1
34
intermittent provoked spasms. The vital signs were nor-
mal. The assessment was moderate tetanus. The septic
wound was debrided and managed, and it healed after
seven days. He was given anti-tetanus serum 10,000
units stat and intravenous metronidazole 200mg eight-
hourly for seven days. He also had a cocktail of titrated
intravenous diazepam 5mg/kg/day, intramuscular phe-
nobarbitone 7.5mg/kg/day and intravenous chlorpro-
mazine 25mg every 12 hours for fourteen days. Five
days into treatment the spasms stopped, but by the third
week of therapy there was no improvement in trismus.
By this time the maximal inter-incisors distance was
Deep penetrating dirty wounds such as noted in this
report favour the occurrence of tetanus. The first, unmis-
takable feature of tetanus in most cases1,2 as in this case is
trismus due to masseter muscle spasm.
Nuchal rigidity and dysphagia produce the scornful fa-
cial appearance termed risus sardonicus. Opisthotonus
may occur with severe and frequent spasms. Sound,
light or touch can trigger these spasms. The patient re-
mains conscious, but unfortunately in agony because of
the fear of the next spasm. Cranial nerv1e3palsy and facial
spasms are features of cephalic tetanus.
0
and could interact with others except that he could nei-
ther talk nor eat solids.
.5cm, he was spasm free,was fully conscious, ambulant
For spasm control, centrally acting and skeletal muscle
relaxants are options. The former has the advantage of
tranquilizing the patient while controlling spasms. How-
ever, the need for respiratory support in some cases ne-
cessitates caution in their use. Magnesium sulphate is
He was then started on oral baclofen (compounded into
syrup) at 10mg daily. Five days later the maximal inter-
incisors’ distance was 1.0cm, and a week later it was
increasingly being 1used as an option in controlling teta-
4-16
nus muscle spasm
and intratheccal baclofen is also
2
second week of oral baclofen there was complete resolu-
tion of trismus and recovery of speech.
.5cm. There was improvement in speech and by the
used to produce skeletal m1u7s,1c8le relaxation and to control
spasms during the disease. Guglani et al have used
enteral baclofen to contro19l spasms that was unresponsive
to high dose midazolam.
Discussion
Conclusion
The relationship between poor wound management cum
dirty environmen4tal conditions and tetanus has long
been established.
The successful treatment of prolonged trismus following
tetanus in this report indicates the need for further stud-
ies on the use of enteral baclofen in the treatment of
mild to moderate tetanus. Although intratheccal baclofen
is currently in use, in less severe cases early commence-
ment of enteral baclofen may reduce the severity and
morbidity of the disease. Again, oral baclofen is
This in part explains the differences in the burden of
tetanus prevalence and mortality between developed and
5
developing countries. The disease is prevalent in devel-
oping countries because of low coverage of tetanus v-8ac-
6
non-invasive and it is available in poor countries.
cination amongst pregnant women and children. It
was reported in separate Nigerian studies that neonatal
tetanus is a reasonable contributor to newborn morbidity
and mortality in some parts of the country.
Conflict of interest : None
Funding : None
9
-11
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