A 79-year-old man with history of alcohol abuse presented with severe epigastric pain. Acute pancreatitis was diagnosed. The patient received supportive care with fluid hydration, pain medication, and bowel rest. And his symptoms had improved 3 days after hospital admission. On the fourth day, he developed nuchal rigidity; dysphagia; trismus, the inability to open the mouth fully owing to rigidity of the masseters; muscle spasms in the masticatory and neck musculature (Fig. 1); and a characteristic ‘Risus Sardonicus’ face, a painful muscle spasm of the facial muscles resembling a smile (Fig. 2). Although there was no history of trauma and no wound was seen on his body, his condition was clinically diagnosed as tetanus, and tetanus toxoid (TT; 0.5 mL, IM), human tetanus immunoglobulin (TIG; 4500 IU, div) and penicillin G (40 million IU/day, div) were administered. On the fifth day, convulsions occurred and did not remit. Because of respiratory difficulties, tracheal intubation was performed and the patient underwent artificial respiratory management. Anticonvulsant and sedative medications were concomitantly administered, but convulsions were readily induced by minor stimuli such as simple medical and nursing procedures. Autonomic disturbance with sustained labile hypertension, tachycardia, and sweating started 5 days after intubation. The frequency and intensity of the convulsive seizures started to decrease slightly approximately 15 days after onset, and a tapering of the intravenous anticonvulsant injections was initiated. He was waned from the ventilator 20 days after onset. On the 35th day after admission, he was discharged and his symptoms had recovered completely. Fig. 3, Fig. 4 show his face and normal mouth opening after he was discharged. Although tetanus is now a rare disease in developed countries, it is still encountered with a reported occurrence rate of approximately 100 cases/year in Japan. Tetanus can be prevented by vaccination. Tetanus toxoid became commercially available as a voluntary inoculation in 1952 and as a routine vaccination in 1968 [1]. However, despite recommended booster vaccinations every 10 years [2], most Japanese adults do not receive it because of a physical injury or when they travel overseas. Therefore, many adults with an inadequate vaccination history are at a higher risk of contracting tetanus.
Fig. 1.
Muscle spasms.
Fig. 2.
'Risus Sardonicus' face.
Fig. 3.
Recovered patient's face.
Fig. 4.
Recoverd mouth opening.
References
- 1.Infectious Disease Surveillance Center. Tetanus in Japan as of December 2008. Infectious Agents Surveillance Report 30: 349, 2009 (in Japanese).
- 2.Kretsinger K., Broder K.R., Cortese M.M., Joyce M.P., Ortega-Sanchez I., Lee G.M. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006;55(RR-17):1–37. [PubMed] [Google Scholar]