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A 59 year old man had a benign scalp tumour (figure A) for over 20 years. He had not received primary immunisation against tetanus. He experienced generalised tetanus, manifested by rigidity of the masseter muscles (trismus, figure B), followed 24 hours later by rigidity of the axial musclatures (opisthotonus) and paroxysmal, violent muscle contractions (reflex spasms). The patient underwent complete surgical removal of the scalp tumour because of the lack of other possible sources of tetanus. The tumour was a solitary trichoepithelioma, and anaerobic cultures showedClostridium tetani. The identification ofClostridium tetani in this case was based on the characteristic slender shape of the anaerobic bacillus with a terminal spherical spore (figure C, gram stain, originally×1000) and the mouse toxin neutralisation test. The patient’s muscle rigidity and spasms were controlled by benzodiazepine and neuromuscular blockades under ventilatory support, and he was successfully treated by a combination of human tetanus immunoglobulin, tetanus toxoid, and antibiotics.
Tetanus usually follows an acute injury in which the spores are introduced into the injured tissue. Malignant hypoxic necrotic tumours are occasional but unusual sites of infection. However, no patients with tetanus originating in a benign skin neoplasm have been reported previously. Our present case shows that a benign neoplasm of the skin can be predisposed to clostridial infection.
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