Question: Spasms
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You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air.
A resident November 26, 2019 - 11:04 am
Say what you will, that kiddo is livng the 1600s bucolic dream.
Kelly November 26, 2019 - 12:03 pm
A) Metronidazole, immune globulin, diazepam, and magnesium
The patient described has tetanus, and was actually (I added some misdirection embellishments) reported in a CDC case report https://www.cdc.gov/mmwr/volumes/68/wr/mm6809a3.htm. After Clostridium tetani spores from soil enter the body through a wound, disease can develop in 3-21 days in unimmunized patients. Symptoms include trismus aka lockjaw (jaw muscle spasms and difficulty opening), respiratory distress, neck and back arching (opisthonus), muscle contractions, and autonomic overactivity (tachycardia, hypertension, sweating, fever). Treatment includes halting toxin production by cleaning the wound and giving antibiotics (metronidazole or penicillin first-line), tetanus immune globulin administration, and controlling spasms with benzodiazepines. Magnesium may also help with spasms. B is the treatment for dystonic reaction, C for malignant hyperthermia, D for status epilepticus, and E for hypocalcemic tetany.