Tetanus

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• A non-communicable infectious disease
• An acute, spastic paralytic illness caused by a
neurotoxin produced by Clostridium tetani
• C. tetani is not a tissue invasive organism and instead
causes illness through the toxin, tetanospasmin ,
more commonly referred to as tetanus toxin

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 Epidemiology
• Occurs worldwide and is endemic in many
developing countries
• Approximately 57,000 deaths were caused by
tetanus globally in 2015
• Of these, approximately 20,000 deaths occurred in
neonates and 37,000 in older children and adults

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• Most mortality from neonatal (or umbilical) tetanus
occurs in South Asia and Sub-Saharan Africa
• Mortality in adults is largely caused by maternal
tetanus, which results from postpartum, postabortal,
or postsurgical wound infection with C. tetani.
• Most non-neonatal cases of tetanus are associated
with a traumatic injury, often a penetrating wound
inflicted by a dirty object such as a nail, splinter,
fragment of glass, or unsterile injection

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• The disease may also occur in association with
animal bites, abscesses , ear and other body
piercing, chronic skin ulceration, burns,
compound fractures, gangrene, intestinal
surgery
• What are the risk factors for neonatal
tetanus?

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 Pathogenesis
• Tetanus spores access to damaged human tissue
• After inoculation, C. tetani transforms into a
vegetative rod-shaped bacterium and produces the
metalloprotease tetanus toxin
• Reach the spinal cord & brainstem via retrograde
axonal transport within the motor neuron
• Toxin is secreted and enters adjacent inhibitory
interneurons, where it blocks neurotransmission by
its cleaving action on the membrane proteins
involved in neuroexocytosis
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• The net effect is inactivation of inhibitory
neurotransmission that normally modulates anterior
horn cells and muscle contraction
• This loss of inhibition of anterior horn cells and
autonomic neurons results in increased muscle tone,
painful spasms, and widespread autonomic
instability
• Lack of neural control of adrenal release of
catecholamines induced by tetanus toxin produces a
hyper-sympathetic state that manifests as sweating,
tachycardia, & hypertension
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 Clinical Manifestations
• Tetanus can present in one of four clinical
patterns
1. Generalized
2. Local
3. Cephalic
4. Neonatal

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• Incubation period of tetanus is 8 days but ranges
from 3 to 21 days; shorter in neonatal tetanus
• Inoculation of spores in body locations distant from
the CNS (eg, the hands or feet) results in a longer
incubation period

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 Generalized tetanus
• Most common and severe clinical form of tetanus
• Trismus (lockjaw) in more than 50% of cases
• Autonomic over activity that may manifest in the
early phases as irritability, restlessness, sweating,
and tachycardia----in later phases of illness, profuse
sweating, cardiac arrhythmias, labile hypertension or
hypotension, and fever
• Tonic contraction of skeletal muscles & intermittent
intense muscular spasms

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• Pts with tetanus have no impairment of
consciousness or awareness, both the tonic
contractions and spasms are intensely painful.
• Tetanic spasms may be triggered by loud noises or
other sensory stimuli such as physical contact or light

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• Tonic and periodic spastic muscular contractions are
responsible for most of the classic clinical findings of
tetanus:
 stiff neck
 opisthotonus
 risus sardonicus (sardonic smile),
 board-like rigid abdomen, periods of apnea
and/or upper airway obstruction due to vise-like
contraction of the thoracic muscles and/or glottal
or pharyngeal muscle contraction, respectively,
 dysphagia
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Lockjaw: spasm of facial muscles.

Risus sardonicus: A sardonic smile (facial muscle spasms)

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 Opisthotonus

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• During generalized tetanic spasms, pts characteristically
clench their fists, arch their back, and flex and abduct their
arms while extending their legs, often becoming apneic
during these dramatic postures

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 Local tetanus
• Rarely, tetanus presents with tonic & spastic
muscle contractions in one extremity or body
region
• Often evolves into generalized tetanus
• Dx can be difficult

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 Cephalic tetanus
• In pts with injuries to the head or neck
• Involving initially only cranial nerves
• Like other forms of local tetanus, pts with cephalic tetanus
often subsequently develop generalized tetanus
• The facial nerve is most commonly involved

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 Neonatal tetanus
• The infantile form of generalized tetanus, typically
manifests within 3-12 days of birth
• It presents as progressive difficulty in feeding
(sucking and swallowing), associated hunger, and
crying
• Occurs as a result of the failure to use aseptic
techniques in managing the umbilical stump in
offspring of mothers who are poorly immunized

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 Clinical manifestation neonatal
tetanus
• Diagnosis is clinical as confirming the infection is
difficult
• The newborn usually exhibits:
 irritability
 poor feeding, difficulty in opening the mouth
 rigidity
 facial grimacing
 severe spasms with stimulation

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• The umbilical stump, which is typically the
portal of entry for the microorganism, may
retain remnants of dirt, dung, clotted blood,
or serum, or it may appear relatively benign
• Without good supportive care, case fatality
rates can exceed 90%.

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 Assignment
• Write the Case definition for neonatal
tetanus!

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 Severity of illness
• May vary from case to case, depending upon the amount of
tetanus toxin that reaches CNS
• The severity is related to the incubation period of the illness
& the interval from the onset of symptoms to the appearance
of spasms, the longer the interval, the milder
• Illness may be milder in pts with preexisting but
nonprotective levels of antitetanus antibodies

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 Duration of illness
• Tetanus toxin-induced effects are long lasting
because recovery requires the growth of new
axonal nerve terminals
• The usual duration of clinical tetanus is four to
six weeks.

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 dx
• Usually obvious and can generally be made based upon
typical clinical findings outlined above
• The typical setting is an unimmunized pt(and/or mother) who
was injured or born within the preceding 2 wk, who presents
with trismus, dysphagia, generalized muscle rigidity and
spasm, and a clear sensorium
• Results of routine lab studies are usually normal
• An assay for antitoxin levels is not readily available, although
a serum antitoxin level of ≥0.01 IU/mL is generally considered
protective and makes the dx of tetanus less likely

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 ddx
• Drug-induced dystonias such as those due to
phenothiazines
• Trismus may result from parapharyngeal,
retropharyngeal, or dental abscesses or rarely from
acute encephalitis involving the brainstem

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 Complications
• Laryngospasm
• Hyperactivity of the ANS leading to HTN, abnormal heart rate,
or both
• Fractures of the spine or long bones as a result of sustained
contractions and convulsions
• Nosocomial infections
• Pulmonary embolism
• Aspiration pneumonia
• Death

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 Goals of Rx
• Halting the toxin production
• Neutralization of the unbound toxin
• Airway management
• Control of muscle spasms
• Mgt of dysautonomia
• General supportive management

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 Halting toxin production
• Wound Mgt-----surgery
 surgical wound excision and debridement are
often needed to remove the foreign body or
devitalized tissue that created the anaerobic
growth conditions necessary for replication
• Antimicrobial therapy: Oral (IV) metronidazole (30
mg/kg/day, given at 6 hr intervals; maximum dose, 4
g/day) decreases the number of vegetative forms of
C. tetani and is currently considered the antibiotic of
choice
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• Parenteral penicillin G (100,000 U/kg/day,
administered at 4-6 hr intervals, with a daily
maximum 12 million U) is an alternative Rx
• Antimicrobial therapy for a total duration of 7-
10 days is recommended.

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 Neutralization of unbound toxin
• Since tetanus toxin is irreversibly bound to tissues,
only unbound toxin is available for neutralization
• Human tetanus immune globulin (TIG) should be
readily available and is the preparation of choice
• A dose of 3000 to 6000 units IM should be given as
soon as the dx of tetanus is considered, with part of
the dose infiltrated around the wound

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• In parts of the world where it is available, another
alternative may be equine derived TAT
• A dose of 1,500-3,000 U is recommended and
should be administered after appropriate testing for
sensitivity and desensitization,

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 Control of muscle spasms
• All pts with generalized tetanus should receive
muscle relaxants
• Diazepam has been used most frequently
• The initial dose of 0.1- 0.2 mg/kg every 3-6 hr
intravenously is subsequently titrated to control the
tetanic spasms
• Magnesium sulfate, other benzodiazepines
(midazolam), chlorpromazine, dantrolene, and
baclofen are also used

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• Favorable survival rates in generalized tetanus have
been described with the use of neuromuscular
blocking agents such as vecuronium and
pancuronium, which produce a general flaccid
paralysis that is then managed by mechanical
ventilation.

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 Mgt of autonomic dysfunction
• Several drugs have been used to produce adrenergic blockade
and suppress autonomic hyperactivity;
• Only Rx with magnesium sulfate has been studied in a
randomized clinical trial in tetanus
• Beta blockade--Labetalol(0.25 to 1.0 mg/min) has frequently
been administered because of its dual alpha- and beta-
blocking properties
• Morphine sulfate (0.5 to 1.0 mg/kg per hour by continuous
intravenous infusion) is commonly used to control autonomic
dysfunction as well as to induce sedation.

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 Airway Mgt and other supportive
measures
• Oxygen should be available
• Endotracheal intubation
• Early tracheostomy
• Prophylactic subcutaneous heparin may be of
value, but it must be balanced with the risk of
hemorrhage

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 Factors Associated with a Poor
Prognosis in Tetanus
• Age >70 years
• Incubation period <7 days
• Short time from first symptom to admission
• Puerperal, IV, postsurgery, burn entry site
• Period of onset <48 h
• Heart rate >140 beats/min
• Systolic blood pressure >140 mmHg
• Severe disease or spasms
• Temperature >38.5°Cb
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 Factors Associated with a Poor
Prognosis in Tetanus---neonatal
• Younger age
• Premature birth
• Incubation period <6 days
• Delay in hospital admission
• Grass used to cut cord
• Low birth weight
• Fever on admission

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 Prevention
• Easily preventable disease
• A serum Ab titer of ≥0.01 U/mL is considered protective
• Active immunization should begin in early infancy(6-10-
14wks) and with boosters at 4-6 yr and 11-12 yr of age, and at
10 yr intervals thereafter throughout adult life with tetanus
toxoid
• Immunization of women with tetanus toxoid prevents
neonatal tetanus

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