Letters to the Editor

Indian Pediatrics 2000;37: 223-224

Tetanus in Immunized Children

The incidence of tetanus has declined dramatically because of the increased coverage of DPT, DT vaccination and post-exposure prophylaxis with tetanus toxoid. However, tetanus has occurred in individuals with prior immunization(1_5). We describe two children who developed tetanus even though they had received the complete immunization.

A 4½-year-old girl presented in the emergency department with complaints of sore throat for 4 days, neck stiffness and pain in the nape of the neck for 3 days, accompanied by difficulty in opening the mouth and repeated episodes of arching of body, especially on stimulation. There was no history of fever or trauma. The child had received 3 doses of DPT during infancy and a booster at 1.5 years age. On examination, the child was conscious, alert and hemodynamically stable. The child had risus sardonicus and trismus. Stimulation led to opisthotonic posturing. A clinical diagnosis of cryptogenic tetanus was made. The CSF examination and serum calcium were normal. Computed tomography of the neck ruled out possibility of retropharyngeal abscess. The child received 1500 IU of human tetanus immunoglobulin and crystalline penicillin. For control of spasms, diazepam was administered as a continuous infusion. The frequency of spasms reduced gradually and the diazepam drip was discontinued successfully after 5 days.

Another 3-year-old girl presented with history of purulent discharge from the right ear for 5 days, difficulty in swallowing for 2 days and fever for a day prior to admission. There was no history of trauma. As per records, the child was completely immunized for age. On examination, the child was irritable, had trismus, opisthotonic posturing and recurrent spasms. At admission, a clinical diagnosis of otogenic 

tetanus was made. The CSF examination was normal. This child was also treated with human tetanus immunoglobulin 1500 IU intra-muscularly, 1500 IU of human tetanus immunoglobulin intrathecally and crystalline penicillin. The child required diazepam and pancuronium drip for control of spasms and both were withdrawn by day 12, when the child was free of spasms.

The active immunization with tetanus toxoid has an estimated failure rate of less than 4 per 100 million immunocompetent persons(6). In a Finnish survey, 4.7% of the tetanus patients were children and all had received complete tetanus immunization. These children had a mild or moderate disease and none needed ventilator care. However, antitoxin levels were not performed in these patients(2). The disease could be classified as mild to moderate tetanus in both our patients and they recovered completely. In both the cases, although antitoxin levels could not be determined, reliable immunization records were available. This report highlights the importance of considering a clinical possibility of tetanus even in immunized children.

Rakesh Lodha,
Aarti Sareen,
Rohit Manoj Kumar,
Narendra K. Arora,

Department of Pediatrics,
All India Institute of Medical Sciences,
New Delhi 110 029,


1. Edsall G. Specific prophylaxis of tetanus. JAMA 1959; 171: 417-427.

2. Luisto M, Matti I. Tetanus of immunized children. Dev Med Child Neuro 1993; 35: 351-355.

3. Passen EL, Andersen BR. Clinical tetanus despite a `protective' level of toxin neutralizing antibody. JAMA 1986; 255: 1171-1173.

4. Berger SA, Cherubin CE, Nelson S, Levine L. Tetanus despite pre existing antitetanus antibody. JAMA 1978; 240: 769-770.

5. Edsall G. Modified tetanus. N Engl J Med 1962; 267: 520.

6. Band JD, Bennett JV. Tetanus. In: Infectious Disease. Ed. Hoeprich PD. Harper and Row, Philadelphia, 1983; pp 1107-1114.


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