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Information ⬇

[Section Outline]

Microbiology, Epidemiology, and Pathogenesis !!navigator!!

Tetanus is characterized by increased muscle tone and spasms caused by tetanospasmin (“tetanus toxin”), a toxin produced by Clostridium tetani.

  • C. tetani is a spore-forming, anaerobic gram-positive rod that is ubiquitous in soil and whose spores are highly resilient.
  • Tetanus is a rare disease in the developed world: 26 cases were reported in the United States in 2013. Most cases occur in incompletely vaccinated or unvaccinated individuals.
  • After spores contaminate wounds (typically puncture wounds or, in the case of neonates, the umbilical stump) and reach a suitable anaerobic environment (e.g., devitalized tissue), organisms proliferate and release toxin.
    • The toxin blocks release of inhibitory neurotransmitters (glycine and γ;-aminobutyric acid) in presynaptic terminals, and rigidity results from an increased resting firing rate of the α-motor neurons.
    • A toxin dose as low as 2.5 ng/kg can be fatal.

Clinical Manifestations !!navigator!!

C. tetani can cause a usually mild local disease confined to the muscles near the wound or a more severe generalized disease (e.g., neonatal disease).

  • If the cranial nerves are involved in localized cephalic tetanus, the pt may aspirate or develop airway obstruction due to pharyngeal or laryngeal muscle spasm. This situation is associated with a poor prognosis.
  • The early signs and symptoms of generalized tetanus often include trismus (lockjaw), muscle pain and stiffness, back pain, and difficulty swallowing. As the disease progresses, painful muscle spasms develop and can sometimes be strong enough to cause crush fractures.
    • Without ventilatory support, respiratory failure is the most common cause of death in tetanus.
    • Autonomic disturbance (e.g., labile blood pressure; GI stasis; increased tracheal secretions; acute, high-output renal failure) is maximal during the second week of severe tetanus, and death due to cardiovascular events becomes the major risk.

Diagnosis !!navigator!!

The diagnosis is made on clinical grounds. Culture of C. tetani from a wound provides supportive evidence.

TREATMENT

Tetanus

  • The mainstays of early treatment are the elimination of ongoing toxin production and the neutralization of circulating toxin.
    • The entry wound should be identified, cleaned, and debrided of necrotic material in order to remove anaerobic foci of infection and prevent further toxin production.
    • Metronidazole (400 mg rectally or 500 mg IV q6h for 7 days) is the preferred antibiotic. Penicillin (100,000-200,000 IU/kg qd) is an alternative but theoretically may increase spasms.
    • Antitoxin should be given as early as possible.
    • Standard treatment consists of a single IM dose of tetanus immune globulin (TIG; 3000-5000 IU) or equine antitoxin (10,000-20,000 IU). However, there is evidence that intrathecal TIG (50-1500 IU) inhibits disease progression and leads to a better outcome than IM-administered TIG. TIG is preferred as it is less likely to cause an anaphylactoid reaction.
  • Monitoring and supportive care in a calm, quiet environment are important because light and noise can trigger spasms.
    • Spasms are controlled by heavy sedation with benzodiazepines, chlorpromazine, and/or phenobarbital; magnesium sulfate can also be used as a muscle relaxant. The doses required to control spasms also cause respiratory depression; thus, it is difficult to control spasms adequately in settings without mechanical ventilation.
    • Cardiovascular instability in severe tetanus is notoriously difficult to treat; increased sedation (e.g., with magnesium sulfate, fentanyl, or morphine) or administration of short-acting agents that work specifically on the cardiovascular system (e.g., esmolol, calcium antagonists, inotropes) may be required.
  • Recovery from tetanus may take 4-6 weeks. Because natural disease does not induce immunity, recovering pts should be immunized.

Prevention !!navigator!!

Vaccination effectively prevents disease.

  • “Catch-up” vaccination schedules recommend a three-dose primary course followed by two further doses for unimmunized adolescents. For persons who have received a complete primary course in childhood but no further boosters, two doses at least 4 weeks apart are recommended.
  • Individuals sustaining tetanus-prone wounds should be immunized if their vaccination status is incomplete or unknown or if their last booster was given >10 years earlier. Pts sustaining wounds not classified as clean or minor should also undergo passive immunization with TIG.

Prognosis !!navigator!!

A shorter incubation period (time from wound to first symptom) or onset period (time from first symptom to first generalized spasm) is associated with worse outcome.

Outline ⬆

Section 7. Infectious Diseases