title: Treatment of severe tetanus with intrathecal baclofen via implantable infusion device: a case report.
abstract: OBJECTIVE
  Severe tetanus remains a serious issue in less developed countries, leading to prolonged hospitalization due to prolonged neuromuscular contraction of muscles. We present a case of severe tetanus in the United States that was successfully managed with intrathecal baclofen.
  
  
  METHODS
  A 42-year-old male without tetanus vaccination history presented to the emergency department with intractable jaw pain and worsening diffuse muscle contractures due to severe generalized tetanus requiring prolonged paralysis and ventilator support. After 14 days of continuous neuromuscular treatment with benzodiazepines, vecuronium, propofol, and magnesium sulfate, a baclofen pump trial was performed 14 days post-admission as an alternative to prolonged neuromuscular blockade. After demonstrable improvement in spasms and paroxysmal contractures due to intrathecal baclofen (ITB), a baclofen pump was implanted on hospital day 17. The catheter was threaded to T4 for maximal effect of intrathecal baclofen on the upper and lower extremities at an initial rate of 100 μg/day. ITB was titrated upward, the vecuronium was slowly weaned, and the patient was weaned off a ventilator by day 14 of ITB treatment. At an ITB dose of 450 μg/day, propofol was discontinued. ITB was continued over the next four weeks and eventually weaned over the next two weeks. The ITB pump was removed eight weeks after placement, and the patient was successfully discharged to home.
  
  
  CONCLUSIONS
  Due to prolonged muscle weakness associated with long-term use of paralytic agents and sedation, early ITB trial and pump placement should be considered as an alternative in the treatment of severe tetanus to shorten length of stay and improve the functional outcome of the patient.
authors.affiliation: Department of Physical Medicine and Rehabilitation Oakwood, School of Medicine, Wayne State University, Dearborn, MI, USA.
authors.forename: Geraldine
authors.initials: G
authors.lastname: Dapul
authors.forename: Pritesh
authors.initials: P
authors.lastname: Patel
authors.forename: Tejpaul
authors.initials: T
authors.lastname: Pannu
authors.forename: Jay
authors.initials: J
authors.lastname: Meythaler
mesh_terms: D000328:Adult; D001418:Baclofen / Q000008:administration & dosage*; D006801:Humans; D015918:Infusion Pumps, Implantable; D008297:Male; D009125:Muscle Relaxants, Central / Q000008:administration & dosage*; D013742:Tetanus / Q000188:drug therapy*
chemical_list: D009125:Muscle Relaxants, Central; D001418:Baclofen
keywords: Intrathecal baclofen; severe tetanus