Abstract
A 41 year-old male with no prior history of seizure disorder presented to the emergency department complaining of four “seizure” episodes which began a few hours prior to arrival. Within minutes of triage, one of the episodes was witnessed and inconsistencies with seizure activity including an absence of clonus, consciousness throughout the event and lack of a post-ictal state were noted. Further examination led to discovery of an untreated laceration on the patient’s left hand which had been sustained 1-week prior on a rusted metal fence. More extensive history also revealed recurrent episodes of muscle spasm in his left hand which preceding the generalized attacks. A presumptive diagnosis of wound tetanus with secondary, generalized manifestation was made and the patient was treated with local and intramuscular tetanus immunoglobulin as well as intravenous metronidazole and diazepam. The patient was admitted to the Neurologic Intensive Care Unit and, after 1 week of therapy, made a full recovery. While rare in the developed world, acute tetanus remains a disease associated with a significant morbidity and mortality (even in the United States). The high rate of lapsed adult immunization as well as the prevalence of insufficient effective antibodies even in those sufficiently immunized mandates vigilance on the part of the emergency physicians-particularly in patients with atypical neurological presentations.
Highlights
A 41 year-old male with no prior history of seizure disorder presented to the emergency department complaining of four “seizure” episodes which began a few hours prior to arrival
While preparations were made to transport the patient for a Computed Tomography (CT) scan of the head, a secondary assessment revealed an open poorly-healing laceration on the palmar surface of the left hand approximately 3 cm in length
It was bandaged loosely, exhibited granulation tissue, and had no evidence of purulent drainage or a foul odor. The patient reported he had cut his hand on a metal fence approximately one week ago and had not sought medical attention. He noted a loss of sensation in his hand along with localized muscle spasms extending up his arm that began 3 days after the injury
Summary
A 41 year-old male with a past medical history of insulindependent diabetes mellitus presented to the Emergency Department (ED) reporting recurrent “seizure” activity which began a few hours prior to arrival. Hortly after arrival in the resuscitation bay, the patient suffered another attack involving a full-body spasm with leftward deviation of the head and flexion of the upper extremities. He noted a loss of sensation in his hand along with localized muscle spasms extending up his arm that began 3 days after the injury.
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