A case report of tetanus complicated by multiple cerebral infarcts and iliopsoas hematoma

Severe generalized tetanus causes autonomic dysfunction with hemodynamic instability. While thromboembolic and hemorrhagic complications are recognized, cerebral infarcts secondary to tetanus-related dysautonomia have not been documented. A previously healthy 79-year-old unvaccinated woman presented with trismus and neck stiffness and was diagnosed with severe generalized tetanus. She received human tetanus immunoglobulin, tetanus toxoid, and intravenous metronidazole, and was intubated and managed in the ICU under deep sedation. She developed severe dysautonomia requiring vasopressors. Fever on day 6 was attributed to ventilator-associated pneumonia, treated with ampicillin-sulbactam for seven days; sepsis and infective endocarditis were excluded. Subcutaneous heparin calcium was administered for deep vein thrombosis (DVT) prophylaxis from day 1, and was switched to edoxaban on day 14 for both prophylaxis and treatment of internal jugular vein thrombosis. Neuroimaging after ICU transfer revealed asymptomatic multiple cerebral infarcts presumed to result from hemodynamic instability. A left iliopsoas hematoma was incidentally identified on day 21, leading to edoxaban discontinuation. Thereafter, no pharmacological treatment was administered for the hemodynamic stroke or iliopsoas hematoma. Follow-up MRI examinations demonstrated progressive improvement in imaging findings. The patient underwent rehabilitation and was transferred to a rehabilitation facility on day 51. A literature review revealed that iliopsoas hematoma occurs in approximately 20% of patients with tetanus, yet remains underrecognized by physicians. This is the first documented case of tetanus complicated by cerebral infarction suggestive of hemodynamic stroke. Physicians should be aware that severe tetanus-related dysautonomia may cause cerebral infarction, and that iliopsoas hematoma may represent a disease-related complication.