Autonomic complications in a case of severe tetanus

Severe tetanus developed in an elderly white man and he was treated with tracheostomy, therapeutic paralysis with curare and intermittent positive pressure ventilation. Over the initial few days, labile hypertension and tachycardia developed, which were eventually controlled with a trimetaphan infusion and intravenous propranolol. These drugs were withdrawn when profound hypotension developed, and over the next 5 days frequent physical stimulation was necessary to maintain an adequate level of cardiovascular activity. At this time the patient appeared comatose, his muscle tone was flaccid, and there was a marked similarity between the levels of cardiovascular and electroencephalographic activity. The end of the period was marked by a spontaneous increase in electroencephalographic activity and a better maintained blood pressure. Over the next 2 days, muscle spasms and hypertension reappeared, body temperature increased and consciousness returned. Eventual recovery was complete but delayed by a prostatic operation. It appears that in some elderly patients with severe tetanus a transient phase of sympathetic overactivity is followed by a phase when spontaneous sympathetic activity is minimal. During this second phase, massive sympathetic activation can be evoked by various stimuli provided drug-induced depression is avoided.