A rare case of non-wound tetanus mimicking botulism successfully managed in the ICU

Tetanus and botulism are neurotoxin-mediated diseases caused by Clostridium species but differ in their clinical manifestations and mechanisms of paralysis.

A 36-year-old woman presented with presented with rapidly progressive trismus, dysarthria, and facial paresthesia without an identifiable wound. Neuroimaging was normal. She had undergone laser eye surgery two days earlier and consumed home-canned food two weeks before admission. One month prior, her house had been flooded, and she recalled possible minor hand injuries sustained during post-flood cleaning. Given the typical rigidity and absence of focal neurological lesions, tetanus was suspected. Human tetanus immunoglobulin (HTIG, 500 IU intramuscularly) and intravenous metronidazole were administered, leading to complete resolution of symptoms within 24 h.

This case illustrates that even minimal or unnoticed injuries can serve as a portal of entry for Clostridium tetani. Non-wound tetanus should be considered in patients presenting with trismus and cranial symptoms, even when no wound is apparent.