INTRAVENOUS MAGNESIUM SULPHATE AS ADJUNCTIVE TREATMENT OF PEDIATRIC SEVERE TETANUS A CASE REPORT
Agatha Febrina Christie,Stephanie Amanda Hatibie,Mulya Rahma Karyanti
Faculty of Medicine Universitas Indonesia Cipto Mangunkusumo Hospital
Background : Tetanus is a life-threatening disease caused by Clostridium tetani. The case fatality ratio ranged from 10-70%. Cardiovascular events secondary to sympathetic over-activity is the majority caused of mortality in severe tetanus. Benzodiazepines, opiates, and muscle relaxants are widely used to control the spasms and autonomic dysfunction. Magnesium sulphate has been described for treating the rigidity and autonomic dysfunction in severe tetanus.
Case Presentation Summary : A-13-year-old boy presented with trismus, generalized muscle rigidity, and reflex spasm one day prior to admission. Tetanus was diagnosed clinically with the nail-injured left sole as the port d’entree. His immunization status was unclear; human tetanus immunoglobulin 6000 IU, tetanus toxoid and antibiotics were administered. He was intubated and mechanically ventilated in the pediatric intensive care unit. Diazepam and intravenous midazolam were started to control generalized spasm. However the spasm worsened, therefore vecuronium was then added. He continued to have prolonged spasms and showed evidence of severe autonomic dysfunction such as swings in blood pressure and arrhythmia. Intravenous magnesium sulphate at 100 mg.kg-1.day-1 was then initiated as adjunctive therapy. Continuous cardiac monitoring and serial blood pressure recording were done. Magnesium and calcium serum levels were measured daily, mean magnesium level was 3.8 mg/dl (2.68 - 7.77 mg/dl) and calcium level was 1.18 mmol/L (1.09 - 1.4 mmol/L). Magnesium adverse effects were observed including respiratory muscle paralysis, hypotension, and bradycardia. After administration of magnesium sulphate, then discontinued tapered dose within 21 days. While sedation drugs were tapered, physical physiotherapy started to be given. At discharge, he was able to walk with support and speak in short sentences.
Learning Points/Discussion : Magnesium sulphate can be used as an adjunctive treatment for controlling muscle spasm and autonomic dysfunction in severe tetanus with continuous monitoring of its adverse effects.
Keywords: tetanus magnesium sulphate pediatric
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