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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 specific signs like [[trismus]], that are 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==
Tetanus may initially present with [[muscle]] stiffness. The distribution may vary with the type of tetanus. Maseters are commonly involved initially with an  accompanying [[headache]]. [[Neck]] stiffness, difficulty [[swallowing]], [[spasms]] involving various muscles groups including the abdominal muscles and [[sweating]] may be seen later in the disease. Physical examination of tetanus may also lead to the following:<ref>{{Cite journal
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]].
 
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]]
  | author = [[Mohamed Amirali Gulamhussein]], [[Yueyang Li]] & [[Abhijit Guha]]
  | title = Localized Tetanus in an Adult Patient: Case Report
  | title = Localized Tetanus in an Adult Patient: Case Report
Line 40: Line 45:
  | pmid = 24052566
  | pmid = 24052566
}}</ref>
}}</ref>
===General Appearance===
===General Appearance===
*Severe muscular spasm (varying with respect to the type)
*Severe [[Muscle spasm|muscular spasm]] (location varies with the type)
**[[Opisthotonos]]
**[[Opisthotonos]]
**Leg [[extension]] with arm [[flexion]]  
**Leg [[extension]] with arm [[flexion]]  
Line 54: Line 58:


===Musculoskeletal===
===Musculoskeletal===
**[[Spasms]] of the [[diaphragm]] and [[intercostals]]  
*[[Spasms]] of the [[diaphragm]] and [[intercostals]]  
**Stiff [[abdominal wall]]  
*Stiff [[abdominal wall]]


===Respiratory===
===Respiratory===
Line 62: Line 66:


===Cardiovascular===
===Cardiovascular===
*S1 and S2 normal
*Normal [[Heart sounds|S1 and S2]]
*[[Hypertension]]
*[[Cardiac arrhythmia|Arrhythmia]]


===Autonomic Dysfunction===
===Autonomic===
*Intervals of  
*Intervals of  
**[[Bradycardia]] and [[hypotension]] accompanied by of   
**[[Bradycardia]] and [[hypotension]] accompanied by of   
**[[Tachycardia]] and [[hypertension]]  
**[[Tachycardia]] and [[hypertension]]  


===Abdominal===
*Stiffening of the [[Muscles of the abdominal wall|abdominal muscles]]




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


The physical examination may according to the type of tetanus. This includes:
'''Local Tetanus'''
 
*'''Local Tetanus'''


**Limited area of spasm
*Limited area of [[spasm]]
**Anatomic area is similar to the injured area
*The affected area is in close proximity to a contaminated wound
**Contraction is usually [[painful]] and associated with [[swelling]]
*Contraction is usually [[painful]] and associated with [[swelling]]
**A contaminated wound may be seen
*Generalized tetanus may follow localized tetanus
**Generalized tetanus may follow localized tetanus
'''Cephalic Tetanus'''<ref>{{Cite journal
 
*'''Cephalic Tetanus'''
 
Various features of cephalic tetanus include:<ref>{{Cite journal
  | author = [[L. Weinstein]]
  | author = [[L. Weinstein]]
  | title = Tetanus
  | title = Tetanus
Line 107: Line 110:
  | pmid = 24052566
  | pmid = 24052566
}}</ref>
}}</ref>
   
*[[Ear infection]] or [[head]] injury may be seen
**[[Ear infection]] or [[head]] injury may be seen
*[[Trismus]]
**Trismus
*Signs of [[Cranial nerves|CN III, IV, VI, VII and XII]] involvement including:
**Patient may be staring in the air
**Tilting of the mouth
**Signs of [[facial nerve]] involvement
**Inability to close the eye  
***Tilting of the mouth
**Inability to move the tongue
***Inability to close the eye  
**[[Diplopia]]
**May involve CN III, IV, VI, and XII
*Abnormal eye movements  
***Abnormal eye movements
**[[Dysphagia]]
**Dysphagia
*[[Confusion]]
**Confused patient with a stroke
*Symptoms of [[Ischemic stroke history and symptoms|stroke]]
 
'''Generalized Tetanus'''
*'''Generalized Tetanus'''
*Descending [[spasm]]
 
*[[Trismus]] may present initially
The generalized tetanus may show:
**Followed by [[Neck stiffness|stiffness of the neck]]
**Descending spasm  
**Difficulty in [[swallowing]]
**[[Trismus]] initially
**Stiffness of [[abdominal muscles]]
***Followed by stiffness of the neck
*Other symptoms include
***Difficulty in [[swallowing]]
**Elevated temperature
***Stiffness of [[abdominal muscles]]
**[[Sweating]]
**Other symptoms include
**Elevated [[blood pressure]]
***Elevated temperature
**Episodic rapid [[heart rate]]
***[[Sweating]]
*[[Spasms]] may occur frequently and last for several minutes
***Elevated [[blood pressure]]
*[[Spasms]] may continue for 3-4 weeks
***Episodic rapid [[heart rate]]
*Complete recovery may take months
**[[Spasms]] may occur frequently and last for several minutes
'''Neonatal Tetanus'''<ref>{{Cite journal
**Spasms may continue for 3-4 weeks
**Complete recovery may take months
 
*'''Neonatal Tetanus'''
Various features of neonatal tetanus include:<ref>{{Cite journal
  | author = [[Martha H. Roper]], [[Jos H. Vandelaer]] & [[Francois L. Gasse]]
  | author = [[Martha H. Roper]], [[Jos H. Vandelaer]] & [[Francois L. Gasse]]
  | title = Maternal and neonatal tetanus
  | title = Maternal and neonatal tetanus
Line 149: Line 147:
  | pmid = 17854885
  | pmid = 17854885
}}</ref>
}}</ref>
**Unhealed, unhygienic [[umbilical]] stump may be seen
*Unhealed, unhygienic [[umbilical]] stump
**Trismus (spasm of masseter muscle)
*[[Trismus]] (spasm of [[masseter muscle]])
**Risus sardonicus (spasm of facial muscles)
*[[Risus sardonicus]] (spasm of facial muscles)
**Clenched hands
*Clenched hands
**Dorsiflexion of the feet
*[[Dorsiflexion]] of the feet
**Opisthotonus (spasm of spinal muscles)
*[[Opisthotonus]] (spasm of spinal muscles)
**Very rare


===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}}
{{WH}}
{{WS}}


[[Category:Disease]]
[[Category:Disease]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Primary care]]
[[Category:Neurology]]
 
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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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