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Key Features

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Essentials of Diagnosis
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  • Nonimmunized or partially immunized patient

  • History of skin wound

  • Spasms of jaw muscles (trismus)

  • Stiffness of neck, back, and abdominal muscles, with hyperirritability and hyperreflexia

  • Episodic, generalized muscle contractions

  • Diagnosis is based on clinical findings and the immunization history

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General Considerations
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  • Caused by Clostridium tetani

  • In unimmunized or incompletely immunized individuals, infection follows contamination of a wound by soil containing clostridial spores from animal manure

  • Two-thirds of cases in the United States follow minor puncture wounds of the hands or feet

  • In many cases, no history of a wound can be obtained

  • Injecting substances and drug abuse may be risk factors (in individuals who are not tetanus-immune)

  • In the newborn, usually in underdeveloped countries, infection generally results from contamination of the umbilical cord

  • Incubation period typically is 4–14 days but may be longer

  • In the United States, cases in young children are due to failure to immunize

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Clinical Findings

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Symptoms and Signs
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  • First symptom often is mild pain at the site of the wound, followed by hypertonicity and spasm of the regional muscles

  • Characteristically, difficulty in opening the mouth (trismus) is evident within 48 hours

  • In newborns, the first signs are irritability and inability to nurse

  • The infant may then develop stiffness of the jaw and neck, increasing dysphagia, and generalized hyperreflexia with rigidity and spasms of all muscles of the abdomen and back (opisthotonos)

  • Facial distortion resembles a grimace (risus sardonicus)

  • Difficulty in swallowing and convulsions triggered by minimal stimuli such as sound, light, or movement may occur

  • Individual spasms may last seconds or minutes; recurrent spasms are seen several times each hour, or they may be almost continuous

  • In most cases, the temperature is normal or only mildly elevated

  • A high or subnormal temperature is a bad prognostic sign

  • Patients are fully conscious and lucid

  • A profound circulatory disturbance associated with sympathetic overactivity (elevated blood pressure, tachycardia, arrhythmia) may occur on the second to fourth day, which may contribute to the mortality rate

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Differential Diagnosis
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  • Bacterial meningitis

  • Phenothiazine reactions

  • Decerebrate posturing

  • Narcotic withdrawal

  • Spondylitis

  • Hypocalcemic tetany

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Diagnosis

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  • Clinical

  • There may be a mild polymorphonuclear leukocytosis

  • CSF is normal with the exception of mild elevation of opening pressure

  • Serum muscle enzymes may be elevated

  • Anaerobic culture and microscopic examination of pus from the wound can be helpful, but C tetani is difficult to grow, and the drumstick-shaped gram-positive bacilli often cannot be found

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Treatment

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General Measures
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  • Treatment best accomplished in an intensive care unit

  • Patient is kept in a quiet room with minimal stimulation

  • Control of spasms and prevention of hypoxic episodes are crucial

  • Benzodiazepines can be used to help control spasms and provide some sedation

  • Mechanical ventilation and muscle ...

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