Clinical Findings
A. Symptoms and Signs
The first symptom often is mild pain at the site of the wound, followed by hypertonicity and spasm of the regional muscles. Characteristically, difficulty in opening the mouth (trismus) is evident within 48 hours. In newborns, the first signs are irritability and inability to nurse. The infant may then develop stiffness of the jaw and neck, increasing dysphagia, and generalized hyperreflexia with rigidity and spasms of all muscles of the abdomen and back (opisthotonos). The facial distortion resembles a grimace (risus sardonicus). Difficulty in swallowing and convulsions triggered by minimal stimuli such as sound, light or movement may occur. Individual spasms may last seconds or minutes. Recurrent spasms are seen several times each hour, or they may be almost continuous. In most cases, the temperature is normal or only mildly elevated. A high or subnormal temperature is a bad prognostic sign. Patients are fully conscious and Iucid. A profound circulatory disturbance associated with sympathetic overactivity may occur on the second to fourth day, which may contribute to the mortality rate. This is characterized by elevated blood pressure, increased cardiac output, tachycardia (> 20 beats/min), and arrhythmia