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Tetanus: an unusual source and site of infection
ffournal of Infection (1983) 7, 72-73
CASE R E P O R T Tetanus:
an unusual source and site of infection
J. E. E a r i s , A. N. H i l l i s a n d M. B. M a c a u l a y
Intensive Care Unit, Walton Hospital, Liverpool Summary Tetanus is reported in a previously immunised patient who was exposed to the dust of old building plaster containing horse hair. The site of infection was a squamous cell carcinoma of the scalp. Case report Over a period of several months a 66-year-old spinster had noted an ulcerating lesion on her scalp which was gradually extending. Without covering this scalp lesion, she scraped the walls and ceilings of her 6o-year-old terrace house in preparation for redecoration. T e n days later, she developed trismus followed by painful muscle spasms of the pharynx, face and chest and was admitted to hospital. On examination, there was a fungating tumour 5 cm in diameter over the occipital area of the scalp. She had generalised muscle rigidity and the slightest movement induced severe reflex spasms resulting in episodes of apnoea. H u m a n antitetanus immunoglobulin and benzyl penicillin were administered, an emergency tracheostomy performed, and the patient electively ventilated. Following excision of the scalp tumour, the frequency and severity of the tetanic spasms rapidly decreased and spontaneous ventilation returned after only 4o hours. Clinical recovery was marred by a pulmonary embolus but was otherwise uneventful. T h e tumour was a squamous cell carcinoma from which Staphylococcus pyogenes and a spore-forming bacillus were cultured. Inoculation of the bacillus into mice produced clinical tetanus and the organism was recovered from the infected mice, confirming it to be Clostridium tetani. Microscopic examination of plaster scrapings taken from the patient's house revealed many animal hair fragments, but anaerobic culture of the small amounts of plaster available did not grow C. tetani. Culture of the patient's faeces similarly failed to isolate the organism.
Comment A fungating and necrotic squamous cell carcinoma of the scalp produced suitable conditions for C. tetani to multiply, resulting in the clinical manifestations of tetanus. T o our knowledge a skin tumour has only once before been implicated as the site of such an infection) In the two weeks before admission to hospital the patient's unprotected head was heavily exposed to plaster scrapings from the walls and ceilings of her Correspondence to Dr J. E. Earis, Department of Thoracic Medicine, Fazakerley Hospital, Longmoor Lane, Liverpool L 9 7AL. o163-4453/83/OlOO72+o2 $02.oo/0
© I983 The British Society for the Study of Infection
Tetanus
73
6o-year-old house. Until the introduction of plaster boards in the I94os it was c o m m o n practice to strengthen such building plaster with horse hair, and in old operating theatres this has been implicated as the source of post-operative tetanus infections. ~ I n the present case, it is likely that the plaster was contaminated with viable clostridial spores. T h e failure to culture C. tetani from the small a m o u n t s of plaster available is not against this association as it is often impossible to demonstrate the organism in the p r i m a r y source of contamination? T h e u n u s u a l source and site o f C . tetani infection in this patient, who believed that she had been fully i m m u n i s e d in 1942 while serving with the A r m y , underlines the importance of current i m m u n i s a t i o n for all m e m b e r s of the population. Even recovery from this often fatal disease does not confer i m m u n i t y f r o m f u r t h e r infection? (We are grateful to Dr H. T. Green, Consultant Microbiologist, for her help and advice in preparing this report.) References i. Edmondson RS, Flowers MW. Intensive care in tetanus; management, complications and mortality in Ioo cases. Br Medff I979; I : I4ox-x4o4. 2. Sevitt S. Source of two hospital infected cases of tetanus. Lancet I949; ii: Io75-zo78. 3. Weinstein L. Current concepts: tetanus. N EnglJ Med I973; 289: I293-I296.
CASE R E P O R T Tetanus:
an unusual source and site of infection
J. E. E a r i s , A. N. H i l l i s a n d M. B. M a c a u l a y
Intensive Care Unit, Walton Hospital, Liverpool Summary Tetanus is reported in a previously immunised patient who was exposed to the dust of old building plaster containing horse hair. The site of infection was a squamous cell carcinoma of the scalp. Case report Over a period of several months a 66-year-old spinster had noted an ulcerating lesion on her scalp which was gradually extending. Without covering this scalp lesion, she scraped the walls and ceilings of her 6o-year-old terrace house in preparation for redecoration. T e n days later, she developed trismus followed by painful muscle spasms of the pharynx, face and chest and was admitted to hospital. On examination, there was a fungating tumour 5 cm in diameter over the occipital area of the scalp. She had generalised muscle rigidity and the slightest movement induced severe reflex spasms resulting in episodes of apnoea. H u m a n antitetanus immunoglobulin and benzyl penicillin were administered, an emergency tracheostomy performed, and the patient electively ventilated. Following excision of the scalp tumour, the frequency and severity of the tetanic spasms rapidly decreased and spontaneous ventilation returned after only 4o hours. Clinical recovery was marred by a pulmonary embolus but was otherwise uneventful. T h e tumour was a squamous cell carcinoma from which Staphylococcus pyogenes and a spore-forming bacillus were cultured. Inoculation of the bacillus into mice produced clinical tetanus and the organism was recovered from the infected mice, confirming it to be Clostridium tetani. Microscopic examination of plaster scrapings taken from the patient's house revealed many animal hair fragments, but anaerobic culture of the small amounts of plaster available did not grow C. tetani. Culture of the patient's faeces similarly failed to isolate the organism.
Comment A fungating and necrotic squamous cell carcinoma of the scalp produced suitable conditions for C. tetani to multiply, resulting in the clinical manifestations of tetanus. T o our knowledge a skin tumour has only once before been implicated as the site of such an infection) In the two weeks before admission to hospital the patient's unprotected head was heavily exposed to plaster scrapings from the walls and ceilings of her Correspondence to Dr J. E. Earis, Department of Thoracic Medicine, Fazakerley Hospital, Longmoor Lane, Liverpool L 9 7AL. o163-4453/83/OlOO72+o2 $02.oo/0
© I983 The British Society for the Study of Infection
Tetanus
73
6o-year-old house. Until the introduction of plaster boards in the I94os it was c o m m o n practice to strengthen such building plaster with horse hair, and in old operating theatres this has been implicated as the source of post-operative tetanus infections. ~ I n the present case, it is likely that the plaster was contaminated with viable clostridial spores. T h e failure to culture C. tetani from the small a m o u n t s of plaster available is not against this association as it is often impossible to demonstrate the organism in the p r i m a r y source of contamination? T h e u n u s u a l source and site o f C . tetani infection in this patient, who believed that she had been fully i m m u n i s e d in 1942 while serving with the A r m y , underlines the importance of current i m m u n i s a t i o n for all m e m b e r s of the population. Even recovery from this often fatal disease does not confer i m m u n i t y f r o m f u r t h e r infection? (We are grateful to Dr H. T. Green, Consultant Microbiologist, for her help and advice in preparing this report.) References i. Edmondson RS, Flowers MW. Intensive care in tetanus; management, complications and mortality in Ioo cases. Br Medff I979; I : I4ox-x4o4. 2. Sevitt S. Source of two hospital infected cases of tetanus. Lancet I949; ii: Io75-zo78. 3. Weinstein L. Current concepts: tetanus. N EnglJ Med I973; 289: I293-I296.