Case: Meningitis
Case Study: Severe Facial Pain and Stiff Neck
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“For the past three days I’ve had a pain in my jaw and it’s really hard to swallow. I also have a really stiff neck and I feel sort of feverish and anxious. Could I have meningitis?”
Case: Joelle is a 32-year-old woman who works as a freelance videographer in a busy urban area. She works approximately 50 hours a week, traveling to various locations within the state to shoot TV commercials. She denies any foreign travel or exposure to a known infectious agent. She works out frequently and denies any drug or alcohol use. She is a vegetarian and cooks most of her meals at home using fresh produce from local farm stands. She currently lives with her lesbian partner of many years.
Past medical history is negative for surgeries, illnesses, or allergies. She states that prior to this incident she’s been “healthy as a horse.” She takes no over-the-counter medications other than an occasional aspirin for various joint and muscle aches and a “natural” multivitamin. Her last medical encounter was more than 14 years ago when she presented to the ED for removal of a piece of glass from her foot. She is certain that she received a tetanus booster at that time, but due to her parents’ concern about vaccines does not believe she received any or all of her pediatric vaccines. She was advised at the time of the ER visit to finish the vaccine cycle, but forgot. Patient notes that she pierced herself for an umbilical ring three weeks ago using a needle she had sterilized. No muscular pain in abdomen or back.
On physical examination, she appears restless and anxious. Temperature is 101.1°F; she is mildly diaphoretic. BP 120/60; heart rate is 96 and respiration is normal. HEENT: mild, sporadic spasms of the jaw and neck. Neck is painful on rotation in either direction, but there is no nuchal rigidity. Abdominal examination: pierced umbilicus with an embedded ring, surrounded by erythema and purulent discharge. Remainder of examination is unremarkable.
How would you proceed?
Discussion
The presence of a purulent wound at a puncture site in conjunction with the jaw/neck symptoms suggests that Joelle might have grade 1 tetanus. Despite the fact that the prevalence of tetanus has decreased more than 99% in the United States since the 1940s, it remains a rare but life-threatening disease in the United States.[1]
Tetanus is an infectious disease caused by a neurotoxin secreted from the spores of gram-positive anaerobic bacillus, clostridium tetani. The usual entry point is a puncture wound, laceration, or abrasion from a dirty or infected object, which can become contaminated with the bacterial spores. Infection occurs when the spores become activated and develop into gram-positive bacteria that multiply and produce a powerful toxin, which causes muscle rigidity and spasms. Symptoms usually begin around eight days after infection, but may range in onset from three days to three weeks. The rigidity usually involves the jaw (trismus or lockjaw) and neck first, and then becomes more generalized.
Tetanus is the only vaccine-preventable disease that is infectious but not contagious. As there are no laboratory findings that are characteristic of tetanus, the diagnosis is entirely clinical and does not depend upon bacteriologic confirmation. In fact, C. tetani is recovered from the wound in only 30% of cases and can also be isolated from patients who do not have tetanus.
Joelle should be referred immediately to an infectious disease specialist and hospitalized.
Treatment will likely consist of wide surgical wound debridement and removal of the umbilical ring, followed by a single intramuscular dose of tetanus immune globulin (TIG) 3000 to 5000 units with some of the dose injected near the wound site. Joelle also should be immediately re-immunized with a tetanus/diphtheria (Td) booster and urged to finish the primary vaccination cycle she missed as a child; because of the extreme potency of the toxin, tetanus disease does not result in tetanus immunity.[2] Because antitoxin levels decrease with time, routine boosters, such as Td or Tdap, are recommended for adults every 10 years. If a dose is given sooner as part of wound management, the next booster is not needed for 10 years thereafter. More frequent boosters are not indicated and have been reported to result in an increased incidence and severity of local adverse reactions.[2]
While antibiotic therapy against tetanus is less critical than proper wound care and immunization, it is still used.[2] When antibiotics are required for patients with suspect wounds, the recommended regimen is metronidazole 500 mg IV every six hours or orally for 10 to 14 days.[3] Penicillin G (2-4 million units IV every 4-6 hours) is another option.[4,5]
According to the Centers for Disease Control and Prevention, inadequate tetanus vaccination, wound prophylaxis, and intravenous drug use remain the most important factors associated with tetanus.[1,2,6] Surveys of adults have shown declining vaccination coverage with increasing age and missed opportunities to vaccinate adult women and older adults in primary care settings are common.[7] Patients might not receive optimal tetanus prophylaxis as part of routine wound management because of the trivial appearance of many wounds and the failure of healthcare providers to obtain a vaccination history, particularly from those who are not up to date with their tetanus vaccination. Providers should review vaccination status during adult healthcare visits to ensure that persons with inadequate vaccination complete the primary tetanus series and are up to date with booster doses.
Published on May 31, 2011
Updated on June 8, 2011
References
- Centers for Disease Control and Prevention. Tetanus surveillance—United States, 2001-2008. MMWR Morb Mortal Wkly Rep. 2011;60(12):365-269.
- Tetanus. In: Atkinson W, Wolfe S, Hamorsky J, eds. Centers for Disease Control and Prevention, Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th ed. Washington, DC: Public Health Foundation; 2011:291-300.
- Afshar M, Raju M, Ansell D, Bleck TP. Narrative review: tetanus–a health threat after natural disasters in developing countries. Ann Intern Med. 2011;154(5):329-335.
- Yen LM, Dao LM, Day NPJ. Management of tetanus: a comparison of penicillin and metronidazole. Symposium of antimicrobial resistance in southern Viet Nam, 1997.
- Saltoglu N, Tasova Y, Midikli D, et al. Prognostic factors affecting deaths from adult tetanus. Clin Microbiol Infect. 2004;10(3):229.
- Hopkins RS, Jajosky RA, Hall PA, et al. Summary of notifiable diseases–United States, 2003. MMWR Morb Mortal Wkly Rep. 2005;52(54)1-85.
- Nowalk MP, Zimmerman RK, Cleary SM, Bruehlman RD. Missed opportunities to vaccinate older adults in primary care. J Am Board Fam Pract. 2005;18(1):20-27.
MR of neck. Possible retropharyngeal abcess.
culture pierce, admit, iv antibiotics, observe
possible tetanus
Remove the piercing and start her on broad spectrum antibiotics.
Possible tetanus
Check throat,mri /ct neck,admit,pain in troat jaw unlikely in tetanus,meningitis
Tetanus immunization. Hyperimmune globulin. Culture pierced area. IV antibiotics.
Agree with TETANUS as a primary DX.
Agree with plan!
Agree with the plan
Facial nerve inflammation
Antibiotics for tetanus, admit and observe for meningitis symptoms
Labs, we know she has an infection from the piercing
routine cultures: pierce, urine, blood, admit, IV antiibotics, observe
Debride & culture wound. Empiric tetanus toxoid and tetanus immune globulin. Admit and give IV penicillin G q 4 hr.
Access throat for abscess, cx, TT and TIG debide and cx umbilicus area also admit IV Abs broad spectrum with a MRI/CT of neck
admit, culture and debride wound, give broad spectrum antibiotics, tetanus shots, work her up for tetanus- does she have the classic risus sardonicus appearance?
iv antibiotic coverage for Clostridium (flagy) , Tetenus IG, wound and blood cx, benzo for muscle spasms, admit
Tetanus
admit patient, hydrate, culture wound, administer tet prophylaxis, if positive for cl tetanii, need high dose penicillins, immune serum therapy, all support Rx,respiratory, nutrition, metabolic assit etc, further rx on further results etc
Gram stain for postive rods, get anarobic cultures and treat tetanus immnoglobulin
Could be localized tetanus since has had some immunization, and used punctured near the umbilicus. Get cultures, remove ring and possibly debride, CT scan area, use penicillin and amoxicillin/sulbactam. Would use tetanus antitoxin. Use diazapam and watch for deteriorating resp failure.
Admit, observe, IV hydration, CBC w/diff, Tetanus immune globulin, tetanus toxoid (since she thinks she did receive vaccine partially) Pen G IV, Diazepam, wound debridement with culture
Admit. Give Tetanus immunoglobulin (Lockjaw)maintain an adequate airway& culture wound,then start giving penni- cilline G.(2million u IV every 6 hours).
admit to observation unit, hydrate,cultures of the pierced site, tetanus shot,tylenol prn, CBC and CMP, broad spectrum antibiotics iv ,
In what part of the world is tetanus the most likely principal diagnosis???
Most likely Tetanus. Need Blood cultures and wound c&s.Iv Pencllin G,Td Tetanus Immuneglobulin.
I agree with tetanus as the diagnosis.
Would admit and administer medications for the muscle spasms.Close observation in the ICU for resp difficulty. Culture and treat her infected umbical site with IV broad spectrum antibotics. She will also need tetanus immune globlin. She will also need debridement of the wound far enough out to healthy tissue. This should not be done immmediately.
THis is probably tetanus- Needs admission, IV antibiotics, close monitoring, management of spasms.
tetanus until proven otherwise. timeline fits although she has not yet developed the typical hydrophobia and risus sardonicus. labs, iv hydrate, tetanus IgG, toxoid, briaod spectrum abtx, would not debride the wound yet but incise and drain it to take away the anaerobic environment, diazepam PRN, put in noise and light isolation.
Well written! If I were the patient, you’d be th one I’d pick, despite many of your colleagues saying much of the same. You put it succinctly and it looked complete. How’s your bedside manner?
Agree, suspect Tetanus. use Red Book rec for cx/tx.
This patient needs neck Ct-Scan with contrast to R/O Parapharyngeal abcess, and empiric ABX including Psuedomonus until things clarified.
good thing she didnt pierce har vagina
admit and culture wound site adminster penicillin. remove ring and debride area if necessary. diazepam for spasms and hydrate