Abstract / Summary
Abstract Background: Neonatal tetanus is a life-threatening, vaccine-preventable disease that still occurs in low-resource settings, such as Somalia, often following unhygienic umbilical cord care during home deliveries. Management in intensive care is complex, especially when toxin-mediated motor overactivity coexists with suspected seizures and sepsis, and persistent rigidity prevents weaning from mechanical ventilation. This case is notable for the successful use of high-dose enteral baclofen to control refractory rigidity and enable extubation in severe neonatal tetanus in a low-resource neonatal intensive care unit setting. Case presentation: An 8-day-old term male neonate born at home to an unimmunized multigravida mother presented with respiratory distress, severe trismus, generalized rigidity, high fever, hemodynamic instability, and recurrent tonic–clonic seizures. Bedside electroencephalography was not performed because transfer was unsafe owing to ventilator dependence. Broad-spectrum antimicrobials, vancomycin and meropenem, were initiated for presumed sepsis, along with a single dose of human tetanus immunoglobulin and scheduled intravenous diazepam for tetanic spasms. Empirical antiepileptic therapy with phenobarbital and levetiracetam was administered for suspected cortical seizures. Over an eight-week intensive care course, fever and clinically apparent seizure-like episodes resolved, allowing for the discontinuation of antiepileptic drugs. However, marked axial and limb hypertonia with stimulus-induced spasms persisted and contributed to two failed extubation attempts, despite improved sepsis markers. Brain magnetic resonance imaging revealed only subtle chronic susceptibility foci without acute lesions. The introduction and careful titration of high-dose enteral baclofen, combined with low-dose oral diazepam and targeted physiotherapy, led to a sustained reduction in rigidity and spasms, successful weaning from intravenous benzodiazepines, extubation to room air, and progression to full oral feeding. The infant was discharged on tapering oral baclofen, with residual lower limb deformities and planned physiotherapy follow-up.
Conclusions: This case illustrates that in severe neonatal tetanus with persistent rigidity in a low-resource setting, adjunctive high-dose enteral baclofen may help control post-acute muscular hypertonia and facilitate liberation from prolonged mechanical ventilation when advanced monitoring is limited.