**4. Clinical features**

On the basis of clinical findings, four different forms of tetanus have been described.

*DOI: http://dx.doi.org/10.5772/intechopen.104876 ICU Management of Tetanus*


## **4.1 Generalised tetanus**

Generalized tetanus is the most common form of tetanus accounting for up to 80% of reported cases. It attacks muscles throughout the entire body. Generalized tetanus attacks and inhibits mostly the motor neurons of the CNS and later the neurons of the ANS as well thereby presenting with a descending pattern with uncontrollable muscle contraction affecting muscles of the face and jaw (trismus or locked jaw) being the first sign followed by stiffness of the neck, difficulty in swallowing, and rigidity of abdominal muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms may occur frequently and can last for several minutes. Spasms continue for 3–4 weeks. Complete recovery may take months.

## **4.2 Localised tetanus**

Localized tetanus is an uncommon form of the disease in which patients have persistent contraction of muscles in the same anatomic area as the injury. It is most commonly confined to the extremities. These contractions may persist for many weeks before gradually subsiding. Localized tetanus may precede the onset of generalized tetanus but is generally milder.

## **4.3 Cephalic tetanus**

Cephalic tetanus is rare, and results from head injuries or otitis media in which *C. tetani* is present in the flora of the middle ear or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area and patients may present with facial nerve palsies. The infection may become generalized.

## **4.4 Neonatal tetanus**

Neonatal tetanus is a form of generalized tetanus that occurs in newborn infants born without protective passive immunity because the mother is not immune. It results in high mortality in developing countries and is responsible for up to 50% of death due to tetanus. The infection usually arises from contamination of the umbilical cord during unsanitary delivery practices, absent maternal vaccination and unhygienic cultural practices such as the application of cow dung to the umbilical stump during the neonatal period. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days [4].

Generally, symptoms of tetanus can be summarized to include neck stiffness, sore throat, dysphagia and trismus. Muscle spasms are extremely painful and can cause tendon to rupture, joint dislocation and bone fractures. Spasm that extends to the facial muscles causes the typical facial expression known as *risus sardonicus*. Truncal spasm causes *opisthotonus*. Severe hypoventilation and life-threatening apnoea may occur during prolonged spasms. Hypertension and tachycardia occur mainly from

increased sympathetic tone. Autonomic storms are associated with raised catecholamine levels. These alternate with episodes of sudden hypotension, bradycardia and asystole. Other features of autonomic disturbance include salivation, sweating, increased bronchial secretions, hyperpyrexia, gastric stasis and ileus [5].
