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An elderly man with a locked jaw

      Case description

      An 86-year-old man with diabetes mellitus presented to our hospital with a 3-day history of difficulty opening his mouth. He reported that he had injured his right index finger while farming 15 days ago, resulting in a 1-cm-diameter red bruise. He had not received any diphtheria, tetanus, and pertussis vaccinations. He was afebrile and alert, presenting no mental status changes. Physical examination revealed a stiff neck, trismus, and spasmodic laughter (Fig. 1). Blood tests showed leukocytosis, high creatinine kinase, and high glucose levels. Neck computed tomography showed normal results.
      Fig 1
      Fig. 1Trismus and spasmodic laughter of an 86-year-old man on the time of admission.
      What is the diagnosis?

      Discussion section

      The patient was diagnosed with tetanus based on the clinical findings. He was hospitalized and treated with tetanus immunoglobulin, tetanus toxoid, intravenous metronidazole, and wound site debridement. After admission, he was intubated, placed on mechanical ventilation to protect the airway, and administered sedatives. The following day, a muscle spasm of the upper limb started, and a tracheostomy was performed. As his spasms gradually decreased, mechanical ventilation was discontinued, and sedatives were stopped 3 weeks after admission. The patient started opening his mouth (Fig. 2) and was discharged for rehabilitation.
      Fig 2
      Fig. 2Opening mouth after treatment when muscle spasms were disappeared.
      Tetanus is caused by neurotoxins of Clostridium tetani, an anaerobic gram-positive rod ubiquitous in soil and animal feces worldwide. It is introduced into tissues through wounds. It is a rare disease in developed countries, with about 90 cases per year in Europe, but a fatal disease, causing more than 55,000 deaths from tetanus worldwide in 2015 [
      • Kyu HH
      • Mumford JE
      • Stanaway JD
      • et al.
      Mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015.
      ]. Generally, tetanus diagnosis is based on clinical findings. The treatment includes antitoxin, immunization, antibiotics, and the management of complications, including airway muscle spasms and autonomic dysfunction [
      • Yen LM
      • Thwaites CL.
      Tetanus.
      ]. Tetanus is a vaccine-preventable disease, and national vaccine programs are implemented in many countries. Elderly people are at high risk than younger people because of their lower antibody titer, and hence, the importance of appropriate additional vaccination for the elderly is advocated [
      • Weinberger B.
      Adult vaccination against tetanus and diphtheria: the European perspective.
      ].

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Ethical approval

      For this type of study, Toyama University Hospital's ethics committee required patient agreement to the informed consent.

      Informed consent

      The patient gave his informed consent and agreed to the anonymized retrospective publication.

      Author Contributions

      AU contributed to patient care and drafted the manuscript. IS and YY were responsible for the medical care of the participants. YY was responsible for the overall organization of this study. All authors contributed to the final manuscript.

      Declaration of Competing Interests

      The authors have declared no conflicts of interest associated with this manuscript.

      References

        • Kyu HH
        • Mumford JE
        • Stanaway JD
        • et al.
        Mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015.
        B.M.C. Public Health. 2017; 17: 179https://doi.org/10.1186/s12889-017-4111-4
        • Yen LM
        • Thwaites CL.
        Tetanus.
        Lancet. 2019; 393 (1657–6833131-3): 1657-1668https://doi.org/10.1016/S0140-6736(18)33131-3
        • Weinberger B.
        Adult vaccination against tetanus and diphtheria: the European perspective.
        Clin Exp Immunol. 2017; 187: 93-99https://doi.org/10.1111/cei.12822