Practice Lesson of the Week

Generalised tetanus in a patient with a chronic ulcerated skin lesion

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4419 (Published 13 November 2009) Cite this as: BMJ 2009;339:b4419

This article has a correction. Please see:

  1. Beatriz Aranegui, specialist registrar,
  2. Ángeles Flórez, dermatologist,
  3. Ignacio Garcia-Doval, dermatologist,
  4. Aránzazu García-Cruz, specialist registrar,
  5. Carlos de la Torre, dermatologist,
  6. Manuel Cruces, head of department
  1. 1Department of Dermatology, Hospital Provincial, Complexo Hospitalario de Pontevedra, 36002 Pontevedra, Spain
  1. Correspondence to: B Aranegui baranegui{at}gmail.com
  • Accepted 6 June 2009

Chronic ulcerated skin lesions and skin biopsies should be considered as wounds prone to tetanus

In developed countries, tetanus is uncommon and cases are usually diagnosed in elderly patients.1 2 3 4 Levels of tetanus antibodies are progressively lower with increasing age in groups over 50 or 60 years old.4 5 6 7 8 Acute injuries and chronic wounds can allow entrance of Clostridium tetani.1 9 10 11 We report the case of a non-immunised patient with generalised tetanus after biopsy of a chronic ulcerated skin lesion.

Case report

A 67 year old man was referred to the dermatology department with a two year history of skin lesions on his right leg. The patient was otherwise healthy and not taking any drugs. On physical examination he had painless subcutaneous nodules on the distal part of the right thigh (fig 1) and an asymptomatic eroded, scabbed, violaceous, well defined plaque on the upper side of the right ankle (fig 2]). He had no signs of infection, arterial or venous disease, or history of trauma. Possible diagnoses included lupus vulgaris or other mycobacterioses, necrobiosis, and sarcoidosis. Biopsy specimens were taken from both lesions in the operating theatre under standard aseptic conditions. The patient was told to care for the wounds by daily washing with water and soap and applying a topic antiseptic until stitches were removed.

Figure1

Fig 1 Painless subcutaneous nodules on the distal part of the right thigh; adjacent skin shows scar of biopsy performed two years previously

Figure2

Fig 2 Eroded, scabbed, violaceous, well defined plaque with eschars inside the right ankle

Three weeks after the biopsies, the patient presented to the emergency service with acute dysphagia, odynophagia, and trismus. Symptoms evolved to cervical hyperextension, rigidity of the scapular waist muscles, and finally opisthotonos. On admission, the lesion on the right ankle had been dirty and necrotic (fig 3); the patient had not been vaccinated against tetanus and did gardening at home. A diagnosis of generalised tetanus was considered, and he was transferred to the intensive care unit, where he received tetanus immunoglobulin and antitetanus toxoid. He developed respiratory difficulties and signs of autonomic dysfunction and needed sedation, intubation, assisted ventilation and, later, tracheostomy, neuromuscular blocking agents, drugs to control autonomic nervous system dysfunction, and intravenous antibiotics. He developed a pneumothorax, a pleural effusion that required chest tube drainage, two episodes of pneumonia due to mechanical ventilation, and catheter related bloodstream infection. Alcaligenes sp and meticillin sensitive Staphylococcus aureus grew in cultures from the skin lesion on the right ankle. C tetani was not isolated, but tetanus (severity 3b) was diagnosed on clinical grounds.12

Figure3

Fig 3 Lesion on inside of right ankle was dirty and necrotic when patient was admitted, three weeks after biopsy

The patient stayed in the intensive care unit for 49 days until he was successfully extubated; he was transferred to the internal medical floor and discharged two months after admission. Leg lesions were diagnosed as sarcoidosis with cutaneous and pulmonary involvement and were treated with corticosteroids.

Discussion

The annual incidence of tetanus has decreased dramatically in developed countries since the introduction of tetanus toxoid and is now 0.16 per million population in the United States.1 International prophylaxis recommendations13 may be modified by local directives.14

In developed countries tetanus occurs mainly in elderly people, who have had irregular booster shots in adulthood.1 The concentration of tetanus antibodies reduces with age, so that in a serological analysis carried out in the US only 31% of 70 year olds, and 47% in Australia, had protective levels of tetanus antibodies, whereas in England and Wales 53% of people over 60 had protective levels.4 7 8 In Spain, a national seroprevalence survey in 1996 showed that only 55% of people born before 1966 had protective levels of antibodies.14

The risk of developing tetanus through chronic ulcerated skin lesions tends to be overlooked, even though varicose ulcers, dermatosis, and necrosed tumours have been the point of entry in 11% to 14% of cases.9 10 In diabetic patients with foot ulcerations, tetanus enters through these wounds in up to 25% of cases.15 The death rate is higher in such cases than in cases related to acute trauma.16 Up to 47% of patients with chronic leg ulcers—which affect 3-5% of people over 6517—have insufficient IgG concentrations for immunity, rising to 70% in patients aged over 80.9 Consequently, chronic ulcerated wounds should be considered as prone to tetanus, and recommendations highlight the importance of prophylaxis.9 11 15 18

Tetanus after surgery is uncommon. Most cases develop within 24 hours after gastrointestinal or gynaecological surgery.19 20 Both exogenous and endogenous sources could be responsible, as spores of C tetani can be found in operating rooms or in the intestinal content of asymptomatic colonised patients.9 19 Giving IgG before gastrointestinal surgery has been proposed.21

Our patient developed severe generalised tetanus three weeks after the biopsy of a chronic ulcerated skin lesion, and the port of entry was probably the lesion. This case is unlikely to be considered as postsurgical tetanus, but the biopsy wound could have opened a route. Wound cultures did not isolate C tetani (but cultures are positive in only 32-50% of patients11) and a diagnosis of tetanus could be made on clinical grounds.12 Our patient had not been vaccinated. His long hospital stay with intensive care produced high risks and costs as a result of what is a preventable disease.

What can general practitioners do to prevent these cases?

To ensure high population coverage of tetanus vaccination, every opportunity should be taken to offer boosters to adults. Acute wounds are not the only lesions that should be considered as tetanus prone. Chronic ulcerated lesions like pressure ulcers, venous stasis ulcers, necrosed tumours, or diabetic feet, which are common in elderly people, should also be considered , and such patients should receive tetanus prophylaxis according to local directives. Skin biopsy of these sort of lesions could be another opportunity to ensure the immunisation status of patients.

Notes

Cite this as: BMJ 2009;339:b4419

Footnotes

  • Contributors: BA identified and managed the case, performed the literature search, and wrote the article. AF identified and managed the case, performed the literature search and revised the article. IG-D had the idea for the article, performed the literature search and revised the article. AG-C and CdelaT managed the case. MC revised the article. BA is guarantor.

  • Funding: None.

  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.

References

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