More commonly, tetanus infection presents as a systemic condition with increased tone and episodic spasm, initially affecting the muscles of the head and neck and subsequently spreading caudally. Characteristic features of these episodic spasms include contorting facial contractions (risus sardonicus) and forced flexion of the arms with an arching of the back (opisthotonus). Tetanus localized near the site of a peripheral injury is much rarer but can progress to generalized involvement. The key features which initiated concern for the diagnosis is the untreated peripheral wound, the absence of a post-ictal state or loss of bladder or bowel control, and the rarity of new-onset seizures. The most common cause of death in untreated tetanus patients is ventilatory failure related to spasm of the respiratory musculature.

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