O2209: Trauma, or is it?

Introduction: A 6-year-old previously healthy unvaccinated male presenting for evaluation of neck pain in the setting of suspected abnormal cervical spine radiographs.

Case Description: The patient presented with one day of mild neck and back pain after using an electronic massager (“massage gun”) on his neck. On arrival to the emergency department, his vital signs were appropriate. He reported episodes of intermittent abdominal pain lasting several minutes. On physical exam there was midline tenderness over the cervical spine, diffuse back tenderness, and hypertonicity. The patient had difficulty protruding the tongue and elevating the palate. He complained of pain when shrugging the shoulders. Cranial nerves were otherwise intact; sensation to light touch and motor function were intact in all extremities. There was concern for fracture on cervical spine radiographs.

As his presentation was concerning for tetanus, intravenous metronidazole 10 mg/kg every 8 hours, tetanus immunoglobulin (TIG) 500 IU, and tetanus, diphtheria, and acellular pertussis (Tdap) vaccine were promptly administered.

He continued to worsen and developed opisthotonus. He was hypoxemic during muscle spasms and required transfer to the pediatric intensive care unit for intubation and mechanical ventilation. He required pharmacologic sedation and paralysis to maintain oxygenation and ventilation.

On day 21 of hospitalization, he was successfully extubated. Fasciculations persisted through much of his hospital course, although they resolved prior to discharge.

Discussion: Tetanus is a toxin-mediated illness caused by the anaerobic bacteria Clostridium tetani. Clinical manifestations are preceded by asymptomatic infection with C. tetani spores, which germinate and produce toxin. The incubation period ranges from 3 to 21 days with most cases occurring within 8 days of exposure. The toxin, aptly named tetanospasmin, binds to the presynaptic motor neurons and prohibits release of gamma-aminobutyric acid. This loss of inhibition results in unopposed muscle spasms. Tetanus can be localized or diffuse; clinical manifestations include local, cephalic, and generalized tetanus. Management includes debridement of wounds, administration of intramuscular tetanus immune globulin, metronidazole, and supportive cares. The tetanus vaccine is the most effective prevention strategy.

Conclusion: This patient presented with neck pain after recent massage gun use and concern for fracture on cervical spine imaging. Tetanus was astutely included in the differential diagnosis early in this patient’s clinical course, and he received timely and appropriate management of his tetanus infection. Maintaining a broad deferential, continuously updating clinical assessments, and avoiding anchoring bias ensured that an accurate diagnosis was made.