Female patient, 21 years old, university student, living in the city of Santiago, with no relevant morbid history.
She presented to the emergency department for the first time for two days of headache, myalgia, nausea and odynophagia.
The clinical picture was interpreted as a viral infection indicating symptomatic management; however, she consulted for a second time 48 h later for severe holocraneal headache and odynophagia.
The patient was discharged with metmizole, paracetamol and ketoprofen IV, but returned to the hospital on the same day due to recurrence of symptoms.
Physical examination revealed absence of meningeal signs and a wet patient.
The symptoms again remitted to combined parenteral analgesic therapy.
He returned for the fourth time four days after the onset of symptoms.
Computed tomography (CT) of the brain and cervical and cerebral vessels showed no abnormalities.
However, due to the persistence of symptoms, it was decided to admit the patient.
Physical examination revealed no abnormalities.
His axillary temperature was normal (36.6oC), his blood pressure (132/78 mmHg) and pulse oximetry (97% environmental), but he had a slight tendency to tachycardia (96/min).
Neurological examination revealed an uneasy and frightened patient with spasms and curvature of the lumbar back spine (opisthotonous and transient) when evaluating meningeal signs or mild spinal cord paralysis.
In addition, he presented an intense and sudden cervical and lumbar contraction when performing a sound test on the piece (plause).
His level of consciousness was normal and there were no other abnormalities on physical examination.
She reported photophobia; however, light exposure did not cause muscle spasms or involuntary contractions, as previously described.
In a directed way, the patient was questioned for trauma, tattoos or piercing without finding such exposures.
Nor did he report drug or drug consumption, recent travels or vaccines.
However, she reported having suffered multiple scratches and bites from her domestic cat for two months to about seven weeks before the onset of symptoms.
These injuries occurred in the hands and thighs and some of them bleed, although they did not seek medical attention.
Then his pet died from a canine attack.
The patient had received a booster of tetanus toxoid five years before for a rabbit bite.
The initial study revealed normal laboratory tests in the red series, white blood cells, platelets, renal function tests, liver and biochemical values in blood, including calcemia (10 mg/dL).
In addition, CSF study showed a colorless liquid without pleocytosis, with normal glucose and protein levels.
Residents of CSF for herpes virus by PCR were all negative, as well as adenosine deaminase values in this fluid.
The Chinese ink test and Ziehl Neelsen staining in CSF were also negative.
Additionally, blood tests for HIV, syphilis and Mycoplasma infection were also negative and CSF cultures showed no bacterial growth.
The patient had no history of drug use that induced spasms, muscle rigidity or hemodynamic instability, such as phenotypes or neuropathies, or dental infection.
No infectious focus was detected on admission.
Due to the strong suspicion of generalized tetanus (opisthotones), the patient was placed in an Intermediate Treatment Unit for observation, in an environment protected from noise and light and received intramuscular immunoglobulin 6.
The Dakar severity score gave 1 point (maximum 6) and the tetanus severity score or TSS (tetanus severity score) was ≥ 8 points, respectively, indicating a mild (severe) condition.
The patient did not receive antibacterials.
The patient was admitted with a rapid regression of her discomfort in the first 72 h.
Severe headache, distress, irritation to noise and light, tendency to opisthotonous and cervical noise contraindications decreased.
Due to her good evolution she was discharged seven days after admission.
At the first outpatient follow-up one week after discharge, a certain degree of global muscle stiffness persisted and was managed with clonazepam.
One month after discharge, the patient was completely normal.
Three doses of tetanus vaccine were prescribed.
