The implementation of childhood vaccination programmes worldwide has caused a significant reduction in the incidence of Tetanus cases. However, it still remains a cause for concern among the groups at extremes of age. In the developed nations it is primarily a disease afflicting the elderly [8, 9]. Immunity against Tetanus can only be gained through immunization, with inactivated Tetanus toxoid (TT) containing vaccines. These vaccines maybe single antigen vaccines (monovalent) or more commonly part of a Tetanus Toxoid containing vaccines (TTCV) e.g., diptheria, tetanus and acellular pertussis (DTP), pentavalent (5 in 1) or hexavalent (6 in 1) vaccines [10]. In the United Kingdom, as per NHS guidance the hexavalent vaccine [Infanrix hexa®] is administered at 8, 12 and 16-weeks following birth and confers protection against Tetanus. An interval of 4 weeks between each dose is needed to induce adequate immune response and after the 3rd dose the effectiveness is very high. In UK subsequent TT containing vaccine booster doses are given at pre-school (3 years 4 months) and at adolescence (14 years) to ensure sufficient immunity to last through early adulthood which helps prevent Tetanus. [11, 12] As the vaccination programme had only commenced after 1961, those born before this year are naturally more vulnerable to develop Tetanus as a complication and in the United Kingdom with an ageing population the highest incidence of Tetanus was noted in those above the age of 65 years [5].

Identifying wounds at risk for Tetanus is crucial as it will help dictate immediate management which could be lifesaving. When clinically relevant, wounds should be classified as Tetanus-prone wounds when they include (a) puncture type wounds e.g., due to gardening, (b) when they contain foreign bodies and debris or (c) associated with compound fractures (d) burns with systemic sepsis or (e) are wounds that are due to certain animal bites and scratches. The risk category is further increased to high-risk tetanus-prone wounds when there is greater contamination, extensive devitalised tissue and wounds that required surgical debridement but were delayed greater than 6 h. The initial principals of management include wound care and if needed early debridement, use of antibiotics with adequate spectrum of anaerobic cover and based on risk assessment timely post exposure prophylaxis(PEP). [12, 13] When the wound is Tetanus prone, the need of PEP also depends on the vaccination history e.g., having received a priming course and booster doses, or if there is uncertain immunisation history and if the patient was born before 1961. If the latter two criteria are met the current guidance strongly recommends the use of PEP with Immunoglobulins to hasten the escalation of antibody levels in those lacking adequate antibody levels or with inadequate rapid memory response due to incomplete or no prior vaccination. The recommendation is to administer intra-muscular tetanus immunoglobulin (IM-TIG) 250 IU immediately or 500 IU if more than 24 h have passed. This will result in adequate anti-toxin levels 2–3 days post administration which can last up to 4 weeks. If IM-TIG is unavailable a recommended alternative option is human normal immunoglobulin (HNIG), the dose of which dependant on body weight. Additionally, IM Tetanus toxoid should also be co-administered at a separate site as Tetanus does not induce immunity [Supplementary table] [12,13,14,15,16]. The value of immunoglobulins even when there is delay to seek medical care is justified due to the variable incubation period. The mechanism of action of immunoglobulins is by neutralizing the circulating unbound toxin, tetanospasmin. However, once tetanospasmin binds to neural tissue the damage is irreversible, stressing the need for early accurate identification of Tetanus prone wounds and the timely use of IM-ITG or an equivalent [15] as this has shown to improve survival [17].

Clostridrium Tetani has a variable incubation period ranging from 1-day up to 60 days, with shorter period of incubation being associated with severe symptoms. The patterns of presentation of Tetanus is variable but generalised Tetanus is the commonest in adults while cephalic and localised forms are seen less often. The classical “Lock Jaw” tends to be seen frequently and usually tends to be the first sign of an evolving spectrum of manifestations [18]. Based on severity of neuromuscular manifestations and cardiorespiratory compromise Tetanus can be graded from Stage I-IV according to Ablett’s classification [19]. The focus of management at this point shifts towards supportive care with ample use of benzodiazepines for spasm, monitoring and managing autonomic dysfunction, maintaining ventilation and efficient nursing with good bed care [12]. Tetanus can cause a spectrum of cardiac manifestations due to autonomic dysfunction ranging from labile blood pressure to arrythmias and can result in sudden cardiac arrest and death. It has become an important cause of mortality in severe forms of Tetanus more so than respiratory failure due to the improvements in mechanical ventilation and ICU care [20, 21].

Takotsubo cardiomyopathy is a form of reversible heart-failure that occurs as an infrequent complication to a stressor, and this phenomenon is mostly observed in postmenopausal elderly females. The stressor can either be a physical or an emotional trigger [22]. The postulated mechanisms include hypothalamic pituitary adrenal axis activation with an ensuing catecholamine surge that causes cardiac insult. This insult occurs due to either direct myocardial toxicity or is indirectly brought about by myocyte hypoxia caused by a mismatch between oxygen supply and demand. This ensuing myocardial damage usually causes regional wall abnormalities in multiple territories beyond a single coronary vascular bed and results in heart failure, as was observed in our patient [Supplementary data] [23, 24] Bacterial, viral and parasitic Infections can trigger cardiomyopathy due to complex mechanisms, similarly they can also precipitate acute cases of Takotsubo cardiomyopathy which are documented [25]. Sympathetic overactivity resulting in adrenergic crisis is a phenomenon seen in Tetanus, and Takotsubo cardiomyopathy has been rarely documented in patients complicated with severe Tetanus [26, 27].

Tetanus can be fatal and has a variable rate of mortality ranging from 10% up to 90% in different countries [12, 28]. Adequate intensive care facility along with good supportive care and rehabilitation plays a pivotal role in reducing fatality rates which may explain the comparatively lower mortality rates in developed nations [29]. Regardless due to the nature of the illness, the period of hospitalisation usually tends to be prolonged with a similar time needed for rehabilitation and return to baseline functionality [9]. Furthermore, when it comes to elderly patients this situation gives rise to concern as to the uncertainty of final outcome and possible increased mortality, as prolonged ICU stay in elderly has been shown to have a higher mortality [30, 31], as elderly patients tend to be at a poor baseline health status to begin with, and concomitant comorbidities which may determine the patient outcome [31]. Because of this, there is also an added financial burden on the healthcare system, as the overall cost per patient can be very high when managing Tetanus [9]. This highlights the importance of prevention rather than actively managing the complication of a fully evolved Tetanus. In such situations referring proper guidance is vital, either hospital trust guidelines or National guidelines. To reinforce this NHS UK provides clear, updated and comprehensive guidance with a dedicated chapter on Tetanus in the Immunization against infectious disease (green book), the national guidelines for vaccines and infectious diseases [12].

Our patient was a classic example of an at-risk individual by virtue of her age and the absence of childhood vaccination. She sustained a typical Tetanus prone wound and did not receive appropriate PEP. There was rapid evolution of symptoms implying a short incubation period as she developed a severe generalised tetanus with cardiac complications. She was the text book example of a patient whose clinical manifestation of Tetanus could have been avoided had there been timely recognition of her predisposing risk factors e.g., her age and exposure and that she met the criteria met for utilisation of PEP.