Tetanus differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Tetanus}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Tetanus]]
{{CMG}}
{{CMG}}
{{MJM}}; {{AE}} {{USAMA}}
{{MJM}}; {{AE}} {{USAMA}}
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==Overview==
==Overview==


Tetanus must be differentiated from [[strychnine poisoning]], [[dental infections]], [[drug reactions]], [[hypocalcemia]], [[meningitis]], [[stroke]] and [[stiff man syndrome]].<ref>{{Cite journal
Tetanus must be differentiated from other diseases that present with [[fever]] and [[rigidity]] such as [[strychnine poisoning]], [[dental infections]], [[drug reactions]], [[hypocalcemia]], [[meningitis]], [[stroke]], and [[stiff man syndrome]].<ref>{{Cite journal
  | author = [[Anisha Doshi]], [[Clare Warrell]], [[Dima Dahdaleh]] & [[Dimitri Kullmann]]
  | author = [[Anisha Doshi]], [[Clare Warrell]], [[Dima Dahdaleh]] & [[Dimitri Kullmann]]
  | title = Just a graze? Cephalic tetanus presenting as a stroke mimic
  | title = Just a graze? Cephalic tetanus presenting as a stroke mimic
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==Differentiating Tetanus from other Diseases==
==Differentiating Tetanus from other Diseases==
Some of the other diseases that need to be considered when trying to diagnose tetanus include:<ref>{{Cite journal
Tetanus must  be differentiated from other diseases that present with [[fever]] and [[Spasticity|rigidity]] such as::<ref>{{Cite journal
  | author = [[E. Andreadou]], [[E. Kattoulas]], [[C. Sfagos]] & [[D. Vassilopoulos]]
  | author = [[E. Andreadou]], [[E. Kattoulas]], [[C. Sfagos]] & [[D. Vassilopoulos]]
  | title = Stiff person syndrome: avoiding misdiagnosis
  | title = Stiff person syndrome: avoiding misdiagnosis
Line 53: Line 53:
  | pmid = 3734821
  | pmid = 3734821
}}</ref>
}}</ref>
*[[Dental abscess]]
*[[Drug]] reactions
*[[Hypocalcaemia]]
*[[Meningitis]]
*[[Stiff man syndrome]]
*[[Strychnine poisoning]]
*[[Parkinson's disease]]
===Differential for Unilateral Involuntary Face Movements===
The differential diagnosis for abnormal one sided movements of the face includes:<ref>{{Cite journal
| author = [[P. D. Thompson]], [[J. A. Obeso]], [[G. Delgado]], [[J. Gallego]] & [[C. D. Marsden]]
| title = Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 49
| issue = 6
| pages = 651–656
| year = 1986
| month = June
| pmid = 3734821
}}</ref><ref>{{Cite journal
| author = [[J. R. Berger]], [[W. A. Sheremata]] & [[E. Melamed]]
| title = Paroxysmal dystonia as the initial manifestation of multiple sclerosis
| journal = [[Archives of neurology]]
| volume = 41
| issue = 7
| pages = 747–750
| year = 1984
| month = July
| pmid = 6743065
}}</ref><ref>{{Cite journal
| author = [[W. B. Matthews]]
| title = Paroxysmal symptoms in multiple sclerosis
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 38
| issue = 6
| pages = 617–623
| year = 1975
| month = June
| pmid = 1151430
}}</ref><ref>{{Cite journal
| author = [[P. D. Thompson]] & [[W. M. Carroll]]
| title = Hemimasticatory spasm--a peripheral paroxysmal cranial neuropathy?
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 46
| issue = 3
| pages = 274–276
| year = 1983
| month = March
| pmid = 6842234
}}</ref><ref>{{Cite journal
| author = [[P. D. Thompson]] & [[W. M. Carroll]]
| title = Hemimasticatory and hemifacial spasm: a common pathophysiology?
| journal = [[Clinical and experimental neurology]]
| volume = 19
| pages = 110–119
| year = 1983
| month =
| pmid = 6568919
}}</ref><ref>{{Cite journal
| author = [[L. R. Jenkyn]], [[D. B. Walsh]], [[C. M. Culver]] & [[A. G. Reeves]]
| title = Clinical signs in diffuse cerebral dysfunction
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 40
| issue = 10
| pages = 956–966
| year = 1977
| month = October
| pmid = 591973
}}</ref><ref>{{Cite journal
| author = [[J. D. Rugh]] & [[W. K. Solberg]]
| title = Psychological implications in temporomandibular pain and dysfunction
| journal = [[Oral sciences reviews]]
| volume = 7
| pages = 3–30
| year = 1976
| month =
| pmid = 775369
}}</ref><ref name="pmid6145537">{{cite journal| author=Bond WS| title=Detection and management of the neuroleptic malignant syndrome. | journal=Clin Pharm | year= 1984 | volume= 3 | issue= 3 | pages= 302-7 | pmid=6145537 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6145537  }} </ref>
   
*Tetanus associated [[trismus]]
*[[Temporomandibular joint]] ([[TMJ]]) dysfunction
*[[Tetany]]
*Unilateral jaw [[dystonia]]
*Exclusive facial myokymia
*Exclusive hemifacial spasm
*[[Multiple sclerosis]] ([[MS]]) associated tonic [[spasms]]
*Focal motor [[epilepsy]]
*Hemimasticatory spasm in the presence or absence hemiatrophy of the face
{| style="border: 2px solid #DCDCDC; font-size: 90%; width: 83%;"
{| style="border: 2px solid #DCDCDC; font-size: 90%; width: 83%;"
|+ '''Differential Diagnosis of Tetanus'''
|+ '''Differential Diagnosis on the basis of Rigidity and Fever'''
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Disease
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Disease
! colspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Diagnosis
! colspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Diagnosis
Line 153: Line 63:
! align="center" style="background:#4479BA; color: #FFFFFF;" |Laboratory Findings
! align="center" style="background:#4479BA; color: #FFFFFF;" |Laboratory Findings
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Tetanus]]  
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Tetanus]]<ref name="pmid27538652">{{cite journal| author=Woldeamanuel YW, Andemeskel AT, Kyei K, Woldeamanuel MW, Woldeamanuel W| title=Case fatality of adult tetanus in Africa: Systematic review and meta-analysis. | journal=J Neurol Sci | year= 2016 | volume= 368 | issue=  | pages= 292-9 | pmid=27538652 | doi=10.1016/j.jns.2016.07.025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27538652  }} </ref><ref name="pmid26598719">{{cite journal| author=Thwaites CL, Loan HT| title=Eradication of tetanus. | journal=Br Med Bull | year= 2015 | volume= 116 | issue=  | pages= 69-77 | pmid=26598719 | doi=10.1093/bmb/ldv044 | pmc=4674006 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26598719  }} </ref>
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
*Tonic contraction of muscles between the spasmodic episodes
*Tonic contraction of muscles between the spasmodic episodes
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* Human TIG
* Human TIG
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Neuroleptic malignant syndrome|Neuroleptic Malignant Syndrome]]  
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Neuroleptic malignant syndrome|Neuroleptic Malignant Syndrome]] <ref name="pmid28533580">{{cite journal| author=Hosseini S, Elyasi F| title=Olanzapine-Induced Neuroleptic Malignant Syndrome. | journal=Iran J Med Sci | year= 2017 | volume= 42 | issue= 3 | pages= 306-309 | pmid=28533580 | doi= | pmc=5429500 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28533580  }} </ref><ref name="pmid28488314">{{cite journal| author=Leenhardt F, Perier D, Pinzani V, Giraud I, Villiet M, Castet-Nicolas A et al.| title=Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome. | journal=J Clin Pharm Ther | year= 2017 | volume=  | issue=  | pages=  | pmid=28488314 | doi=10.1111/jcpt.12531 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28488314  }} </ref>
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
*History of intake of offending drugs e.g [[neuroleptics]] like:
*History of intake of offending drugs e.g [[neuroleptics]] like:
**[[Fluphenazine]]  
**[[Fluphenazine]]  
**[[Haloperidol]]
**[[Haloperidol]]
**[[Olanzapine]]
**[[Risperidone]]
**[[Risperidone]]
*[[Autonomic instability]]
*[[Autonomic instability]]
Line 205: Line 116:
** [[Bromocriptine]]
** [[Bromocriptine]]
|-
|-
| style="background: #F5F5F5; padding: 5px;" | [[Meningitis|Viral Meningitis]]<ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618  }} </ref><ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096  }} </ref>
| style="background: #F5F5F5; padding: 5px;" | [[Meningitis|Viral Meningitis]]<ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618  }} </ref><ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096 }} </ref><ref name="pmid15319091">{{cite journal| author=Tyler KL| title=Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's. | journal=Herpes | year= 2004 | volume= 11 Suppl 2 | issue=  | pages= 57A-64A | pmid=15319091 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15319091 }} </ref>
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* [[Fever]]
* [[Fever]]
Line 235: Line 146:


| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
*CSF/plasma glucose ratio (>0.6)
*[[CSF]] / [[plasma glucose]] ratio (>0.6)
*Lactate (mmols/l) (<2.1)
*[[Lactate]] (mmols/l) (<2.1)
*Lymphocytes>granulocytes
*[[Lymphocytes]] > [[granulocytes]]
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Supportive
* Supportive
Line 243: Line 154:
** [[Acetaminophen]] for [[fever]].
** [[Acetaminophen]] for [[fever]].
* Anti-viral therapy:
* Anti-viral therapy:
** [[Acyclovir]] <sup>[[Viral meningitis medical therapy#cite note-pmid15319091-2|[2]]]</sup>
** [[Acyclovir]]
** [[Pleconaril]]
** [[Pleconaril]]
|-
|-
Line 277: Line 188:
* [[Prednisone]], [[plasmapheresis]], [[IVIG]] ( some success)
* [[Prednisone]], [[plasmapheresis]], [[IVIG]] ( some success)
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Drug]] induced
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Drug]] induced [[Tardive dyskinesia|(Tardive dyskinesia]])<ref name="pmid28552340">{{cite journal| author=Deng ZD, Li DY, Zhang CC, Pan YX, Zhang J, Jin H et al.| title=Long-term follow-up of bilateral subthalamic deep brain stimulation for refractory tardive dystonia. | journal=Parkinsonism Relat Disord | year= 2017 | volume=  | issue=  | pages=  | pmid=28552340 | doi=10.1016/j.parkreldis.2017.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28552340  }} </ref><ref name="pmid28520698">{{cite journal| author=| title=Valbenazine (Ingrezza) for tardive dyskinesia. | journal=Med Lett Drugs Ther | year= 2017 | volume= 59 | issue= 1521 | pages= 83-84 | pmid=28520698 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28520698  }} </ref><ref name="pmid28510661">{{cite journal| author=Voelker R| title=Tardive Dyskinesia Drug Approved. | journal=JAMA | year= 2017 | volume= 317 | issue= 19 | pages= 1942 | pmid=28510661 | doi=10.1001/jama.2017.5537 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28510661  }} </ref>
| style="background: #DCDCDC; padding: 5px;" |  
| style="background: #DCDCDC; padding: 5px;" |  
*History of intake of the offending drug for at least one month
**[[Neuroleptics]] ([[antipsychotics]])
**[[Metoclopramide]]
*Eye deviation
*Eye deviation
*Head and neck jerky movements
*Head and neck jerky movements
*No tonic contraction of the muscles between the spasms
*No tonic contraction of the muscles between the spasms
| style="background: #F5F5F5; padding: 5px; text-align: center;" |  
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* [[Dyskinesia]] of the tongue and lips
* [[Dyskinesia]] of the limbs
* [[Dyskinesia]] of the neck
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* It is a clinical diagnosis depending on
** [[Dyskinetic|Dyskinetic movements]]
** Hx of > 1 month of [[Antipsychotics|antipsychotic]] use
* Labs may be done to rule out other differentials
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Stop the offending agent
* [[Benztropine]]
* [[Benzodiazepines]]
* Injection of [[botulinum toxin]]
* Valbenzine
* [[Tetrabenazine]]
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Strychnine poisoning]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Strychnine poisoning]]<ref>{{Cite journal
| author = [[Charlotte Duverneuil]], [[Geoffroy Lorin de la Grandmaison]], [[Philippe de Mazancourt]] & [[Jean-Claude Alvarez]]
| title = Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report
| journal = [[Forensic science international]]
| volume = 141
| issue = 1
| pages = 17–21
| year = 2004
| month = April
| doi = 10.1016/j.forsciint.2003.12.010
| pmid = 15066709
}}</ref><ref>{{Cite journal
| author = [[B. A. Smith]]
| title = Strychnine poisoning
| journal = [[The Journal of emergency medicine]]
| volume = 8
| issue = 3
| pages = 321–325
| year = 1990
| month = May-June
| pmid = 2197324
}}</ref><ref>{{Cite journal
| author = [[B. J. Maron]], [[J. R. Krupp]] & [[B. Tune]]
| title = Strychnine poisoning successfully treated with diazepam
| journal = [[The Journal of pediatrics]]
| volume = 78
| issue = 4
| pages = 697–699
| year = 1971
| month = April
| pmid = 5547830
}}</ref><ref>{{Cite journal
| author = [[B. Oberpaur]], [[A. Donoso]], [[C. Claveria]], [[C. Valverde]] & [[M. Azocar]]
| title = Strychnine poisoning: an uncommon intoxication in children
| journal = [[Pediatric emergency care]]
| volume = 15
| issue = 4
| pages = 264–265
| year = 1999
| month = August
| pmid = 10460082
}}</ref>
   
| style="background: #DCDCDC; padding: 5px;" |  
| style="background: #DCDCDC; padding: 5px;" |  
*Proper tetanus immunizations
*Hx of up to date tetanus immunizations
*History of intentional or accidental intake
*History of intentional or accidental intake
| style="background: #F5F5F5; padding: 5px; text-align: center;" |  
**''Strychnos nux vomica seeds''
**Rodenticide
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Hypervigilance
* Anxiety
* Mydriasis
* Hypereflexia
* Clonus
* Facial and neck stiffness
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Blood assay
* Tissue assay
* Urine assay
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Initial stabilization
* High dose [[Benzodiazepines]]
* Intubation and airway securing
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Hypocalcaemia]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Hypocalcaemia]]<ref name="pmid27065735">{{cite journal| author=Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK| title=Hypocalcemic tetany: a simple bedside marker of poor outcome in acute pancreatitis. | journal=Ann Gastroenterol | year= 2016 | volume= 29 | issue= 2 | pages= 214-20 | pmid=27065735 | doi=10.20524/aog.2016.0015 | pmc=4805743 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27065735  }} </ref><ref name="pmid24171002">{{cite journal| author=Desai M, Kolla PK, Reddy PL| title=Calcium unresponsive hypocalcemic tetany: gitelman syndrome with hypocalcemia. | journal=Case Rep Med | year= 2013 | volume= 2013 | issue=  | pages= 197374 | pmid=24171002 | doi=10.1155/2013/197374 | pmc=3792521 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24171002  }} </ref>
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |  
*[[Muscle]] [[twitching]] and [[cramping]]
*Circumoral and extremity [[paresthesia]] or [[tingling]]
* [[Altered mental status]]
* [[Irritability]]
* [[Depression]]
* [[Psychosis]]
* [[Seizure]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
** [[Tetany (medical sign)|Tetany]] (carpopedal spasm)
** Latent tetany
*** [[Trousseau sign of latent tetany]] 
*** [[Chvostek's sign]] 
** Hyperactive tendon reflexes
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Decreased blood [[calcium]] levels
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Two [[Ampule|ampules]] of [[intravenous]] [[calcium gluconate]] 10% is given slowly in a period of 10 minutes, or
* If hypocalcemia is severe, [[calcium chloride]] is given instead
* Maintenance doses of both calcium and [[vitamin-D]]
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Dental abscess]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Dental abscess]]<ref name="pmid28317564">{{cite journal| author=Ogle OE| title=Odontogenic Infections. | journal=Dent Clin North Am | year= 2017 | volume= 61 | issue= 2 | pages= 235-252 | pmid=28317564 | doi=10.1016/j.cden.2016.11.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28317564  }} </ref><ref name="pmid27930461">{{cite journal| author=Bertossi D, Barone A, Iurlaro A, Marconcini S, De Santis D, Finotti M et al.| title=Odontogenic Orofacial Infections. | journal=J Craniofac Surg | year= 2017 | volume= 28 | issue= 1 | pages= 197-202 | pmid=27930461 | doi=10.1097/SCS.0000000000003250 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27930461  }} </ref>
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |  
* Tooth pain
* Painful eating and chewing
* [[Fever]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* Poor oral hygiene
* Presence of a dental infection
* Swollen gums
* No progression of spasm with time
* Cheek swelling
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Clinical diagnosis
* Labs may include
** Microscopic exam of stained smear
** Culture of oral swab
** Blood culture
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Improved dental hygiene
** Use of fluoridated water
** Brushing regularly
* [[Antibiotics]]
* Dental extraction in case of severity
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Parkinson's disease]]
| style="background: #F5F5F5; padding: 5px; text-align: center;" | [[Parkinson's disease]]<ref name="pmid11402154">{{cite journal| author=Olanow CW, Watts RL, Koller WC| title=An algorithm (decision tree) for the management of Parkinson's disease (2001): treatment guidelines. | journal=Neurology | year= 2001 | volume= 56 | issue= 11 Suppl 5 | pages= S1-S88 | pmid=11402154 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11402154  }} </ref><ref name="pmid24756517">{{cite journal| author=Connolly BS, Lang AE| title=Pharmacological treatment of Parkinson disease: a review. | journal=JAMA | year= 2014 | volume= 311 | issue= 16 | pages= 1670-83 | pmid=24756517 | doi=10.1001/jama.2014.3654 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24756517  }} </ref>
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px; text-align: center;" |  
* [[Stiffness]]
* Inability to write
* Jerky movements at rest
* [[Constipation]]
* Sleeping difficulty
* Walking difficulty
| style="background: #F5F5F5; padding: 5px; text-align: center;" |
* [[Tremor]]
* Rigidity
* [[Bradykinesia]]
* [[Postural instability]]
* Shuffling gait
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Clinical diagnosis
* Improvement with dopaminergic therapy confirms diagnosis
| style="background: #DCDCDC; padding: 5px;" |
| style="background: #DCDCDC; padding: 5px;" |
* Symptomatic therapy
* [[Dopamine agonists]]
* [[Levodopa]]
* [[Amantadine]]
* [[MAO inhibitors]]
* COMT inhibitors
* [[Anticholinergics]]
|}
|}
=== Differential for Unilateral Involuntary Face Movements ===
Tetanus must also be differentiated from the following diseases that cause abnormal one sided movements of the face:<ref>{{Cite journal
| author = [[P. D. Thompson]], [[J. A. Obeso]], [[G. Delgado]], [[J. Gallego]] & [[C. D. Marsden]]
| title = Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 49
| issue = 6
| pages = 651–656
| year = 1986
| month = June
| pmid = 3734821
}}</ref><ref>{{Cite journal
| author = [[J. R. Berger]], [[W. A. Sheremata]] & [[E. Melamed]]
| title = Paroxysmal dystonia as the initial manifestation of multiple sclerosis
| journal = [[Archives of neurology]]
| volume = 41
| issue = 7
| pages = 747–750
| year = 1984
| month = July
| pmid = 6743065
}}</ref><ref>{{Cite journal
| author = [[W. B. Matthews]]
| title = Paroxysmal symptoms in multiple sclerosis
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 38
| issue = 6
| pages = 617–623
| year = 1975
| month = June
| pmid = 1151430
}}</ref><ref>{{Cite journal
| author = [[P. D. Thompson]] & [[W. M. Carroll]]
| title = Hemimasticatory spasm--a peripheral paroxysmal cranial neuropathy?
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 46
| issue = 3
| pages = 274–276
| year = 1983
| month = March
| pmid = 6842234
}}</ref><ref>{{Cite journal
| author = [[P. D. Thompson]] & [[W. M. Carroll]]
| title = Hemimasticatory and hemifacial spasm: a common pathophysiology?
| journal = [[Clinical and experimental neurology]]
| volume = 19
| pages = 110–119
| year = 1983
| month =
| pmid = 6568919
}}</ref><ref>{{Cite journal
| author = [[L. R. Jenkyn]], [[D. B. Walsh]], [[C. M. Culver]] & [[A. G. Reeves]]
| title = Clinical signs in diffuse cerebral dysfunction
| journal = [[Journal of neurology, neurosurgery, and psychiatry]]
| volume = 40
| issue = 10
| pages = 956–966
| year = 1977
| month = October
| pmid = 591973
}}</ref><ref>{{Cite journal
| author = [[J. D. Rugh]] & [[W. K. Solberg]]
| title = Psychological implications in temporomandibular pain and dysfunction
| journal = [[Oral sciences reviews]]
| volume = 7
| pages = 3–30
| year = 1976
| month =
| pmid = 775369
}}</ref><ref name="pmid6145537">{{cite journal| author=Bond WS| title=Detection and management of the neuroleptic malignant syndrome. | journal=Clin Pharm | year= 1984 | volume= 3 | issue= 3 | pages= 302-7 | pmid=6145537 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6145537  }} </ref><ref>{{Cite journal
| author = [[S. Fahn]], [[S. B. Bressman]] & [[C. D. Marsden]]
| title = Classification of dystonia
| journal = [[Advances in neurology]]
| volume = 78
| pages = 1–10
| year = 1998
| month =
| pmid = 9750897
}}</ref><ref>{{Cite journal
| author = [[Howard L. Geyer]] & [[Susan B. Bressman]]
| title = The diagnosis of dystonia
| journal = [[The Lancet. Neurology]]
| volume = 5
| issue = 9
| pages = 780–790
| year = 2006
| month = September
| doi = 10.1016/S1474-4422(06)70547-6
| pmid = 16914406
}}</ref><ref>{{Cite journal
| author = [[Christine Klein]] & [[Laurie J. Ozelius]]
| title = Dystonia: clinical features, genetics, and treatment
| journal = [[Current opinion in neurology]]
| volume = 15
| issue = 4
| pages = 491–497
| year = 2002
| month = August
| pmid = 12151848
}}</ref>
   
*Tetanus associated [[trismus]]
*[[Temporomandibular joint]] ([[TMJ]]) dysfunction
*Unilateral jaw [[dystonia]]
*Isolated facial [[myokymia]]
*Isolated [[hemifacial spasm]]
*[[Multiple sclerosis]] ([[MS]]) associated tonic [[spasms]]
*Focal motor [[epilepsy]]


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


[[Category:Disease]]
[[Category:Disease]]
[[Category:Needs overview]]
[[Category:Needs overview]]
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Primary care]]
[[Category:Neurology]]
 
{{WH}}
{{WS}}

Latest revision as of 00:24, 30 July 2020

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 must be differentiated from other diseases that present with fever and rigidity such as strychnine poisoning, dental infections, drug reactions, hypocalcemia, meningitis, stroke, and stiff man syndrome.[1]

Differentiating Tetanus from other Diseases

Tetanus must be differentiated from other diseases that present with fever and rigidity such as::[2][3][4]

Differential Diagnosis on the basis of Rigidity and Fever
Disease Diagnosis Treatment
Symptoms Signs Laboratory Findings
Tetanus[5][6]
  • Not significant
Neuroleptic Malignant Syndrome [7][8]
Viral Meningitis[9][10][11]
Stiff man syndrome
  • Marked rigidity
  • Spasms
    • Intermittent
    • Painful
    • Absent during sleep
Drug induced (Tardive dyskinesia)[12][13][14]
  • History of intake of the offending drug for at least one month
  • Eye deviation
  • Head and neck jerky movements
  • No tonic contraction of the muscles between the spasms
Strychnine poisoning[15][16][17][18]
  • Hx of up to date tetanus immunizations
  • History of intentional or accidental intake
    • Strychnos nux vomica seeds
    • Rodenticide
  • Hypervigilance
  • Anxiety
  • Mydriasis
  • Hypereflexia
  • Clonus
  • Facial and neck stiffness
  • Blood assay
  • Tissue assay
  • Urine assay
  • Initial stabilization
  • High dose Benzodiazepines
  • Intubation and airway securing
Hypocalcaemia[19][20]
Dental abscess[21][22]
  • Tooth pain
  • Painful eating and chewing
  • Fever
  • Poor oral hygiene
  • Presence of a dental infection
  • Swollen gums
  • No progression of spasm with time
  • Cheek swelling
  • Clinical diagnosis
  • Labs may include
    • Microscopic exam of stained smear
    • Culture of oral swab
    • Blood culture
  • Improved dental hygiene
    • Use of fluoridated water
    • Brushing regularly
  • Antibiotics
  • Dental extraction in case of severity
Parkinson's disease[23][24]
  • Clinical diagnosis
  • Improvement with dopaminergic therapy confirms diagnosis

Differential for Unilateral Involuntary Face Movements

Tetanus must also be differentiated from the following diseases that cause abnormal one sided movements of the face:[25][26][27][28][29][30][31][32][33][34][35]

References

  1. ↑ 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)
  2. ↑ E. Andreadou, E. Kattoulas, C. Sfagos & D. Vassilopoulos (2007). "Stiff person syndrome: avoiding misdiagnosis". Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 28 (1): 35–37. doi:10.1007/s10072-007-0745-9. PMID 17385093. Unknown parameter |month= ignored (help)
  3. ↑ Lisa Mitchell, William Adams & Francois Aspesberro (2017). "Case 6: Episodic Stiffness in a 30-month-old Girl". Pediatrics in review. 38 (1): 52–53. doi:10.1542/pir.2014-0142. PMID 28044038. Unknown parameter |month= ignored (help)
  4. ↑ P. D. Thompson, J. A. Obeso, G. Delgado, J. Gallego & C. D. Marsden (1986). "Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm". Journal of neurology, neurosurgery, and psychiatry. 49 (6): 651–656. PMID 3734821. Unknown parameter |month= ignored (help)
  5. ↑ Woldeamanuel YW, Andemeskel AT, Kyei K, Woldeamanuel MW, Woldeamanuel W (2016). "Case fatality of adult tetanus in Africa: Systematic review and meta-analysis". J Neurol Sci. 368: 292–9. doi:10.1016/j.jns.2016.07.025. PMID 27538652.
  6. ↑ Thwaites CL, Loan HT (2015). "Eradication of tetanus". Br Med Bull. 116: 69–77. doi:10.1093/bmb/ldv044. PMC 4674006. PMID 26598719.
  7. ↑ Hosseini S, Elyasi F (2017). "Olanzapine-Induced Neuroleptic Malignant Syndrome". Iran J Med Sci. 42 (3): 306–309. PMC 5429500. PMID 28533580.
  8. ↑ Leenhardt F, Perier D, Pinzani V, Giraud I, Villiet M, Castet-Nicolas A; et al. (2017). "Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome". J Clin Pharm Ther. doi:10.1111/jcpt.12531. PMID 28488314.
  9. ↑ Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
  10. ↑ Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
  11. ↑ Tyler KL (2004). "Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's". Herpes. 11 Suppl 2: 57A–64A. PMID 15319091.
  12. ↑ Deng ZD, Li DY, Zhang CC, Pan YX, Zhang J, Jin H; et al. (2017). "Long-term follow-up of bilateral subthalamic deep brain stimulation for refractory tardive dystonia". Parkinsonism Relat Disord. doi:10.1016/j.parkreldis.2017.05.010. PMID 28552340.
  13. ↑ "Valbenazine (Ingrezza) for tardive dyskinesia". Med Lett Drugs Ther. 59 (1521): 83–84. 2017. PMID 28520698.
  14. ↑ Voelker R (2017). "Tardive Dyskinesia Drug Approved". JAMA. 317 (19): 1942. doi:10.1001/jama.2017.5537. PMID 28510661.
  15. ↑ Charlotte Duverneuil, Geoffroy Lorin de la Grandmaison, Philippe de Mazancourt & Jean-Claude Alvarez (2004). "Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report". Forensic science international. 141 (1): 17–21. doi:10.1016/j.forsciint.2003.12.010. PMID 15066709. Unknown parameter |month= ignored (help)
  16. ↑ B. A. Smith (1990). "Strychnine poisoning". The Journal of emergency medicine. 8 (3): 321–325. PMID 2197324. Unknown parameter |month= ignored (help)
  17. ↑ B. J. Maron, J. R. Krupp & B. Tune (1971). "Strychnine poisoning successfully treated with diazepam". The Journal of pediatrics. 78 (4): 697–699. PMID 5547830. Unknown parameter |month= ignored (help)
  18. ↑ B. Oberpaur, A. Donoso, C. Claveria, C. Valverde & M. Azocar (1999). "Strychnine poisoning: an uncommon intoxication in children". Pediatric emergency care. 15 (4): 264–265. PMID 10460082. Unknown parameter |month= ignored (help)
  19. ↑ Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK (2016). "Hypocalcemic tetany: a simple bedside marker of poor outcome in acute pancreatitis". Ann Gastroenterol. 29 (2): 214–20. doi:10.20524/aog.2016.0015. PMC 4805743. PMID 27065735.
  20. ↑ Desai M, Kolla PK, Reddy PL (2013). "Calcium unresponsive hypocalcemic tetany: gitelman syndrome with hypocalcemia". Case Rep Med. 2013: 197374. doi:10.1155/2013/197374. PMC 3792521. PMID 24171002.
  21. ↑ Ogle OE (2017). "Odontogenic Infections". Dent Clin North Am. 61 (2): 235–252. doi:10.1016/j.cden.2016.11.004. PMID 28317564.
  22. ↑ Bertossi D, Barone A, Iurlaro A, Marconcini S, De Santis D, Finotti M; et al. (2017). "Odontogenic Orofacial Infections". J Craniofac Surg. 28 (1): 197–202. doi:10.1097/SCS.0000000000003250. PMID 27930461.
  23. ↑ Olanow CW, Watts RL, Koller WC (2001). "An algorithm (decision tree) for the management of Parkinson's disease (2001): treatment guidelines". Neurology. 56 (11 Suppl 5): S1–S88. PMID 11402154.
  24. ↑ Connolly BS, Lang AE (2014). "Pharmacological treatment of Parkinson disease: a review". JAMA. 311 (16): 1670–83. doi:10.1001/jama.2014.3654. PMID 24756517.
  25. ↑ P. D. Thompson, J. A. Obeso, G. Delgado, J. Gallego & C. D. Marsden (1986). "Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm". Journal of neurology, neurosurgery, and psychiatry. 49 (6): 651–656. PMID 3734821. Unknown parameter |month= ignored (help)
  26. ↑ J. R. Berger, W. A. Sheremata & E. Melamed (1984). "Paroxysmal dystonia as the initial manifestation of multiple sclerosis". Archives of neurology. 41 (7): 747–750. PMID 6743065. Unknown parameter |month= ignored (help)
  27. ↑ W. B. Matthews (1975). "Paroxysmal symptoms in multiple sclerosis". Journal of neurology, neurosurgery, and psychiatry. 38 (6): 617–623. PMID 1151430. Unknown parameter |month= ignored (help)
  28. ↑ P. D. Thompson & W. M. Carroll (1983). "Hemimasticatory spasm--a peripheral paroxysmal cranial neuropathy?". Journal of neurology, neurosurgery, and psychiatry. 46 (3): 274–276. PMID 6842234. Unknown parameter |month= ignored (help)
  29. ↑ P. D. Thompson & W. M. Carroll (1983). "Hemimasticatory and hemifacial spasm: a common pathophysiology?". Clinical and experimental neurology. 19: 110–119. PMID 6568919.
  30. ↑ L. R. Jenkyn, D. B. Walsh, C. M. Culver & A. G. Reeves (1977). "Clinical signs in diffuse cerebral dysfunction". Journal of neurology, neurosurgery, and psychiatry. 40 (10): 956–966. PMID 591973. Unknown parameter |month= ignored (help)
  31. ↑ J. D. Rugh & W. K. Solberg (1976). "Psychological implications in temporomandibular pain and dysfunction". Oral sciences reviews. 7: 3–30. PMID 775369.
  32. ↑ Bond WS (1984). "Detection and management of the neuroleptic malignant syndrome". Clin Pharm. 3 (3): 302–7. PMID 6145537.
  33. ↑ S. Fahn, S. B. Bressman & C. D. Marsden (1998). "Classification of dystonia". Advances in neurology. 78: 1–10. PMID 9750897.
  34. ↑ Howard L. Geyer & Susan B. Bressman (2006). "The diagnosis of dystonia". The Lancet. Neurology. 5 (9): 780–790. doi:10.1016/S1474-4422(06)70547-6. PMID 16914406. Unknown parameter |month= ignored (help)
  35. ↑ Christine Klein & Laurie J. Ozelius (2002). "Dystonia: clinical features, genetics, and treatment". Current opinion in neurology. 15 (4): 491–497. PMID 12151848. Unknown parameter |month= ignored (help)

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