Eradicated? Neonatal tetanus in Western Uganda; a case report of successful management

Abstract

Neonatal tetanus is a life-threatening condition with an almost 100% mortality in resource-limited settings.  The standard of care ventilator support, parenteral nutrition and neuromuscular blockade is often inaccessible. Here, we present the successful workup and management of neonatal tetanus at a regional hospital in Western Uganda. Particular attention is paid to social and cost barriers to history-gathering and treatment and cross-institutional collaboration to improvise care based on pathophysiology. We reviewed records of a neonate treated for neonatal tetanus at Mbarara Regional Referral Hospital, in collaboration with physicians from TTUHSC El Paso, Texas. A term neonate was delivered at home in Western Uganda. She presented with intermittent fevers, refusal to feed and dystonia, which progressed to generalized stiffness and led to presumptive treatment for meningitis at an outside hospital. After referral with worsening symptoms, a sepsis workup was performed and she was started on intravenous antibiotics and phenobarbital. Further maternal history revealed lack of tetanus immunization and unsterile birthing practices. As symptoms progressed to trismus, opisthotonos, risus sardonicus and clinical suspicion for tetanus rose. She received tetanus immunoglobulin, diazepam, magnesium sulfate and supportive care. She was discharged after 19 days and had normal development at 19 months. This case highlights that successful management and survival from neonatal tetanus is possible without access to advanced NICU care. Mutually respectful collaboration enabled diagnosis and care improvisation using local resources to craft a protocol that can be formally evaluated for efficacy. Ongoing communication is key to making such adaptation ethical in global partnerships where resources differ.