Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ Key Features +++ Essentials of Diagnosis ++ 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 +++ General Considerations ++ 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 +++ Clinical Findings +++ Symptoms and Signs ++ 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 +++ Differential Diagnosis ++ Bacterial meningitis Phenothiazine reactions Decerebrate posturing Narcotic withdrawal Spondylitis Hypocalcemic tetany +++ Diagnosis ++ 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 +++ Treatment +++ General Measures ++ 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 ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth