CASE REPORT

TETANUS IN CHILDHOOD
Presenter : Steven Tandean
Day/Date : Wednesday/Feb 24th 2007
Supervisor : dr. Hj. Tiangsa br. Sembiring, SpA(K)

INTRODUCTION
Tetanus is an intoxication characterized by increased muscle tone and
spasms caused by the release of the neurotoxin tetanospasmin by Clostridium
tetani following inoculation into a human host. Tetanus occurs in several clinical
forms, including generalized, cephalic, localized, and neonatal disease.1
Clostridium tetani is found worldwide in soil, on inanimate objects, in
animal feces, and, occasionally, in human feces. The disease is common in areas
where soil is cultivated, in rural areas and in warm climates. In countries without a
comprehensive immunization program, tetanus predominantly develops in
neonates and young children.2
The incubation period is variable, with a usual range of 5 to 14 days;
however, it may be as short as 1 day or as long as 3 or more weeks. The disease
begins insidiously, with progressively increasing stiffness of the voluntary
muscles; generally, the muscles of the jaw and neck are involved first. Within 24
to 48 hours after the onset of the disease, rigidity may be fully developed and may
spread rapidly to involve the trunk and extremities. With spasm of the jaw
muscles, trismus (lockjaw) develops. The wrinkling of the forehead and distortion
of the eyebrows, and the angles of the mouth produce a peculiar facial appearance
called risus sardonicus (sardonic grin). The neck and back become stiff and
arched (opisthotonos). The abdominal wall is board like, and the extremities are
usually stiff and extended.1,2,3
Painful paroxysmal spasms that persist for a few seconds or several
minutes may be provoked by the most trivial kind of visual, auditory, or

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cutaneous stimuli, such as bright lights, sudden noises, and movement of the
patient. Risus sardonicus and opisthotonos are most marked during these spasms.
Initially the spasms occur at infrequent intervals, with complete relaxation
between attacks. Later the spasms occur more often and are more prolonged and
more painful. Involvement of the muscles of respiration, laryngeal obstruction
caused by laryngospasm, or accumulation of secretions in the tracheobronchial
tree may be followed by respiratory distress, asphyxia, coma, and death.
Involvement of the bladder sphincter leads to urinary retention.1,2
The manifestations of sympathetic nervous system involvement may
include labile hypertension, tachycardia, peripheral vasoconstriction, cardiac
arrhythmias, profuse sweating, hypercapnia, increased urinary excretion of
catecholamines, and late-appearing hypotension.1
During the illness the patient’s sensorium is usually clear. The fever is
generally low grade or absent. Patients who recover are usually afebrile. After a
period of weeks the paroxysms decrease in frequency and severity and gradually
disappear. Generally, the trismus is the last symptom to subside. Patients with
fatal disease are usually febrile, with death occurring in most instances before the
tenth day of illness.2,4
The diagnosis is made on clinical grounds. There may be a mild
polymorphonuclear leukocytosis. The CSF is normal with the exception of mild
elevation of opening pressure. Serum muscle enzymes may be elevated. Transient
electrocardiographic and electroencephalographic abnormalities may occur.
Anaerobic culture and microscopic examination of pus from the wound can be
helpful, but Clostridium tetani is difficult to grow, and the drumstick-shaped
gram-positive bacilli often cannot be found.1,4
Management of tetanus requires eradication of Clostridium tetani and the
wound environment conducive to its anaerobic multiplication, neutralization of all
accessible tetanus toxin, control of seizures and respiration, palliation, and
prevention of recurrences. The usual dose of Tetanus Anti Toxin (TAT) is 40.000
U, with half given intramuscularly and the other half given intravenously with 200
cc NaCl 0,9%. It also recommended administered tetanus toxoid 0,5 cc
intramuscular for active protection. The eradication of Clostridium tetani using

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Penicillin Procain (50.000 U/kg/12 hours IM) or Metronidazole (500 mg every 8
hr IV for adults) appears to be equally effective. All patients with generalized
tetanus need muscle relaxants. Diazepam provides both relaxation and seizure
control.1,4

The aim of this paper is to report a case of Tetanus in a 3 years old boy.

CASE
M, 3 years old boy, was admitted to HAM Hospital on January 21th 2010 with
main complaint was seizure since one week before, general seizure with clear
conscious, two times within less than 5 minutes, seizure occur spontaneously and
with stimulation and spasm of the hand and leg. Unable to open mouth because of
the spam since one week before. Continuous fever were found since one week
before without shiver. No wound and trauma history. Smelly and yellowish ear
liquid were found since two weeks before. Patient never receive any
immunization. No cough, no nausea, no vomit and no diarrhoea. Defecation and
urinate normal. Patient was refered from Tanjung Pura hospital with the diagnosis
of tetanus. Patient was given Cefotaxim, dexamethason, diazepam, Tetanus
antitoxin and paracetamol.

Physical examination
Consciousness was alert, body weight 17 kg, body length 104 cm, body
temperature 37,6 oC.. Body weight/ Body length: 100%
General disease were severe and nutritional condition were good
There were no pale, icterus, cyanosis, and edema but dyspnea.(+)
Head : face: spasm of facial and buccal ( risus sardonicus)
Eye : light reflexes (+), isochoric pupil
Ears: yellowish and smelly liquid come out from left ear
Nose: using NGT ( from Tanjung Pura hospital)
Mouth: Trismus (+), mouth can open 1,5 cm
Neck : Lymph node enlargement (-), nuchal rigidity (+)
Chest : Symmetrical fusiform, no retraction

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 HR : 108 bpm,reg,murmur (-)
RR : 30 tpm,reg, rales (-)
Abdominal : Defanse muscular (+), opistotonus (+)
Hepar and Lien: were not palpable
Peristaltis was normal
Extremities : Pulse was 108 tpm,reg, normal tone and volume
Spastic (+)
Right Left
Physiological reflex: KPR/APR +/+ +/+
Biceps/triceps +/+ +/+

Differential diagnosis:
- Tetanus + Chronic otitis media suppuratif sinistra
- Retropharyngeal abscess + Chronic otitis media suppuratif sinistra
- Rabies + Chronic otitis media suppuratif sinistra

Working diagnosis:
- Tetanus + Chronic otitis media suppuratif sinistra

Treatment:
- isolated room
- O2 1 L/i nasal cannule
- IVFD Dextrose 5% NaCl 0,9% 20 gtt/i micro
- Penicillin Procain Injection 50.000 IU/Kg/12 hours  900.000 IU/12
hours/IM  skin test
- Diazepam injection 10 mg/IV  seizure control
- Diazepam injection 9 mg/3 hours/IV  maintenance
- Tetanus Toxoid injection 0,5 cc/ IM
- Paracetamol 3x 250 mg (if needed)
- Nasogastric feeding tube, diet 1700 kkal + 34 gr protein in 1000cc (250 cc
every 6 hours)

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Planning:
- Consult to infection division
- Consult to Ear Nose Throat Department

FOLLOW-UP
January 22th - January 24th 2010
S : Seizure and yellowish and smelly Ear liquid
O: consciousness was alert, T:37,1 oC, BW 17 kg
Head : face: spasm of facial and buccal ( risus sardonicus)
Eye : light reflexes (+), isochoric pupil
Ears: yellowish and smelly liquid from left ear
Nose: using NGT
Mouth: Trismus (+), mouth can open 1,5 cm
Neck : nuchal rigidity (+)
Chest : Symmetrical fusiform, no retraction
HR : 100 bpm,reg,murmur (-)
RR : 26 tpm,reg, rales (-)
Abdominal : Defanse muscular (+), opistotonus (+)
Hepar and Lien: were not palpable
Peristaltis was normal
Extremities : Pulse was 100 tpm,reg, normal tone and volume
Spastic (+)
Right Left
Physiological reflex: KPR/APR +/+ +/+
Biceps/triceps +/+ +/+

Diagnosis: Tetanus + Chronic otitis media suppuratif sinistra

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Treatment:
- isolated room
- O2 1 L/i nasal cannule
- IVFD Dextrose 5% NaCl 0,9% 15 gtt/i micro
- Penicillin Procain Injection 50.000 IU/Kg/12 hours  900.000 IU/12
hours/IM
- Diazepam injection 10 mg/IV  seizure control (if needed)
- Diazepam injection 9 mg/3 hours/IV  maintenance
- Paracetamol 3x 250 mg (if needed)
- Nasogastric feeding tube, diet 1700 kkal + 34 gr protein in 1000 cc (250 cc
every 6 hours)

Answer from Ear Nose Throat department: diagnosis serumen proop duplex +
tetanus and treatment according to pediatric department. Suggestion: reconsult for
serumen toilet after general condition is good.

January 25th - January 28th 2010

S : Mouth hard to open and worm came out with the feses
O: consciousness was alert, T:36,7 oC, BW 17 kg
Head : Eye : light reflexes (+), isochoric pupil
Mouth: Trismus (+), mouth can open 3 cm
Chest : Symmetrical fusiform, no retraction
HR : 108 bpm,reg,murmur (-)
RR : 26 tpm,reg, rales (-)
Abdominal : Hepar and Lien: were not palpable,
Peristaltis was normal.
Extremities : Pulse was 108 tpm,reg, normal tone and volume
Spastic (+) decrease
Right Left

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Physiological reflex: KPR/APR +/+ +/+
Biceps/triceps +/+ +/+
Diagnosis: Tetanus + Ascariasis

Treatment:
- isolated room
- Penicillin Procain Injection 50.000 IU/Kg/12 hours  900.000 IU/12
hours/IM
- Diazepam Injetion 7,5 mg/3 hours/IV  maintenance
- Albendazole 1x 400 mg (single dose)
- Chicken porridge diet 1700 kkal + 34 gr protein

January 29th - January 31th 2010

S : Mouth hard to open
O: consciousness was alert, T:36,7 oC, BW 17 kg
Head : Eye : light reflexes (+), isochoric pupil
Mouth: Trismus (+), mouth can open more than 3 cm
Chest : Symmetrical fusiform, no retraction
HR : 104 bpm,reg,murmur (-)
RR : 28 tpm,reg, rales (-)
Abdominal : Hepar and Lien: were not palpable,
Peristaltis was normal.
Extremities : Pulse was 104 tpm,reg, normal tone and volume

Right Left
Physiological reflex: KPR/APR +/+ +/+
Biceps/triceps +/+ +/+

Diagnosis: Tetanus

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Treatment:
- Penicillin Procain Injection 50.000 IU/Kg/12 hours  900.000 IU/12
hours/IM
- Tablet Diazepam 6,5 mg/3 hours/oral  tapering off 1 mg every day
- Cooked rice diet 1700 kkal with 34 gr protein

The Patient was discharged with control on February 1th 2010. Patient was given
Diazepam tablets to continue tapering off.

DISCUSSION
The picture of tetanus is one of the most dramatic in medicine, and the
diagnosis is established clinically like the presents of trismus, other rigid muscles,
and seizure with clear sensorium. The typical setting is an unimmunized patient
who was injured, perforated otitis media or insect bite. The incubation period
typically is 2–14 days, but it may be as long as months after the injury. In this
case, patient was 3 years old boy without any immunization history and the main
complaint was seizure with clear conscious, unable to open mouth and spasm of
the hand and leg. The trauma history was neglected by the parent but the parent
complaint Smelly and yellowish ear liquid (+) since two weeks before.1, 5
Tetanus induced Sustained trismus, sardonic smile (risus sardonicus),
persistent spasm of the abdominal and back musculature may cause opisthotonus
and clear sensorium. With progression, the extremities become involved in
episodes of painful flexion and adduction of the arms, clenched fists, and
extension of the legs. Noise or tactile stimuli may precipitate spasms and
generalized convulsions. All of the tetanus’s sign was found from the physical
examination of the patient. No laboratory studies and radiology test was done
from this patient because the result usually normal or mild leukocytosis and the
test can induced seizure so the test is not a must.2, 5
Generalized tetanus cannot be mistaken for any other disease. However,
trismus may result from parapharyngeal, retropharyngeal, or dental abscess. Either
rabies or tetanus may present as trismus with seizures. However, rabies may be

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distinguished from tetanus by hydrophobia, marked dysphagia, predominantly
clonic seizures, and pleocytosis. Hypocalcemia may produce tetany that is
characterized by laryngeal and carpopedal spasms, but trismus is absent.2,6
Management of tetanus requires eradication of Clostridium tetani and the
wound environment conducive to its anaerobic multiplication, neutralization of all
accessible tetanus toxin, control of seizures and respiration, palliation, supportive
care and, finally, prevention of recurrences. Tetanus toxin cannot be neutralized
by Human tetanus immunoglobulin (TIG) and Tetanus antitoxin (TAT) after it has
begun its axonal ascent to the spinal cord. Human tetanus immunoglobulin (TIG)
or Tetanus antioxin (TAT) should be given as soon as possible in order to
neutralize toxin that diffuses from the wound into the circulation before the toxin
can bind at distant muscle groups. Human tetanus immunoglobulin (TIG) is
recommended A single total dose of 3000-6000 U for children and adults or
Tetanus Anti Toxin (TAT). Another alternative is administred Tetanus antitoxin
with usual dose 40.000 U, with half given intramuscularly and the other half given
intravenously with 200 cc NaCl 0,9%.. For patient without any history of tetanus
immunization or the last immunization is more than 5 years, it recommended to
administered tetanus toxoid 0,5 cc intramuscular and contralateral with the human
tetanus immunoglobulin (TIG) and tetanus antitoxin (TAT) injection site. the
second administration given 4–6 wk after the 1st and the third administration
given 6–12 mo after the second with the same dose.1,7
Skin test is needed before the administration of tetanus antitoksin because
it usually cause allergic reaction. If skin test for tetanus antitoxin is positive the
administration of tetanus antitoxin using desensitization or besredka test. Tetanus
antitoxin is dilute with Saline 0,9% and given intravenously in thirteen times
every 15 minute. The first administration, 0,1 ml tetanus antitoxin dilute with
saline 0,9% 1/1000, second administration give 0,3 ml tetanus antitoxin dilute
with saline 0,9% 1/1000, third administration give 0,6 ml tetanus antitoxin dilute
with saline 0,9% 1/1000, fourth administration give 0,1 ml tetanus antitoxin dilute
with saline 0,9% 1/100, fifth administration give 0,3 ml tetanus antitoxin dilute
with saline 0,9% 1/100, sixth administration give 0,6 ml tetanus antitoxin dilute
with saline 0,9% 1/100, seventh administration give 0,1 tetanus antitoxin dilute

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with saline 0,9% 1/10, eight administration give 0,3 ml tetanus antitoxin dilute
with saline 0,9% 1/10, ninth administration give 0,6 ml tetanus antitoxin dilute
with saline 0,9% 1/10, tenth administration give 0,1 ml tetanus antitoxin without
dilution, eleventh administration give 0,3 ml tetanus antitoxin without dilution,
twelfth administration give 0,6 ml tetanus antitoxin without dilution and for the
last administration give 1 ml tetanus antitoxin without dilution.
The possibility of developing tetanus directly correlates with the
characteristics of the wound. Wounds should be explored, carefully cleansed, and
properly debrided. Antimicrobials are used to decrease the number of vegetative
forms (source of toxin) of C tetani in the wound to stop toxin production. Oral or
intravenous metronidazole (30 mg/kg per day, given at 6-hour intervals) is
effective in reducing the number of vegetative forms of Clostridium tetani.7,11
Parenteral penicillin procain is an alternative drug (50.000 U/kg per day, given at
12-hour intervals) or eritromycin (40-50 mg/kg per day, divided into 4 dosage).3
For the management of muscular spasms should be the administration of
appropriate drugs to reduce the number and severity of spasms. Diazepam
provides both relaxation and seizure control. The initial dose for controlling the
seizure is 10-20 mg intravenously and can be repeat 3 times. For maintenance,
Diazepam 3-4 mg/kg every 3 hr given intravenously. While the maintenance dose
is given and occur spontan seizure, administered Diazepam 10 mg intravenously
and reschedule the maintenance by shorten the interval or adding diazepam dose
15%.2,8,9
Treatments for this patient was penicillin procain 900.000 U/ 12 hour/ IM
for ten days, tetanus toxoid 0,5 cc/ IM, Diazepam 10 mg/ IV for control the
seizure and maintain with Diazepam 9 mg/ 3 hour/ IV and tetanus toxoid 0,5 cc/
IM. Eradication of Clostridium tetani using penicillin procain is the drug of
choice in Pediatric department of Sumatera Utara University but in other
institution metronidazole is the drug of choice. A higher survival rate was
obtained with metronidazole than with penicillin in one nonrandomized trial. 7,11
The management of muscular spasms for this patient using diazepam is
appropriate and there is no reschedule for the maintenance because no spontan
seizure. Diazepam injection was given for 8 days and switch to oral then tapered

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10% - 15% everyday. Toxin neutralization for this patient was not given because
he already administrated tetanus antitoxin at Tanjung Pura hospital so this patient
only given tetanus toxoid 0,5 cc/ IM. The patient was plan to be given the second
administration 4-6 weeks after the first administration and 6-12 month after the
second administration.3,10,11
From the randomized research, it proven that children with vitamin A
supplement show a significant greater IgG response to tetanus than children that
receive placebo. From the research, this patient is recommended to administrated
vitamin A per oral (60.000 µg retinol equivalent) before the tetanus vaccination.12
Patient’s chronic otitis media suppuratif sinistra was consulted to ear nose
throat department and the treatment is penicillin antimicrobial. b-lactam
antibiotics remains the first-line antibiotic for treating otitis media. After four days
penicillin administration, ear liquid was negative. This patient need to consult to
ear nose and throat department again after muscular spasms resolve for further
examination. Otitis media suppuratif need a proper treatment to prevent the
complication and port d’entrée of microorganism.3
This patient also has ascariasis and the diagnose is been made by the
finding of ascaris worm in the feses. Ascariasis is very common in developing
country but has a good prognosis if treated properly. Ascariasis can be treated by
using albendazole and the dosage depend on the patient age. In this case, the
patient was administrated 400 mg single dose per oral because the patient is more
than 2 years old. The patient need to be check for stool examination after 3 week
albendazole administration for treatment evaluation and if ascariasis is still
positive, treat again the patient with albendazole 400 mg per oral single dose or
alternative drug.12

SUMMARY
It has been reported a case of a child with tetanus. The diagnosis was established
based on anamnesis, clinical sign, symptoms, and physical examination. The
prognostic of this patient was good but need to control for the otitis media
suppuratif and ascariasis to prevent recurency and complication.

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 DAFTAR PUSTAKA

1. Arnon SS. Tetanus (Clostridium Tetani). In: Kliegman RM, Behrman RE, Jenson
HB, Stanton BF, Eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia,
Saunders Elsevier publisher; 2007: 815 – 822
2. Ogle JW, Anderson MS. Infections: Bacterial & spirochetal. In: Hay WW,
Hayward HR, Levin MJ, Sondheimer JM, Eds. Current Pediatric Diagnosis &
Treatment. 16th ed. Colorado, Lange; 2002: 789 – 799
3. Hassan R, Alatas H. Tetanus (“Lockjaw”). In: Hassan R, Alatas H, Eds. Buku
Kuliah 2 Ilmu Kesehatan Anak. Jakarta, Percetakan Infomedika Jakarta.; 2007:
568-572
4. Wilfert C, Hotez P. Tetanus (Lockjaw) and Neonatal Tetanus. In: Gerson A,
Hotez P, Katz S, Eds. Krugman’s Infectious Diseases of Children. 11th ed. New
York, Mosby Inc; 2004: 487 – 490.
5. Cook TM, Protheroe RT, Handel JM. Tetanus: A Review of The Literature. Br J
Anaesth, 2001; 87: 477-87
6. Bhatia R, Prabhakar S, Grover VK. Tetanus. Neurol India, 2002; 50: 398-407.
7. Tolan RW. 2009. Tetanus. Available at:
http://emedicine.medscape.com/article/972901. accessed January 30, 2010
8. Ritarwan K. 2004. Tetanus. USU Digital Library. accesed january 30, 2010
9. Konig K, Ringe H, Dorner BG, Diers A, Uhlenberg, B, Muller D, et al. Atypical
Tetanus in a Completely Immunized 14-Years-Old Boy. Pediatrics, 2007; 120:
e1355-e1358
10. Bunch TJ, Thalji MK, Pellikka PA, Aksamit TR. Respiratory Failure in Tetanus.
Chest, 2007; 122: 1488-1492
11. Semba RD, Scott AL, Natadisastra G, Wirasasmita S, Mele L, Ridwan E, et al.
Depressed Immune Response to Tetanus in Children with Vitamin A Deficiency.
J Nutr, 1992; 122: 101-107
12. Dora-Laskey A, Ezenkwele UA. Ascariasis Lumbricoides. 2009. Available at:
http://emedicine.medscape.com/article/788398. Accessed January 30, 2010.

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