Non-Wound Tetanus Mimicking Botulism in a Low-Resource Setting: Early Recognition and Successful Intensive Care Management

Abstract

Introduction: . Although classically associated with contaminated wounds, the portal of entry may be trivial or unrecognized, resulting in so-called non-wound presentations that can delay diagnosis. Early tetanus may also mimic other toxin-mediated syndromes, including botulism, particularly when cranial or bulbar symptoms predominate. Case Presentation: A 41-year-old man in Somalia presented with rapidly progressive trismus, neck stiffness, dysarthria, perioral paresthesia, and marked masseter rigidity over 12 hours. He had no limb weakness or focal neurologic deficits, and brain MRI and CT angiography were unremarkable. Initial history raised concern for botulism because of recent laser eye surgery and ingestion of home-canned vegetables. Repeated history-taking later revealed extensive post-flood debris cleanup with possible unnoticed hand punctures. His most recent documented tetanus vaccination was in 2020, but prior immunization history was incomplete. He received tetanus toxoid, intramuscular human tetanus immunoglobulin, intravenous metronidazole, and ICU observation. He improved within 24 hours and recovered fully by 48 hours. Conclusion: This case illustrates that tetanus can present without an identifiable wound and may closely mimic botulism when bulbar symptoms and misleading exposure histories are present. In patients with acute trismus and painful rigidity, tetanus should remain a leading consideration despite normal neuroimaging and absent wounds. Early empiric antitoxin, antibiotics, vaccination, and close monitoring can be decisive, and repeated environmental exposure history, especially after flooding or debris handling, may reveal the missing diagnostic link. Importantly, tetanus occurred despite a recent documented vaccination, highlighting uncertainty about protection when prior immunization history is incomplete.