Severe tonic contraction of skeletal muscles was observed in three patients with renal failure. The myospastic state was painful and unrelenting, and it preceded death by a few hours to four months. In each instance there was a peculiar attitude of the lower extremities characterized by rigid extension of the legs, and plantar flexion and internal rotation of the feet (talipes equinovarus position). In one patient, myospasm was so intense that the rectus abdominus muscles were torn. Periumbilical, blue discoloration of the anterior abdomen resulted, simulating Cullen's sign. Myospasm was observed alone, with myoclonus, and with both myoclonus and convulsions. One patient with genuine tetanus had incidental, transient renal failure. Talipes equinovarus position of the feet was absent and the patient lived. Since there is no specific test for tetanus, differential diagnosis of myospastic states in azotemic subjects may be both difficult and uncertain.
Ewer RW, Bissonnette RP, Brakel FJ, Grimm WCH. Tetanic Neuromyopathy and Renal Failure: Diagnostic Implications. JAMA. 1965;192(13):1117–1120. doi:10.1001/jama.1965.03080260005001
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