Emergency Medicine: Open Access
Open Access

Abstract

Jacksonian March Revisited? A Case of Local Tetanus with Generalized Spread

Doss Ryan S and Levy Philip

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.