A 17-year-old young man complains of general weakness, trismus, twitching of the muscles in his left shin. 7 days ago he pierced his foot with a nail. Objectively: at the sole of the foot there is a wound, 0,3x0,2 mm in size, with small amount of serous-purulent discharge, the skin around the wound is hyperemic. What is the most likely diagnosis?

Answer options

1. Phlegmon
2. Tetanus
3. Osteomyelitis
4. Infected wound
5. Erysipelas

Explanation

Tetanus usually follows a recognized injury. Contamination of wounds with soil, manure, or rusty metal can lead to tetanus. It can complicate burns, ulcers, gangrene, necrotic snakebites, middle ear infections, septic abortions, childbirth, intramuscular injections, and surgery. There is a clinical triad of rigidity, muscle spasms, and, if severe, autonomic dysfunction. Neck stiffness, sore throat, and difficulty opening the mouth are often early symptoms. Masseter spasm causes trismus or «lockjaw». Spasm progressively extends to the facial muscles causing the typical facial expression, "risus sardonicus", and muscles of swallowing causing dysphagia. The rigidity of the neck muscles leads to the retraction of the head. Truncal rigidity may lead to opisthotonos and respiratory difficulty with decreased chest wall compliance. In addition to increased muscle tone, there are episodic muscular spasms. These tonic contractions have a convulsion-like appearance affecting agonist and antagonist muscle groups together. They may be spontaneous or triggered by touch, visual, auditory, or emotional stimuli. In the commonest form of tetanus, generalized tetanus, muscles throughout the body are affected. With lower toxin loads and peripheral injuries, local tetanus is seen. Spasm and rigidity are restricted to a limited area of the body. The entry wound may show a localized small area of cellulitis. Exudate or aspirate may give a sample that can be stained to show the presence of gram-positive rods. Cook T. M. Tetanus: A review of the literature. T. M. Cook, R. T. Protheroe, J. M. HandelBr J Aneesh. – 2001. – Vol. 87. – P. 477–87.