746 www.thelancet.com/infection Vol 16 June 2016 Grand Round An unexpected tetanus case Onder Ergonul, Demet Egeli, Bulent Kahyaoglu, Mois Bahar, Mill Etienne, Thomas Bleck 1 million cases of tetanus are estimated to occur worldwide each year, with more than 200 000 deaths. Tetanus is a life- threatening but preventable disease caused by a toxin produced by Clostridium tetani—a Gram-positive bacillus found in high concentrations in soil and animal excrement. Tetanus is almost completely preventable by active immunisation, but very rarely unexpected cases can occur in individuals who have been previously vaccinated. We report a case of generalised tetanus in a 22-year-old woman that arose despite the protective antitoxin antibody in her serum. The patient received all her vaccinations in the USA; her last vaccination was 6 years ago. The case was unusual because the patient had received all standard vaccinations, had no defined port of entry at disease onset, and had symptoms lasting for 6 months. Tetanus can present with unusual clinical forms; therefore, the diagnosis and management of this rare but difficult disease should be updated. In this Grand Round, we review the clinical features, epidemiology, treatment, and prognosis of C tetani infections. Introduction Tetanus is a life-threatening but preventable disease caused by a toxin produced by Clostridium tetani— a ubiquitous, spore-forming, Gram-positive bacillus found in high concentrations in soil and animal excrement. 1,2 The clinical manifestations are due to a potent neurotoxin that produces painful spasms and muscular rigidity. 1 The clinical features of tetanus and its relation to traumatic injuries were well known among the ancient Greeks and Egyptians. In 1884, Nicolaier isolated a strychnine-like toxin from anaerobic soil bacteria. 3 6 years later, Behring and Kitasato described active immunisation with tetanus toxoid. 4 Tetanus is almost completely preventable by use of active immunisation with tetanus toxoid available through global childhood vaccination programmes. Immunisation in children consists of five doses of tetanus vaccination: one dose at months 2, 4, 6, and 15–18, and 4–6 years. Diphtheria, tetanus, and pertussis vaccine should be given to adolescents and adults as a booster shot every 10 years or, in some circumstances, after exposure to tetanus. In developing countries, tetanus is a major cause of death in newborn babies, whereas in developed countries it causes death in adults, particularly those older than 50 years. 5,6 However, unexpected tetanus cases are rarely reported, and these cases are usually in people older than 50 years. 7 In this Grand Round, we describe the case of a 22-year-old woman who presented to our department with tetanus infection despite prior vaccination, and we review the clinical features, epidemiology, treatment, and prognosis of C tetani infections. Case presentation A 22-year-old woman was admitted to the emergency department in Istanbul, Turkey, with high fever, generalised muscle spasms, pain, and stiffness of the left knee. The stiffness of her left knee had started 15 days previously, at the beginning of October, 2012, in her hometown, New York, NY, USA. The patient was unable to bend or extend her knee completely and had trouble walking. A week after the first symptoms, she had onset of chest spasms on her wedding night. These spasms were mild, and she attributed them to her general tiredness. She travelled with her husband to Bulgaria for their honeymoon. On their bus trip from Sofia to Istanbul, she had severe chest spasms lasting for 1 h. The day after her arrival in Istanbul, she was admitted to our emergency department. On review of systems, she reported earache for the last 4 months and chronic headaches. Her childhood vaccinations were completed in the USA. In the emergency department, the patient had frequent generalised painful muscle spasms and seizures. Her temperature was 37·8°C, her pulse was 88 beats per min, her respiratory rate was 20 breaths per min, and her blood pressure was 130/80 mm Hg. She was conscious; her pupils were equal and reactive to light. She had trismus (lockjaw), dysphagia, neck stiffness, and severe abdominal rigidity. Laboratory studies showed normal values for white blood cell count (9·2 × 10⁹/L; 78·2% neutrophils), C-reactive protein (CRP; 1 mg/L), creatine kinase (342 U/L), and calcium. After neurology, internal medicine, and orthopaedics consultations, an infectious diseases consultation was requested. Because of generalised painful muscle spasms, seizures, body temperature of 38°C, trismus, dysphagia, suspected neck stiffness, and severe abdominal rigidity, tetanus was suspected and the patient was admitted to hospital. 2 weeks after admission, the patient recalled her parrot biting her 2 months previously. No other alternative diagnosis was suggested after neurology, internal medicine, gynaecology, and orthopaedic consultations. No pathological abnormalities were detected in the patient’s cranial MRI, electroencephalogram, abdominal ultra- sound, and cerebrospinal fluid examination. The cerebrospinal fluid was clear, glucose concentration was 3·78 mmol/L (range 2·50–4·44 mmol/L), one lymphocyte per μL was detected, and protein concentration was Lancet Infect Dis 2016; 16: 746–52 Infectious Diseases Department, School of Medicine, Koc University, Istanbul, Turkey (Prof O Ergonul MD); Intensive Care Unit (D Egeli MD, Prof M Bahar MD) and Neurology Department (B Kahyaoglu MD), American Hospital, Istanbul, Turkey; New York Medical College, Valhalla, New York, NY, USA (M Etienne MD); and Rush Medical College, Chicago, IL, USA (Prof T Bleck MD) Correspondence to: Prof Onder Ergonul, Infectious Diseases Department, School of Medicine, Koc University, Istanbul 34265, Turkey oergonul@ku.edu.tr Search strategy and selection criteria We identified data for this Grand Round through searches of PubMed and Scopus with the search term “tetanus”. We reviewed English-language articles published between Jan 1, 1935, and Nov 20, 2015, and any relevant references.