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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 28-29

Tetanus following a lion attack


1 Department of Medicine, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
2 Department of Surgery, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Sani Hadiza
Department of Medicine, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_13_19

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  Abstract 


Lion attacks are rarely seen even in hunters. However, there are few reported cases affecting mainly zookeepers. Most patients usually die from injuries sustained and never survive long enough to develop tetanus. We present a case of tetanus complicating lion attack in a 42-year-old zookeeper, who presented with multiple puncture wounds and quadriplegia after being attacked by a lion in the zoo and subsequently developed signs of tetanus 3 days after the bite.

Keywords: Hemorrhage, lion attack, quadriplegia, tetanus


How to cite this article:
Hadiza S, Dodo YP, Nuhu Y, Balarabe AA, Bashir YA. Tetanus following a lion attack. Arch Med Surg 2019;4:28-9

How to cite this URL:
Hadiza S, Dodo YP, Nuhu Y, Balarabe AA, Bashir YA. Tetanus following a lion attack. Arch Med Surg [serial online] 2019 [cited 2019 Nov 13];4:28-9. Available from: http://www.archms.org/text.asp?2019/4/1/28/269231




  Introduction Top


Injuries to humans caused by attacks from large predators are very rare. In the medical literature, few cases are reported on accidents in zoos.[1] In a list of some of the captive wild animal attacks that have occurred in the United States and Canada between 2000 and 2010, only two were by lions.[2] To the best of our knowledge, there have been no reported cases of lion attacks reported from Nigeria in the medical literature.

Tetanus is an infectious disease caused by contamination of wounds with the bacteria – Clostridium tetani spores. The spores produce two toxins – tetanolysin and tetanospasmin. Tetanospasmin inhibits the central inhibitory neuron gamma-aminobutyric acid, leading to excessive and uncontrolled muscular contractions and autonomic dysfunction.[3] Most infections result from grossly contaminated wounds or bites. Fatality due to tetanus is 45%–50% in developing countries due to poor immunization practices.[3] The mortality rate depends on the patient's age, incubation period, period of onset, source of infection, proximity to the central nervous system, and autonomic dysfunction, among others.[4],[5],[6],[7],[8] Diagnosis is clinical and the management involves good supportive care with maintenance of airway, wound debridement, administration of tetanus immunoglobulin, and active immunization. Tetanus occurring following lion attack has, to the best of our knowledge, not previously reported since most patients usually die from severe injuries sustained.[2]


  Case Report Top


A 42-year-old zookeeper was brought to the emergency unit about 10 min following an attack by a lion at the zoo. The presenting features were inability to use both upper and lower limbs, neck pain, and bleeding from multiple puncture wounds in the neck. At presentation, he was conscious and alert, pale, dehydrated, and febrile. He had tachycardia and blood pressure of 90/70 mmHg and had multiple puncture wounds about six on the lateral aspect of the neck on both sides bleeding profusely with an estimated blood loss of 1.5–2 L. He had generalized hypotonia, power of 0/5 in all limbs with no demonstrable sensory level. An initial assessment of quadriplegia due to cervical spine injury and massive hemorrhage complicating lion attack was made.

He was immediately resuscitated, was transfused two units of whole blood, and was given analgesics, antibiotics, and tetanus prophylaxis. He remained stable until the 3rd day of admission when he developed trismus, rigidity, and spasms of the trunk and limbs consistent with tetanus. He was managed appropriately with sedation, intravenous fluids, and adequate supportive care. However, the patient's condition deteriorated rapidly until he gave up sooner that same day while arrangements were made for mechanical ventilation.


  Discussion Top


A case of tetanus complicating lion injury is hereby reported. It is a well-known fact that deep penetrating/crush injuries as was the case here are the risk factors for tetanus. Wild animal attack can be complicated by rabies.[9] However, this diagnosis was not entertained since the patient had classical features of tetanus, and the patient could swallow. Furthermore, worthy of note is the rather short incubation period for tetanus in this case. This could be attributed to the depth of the injuries sustained as well as the site of injury (head-and-neck region). An incubation period of 4 days was previously recorded in case of tetanus complicating a human bite to a finger [10] and 2 weeks following dog bite on the lower limb.[11] Although tetanus prophylaxis (tetanus toxoid and anti-tetanus serum) was administered in this case, it is worthy of note that the process of active immunization takes some time while the passive immunity conferred by the immunoglobulin only acts on unbound toxins and is short lived. If the patient was fully or partially immunized previously, this could have offered some protection against tetanus. The ability to promptly react to a booster injection (immunological memory) is greatly enhanced in persons who have previously received at least two doses of the active immunity as the vaccine is nearly 100% effective in preventing tetanus.[3] Florid tetanus is easy to diagnose; however, emphasis should be to suspect the disease early to avoid fatality, and healthcare workers need to be aware of the atypical situations, leading to tetanus to avoid the fatality of this deadly disease.


  Conclusion Top


In attacks by wild animals, the possibility of tetanus should be kept in mind as the resuscitation of the patient is ongoing. As such, the need for active immunization and booster doses of relevant vaccines in animal handlers cannot be overemphasized.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schiller HJ, Cullinane DC, Sawyer MD, Zietlow SP. Captive tiger attack: Case report and review of the literature. Am Surg 2007;73:516-9.  Back to cited text no. 1
    
2.
Dabdoub CF, Dabdoub CB, Chavez M, Molina F. Survival of child after lion attack. Surg Neurol Int 2013;4:77.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Brauner JS, Vieira SR, Bleck TP. Changes in severe accidental tetanus mortality in the ICU during two decades in Brazil. Intensive Care Med 2002;28:930-5.  Back to cited text no. 3
    
4.
Trujillo MH, Castillo A, España J, Manzo A, Zerpa R. Impact of intensive care management on the prognosis of tetanus. Analysis of 641 cases. Chest 1987;92:63-5.  Back to cited text no. 4
    
5.
Bleck TP, Brauner JS. Tetanus. In: Scheld WM, Witley RJ, Marra CM, editors. Infections of the Central Nervous System. 3rd ed.. New York: Lippincott Williams & Wilkins; 2004. p. 625-48.  Back to cited text no. 5
    
6.
Orellana-San Martín C, Su H, Bustamante-Durán D, Velásquez-Pagoaga L. Tetanus in intensive care units. Rev Neurol 2003;36:327-30.  Back to cited text no. 6
    
7.
Fukutake T, Miyamoto R. Clinical features of tetanus: A review with case reports. Brain Nerve 2011;63:1101-10.  Back to cited text no. 7
    
8.
Miranda-Filho DB, Ximenes RA, Barone AA, Vaz VL, Vieira AG, Albuquerque VM. Clinical classification of tetanus patients. Braz J Med Biol Res 2006;39:1329-37.  Back to cited text no. 8
    
9.
Türkmen S, Sahin A, Gunaydın M, Tatli O, Karaca Y, Turedi S, et al. A wild wolf attack and its unfortunate outcome: Rabies and death. Wilderness Environ Med 2012;23:248-50.  Back to cited text no. 9
    
10.
Agrawal K, Ramachandrudu T, Hamide A, Dutta TK. Tetanus caused by human bite of the finger. Ann Plast Surg 1995;34:201-2.  Back to cited text no. 10
    
11.
Radjou A, Hanifah M, Govindaraj V. Tetanus following dog bite. Indian J Community Med 2012;37:200-1.  Back to cited text no. 11
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Abstract
Introduction
Case Report
Discussion
Conclusion
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