Case Presentation: A 26-year-old male with a history of alcohol and cocaine use presented with acute respiratory distress, holding his neck in a hyperextension to breathe. He reported a “cracking” sensation in his jaw, malocclusion, and 4 days of nausea, vomiting, and diarrhea. Prior to presentation, he ingested 7 beers and a small amount of cocaine orally. In the ED, he had dysphagia, a globus sensation, and intermittent apnea, not responsive to naloxone or diazepam. He was hyperreflexic at the patella, had muscle spasms of the shoulders, and was retaining urine. Labs were notable for hypokalemia. Toxicology was only positive for cocaine. He reported full childhood immunizations in Mexico, but no tetanus booster in the past 10 years. He worked in a fence factory with frequent minor cuts.He received tetanus immunoglobulin with rapid improvement in symptoms. Tetanus immunization series and metronidazole were started, along with magnesium and potassium replacement. At discharge, he had residual but improving muscle weakness.
Discussion: Tetanus results from C. tetani spore inoculation, often through penetrating wounds. Only a minority of patients are not able to recall a clear portal of entry. Incubation time averages 8 days but can vary from 1 day to several months. Shorter inoculation times are associated with wound sites close to the CNS. Major risk factors for disease are lack of vaccination, age > 65, diabetes, and IV drug use. Tetanus is rare in the US due to high vaccination rates, with only 17-34 cases per year between 2016 and 2022 in the US.Diagnosis is clinical and classified as generalized, localized, cephalic, and neonatal. Generalized tetanus, is the most common, features rismus sardonicus, trismus, and intermittent, painful spasms resembling decorticate posturing while patients remain conscious. Airway involvement can result in obstruction or aspiration. Early autonomic symptoms may progress from mild irritability and tachycardia and progress to cardiac arrhythmias, labile blood pressure, and fever. US case mortality rate remains ~11%. The differential for tetanus includes drug-induced dystonias, stiff-person syndrome, dental infection, neuroleptic malignant syndrome, rabies, cerebral malaria, and hypocalcemia. Strychnine poisoning is its closest mimic. In this case, cocaine adulteration was initially considered, but rapid response to immunoglobulin confirmed tetanus.Treatment includes immunoglobulin, tetanus vaccination, wound debridement, and metronidazole. Muscle spasms and autonomic dysfunction are managed with benzodiazepines, neuromuscular blocking agents, magnesium infusion, and non-selective adrenergic blockers. Recovery can take months.This patient demonstrated generalized tetanus with trismus, hyperreflexia, muscle spasms, apnea, and autonomic dysfunction. Substance use complicated his presentation, but high clinical suspicion enabled timely treatment and rapid improvement.
Conclusions: Vaccines have made tetanus rare, but only vigilance and rapid treatment prevent death when it appears. Awareness of clinical symptoms and patient risk factors, as well as timely intervention, are essential to prevent morbidity and mortality.