What are the symptoms of tetanus?
The incubation period for tetanus is an average of 6-14 days, with fluctuations from 1 hour to a month, rarely and more. The shorter the incubation period, the more difficult the process develops. The severity of the disease is determined by the severity of the convulsive syndrome, the frequency and speed of the appearance of seizures from the onset of the disease, their duration, the temperature reaction of the body, the state of the cardiovascular system, respiration, the presence and severity of complications.
Tetanus usually begins acutely, less often (up to a day), which is accompanied by a general malaise, traumatic pains in the wound or already formed scar, fibrillar twitchings of surrounding muscles, an increased reaction of the patient to external stimuli, especially sound and light, even slight touches to the wound or the surrounding muscles lead to a sharp increase in their tone and increased pain. Subsequently, this process extends to all muscles innervated by the affected nerve. Muscle pains are very strong due to their constant tonic tension and become literally unbearable under tetanic contractions - and this is the most characteristic sign of tetanus lesion.
Clinical manifestations are quite typical, but tetanus is rare and doctors, although they remember it, often do not assume that they met with him, and in most cases believe that there is an atypical form of some common disease.
Most often, in practice, there is a descending (generalized) tetanus of the medium-severe course (68%). The prodromal period is short (6-8 days). It is accompanied by an increase in body temperature to 38-39 degrees, abundant, often pouring sweat. Pain in the throat, neck, face. The first thought of the doctor - is it sore throat? For differential diagnosis, it is sufficient to examine the pharynx. But if you carefully look at the patient's face, it clearly shows up with a pathognomonic symptom. Trism caused by tonic contraction of the chewing muscles, as a result of which the patient can not open his mouth.
Sardonic (mocking, snide) smile, caused by convulsions of facial muscles (forehead in wrinkles, eye cracks narrowed, lips stretched and corners of mouth lowered downwards). Dysphagia due to spasm of muscles involved in the swallowing act. By the second day, cramps of the occipital and long muscles of the back join, as a result of which the head throws back, the back bends in the lumbar region so that you can bring your arm under the waist. By the end of the second day, muscles of the limbs are involved in the process. At the same time, tonic convulsions also join tonic convulsions. They can develop on their own from a few within a day to hourly and are accompanied by sharp spasms of the musculature. This develops a typical picture of opisthotonus. The patient arches at the expense of a sharp contraction of the muscles, arching the back of the head, heels and elbows. Unlike hysteria and catalepsy, muscular spasm increases with sound (enough to clap hands) or light (turn on the light) irritation. In addition, in tetanus, only large muscles are involved in the process, the brushes and feet retain mobility, which is never the case with hysteria and catalepsy, on the contrary, the hands are clenched into a fist, the feet are stretched out. With a tetanic contraction of the face and neck, the tongue moves forward and the patient bites it, as a rule, bites, which does not happen with epilepsy, meningitis and craniocerebral trauma, which is characterized by tongue twisting. From the 3rd-4th day a convulsive syndrome in the muscles of the abdomen, chest, joins, which acquire a "rocky" consistency. In the last place, the muscles of the diaphragm are involved in the process. The patient is constantly conscious, screaming for pain. Due to spasm of the pelvic floor muscles, urination and defecation are impaired.
Characteristic changes in internal organs. The first week is characterized by tachycardia, hypertension, loud heart sounds. Breathing is superficial, frequent, stagnant changes in the lungs due to cough suppressed. From the 7th to the 8th day signs of decompensation are formed: deafness of cardiac tones, hypotension, arrhythmias; in the lungs inflammatory and severe stagnant changes are formed. Increases respiratory and heart failure, acidosis and hypoxia, which can lead to paralysis of the heart or respiration. Complications, of course, develop, but with a moderate form do not have a fatal character.
In severe form, the prodromal period is 24-48 hours, after which the entire above-described symptom complex develops rapidly. Aetanic convulsions are pronounced, their duration increases to 1-5 minutes, hourly, and even 3-5 times per hour occur. Complications from the lungs and heart develop quickly and heavier than with the medium-heavy form. Lethality increases due to asphyxia, the development of atelectasis, paralysis of the heart and respiration.
With a very severe form of the prodromal period from a few hours to a day, sometimes tetanus develops lightning fast, without a prodrome. Cardiac and pulmonary insufficiency develops within a day. Aetanic cramps are almost constant, very powerful, which often leads to the development of fractures of bones and muscle ruptures. The lethality is almost 100%.
The clinic of the ascending form of tetanus differs by the initial lesion of the peripheral muscles of the limbs with a gradual extension of the zone of excitability and convulsions until it reaches the roots of the spinal cord and motor centers. Then the clinic of a typical descending form is formed. It should be noted that the prodromal period is more prolonged, up to 2-4 weeks, it proceeds more favorably, the convulsive syndrome is not so pronounced, they are rare, short-lived, there is almost no opisthotonus and lesion of the respiratory musculature.
Light (local) tetanus is rare, the prodromal period is long, the wound has time to heal. But suddenly there are convulsive twitchings (fibrillation) in the area of the former wound, and then also tonic convulsions with raspiruyuschimi pains, tetanic seizures are not noted. The process captures: usually one segment of the limb. Symptoms resemble myositis, but unlike it, tetanus and cramps intensify with tetanus when exposed to external stimuli (light, sound) without touching the site of the lesion, which does not happen with myositis. In neurological practice, facial paralytic tetanus of Rosa may occur. Along with trismus on the affected side develops paralysis of the muscles of the face, and sometimes the eyeball, and on the opposite side muscle tension of the face and narrowing of the eye gap. In fact, a one-sided sardonic smile is formed. It somewhat resembles the manifestation of the neuritis of the facial nerve, but it is not characterized by trismus and muscle tension on the opposite side.
Recovery and reverse development of the process occurs slowly, often within 2-4 weeks. From the 10th to the 14th day, tetanic convulsions are weakened by the frequency of occurrence and intensity, and by the 17-18th day they cease completely. From this moment the period of convalescence begins and the manifestations of complications of tetanus come out on the first place. Tonic convulsions last until 22-27 days, mainly retained in the abdominal muscles, gastrocnemius muscles and back. Trismus usually lasts until the 30th day, and maybe longer. Restoration of cardiac activity occurs only towards the end of the second month from the onset of the disease, the entire period of convalescence remains tachycardia and hypotension. Complications of tetanus
Specific complications, characteristic only for tetanus, no. All of them are determined by the intensity and duration of the convulsive syndrome and the defeat of the respiratory muscles. Violation of the function of respiration and cough reflex results, first of all, in the development of a sick number of pulmonary complications: bronchopneumonia, congestive pneumonitis, pulmonary edema and atelectasis in the obstruction of the respiratory tract. Against this background, purulent complications can develop, up to the generalization of infection in the form of sepsis, which is one of the causes of deaths. Disturbances in ventilation and gas exchange form the development of hypoxia, at first respiratory, and then metabolic acidosis with impaired metabolic processes in all organs and tissues, primarily the brain, heart, liver and kidneys. Hypoxic encephalopathy is formed with a violation of the central regulation of the function of internal organs. The development of hepatorenal syndrome is caused not only by metabolic disturbances, but also by difficulty urinating due to pelvic floor spasm. All this leads to a violation of cardiac activity. The very conductor system of the heart does not suffer, but hypoxic carditis and congestive heart failure are formed.
The consequence of severe tetanic seizures may be muscle ruptures, more often ileo-lumbar and abdominal wall muscles, dislocations, rarely fractures of bones. The histone can lead to compression deformity of the thoracic spine (tetanokiphos), especially in children. Restoration of the structure of the vertebrae occurs within 1-2 years, or various forms of osteochondropathies are formed (in children, the Sheyermann-Mau, Kehler disease is more common). After recovery, muscle hypotrophy, contracture of muscles and joints, paralysis of III, VI, VII pairs of cranial nerves are often formed, which greatly complicate the rehabilitation of the patient.
Infection of newborns with tetanus occurs mainly during childbirths outside a medical institution when they are taken by people who do not have medical education under unhygienic conditions, and the cord is bandaged with non-sterile objects (cut with dirty scissors, a knife, and bandaged with normal untreated threads).
The incubation period is short, 3-8 days, in all cases a generalized severe or very severe form develops. The prodromal period is very short, up to 24 hours. The child refuses to suck breast because of trismus and dysphagia, crying. Soon, powerful tonic and tetanic convulsions join in, which are accompanied by a shrill cry, involuntary discharge of urine and feces, tremor of the lower lip, chin, and tongue. Trismus may not be expressed due to the weakness of the musculature, but a mandatory symptom is blepharospasm (eyes tightly squeezed). In the period of seizures, laryngospasm with asphyxia is often noted, which often leads to death.
The appearance of the child is characteristic, it is cyanotic, all the muscles of the body are tense, the head is thrown back, the face is frozen, with a wrinkled forehead and clenched eyes, the mouth is closed, the lips are stretched, their corners are lowered, and the nasolabial folds are sharply outlined. The handles are bent at the elbows and are pressed to the trunk, the hands are clenched into fists, the legs are bent at the knee joints, crossed. Body temperature is often increased, but there may be hypothermia.
Mortality is very high - from 80 to 100%, only timely and high-quality treatment allows to reduce the mortality rate in children to 50%. Rigidity lasts 2-4 weeks and the subsequent convalescence lasts 1-2 months. Rapid reduction in muscle rigidity is a very unfavorable prognostic sign and indicates an increasing hypoxia.
Tetanus of the brain, tetanus infection of the brain and cranial nerves is a form of localized tetanus. Most often, the latter occurs in children and can manifest as chronic otitis media. The most common disease occurs in Africa and India. In the pathological process, all cranial nerves, especially the 7th pair, can be involved. Tetanus of the brain can pass into generalized.
Acute respiratory failure is the most common cause of death. Spasm of the glottis, as well as rigidity and spasm of the muscles of the anterior abdominal wall, chest and diaphragm lead to asphyxia. Hypoxemia can also cause cardiac arrest, and pharyngeal spasm leads to aspiration of oral contents, which subsequently causes pneumonia, which contributes to the development of hypoxemic death.