Severe rhabdomyolysis and refractory dysautonomia complicating generalized tetanus in an unvaccinated child: A case report

Tetanus has become rare in settings with established immunization programs; however, severe cases continue to pose complex management challenges, particularly in children. We report a 12-year-old unvaccinated boy from an Indigenous community in southwestern Colombia who developed generalized tetanus seven days after a puncture wound, complicated by early severe rhabdomyolysis (creatine phosphokinase peak >32,000 U/L), acute kidney injury, and refractory autonomic instability. While rhabdomyolysis may occur in severe tetanus, its coexistence with marked dysautonomia created a therapeutic dilemma: aggressive spasm control required prolonged neuromuscular blockade, whereas ongoing muscle injury increased the risk of critical illness complications, requiring a multidisciplinary approach in the absence of pediatric-specific guidelines. Despite the severity of the initial presentation, the patient achieved functional recovery with minimal residual deficits. This case highlights early severe rhabdomyolysis and refractory dysautonomia as critical complications of pediatric tetanus that complicate management and may worsen prognosis. Strengthening immunization coverage remains essential to prevent this life-threatening but vaccine-preventable disease.