Clinical Manifestations Diagnosis and Pathology

There is no special characteristic or diagnostic pathology. Lysis of myofibrils and muscle bleeding are secondary to the muscle spasm. The usual incubation period ranges from 2 to 14 days after wounding. Cases of "dormant" tetanus have been reported after several months, probably because spores have remained in a closed wound as a silent abscess. The diagnosis is based entirely on the history and the clinical findings; there are no specific laboratory findings. The differential diagnosis includes strychnine poisoning and dystonic reactions to phenothia-zines and metoclopramide.

The clinical manifestations are usually classified into three forms:

1. Localized tetanus presents with spasm near the site of the injury, usually in an extremity. The fatality rate is 1 percent or less.

2. Generalized tetanus, the more common form, is marked by the classic trismus (lockjaw), fixed grin (risus sardonicus), and backward arching of the trunk (opisthotonos). Tonic seizures of the muscle groups occur in spasms, lead to rigidity, and are very painful. They may be precipitated by any stimulus. Pneumonia may follow respiratory muscle involvement or laryngeal spasm with as piration. Cardiovascular disturbances are common, especially vasoconstriction and a labile blood pressure. Severe spasms may cause vertebral fractures. The course of this form, in survivors, is from 1 to 2 weeks.

3. Cephalic tetanus, an uncommon form of the disease, follows facial wounds, involves the facial nerves, and may be followed by generalized tetanus.

4. Neonatal tetanus following infection of the umbilical cord (discussed in the next chapter) usually begins by the third to tenth day after birth, and then progresses to generalized tetanus.

Death from tetanus is usually due to respiratory failure with hypoxia or pneumonia, and occasionally to circulatory collapse, especially in patients over 60 years old.

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