Cephalic tetanus manifesting as isolated facial nerve palsy- a case report from rural Armenia

Cephalic tetanus is a rare clinical form of tetanus, clinically characterized by trismus and cranial nerve palsy involving one or more cranial nerves, facial nerve being the most common. We report a case of cephalic tetanus with left-sided lower motor facial nerve palsy in a 66-year-old non-immunized patient after an untreated laceration injury. The patient had dysphagia, spasm of the muscles of mastication, asymmetry of the left side of the face, cough, shortness of breath, and stiffness of neck muscles. The presentation was unique given that the facial nerve palsy appeared prior to the occurrence of trismus, which misled the initial diagnosis towards Bell's palsy. He was successfully treated with tetanus antitoxin without any adverse events. Although widespread use of tetanus vaccine has led to a dramatic decline in this fatal disease, sporadic disease occurrence is still possible, particularly in individuals without up-to-date vaccinations. In this case report we illustrate the importance of early recognition of cephalic tetanus prior to the development of the full clinical picture. The early initiation of therapy is the key to recovery from this deadly disease. Physicians are encouraged to include cephalic tetanus as a cause of facial nerve palsy in their differential. In particular, paying attention to cases manifesting early after head or neck injury.

An unusual cause for neck rigidity?

Otogenic tetanus is a subtype of cephalic tetanus, limited to the head & neck, but can progress to a more generalized form. Caused by the spore-forming bacillus, Clostridium tetani, It produces a potent toxin, tetanospasmin, preventing inhibitory neurotransmitters' release, hence causing rigidity.

Cephalic Tetanus without Injury – A Rare Presentation of Tetanus

Tetanus is a rare, severe, and potentially life-threatening disease caused by Clostridium tetani, which accounted 58,900 deaths worldwide in 2013.1 Usually tetanus is generalized, rarely it can be localized also. 20-30% of cases will not have any puncture wound. In this case report, we present a case of tetanus with rare manifestation (localized tetanus presented with trismus without any puncture wound). Multiple rare associations like tetanus presenting with trismus, tetanus occurring in the absence of puncture wound strengthens the need for reporting this case which if left unnoticed would have been detrimental to the patient.

An Unexpected Smile: risus sardonicus and wing-beating tremor in a first office visit

Context: We present a noteworthy reminder of Wilson disease’s classical manifestations, which may become rarer in clinical practice as availability of genetic tests increases, allowing timely diagnosis and treatment. Case report: A 29 year-old woman developed progressive and asymmetric upper limb tremor and dystonia over 1 year, along with speech and feeding impairment in the last two weeks. Examination revealed segmental dystonia with risus sardonicus, open-jaw oromandibular and severe left arm dystonia, along with wing-beating tremor. Bilateral Kayser-Fleischer ring, low serum ceruloplasmin level, high urinary copper level, bilateral putaminal lesions on brain MRI and detection of ATP7B mutation confirmed Wilson disease (WD). A nasoenteric tube was inserted and D-penicillamine was started. Conclusion: This case illustrates the hallmark neuro-ophtalmological signs of WD: wing-beating tremor, risus sardonicus and Kayser-Fleischer ring. The former is probably associated with lesions in the dentato-rubro-thalamic pathway¹ and means a low frequency, high amplitude, posture-induced proximal arm tremor. Risus sardonicus means a fixed smile due to risorius muscle dystonia². Although it is a well-known manifestation of cephalic tetanus, it is also frequent in WD¹. Finally, the Kayser-Fleischer ring is caused by copper accumulation in the Descemet membrane and occurs in almost 100% of patients with neurological WD².

Cephalic Tetanus: A Rare Case Report

Introduction Tetanus is a preventable infectious disease with vaccination. Cephalic tetanus is the rarest form in which local tetanus can involve the cranial nerves. Case Herein, we report a case of cephalic tetanus in a 16-month-old girl who had never been vaccinated. The patient, who had a complaint of a wound on the cheek mucosa for 2 weeks, was seen playing with the soil in the garden 1 week ago and was found to have abundant soil removed by her mother. The patient was diagnosed as cephalic tetanus according to her complaints and clinical findings. Discussion We believe that, this is the first case reported in the literature of cephalic tetanus in such a young child wherein the disease focus of infection from a wound on the cheek mucosa. The symptom we defined as ‘a child who cries when she smiles’ presented in this case could only be associated with this disease. Conclusion In addition to detailed anamnesis and meticulous physical examination, the clinical symptoms that we have described for the first time in a child with cephalic tetanus should also be considered for early and accurate diagnosis.

Cephalic tetanus presenting with bilateral facial palsy

We discuss the case and differential diagnoses of an elderly man who presented with bilateral facial palsy. He had injured his forehead in the garden during a fall on his face and the open wound was contaminated by soil. He then presented to the emergency department with facial weakness causing difficulty speaking. The penny dropped when he started developing muscle spasms affecting his lower jaw a day after admission. It also became clear that he could not open his mouth wide (lock jaw). The combination of muscle spasms and lock jaw (trismus) made tetanus the most likely possibility, and this was proven when he had samples taken from his wound and analysed under the microscope, which showed Clostridium tetani bacilli. C. tetani spores are widespread in the environment, including in the soil, and can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through contaminated wounds. Tetanus in the United Kingdom is rare, but can prove fatal if there is a delay in recognition and treatment.