IDCases 10 (2017) 38–39

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IDCases
journal homepage: www.elsevier.com/locate/idcases

Case study

Tetanus attacks an old person with inadequate vaccination showing ‘Risus MARK
Sardonicus’ face
⁎
Akira Kobayashia, Hiromichi Iwasakib,
a
Division of Internal Medicine, Nanmei-kai Miyagami Hospital, Kagoshima, Japan
b
Department of Infection Control and Prevention, Faculty of Medical Science, University of Fukui, 23-3 Shimoaizuki, Matsuoka, Fukui, 910-1193, Japan

A 79-year-old man with history of alcohol abuse presented with

severe epigastric pain. Acute pancreatitis was diagnosed. The patient
received supportive care with fluid hydration, pain medication, and
bowel rest. And his symptoms had improved 3 days after hospital ad-
mission. On the fourth day, he developed nuchal rigidity; dysphagia;
trismus, the inability to open the mouth fully owing to rigidity of the
masseters; muscle spasms in the masticatory and neck musculature
(Fig. 1); and a characteristic ‘Risus Sardonicus’ face, a painful muscle
spasm of the facial muscles resembling a smile (Fig. 2). Although there
was no history of trauma and no wound was seen on his body, his
condition was clinically diagnosed as tetanus, and tetanus toxoid (TT;
0.5 mL, IM), human tetanus immunoglobulin (TIG; 4500 IU, div) and
penicillin G (40 million IU/day, div) were administered. On the fifth
day, convulsions occurred and did not remit. Because of respiratory
difficulties, tracheal intubation was performed and the patient under-

Fig. 2. 'Risus Sardonicus' face.

Fig. 1. Muscle spasms. Fig. 3. Recovered patient's face.

⁎
Corresponding author.
E-mail address: hiwasaki@u-fukui.ac.jp (H. Iwasaki).

http://dx.doi.org/10.1016/j.idcr.2017.08.009
Received 14 August 2017; Accepted 15 August 2017
2214-2509/ © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
A. Kobayashi, H. Iwasaki
Fig. 4. Recoverd mouth opening.
went artificial respiratory management. Anticonvulsant and sedative
medications were concomitantly administered, but convulsions were
readily induced by minor stimuli such as simple medical and nursing
procedures. Autonomic disturbance with sustained labile hypertension,
tachycardia, and sweating started 5 days after intubation. The fre-
quency and intensity of the convulsive seizures started to decrease
slightly approximately 15 days after onset, and a tapering of the
39
IDCases 10 (2017) 38–39
intravenous anticonvulsant injections was initiated. He was waned from
the ventilator 20 days after onset. On the 35th day after admission, he
was　discharged and his symptoms had recovered completely. Figs. 3
and 4 show his face and normal mouth opening after he was discharged.
Although tetanus is now a rare disease in developed countries, it is still
encountered with a reported occurrence rate of approximately 100
cases/year in Japan. Tetanus can be prevented by vaccination. Tetanus
toxoid became commercially available as a voluntary inoculation in
1952 and as a routine vaccination in 1968 [1]. However, despite re-
commended booster vaccinations every 10 years [2], most Japanese
adults do not receive it because of a physical injury or when they travel
overseas. Therefore, many adults with an inadequate vaccination his-
tory are at a higher risk of contracting tetanus.
References
[1] Infectious Disease Surveillance Center. Tetanus in Japan as of December 2008.
Infectious Agents Surveillance Report 30: 349, 2009 (in Japanese).
[2] Kretsinger K, Broder KR, Cortese MM, Joyce MP, Ortega-Sanchez I, Lee GM, et al.
Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid,
reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the
Advisory Committee on Immunization Practices (ACIP) and recommendation of
ACIP, supported by the Healthcare Infection Control Practices Advisory Committee
(HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep
2006;55(RR-17):1–37.