A pediatric case of generalized tetanus treated with intrathecal baclofen

IntroductionGeneralized tetanus from Clostridium tetani infections is rare in the United States due to widespread use of tetanus toxoid-containing vaccines, and management of these critically ill patients can be challenging. We report a case of generalized tetanus in a pediatric patient treated with multiple sedatives and paralytics whose stabilization was associated with initiation of intrathecal baclofen.CaseA 16-year-old unvaccinated male suffered a puncture wound to his left heel and presented with trismus, difficulty swallowing, diaphoresis, hypertension at 153/86 mmHg, and tachycardia at 120 bpm one week after sustaining the injury. The patient was intubated, received wound debridement, antibiotics, tetanus immune globulin, and a Tdap (tetanus, diphtheria, acellular, pertussis) vaccine. His tetany and autonomic stability worsened. He received norepinephrine, esmolol, midazolam, magnesium, morphine, propofol, vecuronium, dexmedetomidine, dantrolene, and oral baclofen without improvement. Intrathecal baclofen was started on hospital day 18, and within a day vecuronium was discontinued, and multiple sedatives were titrated down. He received intrathecal baclofen until hospital day 35 and was discharged on hospital day 40.DiscussionIntrathecal baclofen is a potential treatment for generalized tetanus which may allow for reduction in paralytic and sedative use, and possibly shorter duration of mechanical ventilation and inpatient time.