Good morning from Japan and LT on his travels. Wanted to share a cool case. We’ll try something new, I’ll give you a brief case presentation, you guys leave your hypotheses/questions comments (a la think like a doctor in the NYT), and then I’ll give you a little more and then the answer.
Case: 78F seen in urgent care for a mech fall with a head lac, sown up sent out. PMH isn’t really contributory. She comes back the next day w/ ptosis and what looks like bell’s palsy, rest of neuro exam normal. No other complaints, labs look normal. What else do you want?
Thanks to Kresh, Rabih, and KD for contributing. I’ll add some answers to questions and give you more data. CT w/ contrast head negative for any abnormality, ESR 33, to Kresh’s question there is NO Horner’s, just ptosis and then some facial droop looks like Bell’s. On HD 3 she begins to complain of bilateral jaw pain worse with chewing, when asked it localizes to the masseter muscles. Otherwise no clinical changes.
Thanks for the great comments all! Yes, confusing combination of exam findings. Last little nugget, on HD 4 she develops trismus, a re-examination of the scalp wound shows poor healing. As guessed, this is a case of cephalic tetanus. teaching points here: four kinds of tetanus: cephalic, generalized (most common), localized (around the wound), and neonatal. The textbook (Victor and Adam’s Neurology) presentation of cephalic tetanus is basically this patient. It carries a high case mortality rate (up to 50% untreated) and often can progress to generalized tetanus. Treatment is anti-toxin or IVIG if not immediately available, this patient got IVIG and did well, able to leave the hospital. Awesome, LT has sent some others so will do this again soon! Thanks for participating!