Infection Prevention and Control

This is a case of a 57-year old female with no known history of immunizations since childhood especially against tetanus who presented with jaw spasm without apparent ear infections or visible bodily injuries and trauma. Patient was admitted with a consideration of pterygomaxillary mass but later to be found out as severe spasm on the left masseter leading to diagnosis of tetanus infection. She continued to develop bilateral masseter spasms and dysphagia, accompanied by dyspnea that required tracheostomy. We report a case of cephalic tetanus with dysphagia, which was progressing to generalized tetanus but prompt intervention prevented disease progression.

Introduction: According to the World Health Organization, the incidence of total reported cases of tetanus infection for 2017 is 1,057. Globally, there is a considerable decrease in the incidence and mortality rate of tetanus due to an overall improvement in the administration of vaccinations, as well as hygiene  practices and antitoxin administration. This was significantly lesser than the total reported cases of tetanus seen in the year 1980 which is 3,080. Tetanus is caused by an exotoxin, tetanospasmin, produced by Clostridium tetani. Diagnosis of tetanus is clinical and can present as someone with trismus, risus sardonicus, neck stiffness, dysphagia, muscle rigidity and spasm, or it can also present as a localized form in which the spasms and rigidity are confined to an anatomic area of the injury. Cephalic tetanus is a very rare type of tetanus which accounts for only 0.9-3% of the total tetanus cases seen. About two-thirds of cephalic tetanus cases progress to generalized tetanus with bad prognosis. It frequently progresses to generalized tetanus and is associated with a high mortality. Thus, we report one of the few cases of cephalic tetanus which presented with left neck stiffness and trismus.

The Case: Presenting the case of a 57-year-old female, gardener, who consulted at the out-patient services due to difficulty opening her mouth. Condition began with left-sided neck stiffness 4 days prior to consult that gradually progressed to development of dysphagia to solids and liquids with difficulty opening her mouth. Neck stiffness worsened 2 days prior causing her to assume rightward neck flexion to alleviate pain. Trismus also started to occur at this time that made eating more difficult. Her illness was not associated with any history of trauma or other symptoms such as pain over gums or throat area, fever, difficulty in speaking or lateralizing signs. Persistence of symptoms prompted consult.Patient is known to frequently pick her teeth with a reusable metal pick. She has not sustained bodily injuries for the past several months. Past medical history and family history were unremarkable. Pertinent physical exam showed she was only able to open her mouth to 2.5cm, temporomandibular joint (TMJ) non-displaced, spastic masseter tone, no cervical lymphadenopathies, the rest of the physical exam was unremarkable. Her other cranial nerves were intact, and the rest of the neurological exam was also unremarkable. She was admitted under ENT service as a case of Pterygomaxillary mass; rule-out Tetanus infection. Diagnostic imaging with contrast MRI of the neck and oropharynx, revealed diffuse disc bulges at C3-C7 levels with stenosis, cervical disc dessication with slightly reversed cervical lordosis from spasm. Plain revealed an enlarged left parotid gland which was suspicious for infection. Chest xray was also unremarkable. Blood tests of CBC (RBC 4.54 WBC 6.2, Hgb 137, Hct 0.41 Platelet 190, Segmenters 64, Lymphocytes 25, Monocytes 10, Eosinphils 1) iCa, Na, K, Bun, Creatinine, aPTT were all normal. Tetanus infection was highly considered during this time patient was started on an initial antibiotic of clindamycin. She was given treatment of IV Metronidazole instead since treatment wise; It is the most preferred choice aside from penicillin. She was started and also treated with Tetanus hyperimmune globulin. She was closely monitored for signs of respiratory distress and placed on standby for intubation or emergency tracheostomy.