CASE REPORT

Niger J Paed 2013; 40 (2): 189 –191

Nte A R

Gabriel-Job N

Tetanus with multiple wedge

vertebral collapses: A case report in

a 13 year old girl

DOI:http://dx.doi.org/10.4314/njp.v40i2,17

Accepted: 6th July 2012

Abstract Data from the case re- from corporal punishment in her

cords of a 13 year old Junior Secon- school. She was diagnosed to have

dary School Class two girl managed tetanus with vertebral collapses of

at the Department of Paediatrics of T3-T6. Tuberculosis and other

the University of Port Harcourt causes of vertebral collapse were

Teaching Hospital were extracted excluded. The tetanus was success-

for presentation to highlight verte- fully treated but she left against

bral collapse as an uncommon com- medical advice and defaulted from

plication of paediatric tetanus and follow-up for the management of

the associated management chal- the vertebral collapses. Poverty,

(

)

Nte A R

Gabriel-Job N

Department of Paediatrics,

University of Port Harcourt Teaching

Hospital,

PMB 6173 Port Harcourt, Nigeria.

E-mail: alicernte@yahoo.com

Tel: +2348033410046

lenges.

ignorance and belief in traditional

The girl presented with complaints health care were major obstacles to

of back pains-11 days, inability to her management.

open her mouth- 9 days, jerking of

the body- 8 days and upper back Key words: Multiple wedge verte-

swelling-6 days following bruises bral collapses in tetanus

Introduction

Case Report

Tetanus occurs when spores of C. tetani gain access into

SA, aged 13 years, presented with complaints of back

pains-11days, inability to open the mouth– nine days,

jerking of the body– eight days, and upper back swelling

– six days. She sustained bruises following corporal

punishment in school. The parents massaged the wounds

with warm water and applied gentian violet. Subse-

quently, she developed severe and sharp pains localized

at the upper back and aggravated by movements but

relieved by rest and analgesics. Two days after she be-

came unable to open her mouth and her teeth clenched

together. Subsequently she developed generalized jerk-

ing of the body provoked by sound, light and touch. She

remained conscious and continent of faeces and urine.

Although stiff, she could walk with support. With wors-

ening of symptoms, she developed a swelling at her up-

per back which progressively increased in size. Home

remedies for the swelling included massaging with hot

water and the application of "mentholatum"; analgesics

and ampiclox capsules. Failure to get relief for the

symptoms made the parents take her to a prayer house

where the back swelling was incised in several sites and

olive oil and other concoctions applied. With further

deterioration in her state, she was brought to the Teach-

ing Hospital. She was unimmunized, had no positive

history of contact with a case of tuberculosis and no

significant past medical and surgical histories.

tissues usually through puncture wounds or lacera-

1

,2

tions. In developing countries, post-neonatal tetanus is

associated with traumatic injury, often a penetrating

wound inflicted by dirty objects like nails, glass, unster-

ilized injection needle, broom sticks, circumcision and

scarification wounds. The injury itself is often trivial

and in 20% of cases, there may be no wound. The spores

however germinate in the wound and release tetanospas-

min which is taken up into motor nerve endings and

transported into the central nervous system where it

3

binds to gangliosides. There, it blocks the release of

neurotransmitters from the presynaptic inhibitory neu-

rons resulting in reflex irritability and autonomic hyper-

activity- cardinal features of tetanus. Reflex spasms de-

velop within one to four days of the first symptoms.

Spasms may be precipitated by minimal stimuli such as

noise, light, or touch and last from seconds to minutes.

They are painful and dangerous, and may cause laryn-

4

geal spasms, apnoea, rhabdomyolysis or fractures. Ver-

tebral fracture from tetanus is often undiagnosed and

can be mistaken for spinal tuberculosis hence the need

for a high index of suspicion. Although vertebral frac-

ture complicating tetanus has been reported among ado-

lescents and adults in Nigeria, none has been seen

among the several cases of tetanus managed in this unit

for about thirty years. The diagnosis of tetanus with

multiple vertebral collapses and the management chal-

lenges necessitated the current case report.

Significant findings on examination were an ill looking,

mildly pale teenager with several spontaneous and pro-

voked spasms, trismus, risus sardonicus, opisthotonus

1

90

and generalized rigidity. She had a firm, tender swelling

at the upper third of the back with desquamation and

excoriation of the overlying skin in some parts; and mul-

tiple scarification marks. Additionally, she had linear

ulcers on the right arm and left lateral chest wall and an

excoriation of the right popliteal area all attributed to the

corporal punishment. She was conscious, well oriented

to time, person and place and had no obvious cranial/

peripheral nerve deficits. She had marked neck stiffness,

generalised hypertonia but no sensory losses.

paedic surgeons reviewed the child, agreed with the di-

agnosis and scheduled her for surgery for the repair of

the vertebral collapses after her recovery from the teta-

nus. Follow up visits were made to the school authority

to intimate it with the child's case and the need to insti-

tute measures to prevent recurrence of such abuses. The

parents however opted for a peaceful settlement with the

school/teacher. When her spasms stopped and she could

walk unaided, she was taken home against medical ad-

vice. In spite of several home visits, she has not been

brought for follow up because the parents want her man-

aged locally.

The initial diagnosis was tetanus co-existing with tuber-

culosis of the spine to exclude multiple vertebral frac-

tures complicating the tetanus. Her full blood count

9

showed a total white cell count of 11.5 x10 /l; neutro-

phils- 80% and lymphocytes- 20%; packed cell volume -

3

3% and Erythrocyte sedimentation rate- 23mm/hour

Discussion

(

Western Green Method). Mantoux test and retroviral

screening were negative. The urinalysis and electrolyte,

urea and creatinine assays were normal. X-rays of the

cervical spine were normal except for the straightening

of the vertebrae. Thoracic spine radiographs showed

kyphoscoliosis, anterior wedge collapses of T3-T6 ver-

tebral bodies with reduction of their intervening disc

spaces (Fig. 1). The other vertebrae, paraspinal soft

tissues and chest were normal on X-rays and did not

suggest tuberculosis.

Lehndroff in 1907 first described spinal lesions from

1

,2

tetanus. Although the prevalence of the fractures is

variable with males being more affected, some have

reported them in about half the cases while Veronesi

found vertebral changes in 87% of a group of tetanus

5

-7

patients aged 1-20 years like our patient . Probably

because most of the cases of tetanus in our setting fol-

low injuries in the limbs, vertebral fractures have not

been reported as complicat₇i_,o₈ns compared to the situation

in other centres in Nigeria.

Fig 1 Radiograph of the

thoracic vertebrae showing

wedge collapse affecting

T3 to T6

The pathogenesis of the vertebral fractures is unknown

but several factors have been suggested such as the pre-

dominant spasms of the flexor group of muscles over the

extensors leading to a prosthotonus with an increase in

the thoracic kyphosis and fracture. Additional factors

include the over acceleration of endochondral ossifica-

tion during the periods of most active body growth,

causing ossification in the metaphyses of the vertebral

bodies to lag behind the predominant proliferation of

Multiple

thoracic

vertebral

wedge

columnar_,₇_,₉cartilage, vascular factors and metabolic

1

collapse

changes.

Furthermore, with the physiological kypho-

sis of the thoracic spine in juveniles, sustained muscular

contraction and tetanic spasms combine to produce frac-

tures of these spongy, relatively delicate bones with the

apex of the thoracic kyphosis usually acting as the ful-

crum. The presentation varies from asymptomatic to

9

back pains and swelling as in our patient. There are

usually no neurologic deficits as in our patient. As in

this patient, the multiple consecutive vertebral fractures

usually involve the fourth to the eighth thoracic (T4-T8)

vertebrae with fractures of T5 and T6 being the most

frequent and severe. It is not unusual to have involve-

ments as high as T3 and as low as T9. The₇ cervical and

lumbar vertebrae are almost never affected.

Pending the receipt of the results of the investigations,

she was commenced on rifampicin, pyrazinamide,

isoniazid and streptomycin for tuberculosis but these

were discontinued when the results were reviewed and

tuberculosis excluded. She was managed with the De-

partment’s protocol for tetanus which comprised of an-

titetanus serum (after a test dose), crystalline penicillin,

metronidazole, chropromazine, diazepam, phenobarbi-

tone and methocarbamol (Robaxin-a central muscle re-

laxant used to reduce skeletal muscle spasms). Ortho-

Although tuberculosis of the spine is one of the com-

monest causes of vertebral wedge collapse in our envi-

ronment, and was initially considered in this patient, the

acute onset of the child's illness as opposed to the in-

siduous onset in spinal tuberculosis with slow disease

progression and the other features excluded tuberculosis.

The usual presentation in tuberculosis consists of pain

overlying the affected vertebrae, low-grade fever, chills,

1

91

weight loss, and nonspecific constitutional symptoms of

varying duration. Paraplegia could be the first sign of

spinal disease in tuberculosis. Varying degrees of weak-

ness, nerve-root compression and sensory involvement

can occ₁u₀r. Weight loss has been recorded in 58% of

There may be single or multiple vertebral involvement

and skip lesions can occur. Paraspinal abscesses respon-

sible for soft tissue swelling may be visible on plain

radiograph. The presence of calcifications within the

abscess is virtually diagnostic of spinal TB. None of

these features was present in this patient.

11

patients and 90% to 100% of patients had back pain.

Neurological involvement varied in different studies

1

2

from 32% to 76% with notable differences in severity.

None of these features were found in our patient. Al-

though a positive test with the Purified Protein Deriva-

tive by Mantoux method was reported in 62-95% of

Conclusion

1

cases of vertebral tuberculosis, a negative test should

not be considered as completely excluding tuberculosis

infection. Furthermore, although, leukocytosis and ele-

vated Erythrocyte Sedimentation Rate (ESR) of over

1

patient did not have these features. Radiographic

changes associated with Pott’s disease present relatively

This 13 year old girl presented with active tetanus com-

plicated by multiple wedge collapses of T3-T6. She

responded to the regimen for tetanus but defaulted from

treatment for the vertebral fractures. Poverty, ignorance

and resort to local treatment remain barriers to success-

ful treatment of children.

11

00 mm/h (Westergreen Method) are suggestive, our

late and plain radiographs describe₀_-₁c₂hanges consistent

1

with TB spine in 91-99% of cases.

Radiographs may

Conflict of interest: None

Funding: None

reveal advanced lesions with vertebral osteolysis and

disc space narrowing affecting more commonly the

lower thoracic vertebrae than the lumbar and cervical

vertebrae.

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