We describe a case of childhood tetanus in a child who had received no vaccination for the disease, and who developed tetanus following a leg injury.

A previously healthy six year old boy was referred from a district hospital to a hospital in Nicosia with trismus (spasmodic contracting of the jaw), mild opisthotonus (spasmodic contracting of the muscles in the neck and back) and aversion to light, but no fever. The reason for the transfer was an episode of muscle spasms accompanied with apnoea (absence of breathing) and cyanosis. Two weeks before admission, the child had been injured just above the right ankle joint after coming into contact with the edge of a tile, causing a deep wound. The child was taken to the accident and emergency department of the district hospital where wound care was given, but no vaccination or tetanus immunoglobulin was offered.

A few days later the wound area became infected and the child’s parents consulted a private surgeon, who cleaned the whole area thoroughly and prescribed amoxicillin with clavulanic acid. However, a few days later, 13 days after the initial injury, the child started to exhibit trismus, which was initially misdiagnosed by the surgeon.

The child’s symptoms persisted after consulting the surgeon, and he was taken back to the emergency department, where the diagnosis of tetanus was made on the basis of clinical manifestations in combination with a history of non-immunisation and the recent history of injury. The child had received no primary immunisations against tetanus, diphtheria or pertussis because of his parents’ objections to vaccinations. The information about his non-immunised status had not been given to staff during the first visit to the emergency department, because the child had been taken to hospital by his grandparents, who did not know his vaccination history.

During his hospital stay, the child was treated with human tetanus immunoglobulin, penicillin and metronidazole, and sedated with diazepam as needed. The child was monitored in a noise-free dark room with limited disturbance. A full series of vaccinations was already begun during his transfer to the referral hospital for admission and was completed on follow up visits. Despite treatment, the child’s condition continued to deteriorate for the first six days after admission to hospital, with frequent episodes of muscle spasms, apnoea and opisthotonus with generalised hypertonia persisting for several hours after such episodes. The child remained in hospital for a total of 19 days. Finally he recovered fully and was discharged home with no further treatment.

Discussion
Tetanus in children is an extremely rare disease in developed countries, and many doctors never see a case during training or subsequent paediatric practice. It is caused by the anaerobic spore-forming bacillus Clostridium tetani, an organism present in soil as well as in human and animal faeces. Tetanus spores usually enter the body through a recent wound, burn or minor scratch [1]. Intravenous drug use has also been reported as a risk factor for tetanus [2,3].

The disease may appear locally, restricted around the area of the injury, or as a more generalised syndrome. It is characterised by painful tonic spasms of the skeletal muscles, the first sign usually being trismus without fever, and occasionally autonomic dysfunction, while in severe cases it may cause opisthotonus and death. Even with appropriate treatment, generalised tetanus usually worsens in the first two weeks after diagnosis, with recovery occurring over the subsequent three to five weeks. Tetanus in children is extremely rare in developed countries because of the high immunisation coverage in this age group, and in the great majority childhood cases occur in non-immunised children [2]. Parents’ objections to immunisation have been a major reason for non-immunisation of children in Europe and the United States [4]. In common with most developed European countries, Cyprus has a very high coverage rate for primary immunisations against diphtheria, tetanus and pertussis. The national vaccination survey performed in 2003 revealed that more than 99% of the infant population was covered [5].

Cases of tetanus in children are much rarer than adult cases as a result of the intensive programme of immunisation against vaccine preventable diseases in this age group. Although tetanus is a rare disease in developed countries, mortality still occurs. Between 1998 and 2000 in a review of tetanus cases performed by the US Centers for Disease Control and Prevention, mortality was estimated to be 18% [2], while in the United Kingdom, mortality between 1984 and 2000 was estimated to be 29% [6]. Incidence and mortality rates are much higher in developing countries [7]. In addition to national vaccination policy to target high risk groups, individual healthcare providers should evaluate the vaccination status of every patient they care for on any given occasion, and offer vaccination as required. Groups at risk include older people, injecting drug users, people who have migrated from countries with poor immunisation coverage and individuals who refuse to participate in the national vaccination programme.