A 7-year-old boy belonging to a low socioeconomic status family, presented in the pediatric casualty. Five days prior to hospital admission, parents noticed child having oral ulcers secondary to tongue biting. Since 3 days, he was having multiple episodes of intermittent tightening of all 4 limbs lasting for few seconds and clinching of teeth during which he sustained multiple tongue bites. During these events, child was conscious, no facial deviation/asymmetry and no bladder bowel incontinence. There was no history of fever, trauma, animal bite or recent vaccination history. There was no history of difficulty in feeding, breathing or arching of body/opisthotonus. Child was having left ear discharge on-and-off since two years of age, for which he was taking treatment from local practitioner.

On examination at admission, child was conscious, following commands, and hemodynamically stable. On oral examination showed multiple cuts on tongue with oral ulcers. There was reflex spasm of masseters on touching the posterior pharyngeal wall (spatula test - positive). Left eye ptosis was present. Rest of the cranial nerves examination including pupillary reactions were normal. During examination child had tightening of all four limbs with teeth clinching lasting for less than a minute. He was conscious during the event which was self-aborted. CNS examination done after this event was normal. Baseline hematological work-up, liver and renal function tests and serum calcium and electrolytes were normal. Lumbar puncture and cranial computed tomography (CECT Head) were normal.

By the history, examination and his unimmunized status, tetanus was strongly suspected and was started on treatment for tetanus in the form of intravenous. Ceftrioxane and metronidazole, along with supportive management. Intramuscular and intrathecal tetanus immunoglobulin (TIG) along with one dose of tetanus toxoid was given. Intravenous diazepam was started to control spasms. He was monitored for neurological and respiratory deterioration. Child started improving clinically, tetanic spasms reduced and diazepam was tapered slowly and was discharged on oral diazepam on the 14th day of admission. The parents were counselled and planned for catch up immunization. He was followed-up one week after discharge, with full recovery of ptosis, no spasms. The otorrhoea had ceased.

Tetanus is strictly a clinical diagnosis, there is no laboratory test to confirm it. In our case the diagnosis was strongly suspected by the history, examination and unimmunized status of child.

The mechanism of cranial nerve palsies is not fully understood but few studies have given explanations like swelling of facial nerve under the influence of the toxin leading to strangulation in the stylo-mastoid canal, third-nerve lesions due to intense absorption of toxin from the orbicularis and ciliary regions, which are supplied by this nerve.

Survival rates in children receiving　 tetanus immunoglobulins via the dual route were significantly higher compared with children who received the intramuscular immunoglobulin only　[5-7] and hence we preferred dual route for TIG administration.

High index of suspicion for tetanus should be considered in an unimmunized child presenting with ptosis without apparent trismus or facial palsy.

Contributors: MS: designed and drafted the manuscript; SG: concept and analyzed the manuscript; MY: helped in data analysis.

Funding; None; Competing interest: None stated.

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