Introduction: Tetanus is a vaccine-preventable disease caused by a neurotoxin produced by Clostridium tetani that proliferates in wound sites. Toxin interference with neuromuscular function leads to spasms. Trismus, risus sardonicus and opisthotonus are classic features, but tetanus can begin with subtler symptoms. Case Description: An 80-year-old man presented with dysarthria. His medical history included hypertension and dyslipidaemia. No other neurological compromise was apparent on admission. Cranioencephalic computed tomography suggested pontine and mesencephalic ischaemia and stroke treatment was implemented. Two days later, the patient displayed dysphagia that required nasogastric intubation. The next day, he developed an apparent tonic seizure with respiratory distress refractory to diazepam and phenytoin, which required sedation and invasive mechanical ventilation. Ultimately, he manifested trismus and generalized spasms. Once the diagnosis of tetanus was established, he was given anti-tetanus immunoglobulin, tetanus toxoid vaccine and metronidazole. Magnetic resonance imaging did not reveal any brain injury. During his intensive care stay, he showed cardiovascular instability, developed nosocomial pneumonia, and required prolonged ventilator support and tracheostomy. He gradually improved during a 70-day hospital stay and regained his previous functional status. Discussion: Dysarthria in an older patient with known cerebrovascular risk factors in addition to possible brainstem ischaemia contributed to an incorrect diagnosis of acute ischaemic stroke. Early manifestations of tetanus can mimic focal deficits. The limitations of brainstem computed tomography should be kept in mind. Conclusion: Older patients present a broader range of signs suggesting tetanus, including a higher frequency of bulbar symptoms, on presentation. A careful anamnesis including previous vaccination history is key for identifying high-risk patients and to widen the differential diagnosis to include tetanus.

We describe a rare presentation of acute pyelonephritis associated with a ruptured abdominal aortic aneurysm. A 68-year-old female presented to the emergency department with a 3 day history of cystitis. General examination revealed the acute onset of pain in the left flank accompanied by fever and chills. Blood tests revealed leucocytosis 25,400x109L and C-reactive protein 495 mg/L (<6.1), while urinary sediment analysis revealed many leucocytes and gram-negative bacteria. The patient was admitted with acute pyelonephritis. On the third day of admission, the urine culture isolated Escherichia coli sensitive to the antibiotic prescribed; however, the patient clinically deteriorated. A computed tomography scan revealed a ruptured abdominal aortic aneurysm involving the left renal artery. The patient underwent an exploratory laparotomy but uncontrollable haemorrhage led to a fatal outcome. This case highlights a rare case of acute pyelonephritis associated with a ruptured abdominal aortic aneurysm. A computed tomography scan or abdominal ultrasound should be considered whenever a patient has acute pyelonephritis with a C-reactive protein >400 mg/L in order to exclude complications and other potentially fatal pathologies.

Neurotoxicity is an unusual iatrogenic effect associated with carbapenems, typically manifested as seizures or hyperactive delirium. We present an 89-year-old female patient with a medical history of hypertension and chronic kidney disease who was admitted for acute tracheobronchitis and anemia related to diverticular disease. As a complication, she developed acute cystitis caused by extended spectrum ß-lactamases producing Klebsiella pneumoniae, so intravenous ertapenem was started. On the second day of antibiotic therapy, the patient manifested visual hallucinations followed by an inattentive and lethargic state suggestive of a hypoactive delirium. An ertapenem-induced neurotoxicity was suspected. Upon substitution by meropenem, the patient improved, and symptom reversal occurred after 72 hours. We present a review of ertapenem-induced hallucinations and address pharmacokinetics aspects namely renal dysfunction and hypoalbuminemia that could potentiate encephalopathy. Although rare, clinicians should be aware of non-seizure ertapenem related neurotoxicity. Ready recognition can lead to rapid improvement and prevent dire outcomes.

Type A aortic dissection is a surgical emergency occurring when an intimal tear in the aorta creates a false lumen in the ascending aorta. The authors report the case of an older woman with a medical history of arterial hypertension, atrial fibrillation, dyslipidemia, heart failure, and osteoarticular spinal pathology, presenting with sudden and persistent retrosternal pain, who was initially misdiagnosed with a lower airway infection and was discovered to have an acute type A aortic dissection. The authors intend to draw attention to medical errors and emphasize the importance of early diagnosis in pathology with a potentially fatal prognosis.

Diffuse alveolar hemorrhage (DAH) is a rare, acute, and life-threatening condition that in most cases is associated with pulmonary-renal syndromes, connective tissue disorders, infections, and drugs. We report a case of a 45-year-old male who developed a diffuse pulmonary hemorrhage after taking 500 mg of acetylsalicylic acid for a month in the context of acute lower back pain. The prolonged use of this acetylsalicylic acid dose led to an increased risk of bleeding. This report describes a rare bleeding site that clinicians should be aware of when managing patients who were exposed to prolonged high dose acetylsalicylic acid.