The arms are flexed and crossed with tightly clenched fists and the toes flexed. The back is very rigid Cyanosis and apnoea accompany the more severe

respiration. 5. Neonatal tetanus - due to sepsis of the umbilical stump. Typically the weekold infant presents with inability to suck because of spasm of facial and pharyngeal muscles, or with generalized convulsions. Crying is hoarse and the face screwed up, with tightly closed eyes and wrinkled forehead The arms are flexed and crossed with tightly clenched fists and the toes flexed. The back is very rigid Cyanosis and apnoea accompany the more severe spasms. Severity of tetanus: Grading Gr. I (mild) - Mild to moderate lockjaw, generalized spasticity, no spasms or respiratory difficulty. Gr. II (moderate) - Well marked rigidity, brief spasms, mild dysphagia, tachypnoea (>3Q-35/min) Gr III (severe) - Severe trismus, generalized spasticity, prolonged spasms often spontaneous, tachypnoea (>4Q/min), apnoeic spells, marked dysphagia, tachycardia, increased autonomic MS disturbance. Gr. IV (very severe) - (Gr. III features plus severe autonomic storms) - severe hypertension and tachycardia alternating with relative hypotension and bradycardia, or severe persistent hypertension. or hypotension Differential Diagnosis -1 Other causes of trismus - (a) Irritant local lesions of teeth (dental abscess, pericoronitis), throat (peritonsillar abscess), temporomandibular joint, masseter muscle and cervical lymph nodes (b) Occasionally postvaccinial and postinfectious encephalitis, serum sickness and even poliomyelitis. It is commonly observed in patients envenomed by sea snakes . 2. Meningitis - Neck rigidity can occur in both tetanus and meningitis. Signs of meningeal irritation, diagnostic CSF. 3. Rabies - Dysphagia associated with spasms of inspiratory and pharyngeal muscles also occurs in rabies. No trismus. Relaxation of ms. inbetween paroxysms. 4. Tetany - Spasms start in periphery with carpopedal spasm. Usually associated with overbreathing or thyroid surgery. 5. Drug dystonia - Dystonic reactions to drugs such as phenothiazines and metoclopramide. Grimacing, spasmodic neck retraction and torticollis, wide opening of the mouth and eyes Prompt response to diazepam or benztropine. 6. Acute peritonitis - Board-like abdominal rigidity as in tetanus, but in tetanus there is little or no tenderness. 7. Functional muscle spasms - Bizarre movements or posture, absence of constant rigidity of involved muscles, history of previous personality disorder. 8. Catatonic schizophrenia - might cause confusion in absence of background information. CLINICAL COURSE - Most deaths occur by 10th day Spasms usually subside by end of second or third week, but residual muscle stiffness may persist for more than a month. Complications 1 Respiratory - (a) Bronchopneumonia common cause of death, results from aspiration of stomach contents, blockage of airways by sticky secretions and lung collapse. (b) Asphyxia - may be due to one or both of the following - (i) Pharyngolaryngeal spasm - Sudden and unexpected stridor, respiratory distress or cyanosis in an early case of tetanus is due to spasm of muscles of upper airway. (u) Respiratory muscle fixation - A patient without any major reflex muscle spasms may still die from complications of chest fixation in which the general hypertonicity involves pectoral muscles, intercostal muscles and muscles of the abdominal wall reducing vital capacity markedly. (c) ARDS-chiefly due to respiratory sepsis. 2. Due to spasms - Spasms can tear muscles and even avulse their insertions, with subsequent articular and