Tetanus Presented as Hemiparesis and Facial Dystonia

Abstract

We report a case of tetanus presenting as the facial dystonia and hemiparesis with complete recovery and video accompanied follow-up. A 78-year-old male, who sustained an abrasion to his right forearm, presented with dysarthria, dysphagia, prominent involuntary painful muscle spasms in the face, blepharospasm, risus sardonicus, trismus (lockjaw), neck muscle rigidity and mild weakness of the distal right upper extremity. The combined treatment of human antitetanus immunoglobulin, tetanus vaccine, penicillin, metronidazole and diazepam were given with no effect. He continued to worsen and due to the risk of the respiratory failure (finally not developed) he was sent to the Intensive Care Unit. The combined treatment was continued, and his symptoms started to improve within 2 weeks. As the muscle rigidity has been improving, the patient developed significant right hemiparesis. The imaging of the brain and cervical spine found no significant pathology. At the follow-up visits the patient presented only slightly impaired dexterity of the right hand that gradually resolved. There are many reports of unusual presentations of tetanus, however, hemiparesis is uncommon, and to our knowledge, only one case was reported in the literature. We highlight the variability of clinical presentation of tetanus, the need to consider tetanus in cases of rapidly evolving muscle spasms following peripheral injuries and provide the guidelines on tetanus prophylaxis.