Risus sardonicus

Abstract

An 81-year-old woman with a history of interstitial lung disease was admitted with complaints of dyspnea, cough, and episodic dysphagia, without fever. Physical examination revealed a deep wound on the right elbow (Figure 1A ). She was treated with bronchodilators and corticosteroids, but within 5 days had gradually developed fever, neck stiffness, painful leg spasms, and occasionally trismus. Cerebrospinal fluid analysis was normal. On the sixth day, painful muscle spasms of the face resembling a smile (Figure 1B) and opisthotonos posture were noted. She could not lift her right arm and passive motion of this limb caused severe pain and generalized muscle spasms. Generalized tetanus was diagnosed. The patient remained completely coherent and recalled falling in her garden 4 days before admission. Treatment included wide debridement of the right elbow wound, 500 units of human tetanus immunoglobulin (HTIG) intramuscularly, metronidazole, benzodiazepines, tetanus–diphtheria toxoid vaccine, and mechanical ventilation with early tracheostomy. The level of anti-tetanus antibodies before receiving HTIG was 0.001 IU/ml (short-term protection level is considered to be >0.1 IU/ml). To date, the patient has shown no autonomic dysfunction, but spasms still occur 4 weeks into her hospitalization. Ventilation is expected to be prolonged, since tetanospasmin binding to the synapses is considered irreversible. Conflict of interest: No conflict of interest to declare.