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{{Tetanus}}
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==Overview==
==Overview==
The diagnosis of Tetanus is completed through a physical examination. Tetanus infection produces some very clear symptoms that will be used for a clinical diagnosis.
Tetanus initially presents with [[muscle]] stiffness. The distribution may vary with the type of tetanus. [[Masseter muscle|The masseter muscles]] are commonly involved with an  accompanying [[headache]]. [[Neck]] stiffness, difficulty [[swallowing]], generalized muscle [[spasms]] including the abdominal and back muscles and [[sweating]] may be seen later in the disease. In severe cases, respiratory paralysis may develop, which presents with [[apnea]], [[Hypoxemia|hypoxia]] and [[hypercapnia]].


==Physical Examination==
==Physical Examination==
Some of the first [[signs]] a patient may present with are [[muscle]] stiffness, especially in the [[jaw]], and [[headaches]]. From there, the patient may complain of symptoms such as [[neck]] stiffness, [[sweating]], [[spasms]], trouble [[swallowing]], and the [[abdominal]] muscles becoming rigid. The following may also result:
Tetanus initially presents with [[muscle]] stiffness. The distribution may vary with the type of tetanus. [[Masseter muscle|The masseter muscles]] are commonly involved with an  accompanying [[headache]]. [[Neck]] stiffness, difficulty [[swallowing]], generalized muscle [[spasms]] including the abdominal and back muscles and [[sweating]] may be seen later in the disease. In severe cases, respiratory paralysis may develop, which presents with [[apnea]], [[Hypoxemia|hypoxia]] and [[hypercapnia]].  


*Many times the patients will be [[afebrile]]
Tetanus must be suspected in patients with:
*An injury involving contact of broken skin with contaminated environment, soil or dust.
*An absent or inconsistent history of [[Immunization|immunizations]].
Physical examination of a patient with tetanus may reveal the following:<ref>{{Cite journal
| author = [[Mohamed Amirali Gulamhussein]], [[Yueyang Li]] & [[Abhijit Guha]]
| title = Localized Tetanus in an Adult Patient: Case Report
| journal = [[Journal of orthopaedic case reports]]
| volume = 6
| issue = 4
| pages = 100–102
| year = 2016
| month = September-October
| doi = 10.13107/jocr.2250-0685.592
| pmid = 28164065
}}</ref><ref>{{Cite journal
| author = [[Yuki Kotani]], [[Kenji Kubo]], [[Satoko Otsu]] & [[Toshihide Tsujimoto]]
| title = Cephalic tetanus as a differential diagnosis of facial nerve palsy
| journal = [[BMJ case reports]]
| volume = 2017
| year = 2017
| month = January
| doi = 10.1136/bcr-2016-216440
| pmid = 28108438
}}</ref><ref>{{Cite journal
| author = [[Anisha Doshi]], [[Clare Warrell]], [[Dima Dahdaleh]] & [[Dimitri Kullmann]]
| title = Just a graze? Cephalic tetanus presenting as a stroke mimic
| journal = [[Practical neurology]]
| volume = 14
| issue = 1
| pages = 39–41
| year = 2014
| month = February
| doi = 10.1136/practneurol-2013-000541
| pmid = 24052566
}}</ref>
===General Appearance===
*Severe [[Muscle spasm|muscular spasm]] (location varies with the type)
**[[Opisthotonos]]
**Leg [[extension]] with arm [[flexion]]
**[[Risus sardonicus]]
*May be in [[respiratory distress]]
 
===Vitals===
*[[Fever]]
*[[Tachycardia]]
*Elevated [[blood pressure]]
 
===Musculoskeletal===
*[[Spasms]] of the [[diaphragm]] and [[intercostals]]
*Stiff [[abdominal wall]]
 
===Respiratory===
*[[Tachypnea]]
*[[Dyspnea]]


*Late stage [[disease]] will show complications of autonomic dysfunction. An example of this would be periods of [[hypotension]] and [[bradycardia]] alternating with periods of [[tachycardia]] and [[hypertension]].
===Cardiovascular===
*Normal [[Heart sounds|S1 and S2]]  
*[[Hypertension]]
*[[Cardiac arrhythmia|Arrhythmia]]


*Patients with severe tetanus can present with:
===Autonomic===
**[[Opisthotonos]]
*Intervals of
**[[Extension]] of the [[legs]], [[flexion]] of the [[arms]]
**[[Bradycardia]] and [[hypotension]] accompanied by of
**[[Spasms]] of the [[intercostal muscles]] and [[diaphragm]] will cause periods of [[apnea]]
**[[Tachycardia]] and [[hypertension]]  
**A rigid [[abdominal wall]] will most likely be present as well


The physical examination can reveal a few different forms of the infection. These include:
===Abdominal===
*Stiffening of the [[Muscles of the abdominal wall|abdominal muscles]]


*'''Local Tetanus'''
**Uncommon form of the [[disease]]
**In the same anatomic area of the [[injury]], there will be persistent contraction of the [[muscles]]
**[[Contractions]] may last for weeks before subsiding gradually
**It may precede generalized tetanus, but it is usually milder
**Approximately 1% of the cases are [[fatal]].


*'''[[Cephalic]] Tetanus'''
The physical examination may vary according to the type of tetanus. Specific findings associated with the various types of tetanus may include:
**Rare form
**May occur with [[ear infections]]
**May occur following [[head]] injury
**There is involvement of [[cranial nerves]], especially the ones in the facial area


*'''Generalized Tetanus'''
'''Local Tetanus'''
**Approximately 80% of reported cases.
**Presents with a descending pattern
**First sign is [[trsimus]]
***Followed by stiffness of the neck
***Difficulty in [[swallowing]]
***Rigidity of [[abdominal muscles]]
**Other symptoms include
***Elevated temperature
***[[Sweating]]
***Elevated [[blood pressure]]
***Episodic rapid [[heart rate]]
**[[Spasms]] may occur frequently and last for several minutes
**Spasms continue for 3-4 weeks
**Complete recovery may take months


*'''[[Neonatal]] Tetanus'''
*Limited area of [[spasm]]
**Occurs in infants without protective [[passive immunity]] because the mother is not [[immune]]
*The affected area is in close proximity to a contaminated wound
**Usually occurs through [[infection]] of the unhealed [[umbilical]] stump
*Contraction is usually [[painful]] and associated with [[swelling]]
***This especially occurs when the stump is not cut with a sterile instrument
*Generalized tetanus may follow localized tetanus
**More common in developing countries (estimated to be around 257,000 annual deaths worldwide in 2000-2003)
'''Cephalic Tetanus'''<ref>{{Cite journal
**Very rare in the USA
| author = [[L. Weinstein]]
| title = Tetanus
| journal = [[The New England journal of medicine]]
| volume = 289
| issue = 24
| pages = 1293–1296
| year = 1973
| month = December
| doi = 10.1056/NEJM197312132892408
| pmid = 4270702
}}</ref><ref>{{Cite journal
| author = [[Anisha Doshi]], [[Clare Warrell]], [[Dima Dahdaleh]] & [[Dimitri Kullmann]]
| title = Just a graze? Cephalic tetanus presenting as a stroke mimic
| journal = [[Practical neurology]]
| volume = 14
| issue = 1
| pages = 39–41
| year = 2014
| month = February
| doi = 10.1136/practneurol-2013-000541
| pmid = 24052566
}}</ref>
*[[Ear infection]] or [[head]] injury may be seen
*[[Trismus]]
*Signs of [[Cranial nerves|CN III, IV, VI, VII and XII]] involvement including:
**Tilting of the mouth
**Inability to close the eye
**Inability to move the tongue
**[[Diplopia]]
*Abnormal eye movements
**[[Dysphagia]]
*[[Confusion]]
*Symptoms of [[Ischemic stroke history and symptoms|stroke]]
'''Generalized Tetanus'''
*Descending [[spasm]]
*[[Trismus]] may present initially
**Followed by [[Neck stiffness|stiffness of the neck]]
**Difficulty in [[swallowing]]
**Stiffness of [[abdominal muscles]]
*Other symptoms include
**Elevated temperature
**[[Sweating]]
**Elevated [[blood pressure]]
**Episodic rapid [[heart rate]]
*[[Spasms]] may occur frequently and last for several minutes
*[[Spasms]] may continue for 3-4 weeks
*Complete recovery may take months
'''Neonatal Tetanus'''<ref>{{Cite journal
| author = [[Martha H. Roper]], [[Jos H. Vandelaer]] & [[Francois L. Gasse]]
| title = Maternal and neonatal tetanus
| journal = [[Lancet (London, England)]]
| volume = 370
| issue = 9603
| pages = 1947–1959
| year = 2007
| month = December
| doi = 10.1016/S0140-6736(07)61261-6
| pmid = 17854885
}}</ref>
*Unhealed, unhygienic [[umbilical]] stump
*[[Trismus]] (spasm of [[masseter muscle]])
*[[Risus sardonicus]] (spasm of facial muscles)
*Clenched hands
*[[Dorsiflexion]] of the feet
*[[Opisthotonus]] (spasm of spinal muscles)


===The Spatula Test===
===The Spatula Test===
The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a gag reflex attempting to expel the foreign object.
The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a [[gag reflex]] attempting to expel the foreign object.


[[Image:Lock-jaw 2857.jpg|thumb|center|150px|Lock-jaw in a patient suffering from tetanus.]]
[[Image:Lock-jaw 2857.jpg|thumb|left|150px|Lock-jaw in a patient suffering from tetanus.- '''[https://commons.wikimedia.org/wiki/File:Lock-jaw_2857.jpg Source:Wikimedia Commons]''']]
[[Image:Neonatal tetanus 6374 lores.jpg|center|thumb|200px|An infant suffering from neonatal tetanus.]]
[[Image:Neonatal tetanus 6374 lores.jpg|left|thumb|200px|An infant suffering from neonatal tetanus.- '''[https://commons.wikimedia.org/wiki/File:Neonatal_tetanus_6374.jpg Source:Wikimedia Commons]''']]


<br style="clear:left" />
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
 
[[Category:Neurology]]
{{WH}}
{{WS}}

Latest revision as of 00:25, 30 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Michael Maddaleni, B.S.; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Tetanus initially presents with muscle stiffness. The distribution may vary with the type of tetanus. The masseter muscles are commonly involved with an accompanying headache. Neck stiffness, difficulty swallowing, generalized muscle spasms including the abdominal and back muscles and sweating may be seen later in the disease. In severe cases, respiratory paralysis may develop, which presents with apnea, hypoxia and hypercapnia.

Physical Examination

Tetanus initially presents with muscle stiffness. The distribution may vary with the type of tetanus. The masseter muscles are commonly involved with an accompanying headache. Neck stiffness, difficulty swallowing, generalized muscle spasms including the abdominal and back muscles and sweating may be seen later in the disease. In severe cases, respiratory paralysis may develop, which presents with apnea, hypoxia and hypercapnia.

Tetanus must be suspected in patients with:

  • An injury involving contact of broken skin with contaminated environment, soil or dust.
  • An absent or inconsistent history of immunizations.

Physical examination of a patient with tetanus may reveal the following:[1][2][3]

General Appearance

Vitals

Musculoskeletal

Respiratory

Cardiovascular

Autonomic

Abdominal


The physical examination may vary according to the type of tetanus. Specific findings associated with the various types of tetanus may include:

Local Tetanus

  • Limited area of spasm
  • The affected area is in close proximity to a contaminated wound
  • Contraction is usually painful and associated with swelling
  • Generalized tetanus may follow localized tetanus

Cephalic Tetanus[4][5]

Generalized Tetanus

Neonatal Tetanus[6]

The Spatula Test

The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a gag reflex attempting to expel the foreign object.

Lock-jaw in a patient suffering from tetanus.- Source:Wikimedia Commons
An infant suffering from neonatal tetanus.- Source:Wikimedia Commons


References

  1. ↑ Mohamed Amirali Gulamhussein, Yueyang Li & Abhijit Guha (2016). "Localized Tetanus in an Adult Patient: Case Report". Journal of orthopaedic case reports. 6 (4): 100–102. doi:10.13107/jocr.2250-0685.592. PMID 28164065. Unknown parameter |month= ignored (help)
  2. ↑ Yuki Kotani, Kenji Kubo, Satoko Otsu & Toshihide Tsujimoto (2017). "Cephalic tetanus as a differential diagnosis of facial nerve palsy". BMJ case reports. 2017. doi:10.1136/bcr-2016-216440. PMID 28108438. Unknown parameter |month= ignored (help)
  3. ↑ Anisha Doshi, Clare Warrell, Dima Dahdaleh & Dimitri Kullmann (2014). "Just a graze? Cephalic tetanus presenting as a stroke mimic". Practical neurology. 14 (1): 39–41. doi:10.1136/practneurol-2013-000541. PMID 24052566. Unknown parameter |month= ignored (help)
  4. ↑ L. Weinstein (1973). "Tetanus". The New England journal of medicine. 289 (24): 1293–1296. doi:10.1056/NEJM197312132892408. PMID 4270702. Unknown parameter |month= ignored (help)
  5. ↑ Anisha Doshi, Clare Warrell, Dima Dahdaleh & Dimitri Kullmann (2014). "Just a graze? Cephalic tetanus presenting as a stroke mimic". Practical neurology. 14 (1): 39–41. doi:10.1136/practneurol-2013-000541. PMID 24052566. Unknown parameter |month= ignored (help)
  6. ↑ Martha H. Roper, Jos H. Vandelaer & Francois L. Gasse (2007). "Maternal and neonatal tetanus". Lancet (London, England). 370 (9603): 1947–1959. doi:10.1016/S0140-6736(07)61261-6. PMID 17854885. Unknown parameter |month= ignored (help)

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