Published in the “British Medical Journal” June 15, 2002. The introduction and case report are reprinted below.

Clinicians should be familiar with Department of Health guidelines for immunoprophylaxis when wounds through which tetanus can be acquired occur. I report on a patient in whom tetanus immunoprophylaxis did not follow the guidelines.

Case Report

A 76-year-old woman fell in her garden and sustained a pretibial laceration. Her wound was cleaned and approximated with Steri-strips (3M; Loughborough) at an emergency department. Her status for tetanus immunization at the time was recorded as “no previous tetanus injection,” and a course of antitetanus treatment was started. However, no immunoglobulin was given.

She returned one week later with a necrotic and malodorous wound. She was unwell and complained of diffuse pains. She was admitted for debridement and split skin grafting.

Her condition worsened. Twenty-four hours later she developed the signs and symptoms of tetanus, with increasing jaw stiffness, opisthotonos, and generalized limb spasticity. Cultures from the wound produced a heavy growth of Clostridium tetanii. She was transferred to intensive care but died 22 days later.

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REPORT #60

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