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Survival from severe generalized tetanus complicated by seizures and multidrug-resistant septic shock: A case report
*Corresponding author: Tariq Ahmed Zayan, Department of Nephrology, Sur Hospital, Ministry of Health, Sur, Oman. tariqzayan@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Mohammed Saeed MA, Masud AA, Zayan TA. Survival from severe generalized tetanus complicated by seizures and multidrug-resistant septic shock: A case report. World Adv Renal Med. doi: 10.25259/WARM_25_2025
Abstract
Tetanus, a vaccine-preventable disease caused by the neurotoxin of Clostridium tetani, remains a significant cause of morbidity and mortality, particularly in low-income countries with inadequate immunization coverage. Severe generalized tetanus, the most common clinical presentation, is characterized by excruciating muscle spasms, rigidity, and autonomic nervous system dysfunction, often necessitating intensive care unit (ICU) admission. The prognosis is further worsened by life-threatening complications such as respiratory failure and sepsis. We present the case of a 49-year-old male with severe generalized tetanus following a contaminated wound, whose hospital course was complicated by multidrug-resistant septic shock. Despite a prolonged and challenging ICU stay, the patient made a remarkable and complete neurological recovery. This case highlights the critical importance of early diagnosis, aggressive multidisciplinary ICU management, and comprehensive rehabilitation in achieving favorable outcomes in the face of overwhelming complications.
Keywords
Bacterial
Critical care
Multidrug resistance
Septic shock
Tetanus
INTRODUCTION
Tetanus is a devastating neurological disorder caused by tetanospasmin, a potent neurotoxin produced by the spore-forming, obligate anaerobic bacterium Clostridium tetani.[1] The spores of C. tetani are ubiquitous in the environment, commonly found in soil, dust, and animal feces. Infection occurs when these spores are introduced into the body through a contaminated wound, burn, or other penetrating injury. In anaerobic conditions, the spores germinate and release tetanospasmin, which then travels via retrograde axonal transport to the central nervous system. The toxin acts by blocking the release of inhibitory neurotransmitters, primarily glycine and gamma-aminobutyric acid (GABA), from presynaptic terminals in the spinal cord and brainstem. This disinhibition of motor neurons leads to the characteristic clinical manifestations of tetanus: Generalized muscle rigidity, painful spasms, and autonomic dysfunction.[2]
Despite the availability of a highly effective vaccine since the 1920s, tetanus remains a major public health problem globally, with an estimated 30,000–50,000 deaths annually.[3] The majority of cases and deaths occur in low- and middle-income countries, particularly in South and Southeast Asia and sub-Saharan Africa, where vaccination coverage is often suboptimal.[4]
Generalized tetanus is the most common and severe form of the disease, accounting for over 80% of cases. It typically presents with trismus (lockjaw), followed by stiffness of the neck, dysphagia, and rigidity of the abdominal and back muscles. Painful, generalized muscle spasms, often triggered by minimal stimuli, can lead to opisthotonus, fractures, and respiratory compromise. Autonomic nervous system dysfunction is a common and life-threatening complication of severe tetanus, manifesting as labile hypertension and tachycardia, arrhythmias, and profuse sweating.[5,6]
The management of severe generalized tetanus is challenging and requires a multidisciplinary approach in an intensive care unit (ICU) setting. The cornerstones of treatment include neutralization of unbound toxin with human tetanus immunoglobulin (HTIG), eradication of C. tetani with appropriate antibiotics, control of muscle spasms with sedatives and neuromuscular blocking agents, and aggressive supportive care, including mechanical ventilation and management of autonomic instability.[7]
This report describes the case of a 49-year-old male with severe generalized tetanus complicated by multidrug-resistant (MDR) septic shock, who survived with an excellent neurological outcome. This case underscores the complexities of managing severe tetanus and its life-threatening complications and highlights the potential for a favorable prognosis with timely and aggressive multidisciplinary care.
CASE REPORT
A 49-year-old male with no significant past medical history presented to the emergency department with a constellation of symptoms suggestive of generalized tetanus. His symptoms, which included trismus (lockjaw), generalized rigidity, and stiffness of the cervical and paraspinal muscles, had been progressively worsening over the preceding few days. The patient also reported episodes of restlessness and agitation, which were only partially alleviated by promethazine and midazolam.
Notably, the patient had sought medical attention twice before at the same emergency department. During his initial visits, he was evaluated by a dentist, who attributed his symptoms to a dental issue and discharged him with a prescription for lidocaine. However, as his symptoms escalated, a more thorough history was obtained, revealing a penetrating injury to his right foot sustained 1 week prior while working on a farm. He reported receiving four injections at a private clinic following the injury, though the exact medications administered could not be verified, and his immunization status for tetanus remained unknown.
One month before his presentation, the patient had undergone an evaluation for suspected pulmonary tuberculosis, which was ultimately ruled out. However, a high-resolution computed tomography (HRCT) scan of the chest at that time revealed bilateral bronchiectatic changes, suggestive of old, healed tuberculosis.
On physical examination, the patient exhibited classic signs of severe tetanus, including trismus, risus sardonicus, and opisthotonus. His abdomen was scaphoid and diffusely rigid. Examination of his right foot revealed a swollen, purulent wound with surrounding necrotic tissue. His vital signs were as follows: temperature, 35.5°C; blood pressure, 116/101 mmHg; and oxygen saturation, 96% on room air. Auscultation of his chest revealed bilateral crackles. His cardiac examination was unremarkable.
Initial laboratory investigations, including a complete blood count, serum electrolytes, and renal and liver function tests, were within normal limits. An electrocardiogram showed a normal sinus rhythm. A chest X-ray confirmed the presence of bilateral bronchiectatic changes, consistent with his previous HRCT findings. A swab of the right foot wound was sent for culture and sensitivity testing. Sequential laboratory and physiologic trends during the hospital course are presented in Table 1.
| Time point | Clinical event | Intervention/Management | Outcome/Response |
|---|---|---|---|
| Day - 2 | Right foot penetrating injury while working on farm | Received 4 undocumented injections at private hospital |
Unknown vaccination status |
| Day- 1 | Second ED visit with worsening symptoms | Dental re-evaluation | Discharged home |
| Day 0 | Third ED presentation with classic tetanus signs |
• Clinical diagnosis of generalized tetanus • Human tetanus immunoglobulin • Magnesium sulfate and diazepam • Broad-spectrum antibiotics • Surgical wound debridement |
Admission to quiet, darkened room |
| Day 1-2 | Development of continuous spasms and seizures | • ICU transfer • Endotracheal intubation • Mechanical ventilation • Sedation and paralysis |
Airway secured, spasm control initiated |
| Day 3-7 | Onset of septic shock with hypotension | • Vasopressor support (noradrenaline) • Blood and wound cultures • Empirical broad-spectrum antibiotics |
Hemodynamic stabilization |
| Day 8-14 | MDR organisms identified in cultures | • Culture-guided antibiotic therapy • Multiple antibiotic regimens • Intravenous immunoglobulins |
Gradual infection control |
| Day 15-21 | Continued ICU support with complications | • Continuous magnesium infusion • Benzodiazepine infusions • Nutritional support • Infection control measures |
Slow clinical improvement |
| Day 22-28 | Weaning from mechanical ventilation | • Gradual ventilator weaning • Tracheostomy performed • Continued wound care |
Successful extubation |
| Day 29-35 | Transfer to medical ward | • Intensive physiotherapy • Rehabilitation program • Wound healing management |
Progressive mobility improvement |
| Day 36-42 | Preparation for discharge | • Tracheostomy decannulation • Independent mobility training • Discharge planning |
Excellent neurological recovery |
| Discharge | Hospital discharge | • Complete neurological recovery • Independent ambulation • Wound healing complete |
Full functional recovery |
ED: Emergency department, ICU: Intensive care unit, MDR: Multidrug resistant.
Clinical course
Given the classic clinical presentation, a diagnosis of generalized tetanus was made, and the patient was admitted to a quiet, darkened room to minimize external stimuli. The initial management plan included the administration of HTIG, intravenous magnesium sulfate, diazepam for spasm control, and broad-spectrum antibiotics. Surgical debridement of the right foot wound was performed, followed by regular dressing changes.
Within 24 h of admission, despite these initial measures, the patient’s clinical condition deteriorated. He developed continuous, severe tetanic spasms, which compromised his respiratory function. Consequently, he was transferred to the ICU, where he was intubated and placed on mechanical ventilation for airway protection and to facilitate sedation and paralysis for spasm control.
His ICU course was further complicated by the development of septic shock, characterized by persistent hypotension requiring vasopressor support with noradrenaline. Blood cultures identified carbapenem-resistant Klebsiella pneumoniae, while wound cultures grew MDR Pseudomonas aeruginosa. His antibiotic regimen was tailored based on the culture and sensitivity results, and he required multiple courses of different antibiotics. In addition to vasopressors and targeted antibiotic therapy, intravenous immunoglobulins were administered for potential immunomodulatory effects in the setting of severe septic shock. His management in the ICU also included continuous infusions of magnesium and benzodiazepines, and comprehensive supportive care, including nutritional support and meticulous infection control measures.
After a prolonged and challenging ICU stay spanning several weeks, the patient’s condition gradually improved. He was successfully weaned from mechanical ventilation and extubated. He subsequently underwent a tracheostomy for long-term airway management, which was later decannulated. Following his transfer from the ICU to a medical ward, he participated in an intensive physiotherapy and rehabilitation program to address his profound deconditioning and residual muscle stiffness. He continued to receive regular wound care for his right foot.
At the time of his discharge from the hospital, the patient had made an excellent neurological recovery. He was independently mobile and had no significant residual neurological deficits. The patient’s chronological clinical course and interventions are summarized in Table 2. The comprehensive ICU management strategy, including spasm control, antimicrobial therapy, and supportive interventions, is summarized in Table 3.
| Time point | Clinical status | Interventions |
|---|---|---|
| Day 1 | Presentation with trismus, rigidity, agitation | Admission; HTIG; IV magnesium; diazepam; antibiotics; wound debridement |
| Day 2 | Clinical deterioration with severe spasms | ICU transfer; intubation; mechanical ventilation; sedation |
| Week 1-2 | Severe spasms; development of septic shock | Vasopressors; targeted antibiotics for MDR organisms; IVIG; continuous sedation |
| Week 3-4 | Gradual improvement | Weaning from ventilation; tracheostomy |
| Week 5-6 | Continued recovery | Decannulation; transfer to ward; intensive physiotherapy |
| Discharge | Excellent neurological recovery | Ambulatory; independent; no residual deficits |
HTIG: Human tetanus immunoglobulin, IV: Intravenous, ICU: Intensive care unit, MDR: Multidrug-resistant, IVIG: Intravenous immunoglobulin.
| Category | Agent/Intervention | Dosage/Details | Duration | Indication | Response |
|---|---|---|---|---|---|
| Antitoxin therapy | |||||
| Human tetanus immunoglobin | 3000 IU intramuscular | Single dose | Day 0 | Neutralize circulating toxin | Good clinical response |
| Spasm control | |||||
| Diazepam | 10-20 mg IV q4-6h initially, then continuous infusion 5-10 mg/h | Days 0-28 | Muscle spasm control | Effective spasm reduction | |
| Magnesium Sulfate | Loading: 4g IV over 20 min, then 2-4 g/h continuous | Days 0-21 | Spasm control, neuroprotection | Synergistic with diazepam | |
| Midazolam | 0.1-0.2 mg/kg/h continuous infusion | Days 2-18 | Sedation, spasm control | Good sedation achieved | |
| Neuromuscular blockade | |||||
| Vecuronium | 0.1 mg/kg bolus, then 0.05-0.1 mg/kg/h | Days 3-14 | Severe spasm control | Complete paralysis achieved | |
| Antimicrobial therapy | |||||
| Metronidazole | 500 mg IV q8h | Days 0-10 | Wound source control | C. tetani eradication | |
| Vancomycin | 15-20 mg/kg IV q12h (trough 15-20 μg/mL) | Days 3-14 | MRSA coverage | Effective against MRSA | |
| Meropenem | 2g IV q8h | Days 5-12 | Broad-spectrum coverage | Good gram-negative coverage | |
| Linezolid | 600 mg IV q12h | Days 8-15 | Alternative MRSA coverage | Used for vancomycin resistance | |
| Vasopressor support | |||||
| Noradrenaline | 0.05-0.3 μg/kg/min | Days 3-10 | Septic shock management | Hemodyna mic stabilization | |
| Respiratory support | |||||
| Mechanical ventilation | Volume control, PEEP 5-8 cmH2O, FiO2 0.4-0.6 | Days 1-28 | Respiratory failure, airway protection | Successful ventilation | |
| Tracheostomy | Percutaneous technique | Day 14 | Long-term airway management | Facilitated weaning | |
| Supportive care | |||||
| Enteral nutrition | 25-30 kcal/kg/day via nasogastric tube | Days 2-35 | Nutritional support | Maintained nutrition | |
| Proton pump inhibitor | Pantoprazole 40 mg IV daily | Days 1-42 | Stress ulcer prophylaxis | No GI bleeding | |
| Deep vein thrombosis prophylaxis | Enoxaparin 40 mg SC daily | Days 1-42 | Thromboembolism prevention | No thrombotic events | |
| Immunomodulation | |||||
| Intravenous immunoglobulin | 0.4 g/kg/day×5 days | Days 5-9 | Sepsis management | Possible benefit | |
| Surgical intervention | |||||
| Wound debridement | Aggressive surgical debridement | Days 0, 2, 5 | Source control | Complete necrotic tissue removal | |
| Rehabilitation | |||||
| Physiotherapy | Progressive mobilization and strengthening | Days 15-42 | Functional recovery | Excellent mobility restoration |
IV: Intravenous; SC: Subcutaneous, q4-6h: Every 4-6 hours, q8h: Every 8 hours, q12h: Every 12 hours, PEEP: Positive end-expiratory pressure, FiO2: Fraction of inspired oxygen, MRSA: Methicillin-resistant Staphylococcus aureus, GI: Gastrointestinal.
DISCUSSION
This case report describes the successful management of a patient with severe generalized tetanus complicated by life-threatening MDR septic shock. The patient’s survival and excellent neurological recovery, despite the severity of his illness, underscore the importance of a high index of suspicion for tetanus in patients with compatible clinical features and a history of a contaminated wound, as well as the critical role of aggressive, multidisciplinary ICU care.
The diagnosis of tetanus is primarily clinical, based on the characteristic signs and symptoms. As illustrated in this case, the initial presentation can be misleading, leading to delays in diagnosis and treatment. Our patient’s initial visits to the emergency department, where his symptoms were attributed to a dental problem, highlight the need for a thorough history and physical examination, particularly in patients with risk factors for tetanus, such as a recent wound and unknown or incomplete immunization status. The 1-week interval between injury and presentation, combined with the progressive nature of symptoms from trismus to generalized rigidity, was characteristic of generalized tetanus.
The management of severe tetanus is a formidable challenge, requiring a multifaceted approach aimed at neutralizing the toxin, controlling muscle spasms, managing autonomic dysfunction, and providing comprehensive supportive care. The administration of HTIG is a critical first step to neutralize circulating tetanospasmin and prevent further binding to the central nervous system. Wound debridement and antibiotic therapy are essential to eradicate the source of the toxin. In our patient, early wound debridement was performed promptly on diagnosis.
Control of muscle spasms and rigidity is a cornerstone of tetanus management. Benzodiazepines, such as diazepam, are the mainstay of treatment, acting as GABA agonists to counteract the effects of the toxin. In severe cases, high doses and continuous infusions are often required. Magnesium sulfate, which has both central and peripheral effects, is a useful adjunct to benzodiazepines. In patients with refractory spasms, as in our case, neuromuscular blocking agents and mechanical ventilation are necessary to prevent respiratory failure and other complications. Our patient required intubation within 24 h of admission due to the severity and frequency of spasms, highlighting the rapid progression that can occur despite initial therapy.
The development of septic shock in our patient, caused by carbapenem-resistant K. pneumoniae and MDR P. aeruginosa, added another layer of complexity to his management. Sepsis is a well-recognized complication of severe tetanus, often arising from nosocomial infections in the setting of prolonged ICU stay and invasive procedures. The presence of carbapenem resistance in particular posed significant therapeutic challenges and required consultation with infectious disease specialists. The successful management of our patient’s septic shock required a combination of vasopressor support, targeted antibiotic therapy based on culture and sensitivity results, and immunomodulation with intravenous immunoglobulins.
The prognosis of severe generalized tetanus has improved significantly with the advent of modern intensive care. However, mortality rates remain high, ranging from 10% to 50%, even in well-resourced settings.[8] Several factors have been associated with a poor prognosis, including a short incubation period, a rapid onset of symptoms, the presence of autonomic dysfunction, and the need for mechanical ventilation.[9] Our patient had several of these poor prognostic factors, making his complete recovery particularly noteworthy. His recovery emphasizes that aggressive ICU support and meticulous attention to complications can overcome even multiple adverse prognostic indicators.
This case also highlights the importance of a multidisciplinary team approach in the management of severe tetanus. The successful outcome was the result of the coordinated efforts of the emergency department, ICU, surgery, infectious diseases, pharmacy, and rehabilitation teams. The patient’s prolonged and challenging ICU course, followed by an intensive rehabilitation program, was instrumental in his recovery.
Finally, this case serves as a stark reminder of the importance of tetanus vaccination. Tetanus is an entirely preventable disease, and routine immunization is the most effective strategy to reduce its global burden. In patients with tetanus-prone wounds, appropriate wound care and post-exposure prophylaxis with tetanus toxoid and, in some cases, HTIG, are crucial to prevent the development of the disease. The unclear immunization status in our patient underscores the ongoing challenge of vaccine coverage and documentation in some populations.
Learning Points
A high index of suspicion for tetanus should be maintained in patients with trismus, rigidity, and a history of a contaminated wound, even in high-income countries.
Early and aggressive management in an ICU setting is crucial for survival in severe generalized tetanus.
A multidisciplinary team approach is essential for managing the complex and life-threatening complications of tetanus.
Complete neurological recovery is possible even in the most severe cases of tetanus.
Tetanus vaccination is the most effective way to prevent this devastating disease.
CONCLUSION
Severe generalized tetanus remains a life-threatening disease, particularly when complicated by septic shock caused by MDR organisms. This case demonstrates that with early diagnosis, aggressive and comprehensive ICU care, and a dedicated multidisciplinary team, even patients with the most severe forms of the disease can achieve a complete and functional recovery. The importance of tetanus vaccination as the primary preventive measure cannot be overemphasized.
Acknowledgments:
We would like to acknowledge the invaluable contributions of the multidisciplinary teams at our institution, including the staff of the Emergency Department, ICU, Department of Surgery, Department of Infectious Diseases, Pharmacy, and the Rehabilitation and Physiotherapy services, for their dedication and expertise in the management of this patient.
Author contributions:
MAMS: Contributed towards patient care and management, data collection, manuscript drafting, and critical review of the manuscript; AAM: Responsible for patient care and management, neurological assessment, data interpretation, and critical review of the manuscript; TAZ: Contributed towards stusdy conceptualization, patient care and management, data collection and analysis, manuscript drafting, literature review, critical revision of the manuscript, responsible for overall manuscript coordination and final approval. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as the patient’s identity is not disclosed or compromised.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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