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.