Tetanus in i.v. heroin users

Tetanus is a toxic infectious state whose overall incidence is declining. In drug users who inject the drug, the incidence of tetanus may be on the rise. Contaminated heroin is the primary cause. Tetanus among intravenous drug users has been reported worldwide, but there are no such reports from Saudi Arabia.

Five tetanus cases were diagnosed at our hospital between October 1997 and September 2000. All were intravenous heroin users. Three presented to the outpatient department (OPD) with painful muscle spasms, while the other two were inpatients receiving treatment for heroin withdrawal. The total number of i.v. heroin users admitted during the same period was 2420 and the number of OPD cases seen was 2973.

All had a generalized form of tetanus. Neck stiffness, opisthotonos and painful back spasms were present in every case. Three subjects had trismus and autonomic instability. Two received neuroleptics in hospital as treatment for withdrawals, and one used it to self-medicate. Neuroleptic-induced side effect was the initial diagnosis. Lack of response to anticholinergics and muscle relaxants led to the suspicion of symptoms being due to tetanus. Two cases were mis-diagnosed at an early stage by the local emergency service.

These cases highlight the importance of the awareness of the possibility of tetanus in IV drug users. Tetanus is a clinical diagnosis. Though still uncommon, the disorder is seen more frequently in some vulnerable groups. Vigilance and a high index of suspicion are required in order not to mis-diagnose.