破傷風回復期に両側横隔膜麻痺を呈した1例(Diaphragmatic paralysis during recovery from tetanus: a case report)

Abstract

Respiratory failure is a common complication in patients with tetanus, and generally caused by respiratory muscle or pharyngolaryngeal spasms. Here we describe a rare case of hypercapnic respiratory failure caused by bilateral diaphragmatic paralysis in a patient with tetanus. A woman in her 80s was admitted to our ICU with tetanus. On admission, she had developed respiratory failure because of pharyngolaryngeal spasm and aspiration, and invasive ventilation was performed immediately. Because of mild general muscle spasm and the absence of autonomic dysfunction, she was ventilated with preserved spontaneous breathing, light sedation and early mobilization. Ten days later, she was extubated with improved rigidity. However, she immediately suffered hypercapnia and was reintubated. Despite tracheostomy on day 13, it was difficult to wean her from mechanical ventilation. Chest radiography showed bilateral diaphragm elevation. Diaphragm sonography showed reduced motion of the bilateral diaphragm, indicating bilateral diaphragmatic paralysis. Phrenic nerve conduction studies revealed reduced compound muscle action potential amplitudes with unremarkable prolonged latencies. Her diaphragmatic paralysis improved over time, and she was weaned from mechanical ventilation on day 23. Diaphragmatic paralysis should be considered as a cause of hypercapnic respiratory failure during recovery from tetanus.