The Gorgas Courses in Clinical Tropical Medicine

Selected Cases Seen by 2009 Course Participants

The Gorgas Course in Clinical Tropical Medicine has moved this week to Iquitos, on the banks of the Amazon River.  Iquitos, with a population of approximately 500,000, is the largest city in the world that is reachable only by air and by river.  The nearest road ends over 400 km away.

The following patient was seen by Gorgas Course participants in the Intensive Care Unit of the 200-bed Hospital de Iquitos.

History:  37 yo male admitted with a 4-day history of difficulty in opening the mouth and difficulty in swallowing, as well as stiffness and spasm in anterior and posterior neck muscles.  This progressed to painful episodic generalized muscle rigidity in the limbs and abdomen.  By the time of admission the patient was drooling and no longer able to control his salivary secretions.  He had suffered trauma to the right arm about 3 weeks prior to admission.  No relevant past medical history.  No suspicious dietary ingestions, no animal bites, and no exposure to anyone that was ill.

Epidemiology:  Lifelong resident of Iquitos.  He does not remember his vaccination history.

Physical Examination:  Afebrile, BP 127/90, pulse 88, respirations 24.  Diaphoretic [Image A].  Trismus exaggerated during periods of spasm [Image B], very limited mouth opening, contraction of paracervical and neck muscles [Image C], and paravertebral muscle spasm with arching of the back [Image D] were present as were generalized spasmodic muscle contractions.  Sensory examination normal.

Laboratory Examination:  No hematologic or biochemical abnormalities.

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