Symptoms of tetanus

Tetanus has an incubation period of 1 to 31 days (1-2 weeks on average), i.e. tetanus symptoms in case of minor injuries (splinter, abrasion, etc.) appear after they have completely healed. It has been proven that the shorter the incubation period, the more severe the disease.

According to the severity of the disease, mild, moderate, severe and very severe forms are distinguished. According to the prevalence of the process, generalized and local tetanus are distinguished.

The onset of the disease depends on its severity. The more severe the disease, the faster the symptoms of tetanus develop. In some cases, prodromal symptoms are possible in the form of general malaise, a feeling of stiffness, difficulty swallowing, chills, irritability. In the area of the entrance gate, more often the limbs, dull pulling pains and fibrillary twitching of the muscles appear.

The first symptom of great diagnostic significance is trismus - tonic tension of the masticatory muscles, which at first makes it difficult to open the mouth, and then makes it impossible to open the teeth. At the very beginning of the disease, this symptom can be detected by a special technique: tapping on a spatula resting on the teeth of the lower jaw provokes contraction of the masticatory muscle. Then, the increase in muscle tone spreads to the facial muscles, facial features are distorted, wrinkles appear on the forehead and around the eyes, the mouth stretches, its corners drop or rise, giving the face a peculiar expression of both crying and an ironic smile (sardonic smile, risus sardonicus). Almost simultaneously, dysphagia appears - difficulty swallowing due to spasm of the swallowing muscles. Trismus, sardonic smile and dysphagia are symptoms of tetanus that do not occur in other diseases and allow tetanus to be diagnosed at the earliest possible stage.

Within two to four days, the muscle tone of the occipital, back, abdomen, proximal parts of the limbs, especially the lower ones, increases. Hypertonicity spreads in a descending manner. Rigidity of the occipital muscles appears, the patient's body takes bizarre poses, patients often lie on their backs, touching the bed only with the occipital and heels (opisthotonus), less often with a strongly developed abdominal press, the body bends forward (emprostotonus). Complete stiffness occurs, the ability to move is preserved only in the hands and feet, the muscles of which are not affected by the increased tone, which has differential diagnostic significance.

Tonic tension affects the intercostal muscles, diaphragm and glottis, resulting in a decrease in the minute volume of respiration, hypoxia and hypercapnia. The peculiarities of muscular system damage in tetanus are constant (without relaxation) hypertonicity of muscles, involvement = process of only large muscles of the limbs, severe muscle pain. At the height of the disease against this background, under the influence of any tactile, auditory stimuli (even insignificant in strength), general tetanic convulsions occur lasting from several seconds to 1 minute.

It should be emphasized that generalized tetanic seizures differ from clonic ones in that the muscles do not relax after the attack. The seizures are extremely painful, during the attack there is cyanosis, hypersalivation, tachycardia, increased sweating, increased arterial pressure. Urination and defecation are difficult due to spasm of the perineal muscles. During the attack, death may occur from asystole, asphyxia, aspiration of the contents of the oropharynx, muscle rupture, tendon rupture, bone fracture are possible.

In uncomplicated cases, body temperature is normal or subfebrile. In severe cases, hyperthermia is possible. As a result of impaired swallowing, starvation and dehydration occur, which is facilitated by increased sweating. hyperthermia and hypersalivation. From the cardiovascular system, tachycardia and increased blood pressure are noted. As the disease progresses, the muffled sounds of the heart increase, and arrhythmia occurs.

There are no specific changes in the internal organs. Consciousness remains clear throughout the disease. Patients are bothered by persistent insomnia. A mild form of tetanus is rare, mainly in individuals with partial immunity. The incubation period exceeds 20 days. Classic symptoms of tetanus are weakly expressed. Muscle tone increases gradually over 5-6 days, hypertonicity is moderate, patients retain the ability to drink and eat. Convulsions are either absent altogether or occur several times during the day. Body temperature is normal or subfebrile, tachycardia is rarely detected. Duration of the disease is up to 2 weeks.

In the moderate form, the incubation period is 15-20 days, the symptoms of tetanus increase more quickly - 3-4 days. The moderate form of the disease is characterized by muscle damage with typical symptoms, tachycardia and an increase in body temperature to 38-39 ° C. The frequency of convulsions does not exceed 1-2 times per hour, and their duration is no more than 15-30 s. Complications do not occur, and the duration of the acute period of the disease is up to 3 weeks.

The severe form is characterized by a shorter incubation period - 7-14 days, the symptoms of the disease increase rapidly (within 2 days), seizures are frequent, prolonged, body temperature up to 40 ° C. In a very severe form, the incubation period does not exceed 7 days. Within 24 hours from the onset of the disease, all symptoms reach full development. Seizures are accompanied by signs of asphyxia, body temperature rises to 40-42 ° C. With the development of convulsive syndrome, damage to the vasomotor center is observed (tachyarrhythmia, unstable blood pressure); as a rule, pneumonia joins. Such forms always require intensive care, the period of severe condition lasts at least 3 weeks. With a favorable course of tetanus, seizures become increasingly rare and by the 3-4th week of the disease they stop completely, but tonic muscle tension remains for about a week after their disappearance. Other symptoms of tetanus regress gradually. In the late convalescence period, signs of myocardial damage (tachycardia, arrhythmia, extrasystole, muffled heart sounds, moderate dilation of the heart borders) and asthenovegetative syndrome are detected, persisting for 1-3 months. In the absence of complications, complete recovery occurs.

Local tetanus is also distinguished, in which pain and tonic tension of muscles at the entrance gate initially appear, then local convulsions join in, new muscle groups are subsequently involved, and the process generalizes. A peculiar variant of local tetanus is paralytic tetanus of Rose, which occurs with wounds, head and face injuries. Against the background of trismus, sardonic smile, rigidity of the muscles of the back of the head, unilateral paresis of the facial, less often the abducens and oculomotor nerve appears. Spasm of the pharyngeal muscles resembles the clinical picture of rabies. The process often generalizes.

Brunner's cephalic (bulbar) tetanus is severe, affecting the upper parts of the spinal cord and the medulla oblongata. Death occurs as a result of paralysis of the heart or breathing.

Gynecological tetanus has an unfavorable course after an extra-hospital abortion or childbirth due to frequent bacterial complications and sepsis.

Severe forms of the disease also include neonatal tetanus, which accounts for the majority of cases in developing countries, since in the absence of post-vaccination immunity in mothers, newborns do not have passive immunity. Violation of aseptic and antiseptic rules when treating the umbilical wound can cause infection with spores of the pathogen. The incubation period is 3-8 days. Due to trismus, the child is restless, refuses to take the breast, pinches the nipple between the gums, and the act of sucking becomes impossible. Soon tetanic convulsions join in, which are accompanied by screaming, tremor of the lower lip, chin and tongue, involuntary urination and defecation. During the attack, cyanosis increases, blepharospasm appears. Rapid weight loss, respiratory distress, early pneumonia and high mortality are characteristic. Symptoms of tetanus develop within 24 hours.

The total duration of the disease with a favorable outcome does not exceed 2-4 weeks, however, after the 10th-15th day, tetanic convulsions occur less frequently and become shorter, and from the 17th-18th day they stop completely. Muscle hypertonia persists longer (up to 22-25 days), trismus disappears last. Tachycardia persists for 1.5-2 months. Various manifestations of autonomic dysfunction can be recorded for several months in those who have had tetanus. Relapses of the disease are rare. In severe cases, leukocytosis is detected due to thickening of the blood and an increase in hematocrit, metabolic acidosis (lactic acidosis), hypoxemia and hypercapnia.

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Complications of tetanus

Complications most often include secondary bacterial infections: pneumonia, pyelonephritis, sepsis, and possible pulmonary atelectasis. In case of extensive wounds, purulent complications in the form of abscesses and phlegmons in the area of the infection portal often occur against the background of tetanus. The force of muscle contraction during convulsions is so great that it can cause compression fractures of the vertebral bodies, muscle detachment from the attachment sites, and rupture of the muscles of the anterior abdominal wall and limbs. As a result of prolonged tonic muscle tension, muscle contractures develop, which requires special treatment.

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Mortality and causes of death

A fatal outcome may occur at the height of convulsions from asphyxia, which develops as a result of spasm of the laryngeal muscles and is combined with a decrease in pulmonary ventilation due to tension of the intercostal muscles and diaphragm. Most often, the cause of death is direct damage to the brainstem, accompanied by respiratory arrest or cessation of cardiac activity. A fatal outcome is also possible by the end of the month that has passed since the onset of the disease, with the development of multiple organ failure.