Intensive management of severe pediatric tetanus complicated by dysautonomia and acute myocardial dysfunction

Abstract

Generalized tetanus is a vaccine-preventable but potentially life-threatening disease that persists in regions with inadequate immunization coverage. In severe cases, it may be complicated by dysautonomia, characterized by catecholamine-induced hemodynamic instability, which can lead to acute myocardial dysfunction and significantly increase morbidity and mortality. Objective: To describe the management and clinical course of a child with severe generalized tetanus complicated by dysautonomia and acute myocardial dysfunction.

Clinical Case: An 8-year-old boy from a rural area in Colombia, with incomplete immunization schedule, presented with a lesion on his foot sole caused by a rusty nail and clinical features consistent with generalized tetanus. He was admitted to the pediatric intensive care unit under invasive mechanical ventilation. Treatment included human tetanus immunoglobulin, tetanus toxoid, and metronidazole, along with magnesium sulfate, deep sedation–analgesia, and neuromuscular blockade due to severe spasms. He developed severe dysautonomia with hemodynamic instability, monomorphic ventricular tachycardia, and cardiorespiratory arrest, which required antiarrhythmic therapy and vasoactive support. Cardiac ultrasound revealed left ventricular systolic dysfunction with marked elevation of troponin and pro-BNP levels, consistent with catecholamine-induced acute myocardial dysfunction. Milrinone and intravenous human immunoglobulin G were administered, with improvement after one week. Tracheostomy was required due to prolonged ventilatory support. He was discharged from the PICU after 47 days and from the hospital after 90 days, without significant residual morbidity.

Conclusions: Severe pediatric tetanus may be associated with possible life-threatening cardiovascular complications. Early recognition, continuous cardiovascular monitoring, and intensive sequential, stepwise, and multimodal support allow for optimized management and favorable outcomes.