Brainstem myoclonus in generalised tetanus

Abstract

Electrophysiological studies of stimulus sensitive myoclonus in a man with generalised tetanus revealed features characteristic of hyperekplexia or brainstem myoclonus.

The Myriad Presentations of Tetanus: Where Do You Look for Clinical Clues in an Intubated Highly Sedated Patient?

“…There has been only one previous report of stimuli-sensitive jerky movements associated with tetanus. 11 However, in that case, the onset of myoclonus was observed over a longer duration after the onset of the illness (11 weeks vs. 13 days in our case) and exhibited different distribution patterns, affecting the eyelids, neck, and arms rather than the trunk. 11 One of the investigative tools for confirming trismus is the masseter inhibitory reflex test, which typically reveals a loss of silent period on electromyography when the masseter is activated, resulting from central neuronal hyper-excitability.…”

“…11 However, in that case, the onset of myoclonus was observed over a longer duration after the onset of the illness (11 weeks vs. 13 days in our case) and exhibited different distribution patterns, affecting the eyelids, neck, and arms rather than the trunk. 11 One of the investigative tools for confirming trismus is the masseter inhibitory reflex test, which typically reveals a loss of silent period on electromyography when the masseter is activated, resulting from central neuronal hyper-excitability. However, it was not performed here because of unavailability, the patient's unstable condition, and the potential for false negatives from high doses of sedation, magnesium sulfate, or timing of the test, which has been reported to occur after 9 weeks of disease onset.…”

“…There has been only one previous report of stimuli‐sensitive jerky movements associated with tetanus 11 . However, in that case, the onset of myoclonus was observed over a longer duration after the onset of the illness (11 weeks vs. 13 days in our case) and exhibited different distribution patterns, affecting the eyelids, neck, and arms rather than the trunk 11 …”

“…Although classic symptoms, such as jaw trismus and generalized muscle spasms are evident in over 80% of cases, atypical forms, such as cephalic tetanus, occur in only 1% to 3% of cases (Table 1). 4,8–11 In our case, we encountered a rare presentation characterized by stimuli‐sensitive jerky movements, strongly indicative of spinal myoclonus—an atypical manifestation of generalized tetanus. There has been only one previous report of stimuli‐sensitive jerky movements associated with tetanus 11 .…”

“…Video content can be viewed at https://onlinelibrary.wiley.com/ doi/10.1002/mdc3.13935 importance of fundamental neurology assessments even in this era of advanced diagnostics, helping to avoid costly and unnecessary extensive tests such as lumbar punctures and extensive autoimmune antibody panels, and lowering the risk of severe autonomic complications, including ventricular tachycardiainduced cardiac arrest. Typical manifestations 4,8 Atypical manifestations [9][10][11] Ablett classifications based on severity Our treatment followed standard protocols, using anti-toxin and metronidazole as primary therapies. 4,18 Additionally, we administered high doses of midazolam for severe muscle spasms.…”