Early Signs and Symptoms of Tetanus and Diphtheria
Tetanus Clinical Presentation
The most characteristic early sign of generalized tetanus in adults is lockjaw (trismus), which occurs in at least 80% of cases presenting as the generalized form. 1, 2
Generalized Tetanus (Most Common Form)
- Trismus (lockjaw) is the hallmark initial symptom, representing involuntary contraction of the masseter muscles that prevents mouth opening 1, 2
- Risus sardonicus develops as facial muscle spasms create a characteristic grimacing expression 2
- Nuchal rigidity and stiffness of the neck muscles appear early in the disease course 2
- Opisthotonus may develop as the disease progresses, with severe arching of the back due to extensor muscle spasms 2
- Generalized muscle rigidity spreads from the jaw and neck to involve the trunk and extremities 1, 2
Local Tetanus
- Persistent muscle rigidity and spasms confined to muscles near the wound site 2
- This form may progress to generalized tetanus or remain localized 2
Cephalic Tetanus
- Cranial nerve dysfunction affecting muscles of the head and neck 2
- Often follows head or facial wounds 2
Critical Diagnostic Context
- Tetanus is diagnosed clinically based on characteristic signs rather than bacteriologic findings, as Clostridium tetani is difficult to culture from wounds 1
- The disease occurs almost exclusively in unvaccinated or inadequately vaccinated individuals 3
- No naturally acquired immunity exists to tetanus toxin, making vaccination the only effective prevention 3
Diphtheria Clinical Presentation
The pathognomonic presentation of diphtheria includes "bull neck" appearance, pharyngeal pseudomembrane, and bleeding when attempting to remove the membrane—findings that distinguish it from common pharyngitis. 4
Respiratory Diphtheria (Most Common)
- Adherent gray-white pseudomembrane covering the tonsils, pharynx, or larynx that bleeds when removal is attempted 4
- "Bull neck" appearance from massive cervical lymphadenopathy and soft tissue edema caused by toxin-mediated vascular damage 4
- Inspiratory stridor indicating upper airway compromise from membrane extension or laryngeal edema 4
- Sore throat with low-grade fever, though systemic symptoms may be mild initially 4
- Serosanguinous nasal discharge in nasal diphtheria 3
Cutaneous Diphtheria
- Sharply demarcated skin lesions with a pseudomembranous base, though appearance may not be distinctive 3
- Usually occurs at wound sites and may be confused with other bacterial skin infections 3
- Most commonly affects indigent adults and certain populations with poor hygiene 3
Critical Diagnostic Features
- Absence of childhood immunization is a key epidemiological clue, as diphtheria occurs almost exclusively in unimmunized or inadequately immunized individuals 4
- Bleeding with attempted membrane removal distinguishes diphtheria from streptococcal pharyngitis or infectious mononucleosis 4
- The combination of bull neck, airway compromise, and bleeding pharyngeal membrane is pathognomonic for diphtheria 4
Important Clinical Distinction
- Unlike streptococcal pharyngitis, diphtheria presents with bull neck, inspiratory stridor, and bleeding with membrane manipulation—features not typical of strep throat 4
- Urgent clinical diagnosis is essential, as diphtheria antitoxin must be administered immediately without waiting for laboratory confirmation 4
Common Pitfalls to Avoid
- Do not wait for culture confirmation before treating suspected diphtheria—antitoxin effectiveness is inversely proportional to illness duration before administration 4
- Do not dismiss tetanus in patients with adequate wound care but uncertain vaccination history—the disease occurs exclusively in unvaccinated or inadequately vaccinated persons 3, 1
- Do not confuse local tetanus symptoms with simple wound infection—persistent muscle rigidity near a wound site warrants immediate evaluation 2
- Consider diphtheria even in developed countries when evaluating unimmunized patients with severe pharyngitis and characteristic membrane formation 4