Tetanus is a major public health concern and an important cause of death worldwide despite being largely preventable. Although endemic in the developing world, vaccination has rendered it rare in the developed world. Recently, however, an outbreak of tetanus in injecting drug users in England and Scotland has occurred.¹

Intensive care treatment has significantly lowered mortality from tetanus, although the multisystem effects of Clostridium tetani infection, as well as prolonged critical illness, continue to provide major therapeutic challenges.²

Here we describe the sub-acute onset of headache and blindness in a patient with severe tetanus. Clinical and neurological features were consistent with posterior reversible encephalopathy syndrome (PRES, previously known as reversible posterior leucoencephalopathy syndrome³), which to our knowledge has not previously been described in a case of tetanus. We suggest that the pathophysiology of PRES in this case is multifactorial and incompletely understood.

Case report

A 27 year old female intravenous/subcutaneous heroin user was admitted with a 12 h history of generalised muscular stiffness, intermittent sweats, and progressive difficulty in mouth opening. On examination, she had risus sardonicus and trismus with less than 5° of mouth opening. She had paroxysms of severe sweating although apyrexial, and had multiple involuntary self-terminating tonic spasms of neck retraction and trunk extension …