A 36-year-old male came to our emergency room with a chief complaint of jaw stiffness that made him difficult to open his mouth. He also complained of having difficulty swallowing. No complaint of abdominal muscle stiffness or whole body spasms. He also did not complain about having palpitation, difficulty in breathing, excessive salivation, nor sweating. He admitted that he had a fever for 2 days and a fishing hook wound on his index right fingertip around 5 days prior. He had dental cavities and did not have history of TB in any form. The patient could not recall his tetanus immunization status.
Upon examination in the emergency room, a slight fever was observed. Other vital signs were within normal limits. On neurological examination, we found meningismus, 2 cm trismus, abdominal spasm, opisthotonus posturing, and spontaneous muscle spasms without dysautonomia. No other neurological findings nor spinal deformity was observed. Laboratory findings showed a slight increase in leukocyte count (12,700 cell/muL), normal electrocardiogram (ECG), normal blood electrolyte and renal function, and no pneumonia in his chest x-ray.
The diagnosis was general tetanus Grade 3 Patel Joag, and he received intravenous metronidazol, human tetanus immunoglobulin, and tetanus toxoid. Benzodiazepine was used to control the spasms in titrated doses. He underwent wound care to eliminate the source of infection, but treatment for dental cavities was postponed due to his locked jaw condition. A tracheostomy was planned as part of the standard procedure, but the patient refused to get one.
During hospitalization, spontaneous and stimulated spasms worsened, and he developed dysautonomia with tachycardia, hyperthermia, hyperhydration, and hypersalivation. On observation, no signs of myocarditis or prolonged Qtc in ECG were found.
In the third week of treatment, while his tetanus condition improved, the patient started to complain about motor weakness in both legs. On examination, we observed 4 out of 5 motor scales, in the British Medical Research Council's (MRC) motor scale, and increased knee-jerk reflexes. Inspection showed painful bulging/gibbus on the patient's back with no pathological reflexes (Figure 1). The findings did not fit features of vertebral compression fracture due to tetanus which is usually mid-thoracic and painless. 
The patient underwent a vertebral x-ray and magnetic resonance imaging (MRI). X-ray images showed a wedge-shaped fracture at the 11th-12th thoracic vertebrae (Figure 1). MRI images showed a compression fracture of 11th-12th thoracic vertebrae with gibbus and change of body intensity that compressed the spinal canal and pressed the spinal cord. Inhomogeneous vertebral body intensity changes in the 11th-12th thoracic vertebrae and the intervertebral disc were also observed, which was in line with the diagnosis of spondylosis TB and spondylodiscitis TB (Figure 1).
A thorough history taking following the MRI revealed a history of backache for 3 years, presumably due to spinal TB. On a deeper anamnesis, it was revealed that he had the diagnosis of spinal TB and had received TB treatment for several months, but he did not realize that the present condition might be related to that.
Treatment for spinal TB was then started using a standard regimen. A consultation for spinal surgery was made, but the patient refused to get operated. After 27 days of hospitalization, the patient recovered from tetanus and went home with 4 on the MRC motor scale. At follow-up, 3 months later, the patient has returned to his routine activity as a food hawker with no motor deficits (Figure 2).