An unexpected tetanus case

Silent Entry: The Diagnostic Challenge of Tetanus Without an Obvious Wound

Tetanus, caused by Clostridium tetani, is a significant health problem, particularly in regions lacking proper vaccination coverage against tetanus. Although it is usually associated with an identifiable wound, diagnosing tetanus without a visible entry site can be difficult. We report a 68-year-old man who was diagnosed with tetanus without any visible wounds or recent trauma. He had classic clinical features, including trismus, risus sardonicus, muscle spasms, and a positive spatula test, which all justified the clinical diagnosis of tetanus. The patient was treated with intramuscular injection of 3,000 IU of tetanus immune globulin, intravenous metronidazole, and muscle relaxants. He improved significantly after 10 days. He was discharged with follow-up and vaccination instructions. This case emphasizes the importance of maintaining a high index of suspicion for tetanus, even without any wound. It also reveals the effectiveness of clinical diagnostic methods and appropriate, timely treatment in rescuing the patient.

An unexpected case of tetanus in a fully immunized 20-year-old female: a case report

BACKGROUND

Widespread vaccinations have significantly decreased the number of tetanus cases in developed countries. Today, most cases of tetanus affect the elderly and those with inadequate immunization in developed countries such as Japan. As vaccinations were believed to be nearly 100% effective in preventing tetanus, tetanus in young, immunized individuals were considered unlikely. However, unexpected tetanus infection has been reported in young adequately immunized individuals.

CASE

We herein describe a 20-year-old immunized female who visited our emergency department with trismus and painful muscle spasms that started after receiving a puncture wound to her right foot. A physical examination revealed an elevated body temperature (38°C), trismus, muscle spasms in her right leg and neck, and a puncture wound at the sole of her right foot. Following the development of dyspnea after admission to the intensive care unit, the patient was intubated and mechanically ventilated. She fully recovered after six days in intensive care.

CONCLUSION

The present case serves as a stark reminder that tetanus may still occur in young, immunized individuals. Patients with a history of immunization may have a better prognosis than those with no immunizations.

Tetanus in a vaccinated soil expert - a case report

BACKGROUND

Tetanus is a life-threatening vaccine-preventable disease found more commonly in tropical climates. It accounted for up to 60 deaths annually until the introduction of the tetanus toxoid. It is now rare in Canada by immunization. This study aims to describe a case of tetanus in Saskatchewan with possible occupational exposure.

CASE REPORT

We describe the case of a vaccinated soil expert with tetanus resulting from skin abrasions. This report highlights the early diagnosis, atypical presentation with possible vaccine attenuation and management approach, including acute care, intensive care unit referral, surgical management and physical rehabilitation. We also describe the public health management provided in this case. Despite the severity, the patient returned to his previous home environment with minimal motor sequelae.

CONCLUSION

Occupational exposure to tetanus is an important risk, even in regions where the disease is rare. Prevention through vaccination is a key public health intervention that must be encouraged to avoid health complications that are often fatal.

Untangling Tetanus: A Comprehensive Case Report Describing Its Diagnosis and Treatment

Tetanus, caused by a grave and potentially lethal bacteria, is a medical condition that severely affects the central nervous system and demands vigilant attention and comprehensive preventive measures to safeguard public health. The onset of this condition is sudden and characterized by the emergence of intense tonic muscle spasms, underscoring its critical nature. In Türkiye, around 50 cases are officially reported each year; however, it is widely suspected that numerous cases remain unreported, contributing to an even more significant impact. This report aims to shed light on a remarkable case involving a 24-year-old male patient. Despite having a complete vaccination history, this individual contracted tetanus and required intensive care and mechanical ventilation due to the severity of his tetanus infection. This case serves as a poignant reminder of the importance of booster administration, highlighting the significance of continued and timely reinforcement of vaccinations.

Uncommon Progressive Systemic Tetanus: A Case Report

Tetanus is a bacterial infection caused by the toxin of Clostridium tetani. While it primarily affects newborns, people with incomplete vaccination schedules, it can also impact people of any age, especially in developing countries. Even though in the last 20 years several initiatives have been implemented worldwide to reduce the impact of this disease, regions like South Asia and sub-Saharan Africa have registered mortality rates highest since 2015-2019. In Latin America, regional immunization coverage rates were reported at 89% in 2017 for diphtheria-tetanus toxoid and pertussis (DTP-3), although Costa Rica has reported decreased coverage rates of the national immunization schedule from 2019 to 2021. In this case study, we present a 53-year-old woman from Puntarenas, Costa Rica diagnosed with progressive systemic tetanus who developed status epilepticus. She previously was assessed in a central hospital of Costa Rica for paresthesia in her right upper limb of three months of duration, myoclonus and difficulty walking in the last weeks; the presumed diagnosis was Guillain-Barré syndrome. During her hospitalization she had three generalized tonic-clonic seizures treated with diazepam and phenytoin. Since there was no improvement, she was transferred to our medium-sized private hospital for the treatment of painful spasms and weakness in the lower limbs. On initial evaluation, no injury was found. She was initially treated with midazolam and magnesium sulfate for presenting seizures-like spasms in the lower limbs and then generalized without loss of consciousness for up to 15 minutes, mainly associated with desaturation, tachycardia and tachypnea. In the differential diagnosis, muscle contractions linked to hypocalcemia, neurosyphilis and epilepsy were ruled out. Despite this, magnetic resonance imaging showed fractures in T11, L1 and L2. Mainly due to the presence of spasms, opisthotonos and history of seizures and a wound on the hand four months ago, she was diagnosed with tetanus.  Among the initial management, tetanus toxoid (Td), antimicrobial therapy, and human antitetanic immunoglobulin (HTIG) were administered, which partially improved the patient's condition, although she remained dependent on the infusions. On the sixth week of hospitalization, the patient developed status epilepticus which is explained by the magnetic resonance findings that show subacute bi-occipital infarcts caused by hypoxia from the previous crises. Lacosamide therapy reversed the condition and kept the patient free of seizures.  It was necessary to carry out a lumbar osteosynthesis which was highly favorable to stabilize the patient's condition. The frequency and intensity of the spasms were gradually reduced, which allowed the gradual suspension of the infusions and the benzodiazepine overlap intravenous (IV) to oral (PO). The patient now has only self-limiting spasms and her maintenance therapy consists of lacosamide and oral clonazepam.  This case highlights the importance of considering tetanus in the differential diagnosis even if the vaccination schedule is complete, especially if there are spasms, convulsions, or a history of wounds or bites. It is important to monitor this type of report to reconsider and update the key elements in the prevention, diagnosis, management, and treatment of tetanus; as well as improve access to essential medicines, including the HTIG, and the patient's prognosis in terms of symptom resolution and associated sequelae.

The threat of a new tetanus outbreak due to urban flooding disaster requires vigilance: a narrative review

Vaccines for tetanus prevention have rapidly progressed, and the number of outbreaks, especially the incidence of tetanus in developed countries, has decreased dramatically. However, the mortality rate associated with severe tetanus remains high. Tetanus eradication is difficult owing to the widespread presence of the spores of tetanus bacteria in the environment, but tetanus can be prevented by acquired immunity from vaccines. Older people, intravenous drug users, and migrants are at a high risk of tetanus in developed countries owing to the lack of booster vaccination programs. Natural disasters, especially floods, often cause an increase in the prevalence of tetanus because of the associated injuries. Precautions should be taken to combat the threat of a new tetanus outbreak due to floods in urban areas owing to global warming. In particular, Japan is facing a high risk of urban flooding-induced tetanus, despite its status as a developed country. This review aims to highlight the data on the epidemiology, causes, treatment, and prevention of tetanus and problems associated with tetanus countermeasures during future floods.

Understanding the Trajectory to a Diagnosis of Tetanus: A Descriptive Study

Background and objective Tetanus is a rare but potentially fatal disease in developed countries, including Japan. It is very difficult to diagnose this condition early because of its broad symptomatology and the lack of familiarity with tetanus among both physicians and patients. In this study, we aimed to describe the clinical manifestations of tetanus and to examine as to which departments/branches of medicine patients consult in order to provide helpful information for diagnosing this challenging condition. Materials and methods This was a descriptive, retrospective study conducted at a single tertiary hospital from January 2011 to December 2021. Patients with generalized tetanus, cephalic tetanus, and local tetanus presenting to our emergency department were included in the study. We examined the clinical manifestations and departments that patients with tetanus visited first. Additionally, the initial diagnosis and diagnostic evaluation before the diagnosis were examined. Results Of the total 10 patients included in the study, nine had generalized tetanus and one had cephalic tetanus; the common initial manifestations were neck stiffness (30%), dysarthria (20%), and trismus (20%). Of note, 80% of patients also complained of dysphagia before the diagnosis. Patients first visited various departments, including a dental clinic (30%) and the department of otorhinolaryngology (20%). Only two patients were accurately diagnosed with tetanus at the first department they visited. Physicians performed head imaging for all the patients. Conclusions Based on our findings, in Japan, patients with tetanus present with symptoms that physicians interpret or suspect to be associated with disorders of the central nervous system. Meanwhile, patients themselves tend to consider the symptoms as indicative of oral or dental issues. Further prospective studies involving a larger number of participants are needed to investigate the clinical course of tetanus until the establishment of a diagnosis.

Seroepidemiology of Tetanus among Healthy People Aged 1-59 Years Old in Shaanxi Province, China

The study aims to determine the seroprevalence of antibodies against tetanus among healthy people aged 1−59 years old in Shaanxi province. IgG against tetanus in serum samples were detected by ELISA. 6,439 subjects were enrolled. The positive rate (≥0.01 IU/mL) was 84.39% and GMC was 0.03 IU/mL. There were significant differences in positive rates (χ2 = 308.944, p < 0.01) and GMC (Z = 5,200,000, p < 0.01) among different age groups. The positive rates (χ2 = 304.3, p < 0.01) and GMCs (χ2 = 146.417, p < 0.01) showed regional differences. Both full protection rate (≥0.1 IU/mL) (χ2 = 36.834, p < 0.01) and GMC (Z = 688,000, p < 0.01) increased with the doses of tetanus-toxoid-containing vaccines (TTCVs) administered. The positive rate (χ2 = 54.136, p < 0.01) and GMC (Z = 140,200, p < 0.01) decreased gradually with the time interval after full immunization with TTCVs. The full protection rate (≥0.1 IU/mL) (χ2 = 176.201, p < 0.01) and GMC (Z = 629,900, p < 0.01) decreased with the interval (years) since the last dose of TTCVs. There were significant differences in the positive rates and GMCs for different ages, regions, immunization histories of TTCVs, and doses of TTCVs administered. The full protection rate and GMC decreased with the interval following full immunization with TTCVs and the interval since the last dose of TTCVs. The importance of using tetanus booster doses should be emphasized in adolescents and adults.

Tetanus-induced rhythmic seizures mimicking the clinical and electroencephalographic presentation of status epilepticus

We describe the case of a woman in her 60s admitted to the intensive care unit after a first generalised tonic-clonic seizure in the context of alcohol withdrawal. She was placed under invasive mechanical ventilation due to persistence of coma despite antiepileptic treatment. Despite continuous sedation with propofol, the frequency and intensity of seizure increased. Seizures were very similar to epileptic tonic-clonic seizures and were recorded with video and electroencephalogram (EEG). A diagnosis of tetanus was considered after a scalp wound was discovered. The patient's husband revealed that a trismus had appeared a few days before hospital admission after a head trauma. EEG showed a pattern of diffuse spikes, which disappeared after a cisatracurium bolus. The diagnosis of tetanus was later confirmed by cultures from wound samples. Therefore, severe tetanus can mimic both the clinical and EEG features of status epilepticus and could be added to the differential diagnosis of epilepsy.

Generalized Tetanus in a Canadian Farmer Following Orthopedic Surgery

Tetanus is extremely rare in developed countries. We report the first documented case of tetanus in the province of Alberta since 2016: a farmer that developed trismus, shoulder stiffness, and fevers eight days following orthopedic surgery. Tetanus immunoglobulin elicited rapid recovery. We highlight risk factors, pathogenesis, epidemiology, and diagnostic challenges.

Rapid Detection of Clostridium tetani by Recombinase Polymerase Amplification Using an Exo Probe

Tetanus is a potentially fatal public health illness resulted from the neurotoxins generated by Clostridium tetani. C. tetani is not easily culturable and culturing the relevant bacteria from infected wounds has rarely been useful in diagnosis; PCR-based assays can only be conducted at highly sophisticated laboratories. Therefore, a real-time recombinase polymerase amplification assay (Exo-RPA) was constructed to identify the fragments of the neurotoxin gene of C. tetani. Primers and the exo probe targeting the conserved region were designed, and the resulting amplicons could be detected in less than 20 min, with a detection limit of 20 copies/reaction. The RPA assay displayed good selectivity, and there were no cross-reactions with other infectious bacteria common in penetrating wounds. Tests of target-spiked serum and pus extract revealed that RPA is robust to interfering factors and has great potential for further development for biological sample analysis. This method has been confirmed to be reliable for discriminating between toxic and nontoxic C. tetani strains. The RPA assay dramatically improves the diagnostic efficacy with simplified device architecture and is a promising alternative to real-time PCR for tetanus detection.

Diphtheria-tetanus-pertussis vaccine: past, current & future

The diphtheria-tetanus-pertussis (DTP) vaccine can prevent diphtheria, tetanus and pertussis. The component antigens of the DTP vaccine had long been monovalent vaccines. The pertussis vaccine was licensed in 1914. The same year, the mixtures of diphtheria toxin and antitoxin were put into use. In 1926, alum-precipitated diphtheria toxoid was registered, and in 1937 adsorbed tetanus toxoid was put on the market. The development of numerous effective DTP vaccines quickly stimulated efforts to combine DTP with other routine vaccines for infants. This overview covers the most important information regarding the invention of DTP vaccines, their modifications and the needs that should be focused on in the future.

Video Anthology of Movement Disorders Due to Infections in South Asia

South Asia, encompassing many populous countries including India, Pakistan, and Bangladesh, is home to a wide variety of infectious diseases several of which are disproportionately prevalent, endemic or distinctive to the region. These result in considerable morbidity and mortality, which can be greatly reduced through public-health measures, timely diagnosis and treatment. Some of these infectious diseases have neurological manifestations including movement disorders either due to the pathogen being neuroinvasive or via an immune-mediated response. For diseases such as Japanese encephalitis, movement disorders are the primary manifestation while for others, they can be a presenting feature. Thus, recognizing these movement disorders is often crucial to the diagnosis of the particular infection, and/or to exclude infection as a cause and arrive at the correct alternate diagnosis. Once diagnosed, the infection-related movement disorders are treated by targeting the infectious agent, or symptomatically. In this article, we describe and illustrate a variety of movement disorders that are seen in patients infected by viruses, bacteria and parasites in South Asia. This would be of value to neurologists practicing in the region and, with the increasing ease in movement of people and pathogens, those practicing elsewhere.

Decline of serologic immunity to diphtheria, tetanus and pertussis with age suggested a full life vaccination in mainland China

Background: Diphtheria-tetanus-pertussis (DTP) vaccine has already been involved in national vaccination program for several decades in China. The immunity against these diseases in the people of all ages is not well investigated.Materials and methods: Serum samples were tested for IgG antibodies to diphtheria toxoid (DT), tetanus toxoid (TT) and pertussis toxin (PT) by using commercial ELISA kits.Results: A total of 666 sera of patients from 1 day to 89 years of age was collected from 2018 to 2019. The protective rates of diphtheria, tetanus and pertussis were 45.5%, 54.4% and 4.7%, respectively. Only 4.7% of the study population had seropositivity against three of the diseases. Young infant (<3 m) and adult (>18y) were generally lack of protective antibody against diphtheria (81.7% and 58.3%) and tetanus (91.5% and 86.2%). An obvious increase in immunity level of diphtheria and tetanus was observed at 3 m-3y, but there was no significant increase of immunity to pertussis at any age group. All age groups showed low immunity to pertussis.Conclusions: The present results revealed the susceptibility to diphtheria and tetanus in young infants and adults, and the susceptibility to pertussis over the ages, which highlight the need to improve the current vaccination program.

Current Immunological and Clinical Perspective on Vaccinations in Multiple Sclerosis Patients: Are They Safe after All?

Vaccines work by stimulating the immune system, and their immunogenicity is key in achieving protection against specific pathogens. Questions have been raised whether in Multiple Sclerosis (MS) patients they could induce disease exacerbation and whether vaccines could possibly act as a trigger in the onset of MS in susceptible populations. So far, no correlation has been found between the vaccinations against influenza, hepatitis B, tetanus, human papillomavirus, measles, mumps, rubella, varicella zoster, tuberculosis, yellow fever, or typhoid fever and the risk of MS. Further research is needed for the potential protective implications of the tetanus and Bacillus Calmette-Guerin vaccines in MS patients. Nowadays with the emerging coronavirus disease 2019 (COVID-19) and recent vaccinations approval and arrival, the risk-benefit in MS patients with regards to safety and efficacy of COVID-19 vaccination in those treated with immunosuppressive therapies is of paramount importance. In this manuscript, we demonstrate how different vaccine types could be related to the immunopathogenesis of MS and discuss the risks and benefits of different vaccinations in MS patients.

Clinical outcomes and healthcare costs of inpatients with tetanus in Korea, 2011-2019

Background

Tetanus is a rare, vaccine-preventable but extremely serious disease. We investigated the recent trend of the clinical outcomes and medical costs for inpatients with tetanus in South Korea over 10 years.

Methods

We conducted a retrospective review to determine the clinical factors and medical costs associated with tetanus at two national university hospitals in South Korea between January 2011 and October 2019.

Results

Forty-nine patients were admitted for tetanus (mean age, 67.0 years [range, 53.0–80.0 years]; 32 women [57.1%]). All the patients had generalized tetanus, and 5 (10.2%) died during hospitalization. The median duration from symptom onset to hospital admission was 4 days. Trismus (85.7%) was the most common symptom, and the median hospital stay was 39 days. Thirty-two patients (65.3%) required mechanical ventilation, and 20 (40.8%) developed aspiration pneumonia. The median total healthcare cost per patient was US $18,011. After discharge, 35 patients (71.4%) recovered sufficiently to walk without disability.

Conclusions

Tetanus requires long hospital stays and high medical expenditures in South Korea; however, the vaccination completion rate is low. Medical staff should therefore promote medical advice and policies on the management of tetanus to the general South Korean population.

Neonatal tetanus in St. Mary's Hospital Lacor: A case report

Umbilical stump sepsis in a nonpassively immunized neonate poses a high risk to neonatal tetanus. Management of neonatal tetanus is still a great challenge in resource-limited settings where some health facilities lack tetanus toxoid containing vaccines, ventilator support, and inaccessibility of tetanus immunoglobulin.

Tetanus in Animals — Summary of Knowledge

Tetanus is a neurologic non-transmissible disease (often fatal) of humans and other animals with a worldwide occurrence. Clostridium tetani is the spore producing bacillus which causes the bacterial disease. In deep penetrating wounds the spores germinate and produce a toxin called tetanospasmin. The main characteristic sign of tetanus is a spastic paralysis. A diagnosis is usually based on the clinical signs because the detection in the wound and the cultivation of C. tetani is very difficult. Between animal species there is considerable variability in the susceptibility to the bacillus. The most sensitive animal species to the neurotoxin are horses. Sheep and cattle are less sensitive and tetanus in these animal species are less common. Tetanus in cats and dogs are rare and dogs are less sensitive than cats. Clinically two forms of tetanus have been recognized, i. e. localized and generalized. The available treatment is not specific because the toxin in neuronal cells cannot be accessed by antitoxin antibodies. The aim of the therapy is to: neutralise the unbound neurotoxin, inhibit C. tetani growth in the wound, and provide supportive care to mitigate the effects of the neurotoxin. The treatment is difficult with an unclear prognosis.

The Survivor: A Clinical Case of Tetanus in a Non-Immunized, Parenteral Drug User, Former Female Convict with HIV and HCV

Tetanus is a serious and potentially fatal systemic disease, caused by the bacterium Clostridium tetani. It is estimated that 1 million cases occur worldwide annually. Immunization programs have drastically decreased tetanus in developed countries, and the sporadic cases have been linked to injecting drug users (IDUs), immunosuppressed individuals, or those older than 65 without complete vaccination. Regrettably, it is still endemic in under-developed countries. In Spain, an average of 10 cases are notified each year, especially affecting those older than 65. The present article describes a case of a 48-year-old Spanish woman, an ex-convict and IDU with infection antecedents of Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV), who was admitted to the Emergency Department of a University Hospital with cervical rigidity and trismus. In a few hours, a neurological and respiratory deterioration was observed, resulting in admittance to the intensive care unit under the suspicion of a generalized tetanus infection. The treatment included hemodynamic support and respiratory therapy, antibiotics, muscle relaxants, sedatives, and tetanus immunoglobulin. Her stay in the ICU lasted 47 days. The clinical suspicion, the antecedents of risk, and the verification of the vaccination records should provide early guidance for diagnostics and the establishment of a treatment in these cases.

Tetanus in animals

Tetanus is a neurologic disease of humans and animals characterized by spastic paralysis. Tetanus is caused by tetanus toxin (TeNT) produced by Clostridium tetani, an environmental soilborne, gram-positive, sporulating bacterium. The disease most often results from wound contamination by soil containing C. tetani spores. Horses, sheep, and humans are highly sensitive to TeNT, whereas cattle, dogs, and cats are more resistant. The diagnosis of tetanus is mainly based on the characteristic clinical signs. Identification of C. tetani at the wound site is often difficult.

Vaccine Production to Protect Animals Against Pathogenic Clostridia

Clostridium is a broad genus of anaerobic, spore-forming, rod-shaped, Gram-positive bacteria that can be found in different environments all around the world. The genus includes human and animal pathogens that produce potent exotoxins that cause rapid and potentially fatal diseases responsible for countless human casualties and billion-dollar annual loss to the agricultural sector. Diseases include botulism, tetanus, enterotoxemia, gas gangrene, necrotic enteritis, pseudomembranous colitis, blackleg, and black disease, which are caused by pathogenic Clostridium. Due to their ability to sporulate, they cannot be eradicated from the environment. As such, immunization with toxoid or bacterin-toxoid vaccines is the only protective method against infection. Toxins recovered from Clostridium cultures are inactivated to form toxoids, which are then formulated into multivalent vaccines. This review discusses the toxins, diseases, and toxoid production processes of the most common pathogenic Clostridium species, including Clostridiumbotulinum, Clostridiumtetani, Clostridiumperfringens, Clostridiumchauvoei, Clostridiumsepticum, Clostridiumnovyi and Clostridiumhemolyticum.

Return of the old guard: a case of tetanus in an unvaccinated patient

A 78-year-old woman with no known medical history presented with severe neck pain that began 4 days prior to admission located in the paraspinal cervical region radiating to the shoulders, legs and back. She had associated stiffness of her neck and progression of pain to her jaw and throat with progression to generalised body spasms with lower extremity stiffness and weakness that limited her ability to walk. She quickly developed dysphagia and odynophagia with subsequent generalised spasms and profound hypoxic respiratory failure requiring nasotracheal intubation. The presumptive diagnosis of tetanus was made and she was given tetanus toxoid immune globulin and Tdap vaccine. She was managed in the intensive care unit and after a week of admission, required a tracheostomy and gastrostomy tube placement. She required a prolonged hospitalisation stay of 21 days before being transferred to a long-term vent facility.

In silico rational design of a novel tetra-epitope tetanus vaccine with complete population coverage using developed immunoinformatics and surface epitope mapping approaches

Presentation of many unwanted epitopes within tetanus toxoid vaccine to lymphocyte clones may lead to production of many unwanted antibodies. Moreover an ideal vaccine must cover all individuals in a population that is dependent to the kinds of human leukocyte antigen alleles. Concerning these issues, our study was aimed to in silico design of a multi-epitope tetanus vaccine (METV) in order to improve population coverage and protectivity of tetanus vaccine as well as reduction of complications. Concerning these issues, a novel rational filtration was implemented to design a novel METV using immunoinformatics and surface epitope mapping approaches. Prediction of epitopes for tetanus toxin was performed in the candidate country in which the frequency had been gathered from almost all geographical distributions. The most strong binder epitopes for major histocompatibility complex class II were selected and among them the surface epitopes of native toxin were selected. The population coverage of the selected epitopes was estimated. The final candidate epitopes had highly population coverage. Molecular docking was performed to prediction of binding affinity of our candidate epitopes to the HLA-DRB1 alleles. At first, 680 strong binder epitopes were predicted. Among them 11 epitopes were selected. Finally, 4 epitopes had the most population coverage and suggested as a tetra-epitope tetanus vaccine. 99.41% of inessential strong binders were deleted using our tree steps filtration. HLA-DP had the most roles in epitope presentation. Molecular docking analysis proved the strong binding affinity of candidate epitopes to the HLA-DRB1 alleles. In conclusion, we theoretically reduced 99.41% of unwanted antibodies using our novel filtration strategies. Our tetra-epitope tetanus vaccine showed 100% population coverage in the candidate country. Furthermore, it was demonstrated that HLA-DP and HLA-DQ had more potential in epitope presentation in comparison to HLA-DRB1.

Tetanus in a partially immunized child

A 13-year-old boy developed tetanus, although he had protective antitoxin antibody raised by three doses of tetanus toxoid vaccine. Four days after injury, he presented with muscle rigidity of his posterior neck, excessive diaphoresis, and risus sardonicus and was subsequently diagnosed with tetanus. Tetanus is rare in developed countries, particularly during childhood, but must be promptly diagnosed based on clinical symptoms.

Tetanus without apparent history of trauma

A-68-year-old male was admitted due to tetanus without apparent history of trauma. Trismus was observed on admission and was improved after treatment.

Vaccine-Preventable Diseases Requiring Hospitalization

BACKGROUND

Plain children often have lower immunization rates than non-Plain children. Penn State Health Children's Hospital is a tertiary medical center with large nearby Plain (Amish and Mennonite) communities. We sought to describe the characteristics of children hospitalized with vaccine-preventable diseases (VPDs). We hypothesized that Amish children would have a higher risk of VPDs than non-Amish children.

METHODS

International Classification of Diseases, Ninth Revision codes were used to identify patients <18 years diagnosed with a VPD from January 1, 2005, to December 31, 2015, at Penn State Children's Hospital. Demographic information, immunization status, and outcomes were obtained from medical records. By using the number of children in our primary service area, we calculated the risk of VPD requiring hospitalization for Amish and non-Amish children. We assessed the relationship between Plain affiliation and vaccination status by using the Pearson correlation coefficient.

RESULTS

There were 215 children with 221 VPDs. Most occurred in non-Plain children: 179 of 221 (81%). Except for pneumococcal infections, VPD occurred mostly in unvaccinated or immunocompromised children, regardless of Plain affiliation. There were 15 Haemophilus influenzae type b and 5 tetanus infections that occurred in children with an unvaccinated or unknown vaccination status. The risk of a VPD requiring hospitalization was greater for Amish than for non-Plain children (risk ratio: 2.67 [95% confidence interval: 1.87-3.82]). There was a strong correlation between Plain affiliation and lack of vaccination (r = -0.63, P < .01).

CONCLUSIONS

Amish children had an increased risk of a VPD requiring hospitalization than non-Plain children. With the exception of those with pneumococcal disease, most vaccinated children hospitalized with a VPD were immunocompromised.

Spontaneous Nosocomial Pseudomonas aeruginosa Meningitis Presenting as Trismus

We describe the case of a 78-year-old female receiving adjuvant postsurgical chemotherapy for colon adenocarcinoma who spontaneously developed nosocomial Pseudomonas meningitis causing severe trismus. The patient was initially admitted for ileus, developing neck stiffness and trismus on the thirteenth day of admission. Cerebrospinal fluid grew pansensitive Pseudomonas aeruginosa. Magnetic resonance imaging of the brain was consistent with bilateral subacute infarcts secondary to meningitis. The patient responded well to 21 days of broad spectrum antimicrobial therapy modified to ceftazidime alone following speciation and sensitivity. Outpatient follow-up at 46 days revealed normal maximal mouth opening with the ability to chew and tolerate a full diet. Trismus is a motor disturbance of the trigeminal nerve with difficulty in opening the mouth. Infectious etiologies commonly described include tetanus, odontogenic infections, or deep neck space infections. This is the first reported case of simultaneous nosocomial Pseudomonas meningitis and trismus in a patient with no history of neurosurgery or lumbar spinal manipulation.