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Título

ACCIDENTAL TETANUS OF ATYPICAL EVOLUTION, A CASE REPORT

RESUMO

ACCIDENTAL TETANUS OF ATYPICAL EVOLUTION, A CASE REPORT
GONDIM, P.A.L.¹;OLIVEIRA, S.N.T.²;GONDIM, I.L.³
Key words: Tetanus; neuroinfectious disease
Case Presentation
A man, 48 years old, rural worker, 210 cm tall, hypertensive and obese, presented for seven days intense pain in the left gastrocnemius.On examination, fixed left gastrocnemius muscle contracture unleashed by light and sound stimulus. Normoreflexia, normoesthesia. Homans sign absent. Trismus/dysphagia absents. Presented two punctate lesions consolidated on the sole of the left foot caused by barbed wire fence, one with 30 days long and the other with 15 days long. No ecographic evidence of deep vein thrombosis, nor phlogistic signs and no signs of clinical severity. Two doses of the dT vaccine, which last one applied 25 years ago.Three visits to the Emergency Room in the last 20 days for trismus as the main complaint, in addition to sardonic laughter, when diazepam being administered for “ansiety”.
Therefore, patient classified as Tetanus grade I (according to the 1956 Ablett scale)in local phenotype.Treatment with antibiotic therapy, muscle relaxation, analgesia was made, administration of equine tetanus-antibody and a 3rd dose of dT.
He was evolved with improvement of muscle spasms after antibodies inoculation, however, remained with muscle pain and required intensive support after showing signs of Respiratory Failure. After discharge from the ICU, he had remission of the initial symptoms.
Discussion
Recent data from the WHO show an increase in tetanus notifications, a preventable disease and compulsory notification in Brazil. In view of that, it is a case that starts with symptoms of generalized disease and developed to a local clinic. This scenario is against with the mechanism of retrograde axonal transport of tetanospasmin, which implies diffuse involvement, in addition of questioning the bioavailability of the toxin due to the size of the patient. Additionally, there is a low clinical suspicion for intoxication by strychnine, since there was no relaxation of the muscles between spasms or maxillary involvement, and also for conditions such as drug withdrawal or hypocalcemia due to the epidemiology and personal history not suggestive.
Final comments
Early diagnosis and treatment are ratified in this scenario and invite specialists to propose a new clinical presentation scale that increases sensitivity for atypical cases of tetanus.

Palavras Chave

Tetanus; neuroinfectious disease