Clinical Scenario:
A 13-year-old girl is brought to the emergency department because of increasing difficulty eating and painful stiffness of the neck and back for the last two days. One week earlier, she had her ears pierced at a local market. Since yesterday, her parents have noticed repeated episodes of painful generalized muscle tightening whenever she is touched or hears a loud sound. She remains fully conscious throughout the episodes and has no fever.
What is the most appropriate specific treatment?
A. Human tetanus immunoglobulin + Metronidazole
B. Ceftriaxone + Vancomycin
C. Diazepam only
D. Intravenous acyclovir
E. Intravenous methylprednisolone
Correct answer & Explanation:
Correct Answer: A. Human tetanus immunoglobulin + Metronidazole
Explanation: Tetanus / Treatment of tetanus
This child most likely has generalized tetanus following contaminated ear piercing.
The diagnosis is suggested by:
- Recent skin injury (ear piercing)
- Difficulty opening the mouth and swallowing
- Progressive stiffness of the neck and back
- Painful muscle spasms precipitated by touch or noise
- Preserved consciousness
- Absence of fever
These features are characteristic of tetanus and help distinguish it from meningitis, encephalitis, hypocalcemia, or seizure disorders.
Management includes:
- Human tetanus immunoglobulin (HTIG) to neutralize unbound toxin.
- Metronidazole to eradicate Clostridium tetani.
- Wound debridement, if necessary.
- Benzodiazepines for spasm control.
- Airway and intensive supportive care.
- Active immunization with tetanus toxoid after stabilization.
Why the other options are incorrect
B. Ceftriaxone + Vancomycin
Broad-spectrum antibiotics do not neutralize tetanus toxin and are not the recommended antimicrobial therapy.
C. Diazepam only
Controls muscle spasms but does not treat the underlying infection or neutralize circulating toxin.
D. Intravenous acyclovir
There are no features suggestive of herpes encephalitis.
E. Intravenous methylprednisolone
Corticosteroids have no proven role in the management of tetanus.
Learning Point
In tetanus, the combination of a recent wound, preserved consciousness, and painful muscle spasms triggered by minimal stimuli is highly characteristic. The cornerstone of treatment is HTIG, metronidazole, wound care, spasm control, and intensive supportive care.
