A0038 A Rare Case of Cephalic Tetanus: Diagnostic Dilemma

Background: Tetanus is an acute toxemic illness caused by soluble exotoxin of Clostridium tetani. Localized tetanus, especially the cephalic component, is extremely rare.

Case Description: The case of a 64-year-old woman with cephalic tetanus is described who went through a stormy hospital stay but ultimately went home in a stable condition. She was admitted with deviation of mouth to the left and slurring of speech without any loss of consciousness or muscle weakness. Next day she was complaining of dysphagia and choking. She was started on methylprednisolone and immunoglobulin suspecting a diagnosis of acute infective demyelinating polyneuropathy with bulbar involvement. At this time, all investigations including CSF analysis and MRI were normal. Over the next day, her symptoms increased and she developed trismus with sudden laryngospasm and respiratory arrest. She was intubated after administration of succinylcholine and ventilated under sedation. Over the next 2 days, she continued to develop autonomic dysfunction and was administered anti-tetanus immunoglobulin 500 IU intramuscularly. She underwent tracheostomy after which she again received 2,000 IU of anti-tetanus immunoglobulin. After this she received magnesium infusion to target a serum magnesium of 3 to 4 mg/dL. She continued to receive magnesium till it was more than 4 mg/dL. As trismus and autonomic dysfunction continued, she was given diazepam 5 mg twice daily orally and dexmedetomidine infusion. Gradually, she was weaned off, and dose of diazepam was increased to 10 mg thrice daily. As a last resort, she was administered intrathecal anti-tetanus immunoglobulin 250 IU. After this she showed gradual improvement in her symptoms and was decannulated. Thus, after almost 4 weeks, she was fit for discharge.

Conclusions: Cephalic tetanus is characterized by frequent laryngeal spasms with danger of death from asphyxia. It was a difficult case with lots of diagnostic dilemma, successfully managed at our institute.