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SUMMARY
Unilateral or bilateral raised hemidiaphragms were observed on chest X-ray in three patients with severe tetanus. Diaphragmatic movement was absent on ultrasonography and fluoroscopy. Nerve conduction study confirmed phrenic nerve palsy. Bilateral involvement caused delayed weaning from the ventilator, whereas unilateral involvement was asymptomatic. There was complete recovery from phrenic nerve palsy in all patients.
Key Words: Tetanus, neuropathy, phrenic nerve palsy, diaphragmatic paralysis, difficult weaning
Tetanus is caused by the neurotoxin liberated by Clostridium tetani, a gram-positive obligatory anaerobe1. It is diagnosed by a history of injury followed by lockjaw, dysphagia, risus sardonicus, neck, abdominal and paraspinal rigidity, opisthotonus, and generalized muscle spasms in a conscious patient1,2,3. Peripheral neuropathy is a known but rare complication of tetanus4,5. Phrenic nerve involvement has not been previously reported in tetanus patients. We observed phrenic nerve palsy in three of the 127 cases of tetanus admitted to our Adult Tetanus Unit in the last four years.
CASE 1
A 20-year-old unimmunized labourer presented to the hospital eight days after sustaining a laceration to his right foot, with increasing difficulty in opening the mouth and stiffness of the neck. A diagnosis of tetanus was made and 500 IU and 250 IU of Human Tetanus Immunoglobulin was administered intramuscularly and intrathecally respectively. CSF examination ruled out meningitis. A 70 cm long central venous catheter was introduced from the right antecubital vein. He was sedated with intravenous diazepam 5 mg every six hours. As the trismus and rigidity increased, the dose and frequency of diazepam administration were increased (maximum 250 mg per day). Once the patient developed generalized tetanic spasms, the airway was secured initially by tracheal intubation, followed by tracheostomy. Intravenous morphine (5 mg every 4-6 hours) was added alternating with diazepam. As the intensity and frequency of spasms increased, the patient was paralysed with pancuronium (1-2 mg/h) and mechanically ventilated. Crystalline penicillin, gentamicin and metronidazole were administered parenterally for seven days.
On the eleventh day, as the spasms subsided, the muscle relaxant was stopped, sedation was tapered, and weaning from the ventilator was started. However, repeated attempts at weaning failed. The patient had low tidal volume, high respiratory rate (>30 per minute), jerky and laboured respiration, and P^sub a^O^sub 2^ of 68 and P^sub a^CO^sub 2^...