Introduction:
Tetanus is caused by Clostridium tetani and has a mortality rate of
4.2% to 50%, but it is a vaccine-preventable disease (1). Higher
mortality rates have been reported from centers with limited intensive
care and ventilator support (2). Despite the dramatic reduction in the
prevalence of the disease thanks to vaccination programs, tetanus
remains a global problem, particularly in low and middle-income
countries due to lack of vaccination or not receiving the booster dose
(3, 4).
As a toxin-producing, anaerobic gram-positive spore-forming bacterium,
Clostridium tetani produces tetanolysin and tetanospasmin. Besides the
role of tetanolysin in intensifying wound damage and providing anaerobic
condition for bacterium growth, most of the clinical manifestations of
tetanus result from tetanospasmin, which inhibits gamma amino butyric
acid (GABA)-ergic and glycinergic neurons (5, 6).
The diagnosis of generalized tetanus is based on the history of the
injury and clinical features (7). Due to the limited capacity for
clinical trials and available management options, there is still
limitations in evidence-based management strategies for the disease (8).
Nevertheless, treatments such as early tracheostomy and administering
benzodiazepines, magnesium sulfate, and morphine are effective and
recommended as first line therapy alongside supportive care. Also,
admission to intensive care unit (ICU) is offered for patients with
high-risk tetanus (4). Phenobarbital is a barbituric acid derivative
that acts as a non-selective central nervous system inhibitor by
mimicking the action of GABA in the brain. It enhances the effects of
GABA by facilitating the passage of Cl through Cl channels in GABA
receptors. Therefore, it appears that phenobarbital may be able to
reverse the inhibitory effects of tetanospasmin on the GABA receptor.
In this paper, we introduce a case of severe generalized tetanus with
respiratory failure, whose spasm did not improve with full doses of
benzodiazepines and muscle relaxant agents, but it was finally managed
with propofol and phenobarbital.