Kazuhito Nomura1, Eiji Sakawaki2, Sonoko Sakawaki2, Ayumu Yamaoka3, Wakiko Aisaka4, Hiroyuki Okamoto5, Yoshihiro Takeyama2, Shuji Uemura4, Eichi Narimatsu4. 1. Department of Emergency Medicine, Sapporo Medical University, Minami 1-jo, Nishi 16-chome, 291, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan. sufjan_beirut@yahoo.co.jp. 2. Department of Emergency Medicine, Hakodate Municipal Hospital, 1-chome 10-1, Minato-cho, Hakodate-shi, Hokkaido, 041-8680, Japan. 3. Department of Neurosurgery, Sunagawa City Medical Center, 3-chome1-1 Nishi 4-jo Kita, Sunagawa-shi, Hokkaido, 073-0196, Japan. 4. Department of Emergency Medicine, Sapporo Medical University, Minami 1-jo, Nishi 16-chome, 291, Chuo-ku, Sapporo-shi, Hokkaido, 060-8543, Japan. 5. Department of Emergency Medicine, Teine Keijinkai Hospital, 12-chome 1-40, Maeda 1-jo, Teine-ku, Sapporo-shi, Hokkaido, 006-0811, Japan.
Abstract
BACKGROUND: Previous studies have reported poor prognosis in cases of tetanus that develops after bacteria enters via breast cancer-related skin ulcers that are not treated with surgical debridement. Herein, we review the literature concerning this presentation and report the first case of complete remission from tetanus without surgical debridement of the skin ulcer. CASE PRESENTATION: An Asian woman aged over 60 years had a history of skin ulcer caused by breast cancer. She was diagnosed with tetanus due to trismus and opisthotonus. Based on the suspicion that the skin ulcer was the portal of entry for tetanus bacteria, we considered several debridement and thoracic surgical options for tetanus treatment. However, debridement was not performed as the surgery was considered high risk and the patient did not consent to it. The patient received treatment with anti-tetanus globulin and metronidazole; sound insulation and shielding were also performed in a dark room. Subsequently, the patient's symptoms improved, and sound insulation and deep sedation management were completed on 19th day of hospitalization. With no symptom recurrence, the patient was discharged on Day 54. To date, over 3 years after treatment, no evidence of tetanus recurrence has been observed. The case was characterized by a lack of autonomic hyperactivity. The tetanus severity was likely representative of the low amount of toxin that the patient was exposed to. CONCLUSION: This case involved moderate severity tetanus originating from a chronic skin ulcer related to breast cancer. The patient survived without undergoing extensive debridement. No evidence of tetanus relapse was observed during the follow-up period, likely due to vaccination that might have restored the patient's active immunity. Debridement is not always necessary for tetanus complicated by breast cancer skin ulcers. Furthermore, appropriate toxoid vaccination is critical for preventing the onset and recurrence of tetanus in these patients.
BACKGROUND: Previous studies have reported poor prognosis in cases of tetanus that develops after bacteria enters via breast cancer-related skin ulcers that are not treated with surgical debridement. Herein, we review the literature concerning this presentation and report the first case of complete remission from tetanus without surgical debridement of the skin ulcer. CASE PRESENTATION: An Asian woman aged over 60 years had a history of skin ulcer caused by breast cancer. She was diagnosed with tetanus due to trismus and opisthotonus. Based on the suspicion that the skin ulcer was the portal of entry for tetanus bacteria, we considered several debridement and thoracic surgical options for tetanus treatment. However, debridement was not performed as the surgery was considered high risk and the patient did not consent to it. The patient received treatment with anti-tetanus globulin and metronidazole; sound insulation and shielding were also performed in a dark room. Subsequently, the patient's symptoms improved, and sound insulation and deep sedation management were completed on 19th day of hospitalization. With no symptom recurrence, the patient was discharged on Day 54. To date, over 3 years after treatment, no evidence of tetanus recurrence has been observed. The case was characterized by a lack of autonomic hyperactivity. The tetanus severity was likely representative of the low amount of toxin that the patient was exposed to. CONCLUSION: This case involved moderate severity tetanus originating from a chronic skin ulcer related to breast cancer. The patient survived without undergoing extensive debridement. No evidence of tetanus relapse was observed during the follow-up period, likely due to vaccination that might have restored the patient's active immunity. Debridement is not always necessary for tetanus complicated by breast cancer skin ulcers. Furthermore, appropriate toxoid vaccination is critical for preventing the onset and recurrence of tetanus in these patients.
Entities:
Keywords:
Tetanus, chronic wound, breast cancer, skin ulcer, non-operative strategy
Authors: James I Campbell; Thi Minh Yen Lam; Thi Loan Huynh; So Diep To; Thi Thu Nga Tran; Van Minh Hoang Nguyen; Thanh Son Le; van Vinh Chau Nguyen; Christopher Parry; Jeremy J Farrar; Tinh Hien Tran; Stephen Baker Journal: Am J Trop Med Hyg Date: 2009-05 Impact factor: 2.345