http://www.annexpublishers.co/full-text/JNND/6103/Tetanus-Presenting-with-Back-Pain.php

Abstract

Tetanus is caused by Clostridium tetani, a Gram-positive bacillus, which one of its toxins, tetanospasmin is the cause of clinical symptoms. The incubation period could be 3 days or 3 weeks. The clinical severity is relevant to the amount of toxin and the neural distance to reach the neuronal body.A 59-year-old man admitted to our outcome neurology clinic with back pain in recent 2 weeks. His pain was intermittent, and was becoming more frequent and severe as the time goes on. For the last couple of days, he also had pain in his chin.He had a history of trauma in his left thumb 18 days ago which caused local swelling and rash. He did not consider the wound serious enough to seek medical treatment, but the wound was not healed. His left thumb was red, swollen and had a scab. The wound was oozing pus.His medical history revealed hypertension and diabetes. He had no idea about his tetanus vaccination history.His medical examination demonstrated intermittent muscles spasms in his back and masseter muscle which could also be triggered by external stimulus.The needle electromyography has demonstrated muscle activity while he defines pain and fotic/auditory stimulation has increased this activity.By retrograde axonal transport, tetanospasmin reaches to presynaptic inhibitory neuron where it blocks the release of inhibitory mediators and cause excitatory effect. This exotoxin affects interneurons inhibiting alpha motor neurons first and pre-ganglionic sympathetic neurones later. The clinic outcome may be localized, generalized and cephalic which can be mild to severe. Trismus, risus sardonicus, dysphagia, abdominal rigidity and opisthotonos can be a part of clinical picture in generalized form.