MWAPE .

C
DCM,Bsc CS (GRU)
Lecturer

TETANUS
 Definition and Overview
∗ Tetanus, also called lockjaw, is a medical condition characterized
by a prolonged contraction of skeletal muscle fibers. The primary
symptoms are caused by tetanospasmin, a neurotoxin produced by
the Gram-positive, obligate anaerobic bacterium Clostridium tetani.
Infection generally occurs through wound contamination, and often
involves a cut or deep puncture wound. As the infection progresses,
muscle spasms in the jaw develop, hence the name lockjaw. This is
followed by difficulty in swallowing and general muscle stiffness
and spasms in other parts of the body. Infection can be prevented by
proper immunization and by post-exposure prophylaxis.
 Aetiology
∗Clostridium tetani is a slender, motile
gram-positive anaerobic spore forming
bacillus
∗Spores viable for years in soil and
animal faeces
∗Tetanus spores survive boiling but not
autoclaving
∗Vegetative cells are killed by
antibiotics, health and standard
 Aetiology

∗Tetanus toxin is 2nd most

poisonous substance known,
surpassed only by
botulinium toxin
 Epidemiology

∗ Clostridium tetani is found worldwide

∗ Occurs in infant whose mother has not been
vaccinated during pregnancy
∗ Mother should receive at least 2 injections during
first pregnancy
∗ Often mother would have delivered at home
∗ Used unsterile razor blade for cutting cord and
unsterile clothe for tying umbilical cord
 Epidemiology

∗Occasionally, there is history

of applying cow dung to the
umbilicus
∗Clinical disease does not
confer immunity
 Pathogenesis
∗Tetanus occurs after spores which have
been introduced into tissue which is
poorly oxygenated germinate, multiply
and produce tetanus toxin
∗Tetanospasmin is produced as the
vegetative cell dies
∗The toxin may enter CNS along the
peripheral motor nerves or may be
blood borne to nervous tissue
 Pathogenesis
∗ Tetanospasmin binds to the ganglioside
membranes of nerve synapses blocking
release of inhibitory transmitter from
the nerve endings
∗ This causes generalised tonic spasticity,
usually superimposed with intermittent
tonic convulsion
∗ Once fixed toxin cannot be neutralized
 TYPES OF TETANUS

∗ 3 MAJOR TYPES ARE;

1. LOCAL TETANUS
2. CEPHALIC TETANUS
3. GENERALISED TETANUS
 Types cont,,,,,

∗ Local tetanus is an uncommon form of the disease, in

which patients have persistent contraction of muscles in
the same anatomic area as the injury. The contractions
may persist for many weeks before gradually subsiding.
Local tetanus is generally milder; only about 1% of
cases are fatal, but it may precede the onset of
generalized tetanus.
 Types cont,,,,,

∗ Cephalic tetanus is a rare form of the disease,

occasionally occurring with otitis media (ear infections)
in which C. tetani is present in the flora of the middle
ear, or following injuries to the head. There is
involvement of the cranial nerves, especially in the
facial area.
 Types cont,,,,,
∗ Generalized tetanus is the most common type of tetanus,
representing about 80% of cases. The generalized form
usually presents with a descending pattern. The first sign is
trismus, or lockjaw, and the facial spasms called risus
sardonicus, followed by stiffness of the neck, difficulty in
swallowing, and rigidity of pectoral and calf muscles.
∗ Other symptoms include elevated temperature, sweating,
elevated blood pressure, and episodic rapid heart rate. Spasms
may occur frequently and last for several minutes with the
body shaped into a characteristic form called opisthotonos.
Spasms continue for 3–4 weeks, and complete recovery may
take months.
 Clinical manifestation

∗Tetanus may be localised or

generalised
∗Incubation period is 2 – 14 days (2-
50 days).
∗However maybe as long as several
months after injury
 Clinical manifestation –
generalised tetanus

∗ Trismus or masseter muscle spasm or lockjaw is the

presenting symptom in 50% cases
∗ Also presents with restlessness and irritability
∗ This is followed by stiffness and neck spasms
∗ Sardonic smile of tetanus (risus sardonicus) results
from intractable spasms of facial and buccal muscles
Clinical presentation – generalised
tetanus

∗ Paralysis spreads to abdomen, lumbar, hip and thigh

muscles
∗ This causes an arched posture called opisthotonus
∗ The opisthotonic posture is due to unrelenting total
contraction of opposing muscles
Clinical manifestation – generalised
tetanus

∗ Laryngeal and respiratory muscle spasms can lead to

airway obstruction and asphyxiation
∗ Tetanus toxin does not affect sensory nerves or
cortical function.
∗ Thus patient remains conscious.
∗ Therefore patient is in severe pain and scared on
next spasm
∗
Clinical manifestation – generalised
tetanus

∗ Seizures are characterized by sudden severe tonic

contractions of the muscles with fist clenching,
flexion and adduction of arms and hyperextension of
the legs
∗ Seizures are initially for a few seconds to few
minutes. However, without treatment, seizures
become progressively sustained and exhausting
Clinical manifestation – generalised
tetanus

∗ Any disturbances by sight, sound or touch triggers a

tetanic spasm
∗ Dysuria and urinary retention may occur from
bladder sphicnter spasm
∗ Forced defecation may occur
∗ Progress of illness: Tetanic paralysis is more severe
in 1st week, stabilises in 2nd week and subsides slowly
over 4 weeks
 Clinical manifestations

Fever maybe as high as 40°C due to high

metabolic rate caused by spasms
Autonomic effects occur which include:
Tachycardia, arrthymias, labile
hypertension and cutaneous
vasoconstricton
Clinical manifestation – Neonatal
tetanus

∗ Typically manifests within 3-12 days of birth as

progressive difficulty in feeding (i.e. sucking and
swallowing)
∗ There is associated hunger and crying
∗ Paralysis or diminished movement, stiffness to touch
and spasms with or without opisthotonus
characterise the disease
∗ Umbilical stump may hold dirt, dung clotted blood,
serum or it may be clean
Clinical manifestation – localised
tetanus

∗ Spasms occur in muscles adjacent to the wound site.

∗ It may precede generalised tetanus
∗ Cephalic tetanus - is localised tetanus of the head
∗ Involves the bulbar musculature
∗ Occurs due to wounds or foreign bodies in the head,
nostrils or face. Can occur in Chronic Otitis media
Clinical manifestations – cephalic
tetanus

Cephalic tetanus characterized

by retracted eyelids, deviated
gaze, trismus, risus sardonicus
and spastic paralysis of tongue
and pharyngeal muscles
 Diagnosis

Regular lab studies usually normal

WBC is increased due to secondary bacterial infection
CSF normal except for increased pressure
EEG normal
C. Tetani not always visible on gramstain. Isolated in
only one third of cases
Diagnosis therefore clinical
 Differential diagnosis

∗Trismus – parapharyngeal abscess

∗Rabies – hyrophobia, dysphagia –
predominantly clonic seizures/
∗Hypocalcaemia – spasms carpo-
pedal and laryngeal, but trimus
absent
 TREATMENT
Aims of treatment
1. To eradicate the C.tetani
2. To neutralize all accessible tetanus toxin
3. To control spasms and tetanic seizures through sedation
and muscle relaxation
4. To avoid as much all unnecessary stimuli
5. To provide supportive care as needed
6. To prevent recurrences
 Treatment

∗ A) Eradicate C. Tetani
∗ - clean and debride wound to remove environment
conducive for anaerobic multiplication. Clean
umbilicus
∗ - administer human tetanus immune globulin -500 –
6000 units
∗ - give antibiotics to eradicate C. Tetani –Penicillin G
100,000 iu/kg/24hrs for 10-14 days in 2-4 divided doses
 Treatment

∗ Metronidazole 7.5mg/kg per dose

twice daily X 7 - 10 days
∗ In allergic patients give Erythromycin
∗ Give adsorbed tetanus toxoid. (It only
becomes effective in about 10 days).
 Treatment

∗ B) Relax the patient

∗ - diazepam. Provides both relaxation and seizure
control. Initial dose 0.1 -0.2mg/kg every 3-6 hrs IV. It is
titrated to control tetanic spasms after which it is
sustained for 2-6 weeks before tapering off to avoid
withdrawal.
∗ - chlorpromazine
∗ - magnesium sulphate
 Treatment

∗ Dancuronium is a neuromuscular blocking agent.

Gives best survival rates

∗ C) Endotracheal intubation maybe required

∗ D) Monitor vital signs, pulse, respiration
∗ E) maintain hydration
∗ Give adequate …………..?
 Complications

∗ Aspiration of secretions and pneumonia

∗ Hazards of mechanical ventilation (pneumothorax)
∗ Seizure may result into laceration of mouth or
tongue, hematomas, rhabdomyolysis with
myoglobinuria and renal failure or fracture of long
bones
 complications

∗ Venous thrombosis, pulmonary emboli, gastric

ulceration possibly with haemorrhage
∗ Iatrogenic apnoeal due to relaxation cardiac
arrthymias
∗ In infants, cerebral palsy, mental retardation
 prognosis

∗ Recovery occurs due to regeneration of synapses

within spinal cord and thereby restoration of muscle
relaxation.
∗ Mortality highest in very young and very old
 Prevention

∗ Tetanus is an entirely preventable disease; a serum antibody

titer of ≥0.01 U/mL is considered protective.
∗ Active immunization should begin in early infancy with
combined diphtheria toxoid-tetanus toxoid-pertussis
vaccine at 2, 4, and 6 mo of age, with a booster at 4–6 yr of
age and at 10-yr intervals thereafter throughout adult life
with tetanus-diphtheria (Td) toxoids.
∗ Immunization of women with tetanus toxoid prevents
neonatal tetanus, and the World Health Organization is
currently engaged in a global elimination of neonatal
tetanus campaign through maternal immunization with at
least two doses of tetanus toxoid.
∗ Thank You

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