Fishing for reasons for stroke symptoms

istockphoto.com
istockphoto.com
Posted: July 15, 2013

One in an occasional series on attempts to solve a medical mystery.

Forty years ago, his wife mistakenly assumed his weekly fishing trips would taper off after the wedding. Then, perhaps after the children came. But throughout his career as a research chemist, through raising three children and supporting his wife's chemistry career, he'd kept up his passion for the hobby. So she had no doubt when he retired last year how he would be spending his days.

She was at an out-of-town conference when she received his call. His right arm didn't feel right when the 70-year-old woke up that morning. Maybe it was an injury, she thought.

Given that the symptom was on just one side of his body, her other thought was that he could be having a stroke, like her father had had years before.

At the time, her father stayed at home and rested, and so she advised him to do the same. As the day went on, he began to have other symptoms. He called his daughter at her biochemistry lab. He was difficult to understand on the phone. She echoed her mother's concern about a stroke. While he was quite healthy, his high blood pressure and 35 years of smoking put him at some risk for stroke. But she knew that waiting at home was not the right thing. She rushed over to take him to the emergency room.

How could my mother not know that a stroke is an emergency, she thought as she raced into the house. If he really was having a stroke and it was caused by a blocked vessel in his brain, time was vital. If he arrived at the ER within a short while after the symptoms of a vessel blockage, the clot could potentially be broken up with medication, and the stroke symptoms could rapidly reverse. Wait too long, and the brain could be permanently damaged.

When he arrived in the emergency room, his blood pressure was high, as was his heart rate. The ER doctor asked him to go through exactly what his symptoms were. The pain in his right arm was a spasm - like a "charley horse." When his daughter remarked on his garbled speech, he noted that he was feeling painful spasms around his mouth. Then he noticed them in the left arm and upper back as well. This did not sound like a stroke to the physician. With these prominent spasms, something else came to mind.

The Solution...

Though he was uncomfortable, the patient was able to answer the physician's detailed questions. He noted that a fishhook had penetrated a finger on his right hand three weeks earlier on a fishing trip to New Hampshire. The finger had swelled up a bit, and he went to his doctor's office 10 days after the injury, when it didn't seem to be improving.

At the time of the visit, the doctor gave him a tetanus booster shot and prescribed antibiotics. The patient told the ER doctor that his last tetanus shot had been perhaps 10 years prior. The physician examined the swollen finger. He noted that the patient's arms were a bit hard to move, and he could see the spasms in the right arm. He got some initial blood tests, which were normal.

With this constellation of spasms and this story of the dirty fishhook, the doctor was considering a disease that he had actually never seen: tetanus.

When the bacteria, Clostridium tetani, are introduced into a wound, spores can germinate in the tissue and produce a toxin that enters nerve endings and moves up the nerves to the spinal cord and brain stem. The toxin then prevents nerves from relaxing muscles, leading to the spasms, including the classic "lockjaw" symptom.

The ER doctor explained all this to the patient and his daughter. "But he had a tetanus shot just over a week ago, right dad?" He nodded.

A tetanus shot should protect when it has been given recently enough prior to an injury so that there are antibodies around to bind up the toxin. In the years after getting a tetanus shot, the level of antibodies in the body drops. It's recommended that people have booster shots every 10 years, but many people don't as they get older. By age 70, only 30 percent of people have enough antibodies to protect them from tetanus. So while tetanus has become very rare in the United States, it's twice as common in people older than 65.

After a dirty injury is cleansed, unless it's clear that a person has received several tetanus immunizations, he or she should get a tetanus shot.A shot of actual tetanus antibody or immune globulin may be needed to prevent the toxin from entering nerves while the vaccine is taking effect.

Because there is no test that determines with certainty that a patient has tetanus, the ER doctor had to act on his clinical instinct. He got the patient into the intensive-care unit and called an infectious diseases consultant. The team of doctors and nurses aggressively treated the patient for tetanus. A breathing tube was placed in case muscle spasms closed off his throat, and he was kept sedated for days. His finger wound was cleaned a bit more. His wife and daughter kept watch at his bedside. He did well and eventually walked out of the hospital.

When one of the doctors who had treated him called to check on him a few weeks later, he didn't answer. When his wife picked up the phone, she asked with a laugh, "Well, where do you think he is?"


Valerianna Amorosa and John Stern are infectious-disease doctors in the University of Pennsylvania Health System. He practices at Pennsylvania Hospital. She practices at the Hospital of University of Pennsylvania and the Philadelphia VA Medical Center.

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