Tetanus are caused by tetanus toxin(tetanospasmin),produced by Clostridium tetani, whose spores survive in soil and cause infection by contaminating wounds. The following is a case of patient with history of pricked by palm oil thorn who was diagnosed with tetanus infection.
61 years old Chinese gentleman presented with difficulty swallowing solids, unable to open mouth, hypersalivation and slurred speech for two days. Works as rubber tapper, had history of herbicide usage (unsure content) without PPE. On arrival patient afebrile, no gastrointestinal symptoms, vital signs stable, limited mouth opening, no excessive sweating, no limb weakness but there was a puncture wound lateral aspect of left knee, which patient claims had been pricked by palm oil thorn two weeks ago. Blood parameters were normal and was referred to dental and ORL team but no abnormalities detected. Clinical diagnosis of tetanus was made in view persistent trismus, history of pricked by palm oil thorn, and unsure history of last tetanus immunization. Patient was treated with intravenous Diazepam, tetanus immunoglobulin 3000 unit, antitetanus toxoid, intravenous Metronidazole, Magnesium Sulphate and Baclofen. Patient was then ventilated in dark room in ICU sedated with Midamorphine infusion. Patient was spasm free from day 17 of admission, however delayed weaning due to patient developed nosocomial infection and was discharged well after 30 days.
Discussion & Conclusion
Tetanus is a clinical syndrome without confirmatory laboratory tests. Differential diagnosis was confusing in view patient had herbiscide exposure and only trismus during presentation which later developed into generalised tetanus. Early diagnosis and treatment is essential to avoid fatal outcome.
tetanus, spasm, palm oil thorn