Tetanus presenting primarily as periocular discomfort in a patient who underwent surgery for sleep apnea: A case report and brief literature review

RATIONALE: Tetanus is caused by a neurotoxin (tetanospasmin) secreted by a spore forming gram-positive, anaerobic rod-shaped motile bacillus, Clostridium tetani. The most common symptoms of tetanus are trismus (100%), dysphagia (70.5%), dysarthria (35.2%), and neck stiffness (29.4%). Respiratory failure, laryngeal spasm, seizure, chest pain, nausea/vomiting, opisthotonus, back pain, and rigid abdominal wall can also be observed during progression of the disease. However, there has been no report of periocular discomfort as an initial manifestation after endoscopic sleep surgery in a patient with tetanus. Here, we report a patient who underwent endoscopic sleep surgery with a concurrent diagnosis of tetanus infection presenting with atypical periocular discomfort as the initial symptom. PATIENT CONCERNS: A 63-year-old man complaining of sleep apnea, snoring, and daytime sleepiness visited our department. He subsequently underwent sleep surgery (anterior pharyngoplasty with tonsillectomy, septoplasty, microdebrider-assisted inferior turbinoplasty, and an endoscopic sinus surgery) for the treatment of his newly diagnosed obstructive sleep apnea. After 3 weeks of surgery, he visited the outpatient clinic of our department with right side periocular discomfort. DIAGNOSES: Four days after presenting with periocular discomfort, he was diagnosed with tetanus by presenting trismus, jaw pain, dysphagia, and ptosis at an emergency department of a different hospital. INTERVENTIONS: Tetanus immunoglobulin and antibiotics were administered. OUTCOMES: His symptoms then resolved after a month without sequelae. LESSONS: Although periocular discomfort is atypical and is not uncommon after nasal and oral surgeries, care should be taken when patients present with periocular pain because it could be a rare initial symptom of tetanus.