CASE REPORT Tetanus: an unusual source and site of infection

Summary Tetanus is reported in a previously immunised patient who was exposed to the dust of old building plaster containing horse hair. The site of infection was a squamous cell carcinoma of the scalp. Case report Over a period of several months a 66-year-old spinster had noted an ulcerating lesion on her scalp which was gradually extending. Without covering this scalp lesion, she scraped the walls and ceilings of her 6o-year-old terrace house in preparation for redecoration. Ten days later, she developed trismus followed by painful muscle spasms of the pharynx, face and chest and was admitted to hospital. On examination, there was a fungating tumour 5 cm in diameter over the occipital area of the scalp. She had generalised muscle rigidity and the slightest movement induced severe reflex spasms resulting in episodes of apnoea. Human antitetanus immunoglobulin and benzyl penicillin were administered, an emergency tracheostomy performed, and the patient electively ventilated. Following excision of the scalp tumour, the frequency and severity of the tetanic spasms rapidly decreased and spontaneous ventilation returned after only 4o hours. Clinical recovery was marred by a pulmonary embolus but was otherwise uneventful. The tumour was a squamous cell carcinoma from which Staphylococcus pyogenes and a spore-forming bacillus were cultured. Inoculation of the bacillus into mice produced clinical tetanus and the organism was recovered from the infected mice, confirming it to be Clostridium tetani. Microscopic examination of plaster scrapings taken from the patient's house revealed many animal hair fragments, but anaerobic culture of the small amounts of plaster available did not grow C. tetani. Culture of the patient's faeces similarly failed to isolate the organism.