Tetanus in an Unvaccinated Amish Woman After a Breech Home Delivery in Kentucky, 2016

Tetanus was suspected at an outlying hospital where a partial dose of tetanus immune globulin and penicillin G were administered prior to her transfer to a tertiary care hospital. Her vital signs were normal. The patient was conscious, lying on her side with her neck arched back, jaw clenched. Because of laryngospasm and to prevent respiratory failure, the patient required intubation and mechanical ventilation. She continued to experience upper extremity contractures in response to any external stimuli; proximal greater than distal. She also experienced intermittent episodes of stiffening followed by tonic-clonic motion of her extremities. Initial laboratory values were within normal limits except for an elevated creatinine phosphokinase (CPK) of 2,352 IU/L (Figure 1). To eliminate ongoing potential source of infection from the uterus, dilation and suction curettage was performed, with limited products of conception removed and specimens sent for Gram stain, culture, and pathology evaluation. Considering the patient’s history of an absence of tetanus vaccination, muscle spasms, and increased CPK, the diagnosis was narrowed exclusively to tetanus, and broad-spectrum therapy was deescalated to metronidazole. In addition, the remaining dose of immune globulin was administered intramuscularly to complete a total dose of 6000 IU. Active vaccination with tetanus and diphtheria vaccine was provided. The Gram stain from the uterine sample revealed no organisms, the culture was negative, and pathology reported severe acute inflammation and necrosis. One week after hospitalization, she developed diaphoresis and severe upper extremity contractures provoked with minimal external stimuli and other complications (Figure 1). She was eventually discharged home in stable condition after a 41-day hospitalization. A public health response was initiated by the state and local health departments to prevent additional cases through vaccination (Yaffee et al., 2017). Tetanus in an Unvaccinated Amish Woman After a Breech Home Delivery in Kentucky, 2016