Objective: This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. Methods: Design: Retrospective Cohort Study Setting: Tertiary National University Hospital Patients: Seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. Demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. Results: Of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. The three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). Results of multivariate logistic regression analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation. No dependent variable/symptoms had a significant effect in predicting discharge and mortality. Conclusion: Clinically diagnosed tetanus can be easily recognized and immediately treated. Most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. In particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality.
tracheotomy ; tetanus ; trismus ; Neck Pain ; Muscle Rigidity

Neuroleptic malignant syndrome (NMS) is an uncommon but potentially lethal idiosyncratic reaction which may emerge in the aftermath of the treatments with neuroleptics demonstrating itself with the symptoms of altered consciousness, high fever, impaired autonomic functions, and muscle rigidity. Although various risk factors have been identified for NMS, its etiology is not completely known. The mortality and morbidity related with NMS could be reduced by early diagnosis, interruption of the neuroleptics used within a short period and aggressive treatment. Our case is different from general NMS cases due to lack of rigidity. A NMS case which developed within a short time in the aftermath of multiple antipsychotic use and wherein no rigidity was observed shall be discussed in this case report.
Antipsychotic Agents ; Consciousness ; Early Diagnosis ; Fever ; Mortality ; Muscle Rigidity ; Neuroleptic Malignant Syndrome ; Risk Factors

A 43-year-old woman with left facial pain caused by occipital neuralgia was scheduled for C2 ganglionotomy and adhesiolysis of left C2 root. General anesthesia, surgical procedure, and emergence have done uneventfully. However, she developed seizure after 5 minutes postoperatively in post-anesthesia recovery unit. She showed loss of consciousness and generalized muscular rigidity after shouting “I want to die”. Neurologic examination and neuroimaging revealed no neuronal damage. Her generalized muscular rigidity improved by her daughter's visit and worsened by mention about her husband, and disappeared after 40 minutes spontaneously.
Adult ; Anesthesia, General ; Facial Pain ; Female ; Humans ; Muscle Rigidity ; Neuralgia ; Neuroimaging ; Neurologic Examination ; Neurons ; Seizures* ; Spouses ; Unconsciousness

Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction that usually occurs after the administration of antipsychotic drugs. Antidepressants, benzodiazepines, and antiepileptic drugs are also suggested to be associated with NMS. It is believed to result from a dopaminergic blockade in the central nervous system. NMS is manifested by hyperthermia, muscle rigidity, autonomic dysfunction, altered mental status, leukocytosis, and elevated serum creatinine phosphokinase. Valproate is commonly used in the treatment of many psychiatric and neurologic disorders. Valproate can precipitate NMS, especially when used with antipsychotic drugs concurrently. A 17-year-old male patient, who presented with fever, muscular rigidity, confusion, sweating, and tachycardia was admitted to the emergency room. He had been taking only valproate for the last two months for bipolar disorder. His laboratory analyses revealed raised serum hepatic enzymes, creatinine phosphokinase, and myoglobin levels. Considering fever, rigidity, autonomic dysfunction, cognitive alteration, and high creatinine phosphokinase levels, the patient was diagnosed with NMS. In this paper, we aim to discuss the association between valproate and NMS.
Adolescent* ; Anticonvulsants ; Antidepressive Agents ; Antipsychotic Agents ; Benzodiazepines ; Bipolar Disorder ; Central Nervous System ; Child ; Creatinine ; Emergency Service, Hospital ; Fever ; Humans ; Leukocytosis ; Male ; Muscle Rigidity ; Myoglobin ; Nervous System Diseases ; Neuroleptic Malignant Syndrome* ; Sweat ; Sweating ; Tachycardia ; Valproic Acid*

Bentazone is classified as a moderately hazardous (class II) herbicide by the World Health Organization. A 53-year-old Korean woman was transferred to the emergency department after a suicide attempt using approximately 500 mL of bentazone one hour prior to admission. Upon admission, she was alert and tachycardia of 125/min was observed. She was treated with gastric lavage and activated charcoal, during which she experienced diarrhea. Two hours after bentazone ingestion, cardiac arrest and muscle rigidity throughout the body occurred. Cardiopulmonary resuscitation was immediately started. Endotracheal intubation after administration of a muscle relaxant (succinylcholine) was unsuccessful because of temporomandibular joint muscle rigidity. Surgical cricothyroidotomy was performed by the emergency physician, but the patient was not resuscitated. For cardiac arrest patients with muscle rigidity caused by bentazone overdose, endotracheal intubation may be challenging because of muscle rigidity, despite appropriate use of muscle relaxants. Early surgical cricothyroidotomy may be the preferred method of airway management in these patients.
Airway Management ; Cardiopulmonary Resuscitation* ; Charcoal ; Diarrhea ; Drug Overdose ; Eating ; Emergencies ; Emergency Service, Hospital ; Fatal Outcome ; Female ; Gastric Lavage ; Heart Arrest ; Humans ; Intubation, Intratracheal ; Methods ; Middle Aged ; Muscle Rigidity ; Suicide ; Tachycardia ; Temporomandibular Joint ; World Health Organization

Opioid-induced chest wall rigidity is an uncommon complication of opioids. Because of this, it is often difficult to make a differential diagnosis in a mechanically ventilated patient who experiences increased airway pressure and difficulty with ventilation. A 76-year-old female patient was admitted to the intensive care unit (ICU) after surgery for periprosthetic fracture of the femur neck. On completion of the surgery, airway pressure was increased, and oxygen saturation fell below 95% after a bolus dose of fentanyl. After ICU admission, the same event recurred. Manual ventilation was immediately started, and a muscle relaxant relieved the symptoms. There was no sign or symptom suggesting airway obstruction or asthma on physical examination. Early recognition and treatment should be made in a mechanically ventilated patient experiencing increased airway pressure in order to prevent further deterioration.
Aged ; Airway Obstruction ; Analgesics, Opioid ; Asthma ; Diagnosis, Differential ; Female ; Femur Neck ; Fentanyl* ; Humans ; Intensive Care Units ; Lung Diseases, Obstructive ; Muscle Rigidity ; Oxygen ; Periprosthetic Fractures ; Physical Examination ; Thoracic Wall* ; Thorax* ; Ventilation

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal outcome caused by sudden discontinuation or dose reduction of dopaminergic agents. We report an extremely rare case of NMS after deep brain stimulation (DBS) surgery in a cerebral palsy (CP) patient without the withdrawal of dopaminergic agents. A 19-year-old girl with CP was admitted for DBS due to medically refractory dystonia and rigidity. Dopaminergic agents were not stopped preoperatively. DBS was performed uneventfully under monitored anesthesia. Dopaminergic medication was continued during the postoperative period. She manifested spasticity and muscle rigidity, and was high fever resistant to anti-pyretic drugs at 2 h postoperative. At postoperative 20 h, she suffered cardiac arrest and expired, despite vigorous cardiopulmonary resuscitation. NMS should be considered for hyperthermia and severe spasticity in CP patients after DBS surgery, irrespective of continued dopaminergic medication.
Anesthesia ; Cardiopulmonary Resuscitation ; Cerebral Palsy* ; Deep Brain Stimulation* ; Dopamine Agents ; Dystonia ; Female ; Fever ; Globus Pallidus* ; Heart Arrest ; Humans ; Muscle Rigidity ; Muscle Spasticity ; Neuroleptic Malignant Syndrome ; Postoperative Period ; Young Adult

Serotonin syndrome, an adverse drug reaction, is a consequence of excess serotonergic agonism of central nervous system receptors and peripheral serotonergic receptors. Serotonin syndrome has been associated with large numbers of drugs and drug combinations, and serotonin-norepinephrine reuptake inhibitor-induced serotonin syndrome is rare. It is often described as a sign of excess serotonin ranging from tremor in mild cases to delirium, neuromuscular rigidity, and hyperthermia in life-threatening cases. Diagnosis is based on the symptoms and patient's history, and several diagnostic criteria have been developed. We experienced a rare case of fibromyalgia accompanied by tremor, hyperreflexia, spontaneous clonus, muscle rigidity, and diaphoresis after 10 days of single use of duloxetine 30 mg. Only one case of serotonin syndrome resulting from administration of duloxetine has been reported in Korea, however that case resulted from co-administration of fluoxetine. We report here on this case along with a review of the relevant literature.
Central Nervous System ; Delirium ; Diagnosis ; Drug Combinations ; Drug-Related Side Effects and Adverse Reactions ; Duloxetine Hydrochloride* ; Felodipine ; Fever ; Fibromyalgia* ; Fluoxetine ; Humans ; Korea ; Muscle Rigidity ; Reflex, Abnormal ; Serotonin Syndrome* ; Serotonin* ; Tremor

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal outcome caused by sudden discontinuation or dose reduction of dopaminergic agents. We report an extremely rare case of NMS after deep brain stimulation (DBS) surgery in a cerebral palsy (CP) patient without the withdrawal of dopaminergic agents. A 19-year-old girl with CP was admitted for DBS due to medically refractory dystonia and rigidity. Dopaminergic agents were not stopped preoperatively. DBS was performed uneventfully under monitored anesthesia. Dopaminergic medication was continued during the postoperative period. She manifested spasticity and muscle rigidity, and was high fever resistant to anti-pyretic drugs at 2 h postoperative. At postoperative 20 h, she suffered cardiac arrest and expired, despite vigorous cardiopulmonary resuscitation. NMS should be considered for hyperthermia and severe spasticity in CP patients after DBS surgery, irrespective of continued dopaminergic medication.
Anesthesia ; Cardiopulmonary Resuscitation ; Cerebral Palsy ; Deep Brain Stimulation ; Dopamine Agents ; Dystonia ; Female ; Fever ; Globus Pallidus ; Heart Arrest ; Humans ; Muscle Rigidity ; Muscle Spasticity ; Neuroleptic Malignant Syndrome ; Postoperative Period ; Young Adult

Opioid-induced chest wall rigidity is an uncommon complication of opioids. Because of this, it is often difficult to make a differential diagnosis in a mechanically ventilated patient who experiences increased airway pressure and difficulty with ventilation. A 76-year-old female patient was admitted to the intensive care unit (ICU) after surgery for periprosthetic fracture of the femur neck. On completion of the surgery, airway pressure was increased, and oxygen saturation fell below 95% after a bolus dose of fentanyl. After ICU admission, the same event recurred. Manual ventilation was immediately started, and a muscle relaxant relieved the symptoms. There was no sign or symptom suggesting airway obstruction or asthma on physical examination. Early recognition and treatment should be made in a mechanically ventilated patient experiencing increased airway pressure in order to prevent further deterioration.
Aged ; Airway Obstruction ; Analgesics, Opioid ; Asthma ; Diagnosis, Differential ; Female ; Femur Neck ; Fentanyl ; Humans ; Intensive Care Units ; Lung Diseases, Obstructive ; Muscle Rigidity ; Oxygen ; Periprosthetic Fractures ; Physical Examination ; Thoracic Wall ; Thorax ; Ventilation