Editing Tetanus (section)

== Signs and symptoms ==

Tetanus often begins with mild [[spasm]]s in the [[Muscles of mastication|jaw muscles]]—also known as lockjaw. Similar spasms can also be a feature of [[trismus]].<ref name="OCF">{{cite web |title=Trismus – The Oral Cancer Foundation |date=19 September 2016 |url=https://oralcancerfoundation.org/complications/trismus/ |access-date=5 April 2022}}</ref> The spasms can also affect the [[facial muscles]], resulting in an appearance called ''[[risus sardonicus]]''. Chest, neck, back, abdominal muscles, and buttocks may be affected. [[Human back#Muscles|Back muscle]] spasms often cause arching, called [[opisthotonus]]. Sometimes, the spasms affect [[Muscles of respiration|muscles utilized during inhalation and exhalation]], which can lead to breathing problems.<ref name=CDC2020Pink>{{cite web | title=Tetanus - Epidemiology of Vaccine-Preventable Diseases | website=CDC | date=2020-05-10 | url=https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html | archive-url=https://web.archive.org/web/20200510154018/https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html | archive-date=2020-05-10 | url-status=live | access-date=2020-05-18|quote=Laryngospasm (spasm of the vocal cords) and/or spasm of the muscles of respiration leads to interference with breathing.}}</ref>

Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups, called [[tetany]]. These episodes can cause fractures and muscle tears. Other symptoms include [[fever]], [[headache]], restlessness, [[irritability]], feeding difficulties, [[respiratory failure|breathing problems]], [[dysuria|burning sensation during urination]], [[urinary retention]], and [[Fecal incontinence|loss of stool control]].<ref>{{Cite book| vauthors = Schleiss MR |title=Nelson Textbook of Pediatrics|editor=Kliegman, Robert |publisher=Elsevier |year=2020|isbn=978-0-323-52950-1 |pages=6253|chapter=Chapter 238: Tetanus}}</ref>

Even with treatment, about 10% of people who contract tetanus die.<ref name=CDC2012Pink/> The [[mortality rate]] is higher in unvaccinated individuals, and in people over 60 years of age.<ref name=CDC2012Pink/>

=== Incubation period ===
The [[incubation period]] of tetanus may be up to several months but is usually about ten days.<ref name="pmid12850356">{{cite journal | vauthors = Vandelaer J, Birmingham M, Gasse F, Kurian M, Shaw C, Garnier S | title = Tetanus in developing countries: an update on the Maternal and Neonatal Tetanus Elimination Initiative | journal = Vaccine | volume = 21 | issue = 24 | pages = 3442–5 | date = July 2003 | pmid = 12850356 | doi = 10.1016/S0264-410X(03)00347-5 }}</ref><ref name="pmid12122532">{{cite journal | vauthors = Brauner JS, Vieira SR, Bleck TP | title = Changes in severe accidental tetanus mortality in the ICU during two decades in Brazil | journal = Intensive Care Med | volume = 28 | issue = 7 | pages = 930–5 | date = July 2002 | pmid = 12122532 | doi = 10.1007/s00134-002-1332-4 | s2cid = 21772357 | doi-access = free }}</ref> In general, the farther the injury site is from the [[central nervous system]], the longer the incubation period. However, shorter incubation periods will have more severe symptoms.<ref name = Farrar>{{cite journal | vauthors = Farrar JJ, Yen LM, Cook T, Fairweather N, Binh N, Parry J, Parry CM | title = Tetanus | journal = J. Neurol. Neurosurg. Psychiatry | volume = 69 | issue = 3 | pages = 292–301 | date = September 2000 | pmid = 10945801 | pmc = 1737078 | doi = 10.1136/jnnp.69.3.292 }}</ref> In ''[[Neonatal tetanus|trismus nascentium]]'' (i.e. neonatal tetanus), symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, four different forms of tetanus have been described.<ref name=CDC2012Pink/>

=== Generalized tetanus ===
Generalized tetanus is the most common type of tetanus, representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is trismus or lockjaw, then facial spasms (called ''[[risus sardonicus]]),'' followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and [[Calf (anatomy)|calf]] muscles. Other symptoms include elevated temperature, sweating, elevated [[blood pressure]], and episodic rapid heart rate. [[Spasm]]s may occur frequently and last for several minutes, with the body shaped into a characteristic form called [[opisthotonos]]. Spasms continue for up to four weeks, and complete recovery may take months.<ref name=CDC2012Pink/>

=== Neonatal tetanus ===
{{main|Neonatal tetanus}}
Neonatal tetanus (''trismus nascentium'') is a form of generalized tetanus that occurs in newborns, usually those born to mothers who themselves have not been vaccinated. If the mother has been vaccinated against tetanus, the infants acquire [[passive immunity]], and are thus protected.<ref>{{cite web|url=http://www.wpro.who.int/immunization/factsheets/tetanus_nt/en/|title=Tetanus and neonatal tetanus (NT)|website=WHO Western Pacific Region|url-status=dead|archive-url=https://web.archive.org/web/20140503223407/http://www.wpro.who.int/immunization/factsheets/tetanus_nt/en/|archive-date=2014-05-03}}</ref> It usually occurs through infection of the unhealed [[Umbilical cord|umbilical stump]], particularly when the stump is cut with a non-sterile instrument. As of 1998, neonatal tetanus was common in many [[Developing country|developing countries]], and was responsible for about 14% (215,000) of all neonatal deaths.<ref name="WHO_2000">{{cite web | title=Maternal and Neonatal Tetanus Elimination by 2005 | date=November 2000 | publisher=UNICEF | url=http://www.unicef.org/immunization/files/MNTE_strategy_paper.pdf | access-date=2007-01-26 | url-status=live | archive-url=https://web.archive.org/web/20070111051802/http://www.unicef.org/immunization/files/MNTE_strategy_paper.pdf | archive-date=2007-01-11 }}</ref> In 2010, the worldwide death toll was approximately 58,000 newborns. As the result of a public health campaign, the death toll from neonatal tetanus was reduced by 90% between 1990 and 2010, and by 2013, the disease had been largely eliminated from all but 25 countries.<ref name="elimination">{{cite web|url=http://www.unicef.org/health/index_43509.html|title=Elimination of Maternal and Neonatal Tetanus|work=UNICEF|access-date=17 February 2014|url-status=live|archive-url=https://web.archive.org/web/20140221230401/http://www.unicef.org/health/index_43509.html|archive-date=21 February 2014}}</ref> Neonatal tetanus is rare in [[Developed country|developed countries]].

=== Local tetanus ===
Local tetanus is an uncommon form of the disease, in which people have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus.<ref name="CDC2012Pink" />

=== Cephalic tetanus ===
Cephalic tetanus is the rarest form of the disease (0.9–3% of cases),<ref name=doshi >{{cite journal | vauthors = Doshi A, Warrell C, Dahdaleh D, Kullmann D | title = Just a graze? Cephalic tetanus presenting as a stroke mimic | journal = Pract Neurol | volume = 14 | issue = 1 | pages = 39–41 | date = February 2014 | pmid = 24052566 | doi = 10.1136/practneurol-2013-000541 | s2cid = 32389452 }}</ref> and is limited to muscles and nerves in the head.<ref name=morales >{{cite journal | vauthors = Del Pilar Morales E, Bertrán Pasarell J, Cardona Rodriguez Z, Almodovar Mercado JC, Figueroa Navarro A | title = Cephalic tetanus following penetrating eye trauma: a case report | journal = Bol Asoc Med P R | volume = 106 | issue = 2 | pages = 25–9 | date = 2014 | pmid = 25065047 }}</ref> It usually occurs after trauma to the head area, including: [[skull fracture]],<ref name=adeleye >{{cite journal | vauthors = Adeleye AO, Azeez AL | title = Fatal tetanus complicating an untreated mild open head injury: a case-illustrated review of cephalic tetanus | journal = Surgical Infections | volume = 13 | issue = 5 | pages = 317–20 | date = October 2012 | pmid = 23039234 | doi = 10.1089/sur.2011.023 }}</ref> laceration,<ref name=adeleye /> eye injury,<ref name=morales /> [[dental extraction]],<ref name=ajayi >{{cite journal | vauthors = Ajayi E, Obimakinde O | title = Cephalic tetanus following tooth extraction in a woman from Nigeria. | journal = J Neurosci Rural Pract | volume = 2 | issue = 2 | pages = 201–2 | date = July 2011 | pmid = 21897694 | pmc = 3159367 | doi = 10.4103/0976-3147.83597 | doi-access = free }}</ref> and [[otitis media]],<ref name="pmid23468033">{{cite journal | vauthors = Ugwu GI, Okolugbo NE | title = Otogenic tetanus: case series | journal = West Afr J Med | volume = 31 | issue = 4 | pages = 277–9 | date = 2012 | pmid = 23468033 }}</ref> but it has been observed from injuries to other parts of the body.<ref name="pmid23346010">{{cite journal | vauthors = Kwon JC, Park Y, Han ZA, Song JE, Park HS | title = Trismus in cephalic tetanus from a foot injury | journal = Korean J. Intern. Med. | volume = 28 | issue = 1 | pages = 121 | date = January 2013 | pmid = 23346010 | pmc = 3543954 | doi = 10.3904/kjim.2013.28.1.121 }}</ref> Paralysis of the [[facial nerve]] is most frequently implicated, which may cause lockjaw, [[Bell's palsy|facial palsy]], or [[Ptosis (eyelid)|ptosis]], but other cranial nerves can also be affected.<ref name=ajayi /><ref name=seo >{{cite journal | vauthors = Seo DH, Cho DK, Kwon HC, Kim TU | title = A case of cephalic tetanus with unilateral ptosis and facial palsy | journal = Ann Rehabil Med | volume = 36 | issue = 1 | pages = 167–70 | date = February 2012 | pmid = 22506253 | pmc = 3309317 | doi = 10.5535/arm.2012.36.1.167 }}</ref> Cephalic tetanus may progress to a more generalized form of the disease.<ref name=doshi /><ref name=seo /> Due to its rarity, clinicians may be unfamiliar with the clinical presentation, and may not suspect tetanus as the illness.<ref name=morales /> Treatment can be complicated, as symptoms may be concurrent with the initial injury that caused the infection.<ref name=adeleye /> Cephalic tetanus is more likely than other forms of tetanus to be fatal, with the progression to generalized tetanus carrying a 15–30% case fatality rate.<ref name=doshi /><ref name=adeleye /><ref name=seo />