A 73-year-old woman, with advanced breast cancer, who consistently refused surgical resection, was admitted in emergency room for an acute respiratory failure, associated with generalized muscle rigidity, trismus, hyperpyrexia, sweating which needed neuromuscular blocking agent and an early tracheostomy to avoid tube biting and obstruction. No previous cardiac history reported. Over the last weeks, for the occurrence of secondary skin ulceration, the patient was advised to apply clay mud over the breast. Subsequently, she developed an extensive local necrosis (Panel A). Microbiological results from necrosectomy revealed Clostridium tetani and Clostridium sporogenes. Human tetanus globulin, intravenous cephalosporin, and high dosage of benzodiazepines were administered. Electrocardiogram on admission showed a prolonged QT interval without any evidence of ST segment depression (InterTAK Score: 56) (Panel B) and hsTroponin was 1.46, peaking 3.95 ng/mL. The clinical course rapidly deteriorated with vegetative crisis and haemodynamic instability associated with atrial fibrillation and ST segment elevation (Panel C). Coronary angiography was performed: no evidence of obstructive epicardial coronary atherosclerosis was observed. Following the 2017 ST elevation myocardial infarction guidelines, left ventricular angiography was performed showing an apical type takotsubo syndrome (TTS), with high left ventricular end-diastolic pressure and left atrial pressure (Panel D; Supplementary material online, Videos S1–S3). Sadly, the patient died less than 48 h later. To the best of our knowledge, this is the first report documenting a TTS in a patient with a diagnosis of tetanus, in which catecholamine levels may increase due to the tetanus toxin. As recently demonstrated, TTS may be a life-threatening condition: early cardiac catheterization is fundamental to make a correct diagnosis.

中文翻译：

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“凯撒大帝，死了，变成了泥土，能堵个洞挡风吗？”

一名 73 岁女性，患有晚期乳腺癌，一直拒绝手术切除，因急性呼吸衰竭被送入急诊室，伴有全身肌肉强直、牙关紧闭、高热、出汗，需要神经肌肉阻滞剂和早期气管切开术以避免咬管和阻塞。既往无心脏病史报告。在过去的几周内，由于继发性皮肤溃疡的发生，建议患者在乳房上涂抹粘土。随后，她出现了广泛的局部坏死（图 A）。来自坏死切除术的微生物学结果显示破伤风梭菌和产孢梭菌。给予人破伤风球蛋白、静脉注射头孢菌素和大剂量苯二氮卓类药物。入院时的心电图显示 QT 间期延长，没有任何 ST 段压低的证据（InterTAK 评分：56）（图 B），hsTroponin 为 1.46，峰值为 3.95 ng/mL。临床病程迅速恶化，伴有与心房颤动和 ST 段抬高相关的植物人危象和血流动力学不稳定（图 C）。进行了冠状动脉造影：没有观察到阻塞性心外膜冠状动脉粥样硬化的证据。根据 2017 年 ST 段抬高心肌梗死指南，左心室血管造影显示心尖型 Takotsubo 综合征 (TTS)，左心室舒张末期压和左心房压高（图 D；在线补充材料，视频 S1-S3）。遗憾的是，患者在不到 48 小时后死亡。据我们所知，这是第一份记录破伤风诊断患者 TTS 的报告，其中儿茶酚胺水平可能因破伤风毒素而升高。正如最近所证明的那样，TTS 可能是一种危及生命的疾病：早期心导管检查是做出正确诊断的基础。