tetanus is a disease characterized by hypertonia and muscular spasms due to the toxin tetanospasmin formed by clostridium tetani .
tetanus continues to be widespread , especially in the developing world though incidences have come down due to immunization .
we present a case of tetanus in a young girl which initially mimicked a striatal toe though the potential cause of inoculation was trauma to nose .
a 16-year - old girl presented with a history of sudden onset of pain in left leg with difficulty in walking for 2 days .
an upturned big toe without fanning of other toes was seen on the left [ figure 1 ] .
a clinical diagnosis of a striatal toe was made and the patient was admitted for further evaluation [ figures 1 and 2 ] .
contrast - enhanced magnetic resonance imaging of the brain revealed no abnormality of the basal ganglia .
liver function test was normal and slit lamp examination did not show a kf ring . corrected serum calcium was 9.8 mg / dl .
on the 3 day after admission , she developed stiffness of bilateral lower limbs followed by episodic spasms of the back and neck .
there were no signs of autonomic hyperactivity and she did not have any seizures . on further probing , patient 's mother revealed that she had suffered a fall a day before onset of her symptoms and hurt her nose .
her mother said that she had received her primary series of tt in infancy and received her last booster 6 years back at around 10 years of age .
she was given tetanus immunoglobulin ( tig ) 5000 units intramuscularly stat and also started on intravenous metronidazole and diazepam infusion .
on the 5 day after admission , she developed mild trismus and opisthotonus completing the clinical picture of generalized tetanus .
she started showing signs of recovery by day 10 and made a complete recovery in 3 weeks from onset of symptoms .
tetanus is caused by the toxin tetanospasmin released by the germinating spores of the anaerobic gram - positive bacilli c. tetani .
as spores of the bacilli occur in the soil , tetanus frequently occurs following a contaminated wound , but cases have also been reported after dental procedures , surgeries , burns , intravenous drug abuse , and intramuscular injections .
our patient presented with a localized form of tetanus affecting initially the left leg that mimicked a striatal toe even though there was no local injury in the leg .
it is possible that our patient had another insignificant trauma to her leg that had gone unnoticed .
a striatal toe is a finding in clinical neurology that reliably localized the lesion to the caudate nucleus and putamen .
the absence of fanning of the rest of the toes differentiates the upturned big toe from the babinski extensor plantar response .
tetanus presenting initially with the classic clinical picture of striatal toe has not been reported before .
thus , it is important to keep localized tetanus in the differential diagnosis of extrapyramidal disorders presenting with such spasticity , especially in the absence of definite history of trauma .
dystonias can be ruled out in such cases by checking for resolution after a dose of benztropine .
severity of tetanus can be graded according to the ablett classification into four grades . according to the ablett classification ,
the world health organization recommends a 5 dose schedule for tetanus vaccination while in india additional doses are recommended in the universal immunization program ( uip ) .
our patient had received three doses as dtp in infancy and another dose between 12 and 24 months of age .
she also had received two booster doses of dtp and td at 5 years and 10 years according to her mother as per the uip .
the advisory committee on immunization practices of the centers for disease control does not recommend either td vaccination or tig for patients who have received more than three doses of tt with the last dose within 5 years .
td is recommended in clean wounds with last booster > 10 years back and other wounds with last booster > 5 years back .
tig should be given in unclean wounds when vaccination status is unknown or patient has received <3 doses .
tetanus prone wounds are > 6 h old , > 1 cm deep , stellate , ischemic , denervated , contaminated or infected .
our patient had received tt immunization at the time of primary wound care as per the recommendations .
she did not receive tig as she had received more than 3 doses of immunization in the past .
identification of vulnerable patients by testing for protective tetanus antibodies is not viable in our setting .
this may be due to a defect in the patients humoral immunity due to which she could nt mount an antibody response . rapid bedside tests to screen for tetanus immunization status have been found to be more effective than medical interview and wound assessment in some studies , but cost effectiveness remains an issue .
wound care , antimicrobial therapy with metronidazole and human tig are cornerstones of therapy of established tetanus .
a full course of active immunization with tt should be started early as neither clinical infection nor tig provide long - term immunity .
cases of tetanus continue to come to medical attention in spite of widespread immunization in this age and time .
we must be alert to the possibility and institute prompt treatment after a clinical diagnosis as early passive immunization reduces morbidity and mortality .
 we report the case of a 15-year - old girl who was initially diagnosed to have a striatal toe . 
 her condition progressed and she later developed clinical features consistent with tetanus . 
 history of blunt trauma to nose was elicited retrospectively . 
 antimicrobial therapy with metronidazole and both active and passive immunization was started immediately . 
 the patient went on to make a complete recovery . 
Introduction
Case Report
Discussion