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Tetanus After Anorectal Abscess
Case Report Tetanus After Anorectal Abscess KENNETH J. MYERS, M . D . , Resident in Surgery*; JACQUES HEPPELL, M . D . , Resident in Colon and Rectal Surgery*; WILLIAM E. BODE, M . D . ; CLYDE E. CULP, M . D . , F.A.C.S., Section of Colon and Rectal Surgery; DELORAN L. THURBER, M . D . , Division of Community Internal Medicine; ROBERT E. VAN SCOY, M . D . , Division of Infectious Diseases and Internal Medicine
As illustrated by this case report, tetanus can occur as a complication of anorectal surgical procedures or abscesses just as it can in other wounds. A synergistic infection of the perineum occurred in a 62-year-old man 8 days after drainage of an anorectal abscess. He was treated with vigorous debridement and antibiotics and was given tetanus prophylaxis. The next day, tetanus developed, presumably from the original abscess. The patient recovered after aggressive therapy, including muscle relaxants and ventilatory support.
The conditions necessary for the development of tetanus are organisms or spores in a wound, favorable anaerobic conditions for bacterial growth, and elaboration of exotoxin. The spores of Clostridium tetani are found worldwide in soil, dust, and intestinal content of humans and animals. Meyer and Spector1 found that stools of 1 % of urban patients who were admitted to a hospital for hernia repair contained this organism. Postoperative tetanus occurs rarely and, in some cases, may be caused by contamination from the patient's intestinal tract. 2 Tetanus has been reported in patients who had recently undergone intestinal operations, such as appendectomy, 3 gastrectomy, 4 resection of gangrenous small intestine, 5 ' 6 hemorrhoidectomy, 7 snare removal of rectal polyps with useofelectrocoagulation, and rubberband ligation of internal hemorrhoids. 8 In this case report, we illustrate that tetanus can complicate an anorectal aerobic-anaerobic synergistic infection and emphasize the need for adequate tetanus immunization or prophylaxis in patients scheduled to undergo anorectal surgical procedures. REPORT OF CASE A 62-year-old farmer was transferred to our institution because of sepsis caused by a gas-forming aerobicanaerobic synergistic infection of the perineum. At a hospital elsewhere, an anorectal abscess had been incised and drained, with use of local anesthesia, 8 days before transfer. On arrival, the patient had a fever, hypotension, tachycardia, and tachypnea; his skin was mottled, and he had a *Mayo Graduate School of Medicine, Rochester, Minnesota. Address reprint requests to Dr. C. E. Culp. Mayo Clin Proc 59:429-430, 1984
429
confused sensorium. Palpable crepitance and extensive cellulitis were evident on the scrotum and left buttock, and a foul-smelling exudate issued from the previous drainage site. A soft-tissue roentgenogram showed air in the scrotum and upper part of the left thigh. The patient was taken quickly to the operating room, and a Swan-Canz catheter and arterial line were placed. All necrotic tissue of the left buttock, scrotum, and perineum was extensively debrided. A large abscess cavity in the left ischioanal fossa communicated with the anal canal. The gluteus muscle contained a superficial area of necrosis. Cram's stain showed gram-negative and gram-positive bacilli and gram-positive cocci. A clinical diagnosis of necrotizing fasciitis was made. Administration of high doses of antibiotics (penicillin G, 20 million U/day by continuous intravenous infusion, and moxalactam, 2 g intravenously every 8 hours) was begun, and the patient received 0.5 ml of tetanus toxoid and 250 U of antitoxin in separate intramuscular injection sites. After 2 days, the dosages were decreased to penicillin C, 10 million U/day, and moxalactam, 1.5 g intravenously every 8 hours, because of a creatinine value of 1.6 mg/dl. The culture results were available after 5 days, and the antibiotic regimen was changed to cefoxitin, 1.5 g intravenously every 6 hours for a duration of 10 additional days. Organisms cultured from specimens from the site where the abscess was first drained were Escherichia coli, Staphylococcus epidermidis, viridans streptococci, Bacteroides fragilis, B. ovatus, B. melaninogenicus, Clostridium innocuum, and Peptococcus magnus. Cultures of specimens from the left buttock extension of the necrosis yielded ß. thetaiotaomicron, B. distasonis, C. innocuum, B. melaninogenicus, and Peptostreptococcus anaerobius. Cultures of specimens from the left thigh extension of the necrosis revealed E. coli, g r o u p F s t r e p t o c o c c u s , ß. thetaiotaomicron, B. distasonis, C. innocuum, and B. melaninogenicus. A suprapubic cystostomy tube had been inserted during
430
TETANUS AFTER ANORECTAL ABSCESS
the initial operation. Twenty-four hours later, minimal debridement was necessary when the wound was reexamined with the patient under general anesthesia, and by both clinical and hemodynamic evaluations, the septic process seemed to be under control. During the next day, the patient was restless, was greatly agitated in response to stimulation, had fasciculations, had rigidity of the extremities, and yet had what appeared to be a contented expression on his face. Excessive diaphoresis and muscle rigidity were progressive. Trismus became more apparent, and a clinical diagnosis of tetanus was made. The patient had no history of ingestion of alcohol. M e n ingitis was excluded by normal findings on lumbar puncture. The patient's record of tetanus immunization was difficult to obtain. He had been in the military service in the early 1940s and had had trauma to the right leg, which necessitated the placement of a skin graft in 1956. He had no other history of possible immunization in the past 26 years. The patient was given 3,000 U of human tetanus antitoxin and was sedated with diazepam (Valium) and morphine. For relief of the muscle spasms, he was paralyzed with pancuronium bromide (Pavulon), 1 to 3 mg intravenously at 1- to 2-hour intervals. A tracheostomy was performed, and an assist-control mechanical respirator was applied to the patient. An additional 2,000 U of antitoxin was given, and a Clinitron bed was used to decrease the possibility of pressure necrosis. Daily physical therapy and splints were used to prevent contractures. The patient's nutritional status was maintained with total parenteral nutrition. No diverting colostomy was performed. He received heparin, 5,000 U every 12 hours, as prophylaxis against deep vein thrombosis while he was immobilized. Wound care was performed every 6 hours. The patient had pronounced evidence of autonomic instability, with wide variations of blood pressure and cardiac arrhythmias; they were controlled with medications. He required controlled ventilation for 17 days before the spasms and rigidity resolved enough to allow normal respiration. W h e n his condition was stable and his wounds were clean, the remaining portion of his scrotum was closed and the testicles were placed in thigh pockets. Also, a split-thickness skin graft was placed on his left buttock. Two major complications occurred during the stay of 35 days in the intensive care unit. Acute parotiditis was successfully treated with intravenously administered oxacillin, 1 g every 6 hours for 5 days, and transient Candida fun-
Mayo Clin Proc, June 1984, Vol 59
gemia from an intravenous catheter was without sequela. The patient was dismissed 51 days after admission. Four months after dismissal, he had regained his normal weight, had no residual neurologic deficit, and had returned to work as a farmer. He continued to have a fistula in ano and at the time of this report was scheduled for definitive treatment in the near future. He began active immunization for tetanus, inasmuch as immunity is not ensured through infection. CONCLUSIONS As a result of increased public awareness, improved health-care delivery, and immunization, the incidence of tetanus in the United States has been greatly reduced. Nevertheless, tetanus is still a threat today. As this case points out, the recognition of a constellation of factors that contribute to the development of tetanus and a high index of suspicion aid in making an expedient and accurate diagnosis. A satisfactory result can be expected only with early diagnosis and aggressive therapy, especially in the older age group or in patients with severe tetanus. Immunization is a necessity and should not be overlooked in the treatment of tetanus victims. 9 REFERENCES 1. Meyer KA, Spector BK: The incidence of tetanus bacilli in the stools and on the regional skin of one hundred urban herniotomy cases. Surg Cynecol Obstet 54:785-789, 1932 2. Cohn IJr, BornsideGH: Infections. In Principles of Surgery. Third edition. Edited by SI Schwartz, GT Shires, FC Spencer, EH Storer. New York, McGraw-Hill Book Company, 1979, pp 204-207 3. Bunch GH, Quattlebaum J: Postoperative tetanus. Am J Surg 61:280-285, 1943 4. Hebraud, Sauvet P: Tetanos apres gastrectomie. Mem Acad Chir 78:722-724, 1952 5. Calvet ): Volvulus du grele et tetanos generalise. Presse Med 2:740-741, 1942 6. Clay RC, Bolton JW: Tetanus arising from gangrenous unperforated small intestine. JAMA 187:856-858, 1964 7. Matas R: The fecal origin of some forms of postoperative tetanus (anorectal, intestinal, puerperal, genital, and lower pelvic operations) and its prophylaxis by proper dietetic or culinary measures. Trans Am Surg Assoc 27:40-45, 1909 8. Murphy KJ: Tetanus after rubber-band ligation of haemorrhoids. BrMed J 1:1590-1591, 1978 9. Christensen NA, Thurber DL: Clinical experience with tetanus: 91 cases. Proc Staff Meet Mayo Clin 32:146-158, 1957
As illustrated by this case report, tetanus can occur as a complication of anorectal surgical procedures or abscesses just as it can in other wounds. A synergistic infection of the perineum occurred in a 62-year-old man 8 days after drainage of an anorectal abscess. He was treated with vigorous debridement and antibiotics and was given tetanus prophylaxis. The next day, tetanus developed, presumably from the original abscess. The patient recovered after aggressive therapy, including muscle relaxants and ventilatory support.
The conditions necessary for the development of tetanus are organisms or spores in a wound, favorable anaerobic conditions for bacterial growth, and elaboration of exotoxin. The spores of Clostridium tetani are found worldwide in soil, dust, and intestinal content of humans and animals. Meyer and Spector1 found that stools of 1 % of urban patients who were admitted to a hospital for hernia repair contained this organism. Postoperative tetanus occurs rarely and, in some cases, may be caused by contamination from the patient's intestinal tract. 2 Tetanus has been reported in patients who had recently undergone intestinal operations, such as appendectomy, 3 gastrectomy, 4 resection of gangrenous small intestine, 5 ' 6 hemorrhoidectomy, 7 snare removal of rectal polyps with useofelectrocoagulation, and rubberband ligation of internal hemorrhoids. 8 In this case report, we illustrate that tetanus can complicate an anorectal aerobic-anaerobic synergistic infection and emphasize the need for adequate tetanus immunization or prophylaxis in patients scheduled to undergo anorectal surgical procedures. REPORT OF CASE A 62-year-old farmer was transferred to our institution because of sepsis caused by a gas-forming aerobicanaerobic synergistic infection of the perineum. At a hospital elsewhere, an anorectal abscess had been incised and drained, with use of local anesthesia, 8 days before transfer. On arrival, the patient had a fever, hypotension, tachycardia, and tachypnea; his skin was mottled, and he had a *Mayo Graduate School of Medicine, Rochester, Minnesota. Address reprint requests to Dr. C. E. Culp. Mayo Clin Proc 59:429-430, 1984
429
confused sensorium. Palpable crepitance and extensive cellulitis were evident on the scrotum and left buttock, and a foul-smelling exudate issued from the previous drainage site. A soft-tissue roentgenogram showed air in the scrotum and upper part of the left thigh. The patient was taken quickly to the operating room, and a Swan-Canz catheter and arterial line were placed. All necrotic tissue of the left buttock, scrotum, and perineum was extensively debrided. A large abscess cavity in the left ischioanal fossa communicated with the anal canal. The gluteus muscle contained a superficial area of necrosis. Cram's stain showed gram-negative and gram-positive bacilli and gram-positive cocci. A clinical diagnosis of necrotizing fasciitis was made. Administration of high doses of antibiotics (penicillin G, 20 million U/day by continuous intravenous infusion, and moxalactam, 2 g intravenously every 8 hours) was begun, and the patient received 0.5 ml of tetanus toxoid and 250 U of antitoxin in separate intramuscular injection sites. After 2 days, the dosages were decreased to penicillin C, 10 million U/day, and moxalactam, 1.5 g intravenously every 8 hours, because of a creatinine value of 1.6 mg/dl. The culture results were available after 5 days, and the antibiotic regimen was changed to cefoxitin, 1.5 g intravenously every 6 hours for a duration of 10 additional days. Organisms cultured from specimens from the site where the abscess was first drained were Escherichia coli, Staphylococcus epidermidis, viridans streptococci, Bacteroides fragilis, B. ovatus, B. melaninogenicus, Clostridium innocuum, and Peptococcus magnus. Cultures of specimens from the left buttock extension of the necrosis yielded ß. thetaiotaomicron, B. distasonis, C. innocuum, B. melaninogenicus, and Peptostreptococcus anaerobius. Cultures of specimens from the left thigh extension of the necrosis revealed E. coli, g r o u p F s t r e p t o c o c c u s , ß. thetaiotaomicron, B. distasonis, C. innocuum, and B. melaninogenicus. A suprapubic cystostomy tube had been inserted during
430
TETANUS AFTER ANORECTAL ABSCESS
the initial operation. Twenty-four hours later, minimal debridement was necessary when the wound was reexamined with the patient under general anesthesia, and by both clinical and hemodynamic evaluations, the septic process seemed to be under control. During the next day, the patient was restless, was greatly agitated in response to stimulation, had fasciculations, had rigidity of the extremities, and yet had what appeared to be a contented expression on his face. Excessive diaphoresis and muscle rigidity were progressive. Trismus became more apparent, and a clinical diagnosis of tetanus was made. The patient had no history of ingestion of alcohol. M e n ingitis was excluded by normal findings on lumbar puncture. The patient's record of tetanus immunization was difficult to obtain. He had been in the military service in the early 1940s and had had trauma to the right leg, which necessitated the placement of a skin graft in 1956. He had no other history of possible immunization in the past 26 years. The patient was given 3,000 U of human tetanus antitoxin and was sedated with diazepam (Valium) and morphine. For relief of the muscle spasms, he was paralyzed with pancuronium bromide (Pavulon), 1 to 3 mg intravenously at 1- to 2-hour intervals. A tracheostomy was performed, and an assist-control mechanical respirator was applied to the patient. An additional 2,000 U of antitoxin was given, and a Clinitron bed was used to decrease the possibility of pressure necrosis. Daily physical therapy and splints were used to prevent contractures. The patient's nutritional status was maintained with total parenteral nutrition. No diverting colostomy was performed. He received heparin, 5,000 U every 12 hours, as prophylaxis against deep vein thrombosis while he was immobilized. Wound care was performed every 6 hours. The patient had pronounced evidence of autonomic instability, with wide variations of blood pressure and cardiac arrhythmias; they were controlled with medications. He required controlled ventilation for 17 days before the spasms and rigidity resolved enough to allow normal respiration. W h e n his condition was stable and his wounds were clean, the remaining portion of his scrotum was closed and the testicles were placed in thigh pockets. Also, a split-thickness skin graft was placed on his left buttock. Two major complications occurred during the stay of 35 days in the intensive care unit. Acute parotiditis was successfully treated with intravenously administered oxacillin, 1 g every 6 hours for 5 days, and transient Candida fun-
Mayo Clin Proc, June 1984, Vol 59
gemia from an intravenous catheter was without sequela. The patient was dismissed 51 days after admission. Four months after dismissal, he had regained his normal weight, had no residual neurologic deficit, and had returned to work as a farmer. He continued to have a fistula in ano and at the time of this report was scheduled for definitive treatment in the near future. He began active immunization for tetanus, inasmuch as immunity is not ensured through infection. CONCLUSIONS As a result of increased public awareness, improved health-care delivery, and immunization, the incidence of tetanus in the United States has been greatly reduced. Nevertheless, tetanus is still a threat today. As this case points out, the recognition of a constellation of factors that contribute to the development of tetanus and a high index of suspicion aid in making an expedient and accurate diagnosis. A satisfactory result can be expected only with early diagnosis and aggressive therapy, especially in the older age group or in patients with severe tetanus. Immunization is a necessity and should not be overlooked in the treatment of tetanus victims. 9 REFERENCES 1. Meyer KA, Spector BK: The incidence of tetanus bacilli in the stools and on the regional skin of one hundred urban herniotomy cases. Surg Cynecol Obstet 54:785-789, 1932 2. Cohn IJr, BornsideGH: Infections. In Principles of Surgery. Third edition. Edited by SI Schwartz, GT Shires, FC Spencer, EH Storer. New York, McGraw-Hill Book Company, 1979, pp 204-207 3. Bunch GH, Quattlebaum J: Postoperative tetanus. Am J Surg 61:280-285, 1943 4. Hebraud, Sauvet P: Tetanos apres gastrectomie. Mem Acad Chir 78:722-724, 1952 5. Calvet ): Volvulus du grele et tetanos generalise. Presse Med 2:740-741, 1942 6. Clay RC, Bolton JW: Tetanus arising from gangrenous unperforated small intestine. JAMA 187:856-858, 1964 7. Matas R: The fecal origin of some forms of postoperative tetanus (anorectal, intestinal, puerperal, genital, and lower pelvic operations) and its prophylaxis by proper dietetic or culinary measures. Trans Am Surg Assoc 27:40-45, 1909 8. Murphy KJ: Tetanus after rubber-band ligation of haemorrhoids. BrMed J 1:1590-1591, 1978 9. Christensen NA, Thurber DL: Clinical experience with tetanus: 91 cases. Proc Staff Meet Mayo Clin 32:146-158, 1957