Plus-Hex CLINICAL measures should be considered in these cases . Signs requesting quiet can also be placed on doors to remind staff members to minimise noise in the vicinity of tetanus patients . In Luther ' s case , the lights were dimmed and staff were asked to close doors quietly and to speak softly when around him and in the ICU . Initially , his eyes were lubricated every 2 hours , and then every 4 hours when he was better able to blink .
Shea et al . [ 8 ] carried out a study to investigate the possibility that dogs with tetanus experience nightmares . The study focused on abnormal behaviour during the rapid eye movement ( REM ) phase of sleep . The REM sleep behaviour disorder was described as ‘ violent ’ or ‘ nightmare-like ’ in 36 % of affected dogs , and ‘ similar to that of an epileptic seizure ’ in another 40 % of animals [ 8 ] . Staff and owners need to be able to recognise the difference between a tetanus-induced nightmare and seizure activity to avoid misdiagnosis . Luther experienced nightmare-like activity , but with good nursing care he recovered well from each episode .
Luther was unable to stand for several days , so to keep blood flowing through all four limbs he received gentle massage , heat therapy and passive range of motion ( PROM ) support . It was noticed that his stiffness and facial expression worsened just before he was due for his next dose of diazepam , so his rehabilitation exercises were timed around his medication administration .
Despite our best efforts , Luther ' s condition declined , so his medication was adjusted . Methocarbamol was increased to 50 mg / kg every 8 hours and antiinflammatory medication was introduced . After 4 days in hospital , and with the adjustments to his medication and continued light physiotherapy , Luther was able to intermittently sit and stand . He was still tense , but seemed to find practising PROM easier and was comfortable enough to be weaned off opioid pain relief .
Luther continued to improve and even managed to pick up a toy on the sixth day of his stay . This was a turning point , as it became clear that it was no longer just the staff working to get him better ; he was working equally hard . He started to want to go outside , was fully ambulatory ( with support ) and was able to open his jaw to 4 cm . He still displayed nightmare-like activity , but the frequency and duration were reducing .
As Luther was doing so well , he was trialled off IV diazepam in preparation for him to go home . Unfortunately , the stiffness returned and he had to be given a one-off IV dose . He was then trialled on oral diazepam at 5 mg every 8 hours , instead of abrupt cessation of the drug . He was offered small amounts of liquid food , orally , which he was happy to lap up and swallow without issue . His mobility improved , so his urinary catheter was removed and conscious urine production was monitored . The changes to Luther ' s medication were successful and he continued to improve and was soon ready for discharge .
Discharge
On 21 April 2023 , Luther was walking with minimal support and was much brighter , so he was discharged with oral medication , including antibiotics , muscle relaxants , pain relief and anti-inflammatories , as well as eye lubrication . His owner had a medical background and was able to manage his oesophagostomy tube at home . The tube was removed once he was eating solids and no longer reliant on the enteral nutrition . Gentle massage , heat therapy and PROM support were continued at home to help with the stiffness . Because Luther was still recovering , he remained hypersensitive to stimuli , so a calm , quiet home environment was encouraged .
At a check-up two and a half weeks after discharge , Luther ’ s limbs were more flexible and he was urinating and defaecating normally , eating solids and drinking well . His cardiovascular and respiratory parameters were within their normal ranges and he could open his mouth up to 10 cm . His toe was still slightly swollen , but no longer sore , and his facial pinch was vastly improved compared with his initial presentation . Following multiple progress assessments , he was given the all clear on 5 June 2023 .
Conclusions
Tetanus takes several weeks to treat : Luther was admitted on 11 April and discharged on 21 April , with contact maintained with his owner post-discharge to monitor his progression . It has been almost a year since he was admitted and Luther is now fully recovered .
REFERENCES
1 Henry R . Etymologia : Tetanus . Emerging Infectious Diseases . 2012 ; 18 ( 10 ): 1635 . Available from : https :// doi . org / 10.3201 / eid1810 . et1810 .
2 Williams K , Barnette C . Tetanus in Dogs . VCA Animal Hospitals . Available from : https :// vcahospitals . com / know-your-pet / tetanus-in-dogs [ Accessed 9 June 2023 ].
3 Hassel B . Tetanus : pathophysiology , treatment , and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms . Toxins . 2013 ; 5 ( 1 ): 73 – 83 . Available from : https :// doi . org / 10.3390 / toxins5010073 .
4 Stämpfli HR . Tetanus in Dogs . MSD Manual . 2022 . Available from : https :// www . msdvetmanual . com / dog-owners / disorders-affectingmultiple-body-systems-of-dogs / tetanus-in-dogs [ Accessed 9 June 2023 ].
5 Ashe C . Can Dogs Get Tetanus ? Whole Dog Journal . 2018 . Available from : https :// www . whole-dog-journal . com / health / can-dogs-gettetanus / [ Accessed 10 June 2023 ].
6 Mar Vista Animal Medical Center . Tetanus in Pets . 2021 . Available from : https :// www . marvistavet . com / tetanus-in-pets . pml [ Accessed 10 June 2023 ].
7 Acke E , Jones BR , Breathnach R , McAllister H , Mooney CT . Tetanus in the dog : review and a case-report of concurrent tetanus with hiatal hernia . Irish Veterinary Journal . 2004 ; 57 ( 10 ): 593 – 597 . Available from : https :// doi . org / 10.1186 / 2046-0481-57-10-593 .
8 Shea A , Hatch A , De Risio L , Beltran E . Association between clinically probable REM sleep behavior disorder and tetanus in dogs . Journal of Veterinary Internal Medicine . 2018 ; 32 ( 6 ): 2029 – 2036 . Available from : https :// doi . org / 10.1111 / jvim . 15320 .
Volume 39 ( 2 ) • April 2024
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