title: Generalized tetanus in a 4-year old boy presenting with dysphagia and trismus: a case report.
abstract: BACKGROUND
  The low incidence of tetanus in developed countries has resulted in a decreased vigilance of this disease. This raises concern, as the prodromal stadium of a generalized tetanus infection may lack the characteristic paroxysmal muscle spasms. Tetanus can rapidly progress into life-threatening muscle spasms accompanied by respiratory insufficiency and/or autonomic dysfunction. This emphasizes the need for early diagnosis and treatment.
  
  
  METHODS
  A 4-year-old Caucasian boy presented with a one-week history of general malaise, mild fever, indolence and anorexia. He subsequently developed dysphagia, sialorrhoea, difficulties opening the mouth and eventually dehydration. Due to parental concerns about the boy's refusal of fluids, a pediatrician was consulted. At that time of presentation he showed signs of trismus and muscle rigidity. Together with the lack of immunization and a toe nail infection, this lead to the suspicion of a generalized tetanus infection. After sedation, endotracheal intubation and ventilation, passive immunization and initiation of antimicrobial treatment, he was immediately transferred to a pediatric intensive care unit (PICU) for further treatment. The frequency and severity of paroxysmal muscle spasms increased progressively during his PICU stay, despite high doses of sedatives. Not before two weeks after admittance, extubation and careful weaning off sedatives was achieved.
  
  
  CONCLUSIONS
  Tetanus infection remains a rare but potentially lethal disease in developed countries. As the full scope of classical symptoms may be absent at first presentation, tetanus should always be considered in non-immunized patients with an acute onset of dysphagia and trismus.
authors.affiliation: Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht, Home mailbox KG.01.319.0, PO Box 85090, 3508 AB Utrecht, The Netherlands. p.r.dejong-9@umcutrecht.n
authors.forename: Petrus Rudolf
authors.initials: PR
authors.lastname: de Jong
authors.forename: Thea
authors.initials: T
authors.lastname: de Heer-Groen
authors.forename: Cornelis Hendrik
authors.initials: CH
authors.lastname: Schröder
authors.forename: Nicolaas Johannes Georgius
authors.initials: NJ
authors.lastname: Jansen