journal of’ Medicine, 37. 294.
Tomasetti,B. J., WaIker, L., Gromley, M. B., Berger, R. and Gold, B. D. (1979). Human bites of the face. Journal of&al Surgery, 37. 565.
The Authors G. I. Muguti, FRCS(Ed), Head,
Department
of Surgery
M. S. Dixon, MRCP(UK), Physician, Department of Medicine Mpilo Central Hospital, PO Box 2096. Bulawayo. Zimbabwe Requests for reprints
to Mr G. I. Muguti.
Paper received 18 March Accepted 3 April 1992.
1992.
