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A 9-year-old girl impaled with a roofing nail in her knee
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This month’s contributor is Michael W. Cater, MD. He is in private practice in Tustin, Calif., and is affiliated with Children’s Hospital of Orange County, Monarch Healthcare and St. Joseph Hospital.
A 9-year-old girl fell while running, impaling a roofing nail into her left knee (Figure 1). She was taken to the local ED, where the knee was imaged with a plain radiograph (Figure 2). Afterward, the nail was removed and the wound cleaned.
James H. Brien
Michael W. Cater
The ED physician was told by the parent that the child’s immunizations were up-to-date (undocumented). She was sent home on cephalexin and told to follow up with her primary physician. A few days later, she reported to the primary provider’s office with some erythema (Figure 3). An infection was suspected, and she was admitted for further evaluation and IV antimicrobial therapy for presumed staphylococcal cellulitis. An MRI revealed no bone involvement. Upon reviewing her actual immunization record, you document that she received four doses of tetanus toxoid between age 2 and 18 months; after which, she has received no further tetanus immunizations.
A 9-year-old girl fell while running, impaling a roofing nail into her left knee (Figure 1). She was taken to the local ED, where the knee was imaged with a plain radiograph (Figure 2).
Source: Brien JH
A few days later, she reported to the primary provider’s office with some erythema (Figure 3).
What tetanus prophylaxis would you give?
A. None
B. Tetanus immune globulin (TIG)
C. Tetanus toxoid
D. Tetanus toxoid plus TIG
The answer is C, tetanus toxoid, and Tdap would be the product recommended for her age. If a child younger than 7 years requires tetanus prophylaxis, DTaP should be used. The only time TIG is recommended is when fewer than three doses of toxoid have been previously given, and it is a tetanus-prone injury. This includes but is not limited to wounds contaminated with dirt, soil, feces or saliva; puncture wounds; avulsions; crush injuries; burns; and frostbite (2013 AAP Red Book Online).
Because this was a dirty puncture wound, it falls into the tetanus-prone category; and although she had received four previous doses of tetanus toxoid, more than 5 years had passed since her last dose. Therefore, she should receive a dose of toxoid, but not TIG. For clean, minor wounds, the recommendation is to give toxoid only if more than 10 years have passed since the last dose.
The vast majority of tetanus occur in Africa and Asia, as shown in Figure 4.
The patient was treated with IV clindamycin with rapid improvement and was sent home on oral clindamycin.
The most common form of tetanus in pediatrics is in the neonate, as a result of unclean deliveries from mothers without tetanus immunity. The vast majority occur in Africa and Asia, as shown in Figure 4; a 2-week-old neonate with tetanus, seen by Louis Giangiulio, MD, while serving with a Battalion Aid Station in Afghanistan in 2003. Through efforts by WHO and UNICEF, neonatal and maternal tetanus has been reduced by about 90% since the turn of the century, but it remains a significant problem. Approximately 58,000 newborns died in 2010 of neonatal tetanus.
Columnist Comments
I would like to thank Mike Cater, MD, of Tustin, Calif., for contributing yet another case to this column. Dr. Cater has sent numerous cases for consideration in the past several years. The first one was a case of necrotizing fasciitis in a patient with varicella, exactly 4 years ago, with several more since. I don’t know what Mike’s practice is like in Tustin, but he obviously has a sharp eye for what might be of interest for a visual diagnosis column, and is obviously handy with a camera.
This is a short column, but with an important message. As immunizations form the foundation of our preventive medicine efforts in children (and adults), time spent reviewing specific aspects of the topic is always time well spent, even with rare diseases such as tetanus. There is usually not a problem in seeing to it that children be immune to tetanus, but rather trying to limit them to receive only what they need. All of us “old-timers” can recall when a child would receive a dose of tetanus toxoid with almost any injury that was severe enough to be seen in a clinic or ED, virtually without regard for his or her immunization status, if it was even available to be considered at all. Nowadays, with electronic records, documented immunization status is more likely to be readily available. Guidelines for tetanus prophylaxis are fairly easy to memorize and apply when the patient’s record is known, and if not known, we probably should err on the side of prevention, especially if tetanus-prone. I would caution using the parent’s personal recollection or what a school nurse told them. I have seen many cases where that proved to be inaccurate information and can potentially place the patient at risk, whether it’s tetanus, or Haemophilus influenzae type b. If it’s important enough to need to know, it’s important enough to have it in a documented format.
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Disclosure: Brien reports no relevant financial disclosures.