Age: 82.0
Sex: F
Vaccine: TTOX
Symptoms: Pupil fixed, Salivary hypersecretion, Tetanus, Trismus, Urine output decreased
Clinical narrative: Initial unsolicited report received from the literature on 31-Dec-2016. The following is verbatim from the article: Abstract: Introduction: This is the 33rd Annual Report. As of 1 January 2015, 55 of the nation's poison centers (PCs) uploaded case data automatically to database. The upload interval was 9.52 [7.40, 13.6] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system. Methods: We analyzed the case data tabulating specific indices from the database. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Poison center cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure. Results: In 2015, 2,792,130 closed encounters were logged by NPDS: 2,168,371 human exposures, 55,516 animal exposures, 560,467 information calls, 7657 human confirmed non-exposures, and 119 animal confirmed non-exposures. PCs also made 2,695,699 follow-up calls in 2015. Total encounters showed a 3.42% decline from 2014, while healthcare facility (HCF) human exposure cases increased by 5.09% from 2014. All information calls decreased by 15.5% but HCF information calls increased 2.67%, and while medication identification requests (Drug ID) decreased 31.7%, human exposures reported to PCs were essentially flat, increasing by 0.149%. Human exposures with less serious outcomes have decreased 2.95% per year since 2008 while those with more serious outcomes (moderate, major or death) have increased by 4.34% per year since 2000. The top 5 substance classes most frequently involved in all human exposures were analgesics (11.1%), household cleaning substances (7.54%), cosmetics/personal care products (7.41%), sedatives/hypnotics/antipsychotics (5.83%), and antidepressants (4.58%). Sedative/Hypnotics/Antipsychotics exposures as a class increased the most rapidly (2597 calls (11.4%)/year) over the last 14 years for cases showing more serious outcomes. The top 5 most common exposures in children age 5 years or less were cosmetics/ personal care products (13.6%), household cleaning substances (11.2%), analgesics (9.12%), foreign bodies/toys/miscellaneous (6.45%), and topical preparations (5.33%). Drug identification requests comprised 35.0% of all information calls. Database documented 1831 human exposures resulting in death with 1371 human fatalities judged related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). Conclusions: These data support the continued value of PC expertise and need for specialized medical toxicology information to manage more serious exposures, despite a decrease in calls involving less serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality. The near real-time, always current status of database represents a national public health resource to collect and monitor exposure cases and information calls. The continuing mission of database is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, viral, bacterial, venomous, chemical agent, or commercial product), the identification of events of public health significance, resilience, response and situational awareness tracking. Database is a model system for the real-time surveillance of national and global public health. This case involves 82-year-old female patient who was vaccinated with TETANUS TOXOID (batch number, expiration date, dose, route and site of administration were not reported) on an unspecified date. Patient had tripped and fell next to chicken coup; wound was sutured. Seven days later patient developed jaw stiffness and had ongoing medical history of atrial fibrillation which was treated with labetalol; later treated with amiodarone and digoxin. Concomitant medication was not reported. On an unspecified date, following vaccination patient developed trismus, hyper salivation, "lock jaw" and could not move neck, had diffuse muscle spasms for which was intubated and sedated with midazolam and fentanyl; magnesium infusion was continued (day 2), developed significant autonomic instability, patient was treated with cisatracurium, lorazepam, midazolam, and fentanyl but her spasms continued, developed hypomagnesaemia (reported as hypermagnesemia) and the infusion was stopped (On Day 3 ), decreased urine output, norepinephrine was increased following profound hypotension (50/30s) paralytic was stopped and the sedation was weaned (on Day 17), pupils were fixed and an EEG showed profound hypoxic injury (Day 21) and based on the prognosis, comfort measures were instituted and died on Day 22. On an unspecified date patient was hospitalized. Laboratory investigation included Blood Pressure: 73/36 Torr, Heart rates: 58 beats per minutes, Respiration rate 20 breaths per minute , oxygen saturation- 95%, sodium-140 mmol/L , potassium- 4.1 mmol/L, calcium-108 mg/dL, carbon dioxide- 20 mmol/L, blood urea nitrogen (BUN) test- 40, Creatinine -2.0 mg/dL, creatine phosphokinase (CPK)- 1132 U/L. On an unspecified date, patient received IVF and norepinephrine for hypotension, received furosemide for decreased urine output, benzodiazepines, magnesium and tetanus immunoglobulin and metronidazole as a corrective treatment. Outcome of event acute tetanus reported as fatal and for other events not reported. On an unspecified date patient was discharged from hospital. Cause of death: tetanus due to her leg lacerations. Manner of death: accidental. Autopsy was not performed. Documents held by sender: none. Sender's Comments: The 82 years old female was reported to have had a fall during which she had wound which was sutured. Seven days later, she presented with jaw stiffness which warranted tetanus immunization. She gradually deteriorated, with symptoms compounding symptoms like lock jaw, muscle spasms, unable to move her neck, hypotension, autonomic instability. A diagnosis of acute tetanus was made. She had a history of atrial fibrillation which was before tetanus and was on treatment with several muscle relaxants, metronidazole, magnesium, lorazepam and then fentanyl was initiated. Norepinephrine was included in the therapy for hypotension. Few days later, she presented with magnesium toxicity and magnesium was discontinued. By day 21 her fixed pupils were fixed with EEG showing serious hypoxic injury. As there was a time lag between the fall, the wound, the development of the full symptoms of tetanus and the administration of the vaccine, it is unlikely that the vaccine (a toxoid) which could be the cause of death. Details regarding presence of tetanus spore from the wound may further aid in confirming the diagnosis and cause of death, which in this case is complications of tetanus. Reported Cause(s) of Death: tetanus.