The case presented above, with a classic picture of tetanus, is an infrequently seen disease process in the United States but offers excellent learning opportunities.

Key Points

• Spore inhalation may be a source of tetanus even if there are no open wounds.
• Trismus that presents without an associated oropharyngeal source should raise concern for tetanus.
• Treatment includes cleaning the wound, halting the toxin, neutralization of the unbound toxin, antibiotics, and supportive management.
• Strychnine poisoning may produce a clinical syndrome similar to tetanus and should be strongly considered in a patient who is fully vaccinated or has no obvious wounds.

Dr. Johnson is a board-certified emergency physician. He serves as the point of care emergency ultrasound director for two hospital sites within his network and enjoys teaching. Dr. Johnson has given many ultrasound lectures to different services within the hospital including the emergency department and surgical team. He continues to lead two emergency departments in POCUS and ultrasound training.

Yehudis Weiss has been practicing as a physician assistant since 2011 and is currently working in the emergency department at Westchester Medical Center in Westchester, N.Y., where she has been for the past eight years.

References

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3. Deinhardt K, Berninghausen O, Willison HJ, et al. Tetanus toxin is internalized by a sequential clathrin-dependent mechanism initiated within lipid microdomains and independent of epsin1. J Cell Biol. 2006;174:459.
4. Schiavo G, Benfenati F, Poulain B, et al. Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin. Nature. 1992;359:832.
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7. Chan TY. Herbal medicine causing likely strychnine poisoning. Hum Exp Toxicol. 2002; 21:467.
8. Afshar M, Raju M, Ansell D, Bleck TP. Narrative review: tetanus-a health threat after natural disasters in developing countries. Ann Intern Med. 2011;154:329.