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An old woman with pressure ulcer, rigidity, and opisthotonus: never forget tetanus!

2014; Elsevier BV; Volume: 384; Issue: 9961 Linguagem: Inglês

10.1016/s0140-6736(14)61832-8

1474-547X

Federico Verde, Giulietta Riboldi, Carlo Zappa, Marco Ferretti, Vincenzo Silani, Daniela Mari, Alberto Priori,

Streptococcal Infections and Treatments

In April, 2014, a 77-year-old woman with advanced Alzheimer's disease and type 2 diabetes was admitted to our geriatrics unit with fever. She lived at home with a carer and had been bedridden for 2 months. She had a stage 4 sacral pressure ulcer that had recently been debrided and treated with amoxicillin-clavulanic acid because of Enterococcus faecalis infection. On admission, chest radiograph showed left lung opacity consistent with pneumonia and she was started on piperacillin-tazobactam and vancomycin. A week after admission she developed intermittent generalised rigidity, opisthotonus (hyperextension of the neck and trunk), flexion of the upper limbs, extension of the lower limbs, trismus (lockjaw), and risus sardonicus (smile-like retraction of the lips). She would suddenly adopt these abnormal postures, often after sensory stimulation such as noise, light, or touch. She was not taking neuroleptics or other drugs that can cause parkinsonism. Head CT showed no acute lesions, cerebrospinal fluid and serum ionised calcium were normal. In view of the characteristic findings on neurological examination and history of infected skin ulcer we diagnosed tetanus, and her son confirmed that she had not received a tetanus vaccine booster for 30 years. We gave a dose of intramuscular tetanus and diphtheria toxoid, intramuscular human tetanus immune globulin 500 U, intravenous metronidazole 500 mg four times daily, and clonazepam 0·7 mg three times daily via nasogastric tube, and she had a repeat surgical debridement of the sacral ulcer. 1 week later her rigidity and spasms had reduced in severity and frequency. However, unfortunately she developed sepsis and died 3 weeks later. Blood cultures grew acinetobacter and enterococcus.