PHYSICAL EXAMINATION

VS: T 38°C, P 130/min, R 36/min, BP 94/48 mmHg

PE: The newborn had trismus, opisthotonus (Fig. 66-1), and hyper-responsiveness to external stimuli. The umbilical cord was covered with dry clay, which when retracted revealed a foul-smelling yellow-green discharge.

FIGURE 66-1 Opisthotonus in a newborn.

(Courtesy of Centers for Disease Control and Prevention, Atlanta, GA.)

LABORATORY STUDIES

Blood

Hematocrit: 38%

WBC: 12,400/μL

Differential: 85% PMNs, 10% lymphs

Blood gases: pH 7.34, pCO₂ 46, pO₂ 75

Serum chemistries: Normal

Imaging

Chest x-ray was normal; head CT scan or MRI was not done.

Diagnostic Work-Up

Table 66-1 lists the likely causes of illness (differential diagnosis). Tetanus is a clinical diagnosis. Electromyography may help in uncertainty, and cultures of umbilical stump wound may be necessary to determine the qualitative nature and extent of wound infection.

TABLE 66-1 Differential Diagnosis and Rationale for Inclusion (consideration)

Dystonic reaction to dopamine blocker

Meningitis (bacterial or viral)

Neonatal tetanus

Neurologic disorder (infectious or noninfectious cause)

Sepsis

Strychnine poisoning

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