Closed Case Friday: The Snow Man

Earlier this week, we gave you a hypothetical patient with the following case:

This week's hypothetical patient is a 65-year-old homeless man who was found lying in a park during a particularly cold and snowy week in South Dakota. The woman who brought him to the hospital was unsure how long the man had been lying in the park. The man was unable to bear weight due to pain in his left hip. Upon examination, his oral temperature was found to be 30.5 degrees C and he had a loss of sensation and motor function in his toes. His feet showed obvious skin damage as they were a yellowish color and had a waxy appearance. His physician ordered x-rays of his hip, which later showed that he had a fracture on his pelvis, which was causing his hip pain. The man was not diabetic. The man had a medical history that included a myocardial infarction. The man's fracture was treated with skeletal traction and he was warmed slowly while being given an infusion to help with the cold injuries to his feet. Withing 72 hours, the patient was showing signs of gangrene in his toes and heels. He was started on intravenous antibiotics and samples of the infected areas were collected to be identified by the medical lab science team on-site. Approximately 6 hours after receiving the antibiotics, the patient developed neck stiffness, opisthotonos, and carpopedal spasms.

Today, we reveal that our hypothetical patient was diagnosed as having: 

Frostbite Complicated by Tetanus

This week's case was based on an actual case reported in 1990. Our hypothetical patient has been exposed to the elements and is showing the signs of frostbite on his feet. Today, it is commonplace to provide tetanus prophylaxis to patients with frostbite, but in this case our patient did not receive this prophylactic treatment and later developed an infection, presumably of Clostridium tetani, the causative agent of tetanus, which later manifested as neck stiffness, spasms of the head, neck, and spine, and involuntary contraction of muscles in the feet. There isn't a cure for tetanus, but treatment typically consists of cleaning and caring for the wound and the administration of medications to ease symptoms. Doctors may prescribe tetanus antitoxins, such as tetanus immune globulin, antibiotics, such as as metronidazole or penicillin to help fight the bacteria, a vaccination for tetanus, sedatives to control muscle spasms, and/or other medications to help support patients in the healing process. Supportive care, such as respiratory support, may also be necessary.

In the real case that this hypothetical case was based on, the patient was given tetanus immunoglobulin and an infusion of diazepam before excising the infected areas. He was also given assisted ventilation and a feeding tube. He was weaned off of the ventilator after 6 weeks, at which point he began partial weight bearing for his hip injury. He was discharged after 27 weeks and was able to walk with the aid of a cane. You can read the report of this case here: https://www.injuryjournal.com/article/0020-1383(90)90013-K/pdf.

Thanks for joining us for this week's Mystery Case and we hope to see you next week!