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Tetanus

Tetanus is a bacterial infection caused by Clostridium tetani, a gram-positive Gram-Positive Penicillins obligate anaerobic bacterium commonly found in soil that enters the body through a contaminated wound. C. tetani C. tetani The cause of tetanus in humans and domestic animals. It is a common inhabitant of human and horse intestines as well as soil. Two components make up its potent exotoxin activity, a neurotoxin and a hemolytic toxin. Clostridia produces a neurotoxin that blocks the release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology of inhibitory neurotransmitters and causes prolonged tonic muscle contractions. It presents with lockjaw, neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess stiffness, opisthotonus, rigid abdomen and severe painful muscle spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy. Diagnosis is made on clinical grounds, as it is rarely possible to isolate the infectious agent from the wound. It is treated with antibiotic therapy and the human tetanus antitoxin. Untreated tetanus can lead to respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure and cardiovascular complications and can be fatal. With appropriate treatment, however, most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will recover.

Last updated: Oct 17, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Tetanus is a nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. Nervous System: Anatomy, Structure, and Classification disorder caused by the bacterium Clostridium tetani.

Etiology

  • Pathogen: Clostridium tetani:
    • Gram-positive Gram-Positive Penicillins bacillus Bacillus Bacillus are aerobic, spore-forming, gram-positive bacilli. Two pathogenic species are Bacillus anthracis (B. anthracis) and B. cereus. Bacillus
    • Spore-forming, obligate anaerobe
    • 10 serotypes have been identified.
    • All 10 of the serotypes contain 2 common toxins: tetanolysin and tetanospasmin tetanospasmin Protein synthesized by Clostridium tetani as a single chain of ~150 kda with 35% sequence identity to botulinum toxin that is cleaved to a light and a heavy chain that are linked by a single disulfide bond. Tetanolysin is the hemolytic and tetanospasmin is the neurotoxic principle. The toxin causes disruption of the inhibitory mechanisms of the CNS, thus permitting uncontrolled nervous activity, leading to fatal convulsions. Clostridia
  • Toxins:
    • Tetanolysin causes local tissue destruction but is not relevant to the pathogenesis of tetanus.
    • Tetanospasmin tetanospasmin Protein synthesized by Clostridium tetani as a single chain of ~150 kda with 35% sequence identity to botulinum toxin that is cleaved to a light and a heavy chain that are linked by a single disulfide bond. Tetanolysin is the hemolytic and tetanospasmin is the neurotoxic principle. The toxin causes disruption of the inhibitory mechanisms of the CNS, thus permitting uncontrolled nervous activity, leading to fatal convulsions. Clostridia is a potent neurotoxin (exotoxin) that causes clinical tetanus.
  • Habitat:
    • Soil
    • Freshwater
    • Marine sediments
    • Intestinal tract of humans and animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic
    • Spores Spores The reproductive elements of lower organisms, such as bacteria; fungi; and cryptogamic plants. Anthrax can be airborne.
Micrograph of group of clostridium tetani bacteria

The micrograph depicts a group of Clostridium tetani bacteria, responsible for causing tetanus in humans:
Note the slender bacillus with a characteristic “drumstick” appearance caused by the spherical terminally located spores Spores The reproductive elements of lower organisms, such as bacteria; fungi; and cryptogamic plants. Anthrax.

Image: “This micrograph depicts a group of Clostridium tetani bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology, responsible for causing tetanus in humans” by CDC. License: Public Domain

Epidemiology

  • Can occur in any age group, but neonates are the age group at highest risk. 
    • Neonatal tetanus is extremely dangerous; it has a mortality Mortality All deaths reported in a given population. Measures of Health Status rate of nearly 100%.
    • Occurs mainly in developing countries with unclean delivery techniques and poor postnatal hygiene
  • Most cases of tetanus occur in countries where there is a lack of immunization.
  • Elderly individuals are also at risk because of reduced immunity.
  • Spores Spores The reproductive elements of lower organisms, such as bacteria; fungi; and cryptogamic plants. Anthrax of C. tetani C. tetani The cause of tetanus in humans and domestic animals. It is a common inhabitant of human and horse intestines as well as soil. Two components make up its potent exotoxin activity, a neurotoxin and a hemolytic toxin. Clostridia are present in the soil irrespective of geographical location.

Mode of infection

  • Through contaminated wounds (most common)
  • Complication of IV drug use
  • Through the middle ear Middle ear The space and structures directly internal to the tympanic membrane and external to the inner ear (labyrinth). Its major components include the auditory ossicles and the eustachian tube that connects the cavity of middle ear (tympanic cavity) to the upper part of the throat. Acute Otitis Media (cephalic tetanus)
  • Through the umbilical stump Umbilical Stump Staphylococcal Scalded Skin Syndrome (SSSS) (neonatal tetanus)
  • Risk factors for developing tetanus: 
    • Burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns
    • Surgical wounds
    • IV drug use
    • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
    • Immunosuppression

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Pathophysiology

Types

  • Generalized tetanus: most common and severe form
  • Local tetanus: mild form with symptoms that develop only near the infected wound
  • Cephalic tetanus: rare but fatal infection that usually enters through the middle ear Middle ear The space and structures directly internal to the tympanic membrane and external to the inner ear (labyrinth). Its major components include the auditory ossicles and the eustachian tube that connects the cavity of middle ear (tympanic cavity) to the upper part of the throat. Acute Otitis Media
  • Neonatal tetanus: due to infection of the umbilical stump Umbilical Stump Staphylococcal Scalded Skin Syndrome (SSSS)

Pathophysiology

Inoculation:

  • C. tetani C. tetani The cause of tetanus in humans and domestic animals. It is a common inhabitant of human and horse intestines as well as soil. Two components make up its potent exotoxin activity, a neurotoxin and a hemolytic toxin. Clostridia has little invasive power.
  • Spores Spores The reproductive elements of lower organisms, such as bacteria; fungi; and cryptogamic plants. Anthrax usually enter the organism through contaminated wounds.
  • Not every inoculation will result in infection.
  • Spores Spores The reproductive elements of lower organisms, such as bacteria; fungi; and cryptogamic plants. Anthrax germinate under anaerobic conditions: wound ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage, tissue necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage, devitalized tissue
  • Average incubation Incubation The amount time between exposure to an infectious agent and becoming symptomatic. Rabies Virus period is 7–10 days (can last from 1 to 60 days).
  • Neonatal tetanus usually presents with a shorter incubation Incubation The amount time between exposure to an infectious agent and becoming symptomatic. Rabies Virus period (5–7 days after birth).

Pathogenesis:

  • Exotoxins Exotoxins Toxins produced, especially by bacterial or fungal cells, and released into the culture medium or environment. Bacteriology ( tetanospasmin tetanospasmin Protein synthesized by Clostridium tetani as a single chain of ~150 kda with 35% sequence identity to botulinum toxin that is cleaved to a light and a heavy chain that are linked by a single disulfide bond. Tetanolysin is the hemolytic and tetanospasmin is the neurotoxic principle. The toxin causes disruption of the inhibitory mechanisms of the CNS, thus permitting uncontrolled nervous activity, leading to fatal convulsions. Clostridia and tetanolysin) are produced by germinated bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology.
  • Tetanolysin may play a role in local tissue destruction, but tetanospasmin tetanospasmin Protein synthesized by Clostridium tetani as a single chain of ~150 kda with 35% sequence identity to botulinum toxin that is cleaved to a light and a heavy chain that are linked by a single disulfide bond. Tetanolysin is the hemolytic and tetanospasmin is the neurotoxic principle. The toxin causes disruption of the inhibitory mechanisms of the CNS, thus permitting uncontrolled nervous activity, leading to fatal convulsions. Clostridia is responsible for the neurologic symptoms.
  • Tetanospasmin tetanospasmin Protein synthesized by Clostridium tetani as a single chain of ~150 kda with 35% sequence identity to botulinum toxin that is cleaved to a light and a heavy chain that are linked by a single disulfide bond. Tetanolysin is the hemolytic and tetanospasmin is the neurotoxic principle. The toxin causes disruption of the inhibitory mechanisms of the CNS, thus permitting uncontrolled nervous activity, leading to fatal convulsions. Clostridia is released into the blood and enters the presynaptic terminals of the neuromuscular end plate of motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology neurons Neurons The basic cellular units of nervous tissue. Each neuron consists of a body, an axon, and dendrites. Their purpose is to receive, conduct, and transmit impulses in the nervous system. Nervous System: Histology.
  • Inhibit release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology of GABA GABA The most common inhibitory neurotransmitter in the central nervous system. Receptors and Neurotransmitters of the CNS and glycine Glycine A non-essential amino acid. It is found primarily in gelatin and silk fibroin and used therapeutically as a nutrient. It is also a fast inhibitory neurotransmitter. Synthesis of Nonessential Amino Acids (inhibitory neurotransmitters)
  • Toxin then travels to the CNS via retrograde axonal transport, where it also blocks GABA GABA The most common inhibitory neurotransmitter in the central nervous system. Receptors and Neurotransmitters of the CNS and glycine Glycine A non-essential amino acid. It is found primarily in gelatin and silk fibroin and used therapeutically as a nutrient. It is also a fast inhibitory neurotransmitter. Synthesis of Nonessential Amino Acids release Release Release of a virus from the host cell following virus assembly and maturation. Egress can occur by host cell lysis, exocytosis, or budding through the plasma membrane. Virology.
  • A lack of inhibitory neurotransmitters causes a continuous excitatory state of the motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology neuron → spastic paralysis
  • Continuous unopposed muscle activity can lead to bone fractures Bone fractures Breaks in bones. Bones: Remodeling and Healing and muscle tears.
Pathophysiological mechanism caused by clostridium tetani

Pathophysiologic mechanism caused by Clostridium tetani:
Tetanospasmin tetanospasmin Protein synthesized by Clostridium tetani as a single chain of ~150 kda with 35% sequence identity to botulinum toxin that is cleaved to a light and a heavy chain that are linked by a single disulfide bond. Tetanolysin is the hemolytic and tetanospasmin is the neurotoxic principle. The toxin causes disruption of the inhibitory mechanisms of the CNS, thus permitting uncontrolled nervous activity, leading to fatal convulsions. Clostridia blocks the binding of neurotransmitters ( GABA GABA The most common inhibitory neurotransmitter in the central nervous system. Receptors and Neurotransmitters of the CNS/ glycine Glycine A non-essential amino acid. It is found primarily in gelatin and silk fibroin and used therapeutically as a nutrient. It is also a fast inhibitory neurotransmitter. Synthesis of Nonessential Amino Acids) to their receptors Receptors Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors on the postsynaptic membrane Postsynaptic membrane Synapses and Neurotransmission, leading to inhibitory neurotransmission Neurotransmission The communication from a neuron to a target (neuron, muscle, or secretory cell) across a synapse. In chemical synaptic transmission, the presynaptic neuron releases a neurotransmitter that diffuses across the synaptic cleft and binds to specific synaptic receptors, activating them. The activated receptors modulate specific ion channels and/or second-messenger systems in the postsynaptic cell. In electrical synaptic transmission, electrical signals are communicated as an ionic current flow across electrical synapses. Synapses and Neurotransmission

Image by Lecturio.

Clinical Presentation and Diagnosis

Clinical presentation

Generalized tetanus is the most common and severe clinical form of tetanus.

  • General malaise Malaise Tick-borne Encephalitis Virus
  • Trismus, or lockjaw (80%): 
  • Stiffness of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess
  • Risus sardonicus, or sardonic smile:
    • Due to tonic rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon involving muscles of the face Muscles of the Face The facial muscles (also called mimetic muscles) control facial expression and are supplied by the facial nerve. Most of them originate from the skull and attach to the skin around the facial openings, which serve as a method to group or classify them. Facial Muscles: Anatomy, neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, and trunk
    • Contraction of the frontalis muscles and muscles of the angle of the mouth produces a characteristic grinning expression.
  • Opisthotonus:
    • A varying degree of rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon develops in the muscles of the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, back, and trunk.
    • The back is usually arched, and the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen appears broad.
  • Rigid abdomen
  • Convulsions Convulsions Seizures
    • Painful, violent, exhausting, reflex spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy that last for 3–4 minutes
    • Develop within 24–72 hours after the initial onset of symptoms
  • Laryngeal spasm: causes difficulty breathing
  • Esophageal spasm: causes dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
  • Urethral spasm: causes urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium
  • Autonomic nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. Nervous System: Anatomy, Structure, and Classification overactivity:
    • Sweating
    • Tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children
    • Fevers
    • Cardiovascular complications: labile blood pressure, arrhythmias

Neonatal tetanus: 

  • Refusal to feed and difficulty opening the mouth due to trismus in an infant previously able to feed and cry properly
  • Poor sucking
  • Irritability
  • Grimacing
  • Clenched hands and dorsiflexed feet
  • Intense rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon and spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy can lead to opisthotonus.
Body rigidity in neonatal tetanus

Neonate Neonate An infant during the first 28 days after birth. Physical Examination of the Newborn displaying body rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon seen in neonatal tetanus

Image: “Neonatal tetanus 6374” by CDC. License: Public Domain

Local tetanus

  • Tonic contractions/ spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy limited to one body region/extremity
  • Will often progress to generalized tetanus

Cephalic tetanus: 

  • Rare, but frequently fatal
  • Trismus
  • Peripheral facial paralysis ( facial nerve Facial nerve The 7th cranial nerve. The facial nerve has two parts, the larger motor root which may be called the facial nerve proper, and the smaller intermediate or sensory root. Together they provide efferent innervation to the muscles of facial expression and to the lacrimal and salivary glands, and convey afferent information for taste from the anterior two-thirds of the tongue and for touch from the external ear. The 12 Cranial Nerves: Overview and Functions most commonly involved)
  • Ophthalmoplegia Ophthalmoplegia Paralysis of one or more of the ocular muscles due to disorders of the eye muscles, neuromuscular junction, supporting soft tissue, tendons, or innervation to the muscles. Orbital and Preseptal Cellulitis
  • Dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
  • Can progress to generalized tetanus

Diagnosis

  • Diagnosis is made on clinical grounds, as it is difficult to isolate C. tetani C. tetani The cause of tetanus in humans and domestic animals. It is a common inhabitant of human and horse intestines as well as soil. Two components make up its potent exotoxin activity, a neurotoxin and a hemolytic toxin. Clostridia from its original site of entry.
  • History:
    • History of a previous tetanus-prone injury
    • History of inadequate immunization for tetanus
    • History of immunosuppression or presence of risk factors
  • Physical exam: 
    • Presence of characteristic findings
    • “Spatula test”: Touching the back of the throat Throat The pharynx is a component of the digestive system that lies posterior to the nasal cavity, oral cavity, and larynx. The pharynx can be divided into the oropharynx, nasopharynx, and laryngopharynx. Pharyngeal muscles play an integral role in vital processes such as breathing, swallowing, and speaking. Pharynx: Anatomy elicits jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint: Anatomy contraction instead of normal gag reflex Gag Reflex Cranial Nerve Palsies.
  • Serum antitoxin level:
    • Not always readily available
    • Level ≥ 0.01 IU/mL makes tetanus less likely.

Management

Supportive management

  • Toxin bound to synaptic endings cannot be neutralized.
  • The effects of toxin can, therefore, last for weeks, and supportive management is required.
    • ICU ICU Hospital units providing continuous surveillance and care to acutely ill patients. West Nile Virus admission
    • Endotracheal intubation Endotracheal Intubation Neonatal Respiratory Distress Syndrome is frequently needed to protect airway Airway ABCDE Assessment.
    • Tracheostomy Tracheostomy Surgical formation of an opening into the trachea through the neck, or the opening so created. Laryngomalacia and Tracheomalacia may be needed if prolonged intubation Intubation Peritonsillar Abscess is required.
    • Maintenance of hydration
    • Enteral feeding to maintain nutrition
    • Prophylaxis Prophylaxis Cephalosporins against thromboembolism Thromboembolism Obstruction of a blood vessel (embolism) by a blood clot (thrombus) in the blood stream. Systemic Lupus Erythematosus by the administration of anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants
    • Prevention and treatment of secondary infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
    • Physical therapy Physical Therapy Becker Muscular Dystrophy after the cessation of spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy
    • Control of muscle spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy:
      • Place the patient in a quiet room and avoid unnecessary stimuli.
      • Benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines/IV diazepam Diazepam A benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant, and amnesic properties and a long duration of action. Its actions are mediated by enhancement of gamma-aminobutyric acid activity. Benzodiazepines
      • Baclofen Baclofen A gamma-aminobutyric acid derivative that is a specific agonist of gaba-b receptors. It is used in the treatment of muscle spasticity, especially that due to spinal cord injuries. Its therapeutic effects result from actions at spinal and supraspinal sites, generally the reduction of excitatory transmission. Spasmolytics is used in a few cases.
    • Management of autonomic dysfunction Autonomic Dysfunction Anterior Cord Syndrome:
      • Magnesium Magnesium A metallic element that has the atomic symbol mg, atomic number 12, and atomic weight 24. 31. It is important for the activity of many enzymes, especially those involved in oxidative phosphorylation. Electrolytes sulfate
      • Labetalol Labetalol A salicylamide derivative that is a non-cardioselective blocker of beta-adrenergic receptors and alpha-1 adrenergic receptors. Subarachnoid Hemorrhage

Halting production of toxin:

  • Debride wound to lower bacterial counts.
  • Antibiotic therapy: 
    • Metronidazole Metronidazole A nitroimidazole used to treat amebiasis; vaginitis; trichomonas infections; giardiasis; anaerobic bacteria; and treponemal infections. Pyogenic Liver Abscess (best choice) for 7–10 days
    • Penicillin Penicillin Rheumatic Fever
    • Doxycycline
    • Cephalosporins Cephalosporins Cephalosporins are a group of bactericidal beta-lactam antibiotics (similar to penicillins) that exert their effects by preventing bacteria from producing their cell walls, ultimately leading to cell death. Cephalosporins are categorized by generation and all drug names begin with “cef-” or “ceph-.” Cephalosporins if co-infection with another organism is suspected

Neutralization of unbound toxin:

  • IM human tetanus immunoglobulin (HTIG) is administered and infiltrated around the wound.
  • If HTIG is not available, then intravenous immunoglobulin may be administered.
  • In countries where HTIG is not readily available, IM equine tetanus immunoglobulin can be administered.
  • Because of high chances of allergic reaction with equine immunoglobulin, a test dose should be administered.

Complications

  • Fractures: Severe spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy can lead to fractures in the vertebrae and other bones.
  • Laryngospasm Laryngospasm Hypoparathyroidism
    • A brief spasm of the larynx Larynx The larynx, also commonly called the voice box, is a cylindrical space located in the neck at the level of the C3-C6 vertebrae. The major structures forming the framework of the larynx are the thyroid cartilage, cricoid cartilage, and epiglottis. The larynx serves to produce sound (phonation), conducts air to the trachea, and prevents large molecules from reaching the lungs. Larynx: Anatomy, usually lasting 30–60 seconds
    • Laryngospasm Laryngospasm Hypoparathyroidism prevents oxygen from reaching the lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs: Anatomy, making breathing difficult.
    • In severe cases, laryngospasm Laryngospasm Hypoparathyroidism leads to asphyxia Asphyxia A pathological condition caused by lack of oxygen, manifested in impending or actual cessation of life. Drowning and ultimately death.
  • Aspiration pneumonia Aspiration pneumonia A type of lung inflammation resulting from the aspiration of food, liquid, or gastric contents into the upper respiratory tract. Pneumonia: Tetanus causes muscle rigidity Rigidity Continuous involuntary sustained muscle contraction which is often a manifestation of basal ganglia diseases. When an affected muscle is passively stretched, the degree of resistance remains constant regardless of the rate at which the muscle is stretched. This feature helps to distinguish rigidity from muscle spasticity. Megacolon, leading to difficulty in coughing and swallowing Swallowing The act of taking solids and liquids into the gastrointestinal tract through the mouth and throat. Gastrointestinal Motility, which can result in aspiration pneumonia Aspiration pneumonia A type of lung inflammation resulting from the aspiration of food, liquid, or gastric contents into the upper respiratory tract. Pneumonia.
  • Acute renal failure Renal failure Conditions in which the kidneys perform below the normal level in the ability to remove wastes, concentrate urine, and maintain electrolyte balance; blood pressure; and calcium metabolism. Renal insufficiency can be classified by the degree of kidney damage (as measured by the level of proteinuria) and reduction in glomerular filtration rate. Crush Syndrome:
    • Severe muscle spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy associated with tetanus can cause rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is characterized by muscle necrosis and the release of toxic intracellular contents, especially myoglobin, into the circulation. Rhabdomyolysis.
    • Rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is characterized by muscle necrosis and the release of toxic intracellular contents, especially myoglobin, into the circulation. Rhabdomyolysis results in the excretion of myoglobin Myoglobin A conjugated protein which is the oxygen-transporting pigment of muscle. It is made up of one globin polypeptide chain and one heme group. Rhabdomyolysis in the urine, leading to acute kidney failure.
  • Complications of prolonged immobilization Immobilization Delirium:
    • Deep vein thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus and pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
    • Nosocomial infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease

Prophylaxis Prophylaxis Cephalosporins

  • Tetanus is a vaccine-preventable disease.
  • Tetanus vaccines are based on tetanus toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination and are available as single or combination vaccines.
  • Combined diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria–tetanus– pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough) vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination is administered as a part of the normal immunization schedule, which provides protection up to adolescence.
  • Administered to pregnant women and those of childbearing age to prevent neonatal tetanus
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship presenting with wounds:
    • Clean wounds: administer vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination:
      • If < 3 previous doses
      • If last dose > 10 years ago
    • Contaminated wounds:
      • Give vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination if last dose > 5 years ago
      • Human tetanus immune globulin if < 3 doses of toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination
  • For patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship affected with tetanus:
    • Immunity following tetanus is incomplete and does not prevent recurrent episodes.
    • A full schedule of active immunization Active immunization Resistance to a disease agent resulting from the production of specific antibodies by the host, either after exposure to the disease or after vaccination. Vaccination is therefore instituted with tetanus and diphtheria Diphtheria Diphtheria is an infectious disease caused by Corynebacterium diphtheriae that most often results in respiratory disease with membranous inflammation of the pharynx, sore throat, fever, swollen glands, and weakness. The hallmark sign is a sheet of thick, gray material covering the back of the throat. Diphtheria toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination–containing vaccines.
Prophylaxis of tetanus

Wound management and prophylaxis Prophylaxis Cephalosporins of tetanus:
The time from the last dose determines the treatment given to an individual to prevent contracting the disease.
Immunity categories:
A: The patient has had a complete course of toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination or a booster within the past 5 years.
B: The patient has had a complete course of toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination or a booster between 5 and 10 years ago.
C: The patient has had a complete course of toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination or a booster dose > 10 years ago.
D: The patient has not had a complete course of toxoid Toxoid Preparations of pathogenic organisms or their derivatives made nontoxic and intended for active immunologic prophylaxis. They include deactivated toxins. Anatoxin toxoids are distinct from anatoxins that are tropanes found in cyanobacteria. Vaccination or immunity status is unknown.

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Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • The majority of those affected will recover with appropriate care.
  • Shorter incubation Incubation The amount time between exposure to an infectious agent and becoming symptomatic. Rabies Virus periods are associated with more severe disease.
  • In resource-limited countries, the case fatality ranges from 5% to 50%.
  • Neonatal tetanus has mortality Mortality All deaths reported in a given population. Measures of Health Status rates of 3%–88%.
  • Residual neurologic deficits Neurologic Deficits High-Risk Headaches are common in survivors.

Differential Diagnosis

  • Strychnine poisoning: Strychnine is a toxic alkaloid used in pesticides. After ingestion, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with symptoms of muscle spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy, cramping, stiffness, agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, tachypnea Tachypnea Increased respiratory rate. Pulmonary Examination, mydriasis Mydriasis Dilation of pupils to greater than 6 mm combined with failure of the pupils to constrict when stimulated with light. This condition may occur due to injury of the pupillary fibers in the oculomotor nerve, in acute angle-closure glaucoma, and in adie syndrome. Glaucoma, and nystagmus Nystagmus Involuntary movements of the eye that are divided into two types, jerk and pendular. Jerk nystagmus has a slow phase in one direction followed by a corrective fast phase in the opposite direction, and is usually caused by central or peripheral vestibular dysfunction. Pendular nystagmus features oscillations that are of equal velocity in both directions and this condition is often associated with visual loss early in life. Albinism. Diagnosis is by a thorough history and laboratory assays of blood, urine, and tissue. There is no specific treatment; only supportive management is required.
  • Phenothiazine overdose: Phenothiazine is a drug used to treat schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia. Symptoms of overdose include deviation of eyes, writhing movements of head and neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, drooling Drooling Peritonsillar Abscess, and shallow breathing. Diagnosis is by detailed history and blood and urine analysis. Treatment is by the administration of the anticholinergic Anticholinergic Anticholinergic drugs block the effect of the neurotransmitter acetylcholine at the muscarinic receptors in the central and peripheral nervous systems. Anticholinergic agents inhibit the parasympathetic nervous system, resulting in effects on the smooth muscle in the respiratory tract, vascular system, urinary tract, GI tract, and pupils of the eyes. Anticholinergic Drugs agent benztropine Benztropine A centrally active muscarinic antagonist that has been used in the symptomatic treatment of parkinson disease. Benztropine also inhibits the uptake of dopamine. Anticholinergic Drugs.
  • Tetany Tetany A disorder characterized by muscle twitches, cramps, and carpopedal spasm, and when severe, laryngospasm and seizures. This condition is associated with unstable depolarization of axonal membranes, primarily in the peripheral nervous system. Tetany usually results from hypocalcemia or reduced serum levels of magnesium that may be associated with hyperventilation; hypoparathyroidism; rickets; uremia; or other conditions. Hypocalcemia: carpopedal spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy, muscle cramps Cramps Ion Channel Myopathy, tremors or spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy of the face, and calf muscles: Tetany Tetany A disorder characterized by muscle twitches, cramps, and carpopedal spasm, and when severe, laryngospasm and seizures. This condition is associated with unstable depolarization of axonal membranes, primarily in the peripheral nervous system. Tetany usually results from hypocalcemia or reduced serum levels of magnesium that may be associated with hyperventilation; hypoparathyroidism; rickets; uremia; or other conditions. Hypocalcemia is caused by hypocalcemia Hypocalcemia Hypocalcemia, a serum calcium < 8.5 mg/dL, can result from various conditions. The causes may include hypoparathyroidism, drugs, disorders leading to vitamin D deficiency, and more. Calcium levels are regulated and affected by different elements such as dietary intake, parathyroid hormone (PTH), vitamin D, pH, and albumin. Presentation can range from an asymptomatic (mild deficiency) to a life-threatening condition (acute, significant deficiency). Hypocalcemia secondary to an underlying disorder or deficiency. Diagnosis is by blood analysis and the presence of 2 clinical signs: Chvostek and Trousseau. Treatment is by the administration of calcium Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes gluconate and resolution of the underlying cause.
  • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis: an inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the meninges Meninges The brain and the spinal cord are enveloped by 3 overlapping layers of connective tissue called the meninges. The layers are, from the most external layer to the most internal layer, the dura mater, arachnoid mater, and pia mater. Between these layers are 3 potential spaces called the epidural, subdural, and subarachnoid spaces. Meninges: Anatomy commonly caused by bacterial and viral infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease: Symptoms include headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, stiff neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess, and lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia, as well as refusal to feed and irritability in infants. Diagnosis is by blood analysis and spinal tap Spinal Tap Febrile Infant. Treatment includes antibiotics or antiviral Antiviral Antivirals for Hepatitis B therapy and supportive management.

References

  1. George EK, De Jesus O, Vivekanandan R. (2020). Clostridium tetani. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482484/
  2. Boloor A, Nayak R. (2018). Exam Preparatory Manual for Undergraduates Medicine. 2nd ed. Xxxxx: Xxxxx, p. 122.
  3. Bourget D. (2020). Tetanus. StatPearls. Retrieved March 12, 2021, from https://www.statpearls.com/articlelibrary/viewarticle/29997/
  4. Ralston SH, et al. (Eds.). (2018). Davidson’s Principles and Practice of Medicine, 23rd ed. Xxxxx: Xxxxx, pp. 1125–1126.
  5. World Health Organization. (2021). Tetanus Disease and Epidemiology. Retrieved March 12, 2021, from http://www.emro.who.int/health-topics/tetanus/vaccine-vaccination.html
  6. Thwaites L. (2020). Tetanus. UpToDate. Retrieved March 12, 2021, from https://www.uptodate.com/contents/tetanus#H1917381

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