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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.
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.


==Physical Examination==
==Physical Examination==
Tetanus may initially present with stiffness of [[muscle]]s. [[Jaw]] muscles i.e the maseters are most commonly involved initially along with [[headaches]]. [[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 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
  | 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 41: Line 41:
}}</ref>
}}</ref>


===General Appearance===
*Severe muscular spasm (varying with respect to the type)
**[[Opisthotonos]]
**Leg [[extension]] with arm [[flexion]]
**[[Risus sardonicus]]
*May be in [[respiratory distress]]
===Vitals===
*[[Fever]]  
*[[Fever]]  
*Autonomic dysfunction
*[[Tachycardia]]
** Intervals of [[bradycardia]] and [[hypotension]] accompanied by of [[hypertension]] and [[tachycardia]] may be seen later in the disease.
*Elevated [[blood pressure]]
*Severe cases of tetanus may show:
 
**[[Opisthotonos]]
===Musculoskeletal===
**[[Extension]] of the [[legs]], [[flexion]] of the [[arms]]
**[[Spasms]] of the [[diaphragm]] and [[intercostals]]  
**[[Spasms]] of the [[diaphragm]] and [[intercostals]] leading to episodes of [[apnea]]
**Stiff [[abdominal wall]]  
**Rgid [[abdominal wall]]  
 
===Respiratory===
*[[Tachypnea]]
*[[Dyspnea]]
 
===Autonomic Dysfunction===
*Intervals of  
**[[Bradycardia]] and [[hypotension]] accompanied by of
**[[Tachycardia]] and [[hypertension]]  
 
 
 


The physical examination can reveal a few different forms of the infection. These include:
The physical examination may according to the type of tetanus. This includes:


*'''Local Tetanus'''
*'''Local Tetanus'''
**Uncommon
 
**Limited area of spasm
**Anatomic area is similar to the injured area
**Anatomic area is similar to the injured area
**Contraction of the [[muscles]] localized initially
**Contraction is usually [[painful]] and associated with [[swelling]]
**Contraction is usually [[painful]] and [[swelling]]
**A contaminated wound may be seen
**[[Contractions]] may last for weeks before subsiding gradually
**Generalized tetanus may follow localized tetanus
**Generalized tetanus may follow localized tetanus


*'''Cephalic Tetanus'''
*'''Cephalic Tetanus'''
Various features of cephalic tetanus include:<ref>{{Cite journal
Various features of cephalic tetanus include:<ref>{{Cite journal
  | author = [[L. Weinstein]]
  | author = [[L. Weinstein]]
Line 85: Line 105:
}}</ref>
}}</ref>
      
      
**Rare form that may follow [[ear infections]] or [[head]] injury
**[[Ear infection]] or [[head]] injury may be seen
**Trismus
**Trismus
**Stare in the air
**Patient may be staring in the air
**Involves [[cranial nerves]] of face, most commonly facial nerve
**Signs of [[facial nerve]] involvement
***Other nerves involved include CN III, IV, VI, and XII
***Tilting of the mouth
***Inability to close the eye
**May involve CN III, IV, VI, and XII
***Abnormal eye movements
**Dysphagia
**Dysphagia
**May be confused with stroke
**Confused patient with a stroke


*'''Generalized Tetanus'''
*'''Generalized Tetanus'''
The generalized tetanus may show:
The generalized tetanus may show:
**Descending spasm  
**Descending spasm  
**[[Trismus]] is the initial presentation
**[[Trismus]] initially
***Followed by stiffness of the neck
***Followed by stiffness of the neck
***Difficulty in [[swallowing]]
***Difficulty in [[swallowing]]
***Rigidity of [[abdominal muscles]]
***Stiffness of [[abdominal muscles]]
**Other symptoms include
**Other symptoms include
***Elevated temperature
***Elevated temperature
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***Episodic rapid [[heart rate]]
***Episodic rapid [[heart rate]]
**[[Spasms]] may occur frequently and last for several minutes
**[[Spasms]] may occur frequently and last for several minutes
**Spasms continue for 3-4 weeks
**Spasms may continue for 3-4 weeks
**Complete recovery may take months
**Complete recovery may take months


Revision as of 15:59, 8 June 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Michael Maddaleni, B.S.

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.

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:[1][2][3]

General Appearance

Vitals

Musculoskeletal

Respiratory

Autonomic Dysfunction



The physical examination may according to the type of tetanus. This includes:

  • Local Tetanus
    • Limited area of spasm
    • Anatomic area is similar to the injured area
    • Contraction is usually painful and associated with swelling
    • A contaminated wound may be seen
    • Generalized tetanus may follow localized tetanus
  • Cephalic Tetanus

Various features of cephalic tetanus include:[4][5]

    • Ear infection or head injury may be seen
    • Trismus
    • Patient may be staring in the air
    • Signs of facial nerve involvement
      • Tilting of the mouth
      • Inability to close the eye
    • May involve CN III, IV, VI, and XII
      • Abnormal eye movements
    • Dysphagia
    • Confused patient with a stroke
  • Generalized Tetanus

The generalized tetanus may show:

  • Neonatal Tetanus

Various features of neonatal tetanus include:[6]

    • Unhealed, unhygienic umbilical stump may be seen
    • Trismus (spasm of masseter muscle)
    • Risus sardonicus (spasm of facial muscles)
    • Clenched hands
    • Dorsiflexion of the feet
    • Opisthotonus (spasm of spinal muscles)
    • Very rare

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.
An infant suffering from neonatal tetanus.

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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