Three days before admission, a 70-year-old woman developed dysphagia. Examination revealed trismus and ulcers of the lower extremities due to chronic venous insufficiency. The following day the patient developed risus sardonicus (figure) and rigidity of the truncal muscles, but no opisthotonus (video). During the following weeks she developed autonomic dysfunction. We diagnosed generalized tetanus, most likely due to skin ulcers infected by Clostridium tetani. Treatment included mechanical ventilation, active and passive tetanus immunization, surgical debridement of the ulcers, and antibiotic therapy (metronidazole and imipenem/cilastatin). The outcome was favorable. The differential diagnosis of tetanus includes stiff-person syndrome, drug-induced dystonia, malignant neuroleptic syndrome, trismus due to dental infection, and strychnine poisoning. The diagnosis of tetanus is clinical. In clinical practice few attempts have been made to culture C tetani. It is difficult to culture, and C tetani may be present without disease in immunocompetent patients.1
Figure Facial muscle contracture resulting in trismus and risus sardonicus
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Supplemental data at www.neurology.org
Disclosure: The author reports no conflicts of interest.
Series editor: Mitchell S.V. Elkind MD, MS, Section Editor
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