Tetanus Presented as Acute Abdomen

Tetanus is commonly seen in the emergency department with a puncture wound. This is an unusual presentation of tetanus without an open wound. A 59 year old male with a past history of hypertension, hepatitis C, prior injection drug use, and homeless presented to the emergency department with altered mental status and hyperthermia with fever of 105 F on a hot July afternoon. Patient was found in his car sleeping. Initially, the patient declined medical care, but was later found unresponsive with a methadone bottle next to him. Given Narcan on field with improvement of mental status. Patient developed acute ridged abdominal pain. A CT scan raised concern for acute abdomen, with portal venous gas, and intestinal pneumatosis. Surgery consulted and was concerned for ischemic colon with perforation. Vancomycin, ceftriaxone and metronidazole were given. Emergency exploratory laparotomy was performed with a small serosal injury on colon repaired with suture. Blood culture came back positive for Clostridium tetani and Mobiluncus curtisii. Infectious disease consulted. Felt tetanus cannot be ruled out. Patient was given tetanus immune globulin (TIG), metronidazole and later tetanus vaccine. Patient has fully recovered, tolerates oral diets, and has been discharged to a nursing facility without any neurological deficit. Tetanus is a neurological disorder caused by the tetanus toxins produced by clostridium tetani, which is a gram positive obligate anaerobes commonly found in soil. It is relevant to note that this bacterium can also be found inside the gut of animals and humans. The disease is well characterized by ancient Greeks, and common symptoms include trismus (“lockjaw”), opisthotonos, and a board-like rigid abdomen. Incubation is usually 7-21 days and this disease is usually prevented by vaccination. This case is unusual because there is no open wound and PE is limited due to patient’s overdose on opiates (methadone). Possible cause for this particular case may be that since there was no open wound, the blood could have been seeded by the perforated bowel because they may also be found in the gut. The patient was given metronidazole as part of Tx for acute abdomen, which happens to also be a treatment for tetanus. Diseases can be presented atypically. This case illustrates the importance of differential diagnosis when considering treatments in any pathology.