Tetanus differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Michael Maddaleni, B.S.; Associate Editor(s)-in-Chief:  Usama Talib, BSc, MD [2]

## Overview

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Tetanus must be differentiated from other diseases that present with fever and rigidity such as strychnine poisoning, dental infections, drug reactions, hypocalcemia, meningitis, stroke, and stiff man syndrome.[1]

## Differentiating Tetanus from other Diseases

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Tetanus must be differentiated from other diseases that present with fever and rigidity such as::[2][3][4]

Differential Diagnosis on the basis of Rigidity and Fever Disease  | Diagnosis  | Treatment

|
|

Symptoms  | Signs  | Laboratory Findings
Tetanus[5][6] |

* Tonic contraction of muscles between the spasmodic episodes
* Trismus or lockjaw
* Neck stiffness
* Swallowing difficulty
* Stiffening of the calf and pectoral muscle groups

* Opisthotonos
* Leg extension with arm flexion
* Risus sardonicus
* respiratory distress

* Not significant

* Diazepam
* Magnesium
* Human TIG

Neuroleptic Malignant Syndrome [7][8] |

* History of intake of offending drugs e.g neuroleptics like:
* Fluphenazine
* Haloperidol
* Olanzapine
* Risperidone
* Autonomic instability
* Rigidity
* Disorientation
* Fever

* Dysphagia
* Pallor
* Dyspnea
* Shuffling gait
* Agitation

*     * Myoglobinemia
* Elevated LDH
* Elevated creatine kinase
* Hyperkalemia
* Elevated AST and ALT
* Hyperphosphatemia
* Elevated alkaline phosphatase
* Hyperuricemia

* Supportive therapy
* Stop the offending agent
* Medical Therapy
* Dantrolene
* Amantadine
* Bromocriptine

Viral Meningitis[9][10][11] |

* Fever
* Irritability
* Lack of appetite
* Lethargy
* Disoriented

* High grade fever
* Severe headache
* Stiff neck
* Sensitivity to bright light
* Nausea
* Vomiting

* Headache
* Photophobia
* Phonophopia
* Pharyngitis in case of enterovirus infeciton
* Orchitis (In mumps)
* Vesicular or macular skin rash
* Petichiae
* Nuchal rigidity
* Signs of meningeal irritation:
* Kernig's sign
* Brudzinski's sign
* Altered mental status
* Hypotonia

* CSF / plasma glucose ratio (>0.6)
* Lactate (mmols/l) (<2.1)
* Lymphocytes > granulocytes

* Supportive
* Analgesics for pain.
* Acetaminophen for fever.
* Anti-viral therapy:
* Acyclovir
* Pleconaril

Stiff man syndrome |

* Marked rigidity
* Spasms
* Intermittent
* Painful
* Absent during sleep

* Diaphoresis
* Arterial hypertension
* Tachypnea
* Cyanosis
* Apnea, tachypnea
* Respiratory arrest
* Dilatation of the pupils
* Tachycardia

* CSF has
* Elevated IgG
* Oligoclonal bands
* Positive anti-GAD antibodies
* Elevated creatine kinase
* Normal CBC & ESR

* Benzodiazepines
* Baclofen
* Vigabatrin
* Valproic Acid, Neurontin
* Injected botulinum toxin
* Prednisone, plasmapheresis, IVIG ( some success)

Drug induced (Tardive dyskinesia)[12][13][14] |

* History of intake of the offending drug for at least one month
* Neuroleptics (antipsychotics)
* Metoclopramide
* Eye deviation
* Head and neck jerky movements
* No tonic contraction of the muscles between the spasms

* Dyskinesia of the tongue and lips
* Dyskinesia of the limbs
* Dyskinesia of the neck

* It is a clinical diagnosis depending on
* Dyskinetic movements
* Hx of > 1 month of antipsychotic use
* Labs may be done to rule out other differentials

* Stop the offending agent
* Benztropine
* Benzodiazepines
* Injection of botulinum toxin
* Valbenzine
* Tetrabenazine

Strychnine poisoning[15][16][17][18] |

* Hx of up to date tetanus immunizations
* History of intentional or accidental intake
* Strychnos nux vomica seeds
* Rodenticide

* Hypervigilance
* Anxiety
* Mydriasis
* Hypereflexia
* Clonus
* Facial and neck stiffness

* Blood assay
* Tissue assay
* Urine assay

* Initial stabilization
* High dose Benzodiazepines
* Intubation and airway securing

Hypocalcaemia[19][20] |

* Muscle twitching and cramping
* Circumoral and extremity paresthesia or tingling
* Altered mental status
* Irritability
* Depression
* Psychosis
* Seizure

*     * Tetany (carpopedal spasm)
* Latent tetany
* Trousseau sign of latent tetany
* Chvostek's sign
* Hyperactive tendon reflexes

* Decreased blood calcium levels

* Two ampules of intravenous calcium gluconate 10% is given slowly in a period of 10 minutes, or
* If hypocalcemia is severe, calcium chloride is given instead
* Maintenance doses of both calcium and vitamin-D

Dental abscess[21][22] |

* Tooth pain
* Painful eating and chewing
* Fever

* Poor oral hygiene
* Presence of a dental infection
* Swollen gums
* No progression of spasm with time
* Cheek swelling

* Clinical diagnosis
* Labs may include
* Microscopic exam of stained smear
* Culture of oral swab
* Blood culture

* Improved dental hygiene
* Use of fluoridated water
* Brushing regularly
* Antibiotics
* Dental extraction in case of severity

Parkinson's disease[23][24] |

* Stiffness
* Inability to write
* Jerky movements at rest
* Constipation
* Sleeping difficulty
* Walking difficulty

* Tremor
* Rigidity
* Bradykinesia
* Postural instability
* Shuffling gait

* Clinical diagnosis
* Improvement with dopaminergic therapy confirms diagnosis

* Symptomatic therapy
* Dopamine agonists
* Levodopa
* Amantadine
* MAO inhibitors
* COMT inhibitors
* Anticholinergics

### Differential for Unilateral Involuntary Face Movements

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Tetanus must also be differentiated from the following diseases that cause abnormal one sided movements of the face:[25][26][27][28][29][30][31][32][33][34][35]

* Tetanus associated trismus
* Temporomandibular joint (TMJ) dysfunction
* Unilateral jaw dystonia
* Isolated facial myokymia
* Isolated hemifacial spasm
* Multiple sclerosis (MS) associated tonic spasms
* Focal motor epilepsy

## References

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1. ↑ Anisha Doshi, Clare Warrell, Dima Dahdaleh & Dimitri Kullmann (2014). "Just a graze? Cephalic tetanus presenting as a stroke mimic". Practical neurology. 14 (1): 39–41. doi:10.1136/practneurol-2013-000541. PMID 24052566. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
2. ↑ E. Andreadou, E. Kattoulas, C. Sfagos & D. Vassilopoulos (2007). "Stiff person syndrome: avoiding misdiagnosis". Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 28 (1): 35–37. doi:10.1007/s10072-007-0745-9. PMID 17385093. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
3. ↑ Lisa Mitchell, William Adams & Francois Aspesberro (2017). "Case 6: Episodic Stiffness in a 30-month-old Girl". Pediatrics in review. 38 (1): 52–53. doi:10.1542/pir.2014-0142. PMID 28044038. Unknown parameter `|month=` ignored (help)
4. ↑ P. D. Thompson, J. A. Obeso, G. Delgado, J. Gallego & C. D. Marsden (1986). "Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm". Journal of neurology, neurosurgery, and psychiatry. 49 (6): 651–656. PMID 3734821. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
5. ↑ Woldeamanuel YW, Andemeskel AT, Kyei K, Woldeamanuel MW, Woldeamanuel W (2016). "Case fatality of adult tetanus in Africa: Systematic review and meta-analysis". J Neurol Sci. 368: 292–9. doi:10.1016/j.jns.2016.07.025. PMID 27538652.CS1 maint: Multiple names: authors list (link)
6. ↑ Thwaites CL, Loan HT (2015). "Eradication of tetanus". Br Med Bull. 116: 69–77. doi:10.1093/bmb/ldv044. PMC 4674006. PMID 26598719.
7. ↑ Hosseini S, Elyasi F (2017). "Olanzapine-Induced Neuroleptic Malignant Syndrome". Iran J Med Sci. 42 (3): 306–309. PMC 5429500. PMID 28533580.
8. ↑ Leenhardt F, Perier D, Pinzani V, Giraud I, Villiet M, Castet-Nicolas A; et al. (2017). "Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome". J Clin Pharm Ther. doi:10.1111/jcpt.12531. PMID 28488314.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
9. ↑ Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
10. ↑ Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.CS1 maint: Multiple names: authors list (link)
11. ↑ Tyler KL (2004). "Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's". Herpes. 11 Suppl 2: 57A–64A. PMID 15319091.
12. ↑ Deng ZD, Li DY, Zhang CC, Pan YX, Zhang J, Jin H; et al. (2017). "Long-term follow-up of bilateral subthalamic deep brain stimulation for refractory tardive dystonia". Parkinsonism Relat Disord. doi:10.1016/j.parkreldis.2017.05.010. PMID 28552340.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
13. ↑ "Valbenazine (Ingrezza) for tardive dyskinesia". Med Lett Drugs Ther. 59 (1521): 83–84. 2017. PMID 28520698.
14. ↑ Voelker R (2017). "Tardive Dyskinesia Drug Approved". JAMA. 317 (19): 1942. doi:10.1001/jama.2017.5537. PMID 28510661.
15. ↑ Charlotte Duverneuil, Geoffroy Lorin de la Grandmaison, Philippe de Mazancourt & Jean-Claude Alvarez (2004). "Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report". Forensic science international. 141 (1): 17–21. doi:10.1016/j.forsciint.2003.12.010. PMID 15066709. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
16. ↑ B. A. Smith (1990). "Strychnine poisoning". The Journal of emergency medicine. 8 (3): 321–325. PMID 2197324. Unknown parameter `|month=` ignored (help)
17. ↑ B. J. Maron, J. R. Krupp & B. Tune (1971). "Strychnine poisoning successfully treated with diazepam". The Journal of pediatrics. 78 (4): 697–699. PMID 5547830. Unknown parameter `|month=` ignored (help)
18. ↑ B. Oberpaur, A. Donoso, C. Claveria, C. Valverde & M. Azocar (1999). "Strychnine poisoning: an uncommon intoxication in children". Pediatric emergency care. 15 (4): 264–265. PMID 10460082. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
19. ↑ Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK (2016). "Hypocalcemic tetany: a simple bedside marker of poor outcome in acute pancreatitis". Ann Gastroenterol. 29 (2): 214–20. doi:10.20524/aog.2016.0015. PMC 4805743. PMID 27065735.CS1 maint: Multiple names: authors list (link)
20. ↑ Desai M, Kolla PK, Reddy PL (2013). "Calcium unresponsive hypocalcemic tetany: gitelman syndrome with hypocalcemia". Case Rep Med. 2013: 197374. doi:10.1155/2013/197374. PMC 3792521. PMID 24171002.CS1 maint: Multiple names: authors list (link)
21. ↑ Ogle OE (2017). "Odontogenic Infections". Dent Clin North Am. 61 (2): 235–252. doi:10.1016/j.cden.2016.11.004. PMID 28317564.
22. ↑ Bertossi D, Barone A, Iurlaro A, Marconcini S, De Santis D, Finotti M; et al. (2017). "Odontogenic Orofacial Infections". J Craniofac Surg. 28 (1): 197–202. doi:10.1097/SCS.0000000000003250. PMID 27930461.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
23. ↑ Olanow CW, Watts RL, Koller WC (2001). "An algorithm (decision tree) for the management of Parkinson's disease (2001): treatment guidelines". Neurology. 56 (11 Suppl 5): S1–S88. PMID 11402154.CS1 maint: Multiple names: authors list (link)
24. ↑ Connolly BS, Lang AE (2014). "Pharmacological treatment of Parkinson disease: a review". JAMA. 311 (16): 1670–83. doi:10.1001/jama.2014.3654. PMID 24756517.
25. ↑ P. D. Thompson, J. A. Obeso, G. Delgado, J. Gallego & C. D. Marsden (1986). "Focal dystonia of the jaw and the differential diagnosis of unilateral jaw and masticatory spasm". Journal of neurology, neurosurgery, and psychiatry. 49 (6): 651–656. PMID 3734821. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
26. ↑ J. R. Berger, W. A. Sheremata & E. Melamed (1984). "Paroxysmal dystonia as the initial manifestation of multiple sclerosis". Archives of neurology. 41 (7): 747–750. PMID 6743065. Unknown parameter `|month=` ignored (help)
27. ↑ W. B. Matthews (1975). "Paroxysmal symptoms in multiple sclerosis". Journal of neurology, neurosurgery, and psychiatry. 38 (6): 617–623. PMID 1151430. Unknown parameter `|month=` ignored (help)
28. ↑ P. D. Thompson & W. M. Carroll (1983). "Hemimasticatory spasm--a peripheral paroxysmal cranial neuropathy?". Journal of neurology, neurosurgery, and psychiatry. 46 (3): 274–276. PMID 6842234. Unknown parameter `|month=` ignored (help)
29. ↑ P. D. Thompson & W. M. Carroll (1983). "Hemimasticatory and hemifacial spasm: a common pathophysiology?". Clinical and experimental neurology. 19: 110–119. PMID 6568919.
30. ↑ L. R. Jenkyn, D. B. Walsh, C. M. Culver & A. G. Reeves (1977). "Clinical signs in diffuse cerebral dysfunction". Journal of neurology, neurosurgery, and psychiatry. 40 (10): 956–966. PMID 591973. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
31. ↑ J. D. Rugh & W. K. Solberg (1976). "Psychological implications in temporomandibular pain and dysfunction". Oral sciences reviews. 7: 3–30. PMID 775369.
32. ↑ Bond WS (1984). "Detection and management of the neuroleptic malignant syndrome". Clin Pharm. 3 (3): 302–7. PMID 6145537.
33. ↑ S. Fahn, S. B. Bressman & C. D. Marsden (1998). "Classification of dystonia". Advances in neurology. 78: 1–10. PMID 9750897.
34. ↑ Howard L. Geyer & Susan B. Bressman (2006). "The diagnosis of dystonia". The Lancet. Neurology. 5 (9): 780–790. doi:10.1016/S1474-4422(06)70547-6. PMID 16914406. Unknown parameter `|month=` ignored (help)
35. ↑ Christine Klein & Laurie J. Ozelius (2002). "Dystonia: clinical features, genetics, and treatment". Current opinion in neurology. 15 (4): 491–497. PMID 12151848. Unknown parameter `|month=` ignored (help)

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