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Post-Operative Tetanus after Hemorrhoidectomy in Jeddah, Saudi Arabia.


On May 29, 1994, a hospital in Riyadh reported a suspected case of tetanus in a patient who had been referred from Jeddah, where he had undergone infrared coagulation for hemorrhoidectomy in a private dispensary five days prior to the onset of tetanus symptoms. We began an investigation to determine why this man developed the infection, to discover similar cases and to review the tetanus surveillance system in the Jeddah area.


We reviewed the medical files in the facilities where the patient had been treated, and we interviewed his family members. We identified non-neonatal tetanus (NNT) cases in the three governmental hospitals in Jeddah and compared them with the index case.


The patient had surgery on May 9, 1994, immediately after he recovered from anal fissure, which was topically treated. After five days he developed typical symptoms of tetanus and became unconscious. He died June 10, 1994. We found no similar cases among those who had undergone the same procedure. The setup of the operation room in the private clinic was clean, and cultures for Clostridium tetani were negative. We checked the surveillance system for the first six months of 1994 and found eight cases of NNT in the three government hospitals only; of those, only one had been reported through the surveillance system.


The infection could be explained by knowing that the spores may persist in normal tissues for several months or years and may be triggered by a subsequent injury. Normal flora could contain Clostridium tetani that may contaminate the fissure or the operation site, although that is rare. The man's relatives also might not have been aware of a past injury. Lack of communication between the Preventive Medicine Department in the Primary Health Care Administration and hospitals' infection control committees is the major factor in the weakness of the surveillance system.