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Rheumatoid arthritis — SCE Rheumatology MCQ

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ModerateVaccinationRheumatoid arthritisSCE Rheumatology

A 56-year-old woman with rheumatoid arthritis sustained a deep crush wound to her forearm 8 hours ago. The wound contains extensive devitalised tissue but was not contaminated with soil or manure, and surgical debridement has been completed promptly. She received five documented doses of tetanus-containing vaccine, the most recent 6 years ago. She received rituximab for refractory rheumatoid arthritis 10 weeks ago, and her peripheral CD19-positive B-cell count remains undetectable. She is not receiving intravenous immunoglobulin. Intramuscular tetanus immunoglobulin is available. Which tetanus-specific post-exposure prophylaxis is most appropriate?

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Correct answer: E — Give tetanus immunoglobulin 250 IU alone

This crush injury with extensive devitalised tissue is a high-risk tetanus-prone wound. Although she completed the primary course and received her last dose within 10 years—so routine UK post-exposure guidance would not require another vaccine dose—recent rituximab with persistent B-cell depletion creates severe immunosuppression and may render prior vaccine-derived protection unreliable. EULAR specifically advises considering passive tetanus immunisation after high-risk exposure in patients receiving B-cell-depleting therapy. Tetanus immunoglobulin 250 IU is therefore appropriate without an additional vaccine dose. A follows the standard algorithm for an immunocompetent, adequately immunised adult, but does not account for current B-cell depletion. B provides active boosting, which may produce a poor or delayed response during rituximab therapy and does not provide the indicated passive protection. C adds an unnecessary vaccine dose because her last documented dose was within 10 years; tetanus vaccination otherwise follows the general-population schedule. E uses the higher immunoglobulin dose, which is reserved for presentation more than 24 hours after injury, heavy contamination or burns. None applies here: she presented after 8 hours, the wound was not heavily contaminated, and the indication for immunoglobulin arises from high-risk devitalised tissue combined with B-cell depletion.

Reference: Tetanus: the green book, chapter 30 (3 June 2025) — https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30 Guidance on the management of suspected tetanus cases and the assessment and management of tetanus-prone wounds (15 March 2024) — https://www.gov.uk/government/publications/tetanus-advice-for-health-professionals/guidance-on-the-management-of-suspected-tetanus-cases-and-the-assessment-and-management-of-tetanus-prone-wounds 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases (2020) — https://ard.bmj.com/content/79/1/39