TETANUS
GILL G.V., BEECHING N.J. TROPICAL MEDICINE, 5 TH EDITION.
BACTERIOLOGY & PATHOGENESIS:
♦. Tetanus is caused by Clostridium tetani, a Gram- positive obligate
anaerobe spore forming bacteria.
♦. Spores are particularly found in soil and are highly resistant to light and
temperature; clinical disease occurs when spores are inoculated into wounds.
♦. Spores germinate under anaerobic conditions at the site of the wound and
the growing bacteria produce two toxin: tetanolysin and tetanospasmin.
BACTERIOLOGY & PATHOGENESIS:
♦. Tetanospasmin enters the presynaptic nerve terminal and prevents
transmitter release.
♦. Tetanospasmin is able to travel retrogradely via axon to cell bodies and
cross synapses, thus reaching the spinal cord, brain and autonomic
nervous system.
♦. It primarily affects glycine and GABA neurones leading to increase firing
and of normal relaxation and causing the classical spasms of tetanus.
CLINICAL MANIFESTATIONS:
♦. The incubation period varies according to the site of
injury and is shorter in severe disease, with average
incubation of 8 days for severe disease.
♦. There are several classical clinical sub-types, which
reflect the main site of action of toxin
GENERALIZED TETANUS:
♦. Generalized tetanus often commences with trismus (lock
jaw) in which the patient is unable to open his mouth or
risus sardonicus, a grimace caused by spasm patient facial
muscle.
♦. The predominant feature is of repeated spasms which
may involve the neck, thorax, abdomen or extremities.
♦. Generalized spasm with opisthotonos also occur.
GENERALIZED TETANUS:
♦. Spasms are painful and full consciousness is retained.
♦. Respiratory compromise may occur due to involvement of
the glottis or diaphragm.
♦. The disease may continue to progress for up to 10 days
after the first symptoms.
♦. In severe tetanus, autonomic dysfunction may occur after
several days.
GENERALIZED TETANUS:
♦. Hypertension, tachycardia, arrhythmias, hyperpyrexia my
all occur and can be extremely difficult to manage.
♦. Recovery may take up to 4 weeks.
♦. Case fatality rates can reach 60%, with death usually
occurring because respiratory or autonomic involvement.
NEONATAL TETANUS:
♦. This is usually caused by infection of the umbilical stump.
♦. The risk of infection is related to the cleanliness of the
environment.
♦. Neonatal tetanus only occurs in the children of non-immune
mothers.
♦. Symptoms and signs occur 1-10 days postpartum .
♦. Initially, generalized weakness and floppiness of the baby are
noticed, with irritability and an inability to suck and feed.
NEONATAL TETANUS:
♦. Subsequently, spasms, opisthotonos and
hypersympathetic states occur.
♦. Up to 90% of affected infants die and mental retardation
is common in survivors.
LOCALIZED TETANUS:
♦. This usually a mild form in which rigidity is limited to muscles near
the site of injury.
♦. Weakness may of the muscles may also occur because of the
action of the toxin at the neuromuscular junction.
♦. Symptoms may mild and persist for months.
♦. If the diagnosis is not made, progression to the generalized form
may occur.
CEPHALIC TETANUS:
♦. This the rarest form and occur in head injuries or with
middle ear infection.
♦. The incubation period is normally 1-2 days.
♦. The major clinical manifestations are caused by
involvement of cranial nerves with facial paresis, dysphagia
and extraocular palsies.
♦. This form can also progress to generalized tetanus.
DIAGNOSIS:
♦. The diagnosis is usually made clinically.
♦. Blood and CSF findings are usually normal.
♦. The differential diagnosis is limited but includes:
strychnine poisoning, dystonic reactions, hypocalcaemia
and seizures in adults and metabolic or neurological
causes of posturing in neonates.
TREATMENT:
♦. Tetanus should be treated by the administration of
tetanus immunoglobulin (human tetanus Ig5 500-5000 IU
i.m. or equine tetanus IG IU i.m.).
♦. Wound should be debrided to prevent further germination
of spores.
♦. Metronidazole or benzylpenicillin should be given to
prevent the multiplication of bacteria.
TREATMENT:
♦. External stimulation should be reduced to prevent precipitation of spasms: patients
should be nursed a quiet, dim room.
♦. The airway should be protected; endotracheal intubation or tracheostomy is
sometimes necessary.
♦. Spasm can be treated by the use of high doses of benzodiazepines; baclofen is
also effective.
♦. Some patients require paralysis with neuromuscular junction blockers.
♦. Intravenous labetalol is useful for the management of hypertension; atropine or
pacing may be needed for bradycardias and sympathomimetics and fluids are
sometimes necessary to treat hypotension.
EPIDEMIOLOGY & PREVENTION:
There has been a significant reduction in the number of cases through the use of
vaccination, particularly maternal vaccination and better obstetric practice.
Tetanus is a vaccine-preventable disease. Immunization with tetanus toxoid is very effective.
A single dose of tetanus toxoid in pregnancy leads to protectives titers in mother and
neonate. Non-immunized mothers should received two doses during pregnancy.
Routine booster doses should be given at 10 yearly intervals, or for tetanus –prone injuries if
not immunized within the last 5 years.
There is no need to give more than five doses in a lifetime.
Gill G.V., Beeching N.J. Tropical Medicine, 5 th edition.
