LAUSR

An 80-year-old Japanese man attended our hospital with a 3-day history of stiffness in his jaw and difficulty moving his right arm. He had no history of ever travelling abroad, but he did have a medical history of hypertension, osteoporosis, and total gastrectomy due to gastric carcinoma. He told us that he had hurt his right hand while working in his garden 10 days ago. On physical examination, we found him to have a stiff neck, trismus, and a fixed sardonic-type smile (figure). Additionally, his abdomen was board-like rigid, and there was muscle rigidity and increased tone in his arms and legs. His temperature was 36·7°C. On the dorsum of his right hand there was a contused, yellowish-coloured, necrotic wound, approximately 2 cm in diameter. He gave no history of tetanus toxoid inoculation, and a blood test showed a white blood cell count of 5·8 × 109 per L and a haemoglobin concentration of 13·0 g/dL. He had no IgG antibodies against tetanus: the ELISA recorded 0·00 IU/mL. Therefore, based on the clinical findings on admission and the laboratory result, we made a diagnosis of generalised tetanus and gave him tetanus immunoglobulin, 3000 units intravenously, and tetanus toxoid, 0·5 mL intramuscularly, and we started him on metronidazole, 500 mg intravenously every 6 h. We surgically debrided the wound on his right hand. An assessment with the Ablett classification of tetanus showed that his condition deteriorated soon after admission—he moved from grade 2 to grade 3 within 24 h—and we decided to put him on a ventilator. Further, because he was at risk of laryngeal spasm, he was given a continuous intravenous infusion of midazolam and dexmedetomidine. He remained on the ventilator for 21 days. He was finally discharged from hospital after an admission of 60 days, which included a 28-day stay on the respiratory step-down unit. He made a full recovery apart from a persistent rigidity in his right hand. Tetanus is caused by a neurotoxin produced by Clostridium tetani, a Gram-positive, obligate anaerobic rod-shaped bacterium that forms spores. C tetani spores occur worldwide as constituents of soil. Tetanus affects an estimated 1 million people worldwide every year, leading to between 48 199 and 80 042 deaths annually, in 2015. The yearly incidence of tetanus in Japan (0·09 per 100 000 population) is higher than that in the USA (0·01 per 100 000), and the EU (0·02 per 100 000). Japan has the world’s largest ageing population and tetanus has been included in the routine childhood vaccination schedule since 1968, resulting in 47% of the country’s inhabitants— ie, those born before 1968—being vaccine-naive with regards to tetanus. Further, 85% of notified cases are people aged 55 years and over. Tetanus toxoid as post-exposure prophylaxis is available under the universal public health-care system; however, unfortunately, few people—including clinicians— recognise the importance of pre-exposure prophylaxis because there is no national catch-up vaccination programme. We advocate that administrators and clinicians should promote education on both pre-exposure and postexposure prophylaxis for tetanus. Tetanus is a vaccinepreventable disease; therefore prophylaxis should be provided for people in developing countries and developed countries with ageing populations.