This 63-year old alcoholic was taken to the emergency room of a local hospital w

Question

This 63-year old alcoholic was taken to the emergency room of a local hospital with obvious gangrene of both feet. He was stupors. During that evening, he had a seizure and was treated with phenytoin and barbiturates. That night he was transferred to a university hospital. At that time, he was noted to have opisthosoma posturing and to have developed increasing rigor respiratory distress, and unresponsiveness. On examination, he had a temperature of 41.7C rectally, a blood pressure of 70/30 mm Hg, a heart rate of 110- beats per minute, and a respiratory rate of 40/min. Examination was notable for marked trismus. The neck was stiff and hyperextended. Necrotic, blackened areas were present over both feet, and several draining ulcers were noted on the heels and toes. Neurologically the patient responded to deep pain with a grimace. On the basis of these findings, specific therapy, in addition to supportive care, was initiated, and the patient ultimately recovered.

Explanation / Answer

From the relevant history and clinical lab findings there is aprobabilityt that the 63 year old is suffering from tetanus caused by a toxin produced by Clostridium tetani. The symptoms include rigidity, muscle spasms, opisthotonus and fever (high temperatures). The unexplained tachycardia (rapid heartbeats - 110 beats/min) and stiff hyperextended neck also signifies presence of tetanus toxin (toxin causes paralysis by blocking release of neurotransmitter GABA and glycine). The toxin also causes proteolytic cleavage of synaptobrevins. Necrotic blackened areas suggest the presence of the exotoxin tetanolysin which causes destruction of tissues (hemolytic activity).

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