Tetanus

OVERVIEW: What every practitioner needs to know

Are you sure your patient has tetanus? What are the typical findings for this disease?

Neonatal tetanus

poor suck and swallow
irritability
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fixed facial expression (“risus sardonicus”)
hypertonicity
muscle spasms
autonomic dysfunction (hypotension, tachycardia, fever)
respiratory failure

Child and adult tetanus

trismus (“locked jaw”)
dysphagia
neck or back stiffness and rigidity
opisthotonos
painful muscle contractions
respiratory failure
glottic spasms
autonomic dysfunction (hypotension, tachycardia, fever)

What other disease/condition shares some of these symptoms?

Conditions that may present with findings similar to those of neonatal tetanus:

Sepsis
Metabolic disorders
Certain neuromuscular conditions, such as neonatal myotonic dystrophy. Most conditions associated with poor feeding in infants, other than tetanus, cause hypotonia.
Hypereflexia

Conditions that may present with findings similar to those of child and adult tetanus:

Neuromyotonia (“stiff person” syndrome; Isaac’s syndrome)
Malignant hyperthermia

What caused this disease to develop at this time?

Neonatal tetanus results from absence of maternal immunity, absence of passive neonatal immunity, and infection with Clostridium tetani during unsanitary obstetrical or neonatal practices. Clostridium tetani, a spore-forming bacillus, infects the umbilical stump, and under anaerobic conditions produces tetanospasmin, a potent neurotoxin. Tetanospasmin binds to gangliosides at the neuromuscular junction and blocks nerve signals that inhibit muscle contraction. Nearly all cases of neonatal tetanus occur in underdeveloped regions.
Child and adult tetanus results from infection with Clostridium tetani, a spore-forming bacillus. Infection occurs through cuts or wounds, septic abortion, or drug use with unsterile needles. In non-immune persons, the bacillus proliferates and produces tetanospasmin. Tetanospasmin, a potent neurotoxin, binds to gangliosides at the neuromuscular junction and blocks nerve signals that inhibit muscle contraction.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Routine laboratory tests are not useful in diagnosing tetanus in infants, children or adults. The diagnosis is made on clinical grounds in the appropriate clinical setting.

Would imaging studies be helpful? If so, which ones?

Imaging studies are not useful in diagnosing tetanus in infants, children or adults. Electrophysiologic studies, consisting of electromyography, may be useful in some cases, especially in children or adults.

Confirming the diagnosis

There are no clinical algorithms available to diagnosis or confirm tetanus.

If you are able to confirm that the patient has tetanus, what treatment should be initiated?

Treatment of suspected tetanus at any age consists of administration of human tetanus immune globulin, debridement of any wounds, administration of antibiotics (metronidazole or penicillin), and supportive care. The latter may consist of mechanical ventilation, tube feedings, and treatment of any autonomic complications (such as fever or hypotension). Muscle spasms may require treatment with benzodiazepines. Unimmunized persons or persons with an unknown immunization status should receive tetanus toxoid, using Td or Tdap (booster tetanus toxoid, reduced diptheria toxoid, acellular pertussis toxoid) at the time of wound management.

What are the adverse effects associated with each treatment option?

Treatments for tetanus are generally well-tolerated.

What are the possible outcomes of tetanus?

Neonatal tetanus, a preventable disease, is associated with high mortality rates, especially in underdeveloped regions. Tetanus in children or adults can also cause death, although most survive with supportive care and administration of tetanus immune globulin and antibiotics.

What causes this disease and how frequent is it?

Epidemiology:

Tetanus occurs worldwide, more often during warmer months. Approximately 30 to 40 cases of tetanus occur annually in the United States among children and adults. Neonatal tetanus is rare in the United States. By contrast, neonatal tetanus causes approximately 7% of neonatal deaths worldwide, corresponding to 50,000 to 60,000 deaths annually.

Tetanus results from infection with Clostridium tetani, a spore-forming bacillus that proliferates under anaerobic conditions and elaborates tetanospasmin, a potent neurotoxin. Clostridium tetani, found worldwide, can be detected in soils and in human excrement. Human to human transmission does not occur.
There are no known genetic factors that predispose to acquiring tetanus.

How do these pathogens/genes/exposures cause the disease?

Infection with Clostridium tetani in children or adults occurs via contaminated cuts or wounds, especially when penetrating, or use of unsterile needles during injection of drugs. Neonatal tetanus results from contamination of the umbilical stump as the result of unsanitary obstetrical or neonatal care.

Other clinical manifestations that might help with diagnosis and management

N/A

What complications might you expect from the disease or treatment of the disease?

Death is a common complication of neonatal tetanus in underdeveloped regions; death can also occur in children or adults with tetanus.

Are additional laboratory studies available; even some that are not widely available?

N/A

How can tetanus be prevented?

Tetanus can be prevented by administration of tetanus vaccine. In the US, it is recommended that children receive 5 doses of DTaP between the ages of 2 months and 7 years. Booster immunizations with tetanus toxoid, using adult-type vaccine combined with vaccine to protect against diphtheria and pertussis (Tdap), should be given routinely every 10 years thereafter to maintain immunity. Unimmunized pregnant women should receive 2 doses of Tdap during pregnancy; this prevents >95% of cases of neonatal tetanus.

What is the evidence?

Recommendations for the management of tetanus in infants, children or adults are based upon the consensus opinions of the World Health Organization, the US Centers for Disease Control and Prevention (CDC), and the Advisory Committee on Immunization Practices of the US Public Health Service.

CDC recommendations can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6001a4.htm?s_cid=mm6001a4_w.

Ongoing controversies regarding etiology, diagnosis, treatment

There is no controversy that adherence to vaccine recommendations prevents cases of tetanus in infants, children and adults. There remain minor controversies regarding the dose of tetanus immune globulin used to treat tetanus (500 U versus 3000 to 6000 U) and regarding the efficacy of local wound administration of tetanus immune globulin. Local public health officials should be consulted regarding management of symptomatic tetanus.

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