Trismus, the first symptom in a challenging diagnosis of Tetanus

Tetanus Overlooked Due to the Involvement of Multiple Departments: A Case Report

Tetanus is a fatal disease caused by a neurotoxin produced by the biotrophic anaerobic bacterium Clostridium tetani, which causes muscle hypertonia and autonomic neuropathy. The diagnosis is based on clinical findings and not the result of specific blood and imaging tests; hence, it is very difficult to diagnose at first sight, despite typical initial findings such as lockjaw, muscle spasms, and neck pain and stiffness. This article discusses the case of a 79-year-old woman who first consulted her local doctor because of a lack of jaw opening. Seeing no improvement, she visited our hospital and was suspected of having tetanus after consulting with nine different departments over seven days from the initial visit. In developed countries, tetanus prevalence has declined due to immunization, leading to clinicians' lack of experience in diagnosing it. Furthermore, the increasing specialization in general hospitals poses a risk of missing a tetanus diagnosis when a patient consults multiple departments.

Progressive encephalomyelitis with rigidity and myoclonus (PERM) associated with anti-glycine receptor antibodies and urothelial carcinoma: a case report

BACKGROUND

Progressive encephalomyelitis with rigidity and myoclonus (PERM) is a rare neurological condition with paraneoplastic etiology in about 20% of cases, usually presenting before or shortly after the oncological diagnosis is established. PERM associated with anti-glycine receptor antibodies is not previously reported in a patient with bladder cancer.

CASE PRESENTATION

A 72-years-old Caucasian male was admitted with acute onset of dysarthria, dysphagia and trismus three years after initial surgical treatment for bladder cancer. The condition was initially diagnosed as tetanus and treated accordingly, but the diagnosis was reconsidered because of progression despite adequate treatment. Diagnostic workup on readmission revealed lung and paraaortal metastases from bladder cancer and anti-glycine receptor (anti-GlyR) antibodies both in the cerebrospinal fluid and in serum, which supplemented with the clinical presentation led to the diagnosis of PERM, presumably related to bladder cancer. The patient showed improvement and stabilization after treatment with intravenous immunoglobulin and chemotherapy against metastatic bladder cancer.

CONCLUSION

To the best of our knowledge, this is the first reported case of anti-GlyR antibody positive PERM related to urothelial carcinoma. The symptoms mimicked tetanus, and responded to chemotherapy and immunotherapy.

Generalized tetanus in a farmer following treatment of an open ankle fracture by a traditional bone setter

This is the case of a 31-year-old farmer diagnosed with an open right ankle fracture and tetanus sustained from an accident after opting for traditional bonesetter treatment. Open fractures increase the risk of tetanus infection therefore herbal treatment should be discouraged. Source control is important for holistic management of tetanus.

Understanding the Trajectory to a Diagnosis of Tetanus: A Descriptive Study

Background and objective Tetanus is a rare but potentially fatal disease in developed countries, including Japan. It is very difficult to diagnose this condition early because of its broad symptomatology and the lack of familiarity with tetanus among both physicians and patients. In this study, we aimed to describe the clinical manifestations of tetanus and to examine as to which departments/branches of medicine patients consult in order to provide helpful information for diagnosing this challenging condition. Materials and methods This was a descriptive, retrospective study conducted at a single tertiary hospital from January 2011 to December 2021. Patients with generalized tetanus, cephalic tetanus, and local tetanus presenting to our emergency department were included in the study. We examined the clinical manifestations and departments that patients with tetanus visited first. Additionally, the initial diagnosis and diagnostic evaluation before the diagnosis were examined. Results Of the total 10 patients included in the study, nine had generalized tetanus and one had cephalic tetanus; the common initial manifestations were neck stiffness (30%), dysarthria (20%), and trismus (20%). Of note, 80% of patients also complained of dysphagia before the diagnosis. Patients first visited various departments, including a dental clinic (30%) and the department of otorhinolaryngology (20%). Only two patients were accurately diagnosed with tetanus at the first department they visited. Physicians performed head imaging for all the patients. Conclusions Based on our findings, in Japan, patients with tetanus present with symptoms that physicians interpret or suspect to be associated with disorders of the central nervous system. Meanwhile, patients themselves tend to consider the symptoms as indicative of oral or dental issues. Further prospective studies involving a larger number of participants are needed to investigate the clinical course of tetanus until the establishment of a diagnosis.

A Case of Foix-Chavany-Marie Syndrome With Asynchronous Bilateral Opercular Infarcts and Chronic Bilateral Cerebellar Infarcts

Foix-Chavany-Marie syndrome (FCMS) is characterized by bilateral facio-glosso-pharyngo-masticatory paralysis of voluntary muscles due to bilateral infarction in the anterior opercular region of the brain. Here, we report a case of a 52-year-old female who presented with FCMS due to an acute left anterior opercular stroke in the setting of a chronic asymptomatic right opercular infarct and asymptomatic bilateral cerebellar infarcts. She also had a concurrent acute-on-chronic episode of congestive heart failure exacerbation. She made a significant recovery by the time of hospital discharge.

Trismus as a Presenting Symptom in a Case of Progressive Encephalopathy with Rigidity and Myoclonus

In this report we present a clinical case of trismus. The patient in question showed symptoms of trismus for 3 days, rapidly leading to respiratory insufficiency. Afterwards she developed myoclonus and progressive encephalopathy. Neurological workup showed no relevant abnormalities. A CT of the abdomen revealed a mass in the lower abdomen, which turned out to be an ovarian teratoma. Progressive encephalopathy with rigidity and myoclonus (PERM) was diagnosed clinically. Treatment with corticosteroids, benzodiazepines, and levetiracetam did not ameliorate the patient's condition. Only after the introduction of plasmapheresis was there a spectacular improvement in her clinical state. In this case we could not detect associated antibodies. The most likely cause of PERM is paraneoplastic disease secondary to ovarian teratoma. This type of tumor has been associated with multiple paraneoplastic neurological conditions, but this is the first case associated with PERM. To date there is only one publication on trismus as a sole presenting sign, with a quite similar disease course.

Return of the old guard: a case of tetanus in an unvaccinated patient

A 78-year-old woman with no known medical history presented with severe neck pain that began 4 days prior to admission located in the paraspinal cervical region radiating to the shoulders, legs and back. She had associated stiffness of her neck and progression of pain to her jaw and throat with progression to generalised body spasms with lower extremity stiffness and weakness that limited her ability to walk. She quickly developed dysphagia and odynophagia with subsequent generalised spasms and profound hypoxic respiratory failure requiring nasotracheal intubation. The presumptive diagnosis of tetanus was made and she was given tetanus toxoid immune globulin and Tdap vaccine. She was managed in the intensive care unit and after a week of admission, required a tracheostomy and gastrostomy tube placement. She required a prolonged hospitalisation stay of 21 days before being transferred to a long-term vent facility.

A case of atraumatic tetanus developed initially with worsening headache in a woman regularly cared for chronic headache at an outpatient clinic

We presented a case of atraumatic tetanus developed initially with severe headache. Headache may be a clue to the presence of tetanus. Clinicians who usually treat headache should consider the possibility of tetanus in patients who present with symptoms that are severe and atypical for a given patient.

Tetanus: A Report of Two Cases and Review of Literature - A Continuing Threat to the Elderly in Japan

Tetanus has become rare in industrialized countries, largely due to the effectiveness of immunization. However, the elderly are susceptible to tetanus because many have not received primary immunization; the incidence of tetanus in Japan is still 120 cases/year. The initial symptoms of tetanus, such as trismus and dysphagia, are observed in the orofacial region. However, because of the disease's rarity, the clinician may be unfamiliar with the clinical presentation and may not suspect tetanus. We report two cases of elderly patients with generalized tetanus. Both patients presented trismus and/or dysphagia and consulted three different departments before the diagnosis of tetanus. Japanese clinicians will encounter tetanus more frequently than practitioners in other countries. Dental surgeons should be familiar with the clinical appearance of tetanus and should consider this disease in a nonimmunized patient presenting as an atypical case of trismus and dysphagia.