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Medicina Clínica (English Edition)
Abstract Volume 159, Issue 3, 12 August 2022, Pages 147-151

Introduction

Section snippets Clinical report

References (10) Tetanus, analysis of 29 cases

Recommended articles (6)
Tétanos, análisis de 29 casos
Alexandre Pérez-González a, b , Isabel Fernández-Castro b, Alejandro Araújo-Ameijeiras a, Judith
Álvarez-Otero c, Antonio Ocampo b, Javier de la Fuente c

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Abstract

Background
Tetanus disease is caused by Clostridium tetani, an anaerobe bacteria found
in dust and soil. Once reached human body through damaged tissues, C.
tetani releases several neurotoxins which block the inhibitory function,
leading to an increased muscle tone, ultimately causing respiratory
failure. Severe tetanus is a life-threatening disease, especially in low-
income-regions.

Methods
This is a retrospective case-series study, undertaken at two hospitals of
Vigo (population area 600,000 inhabitants). Tetanus cases were identified
through the discharge databases of both hospitals between the years
1995–2019. Epidemiological and clinical data were obtained from the
patient's medical records.

Results
A total of 33 cases were identified; median age was 67 years, and most of
patients were women (n = 16, 55.2%). Generalized tetanus was the most
common clinical course, and neck stiffness was the most frequent
symptom. A total of 25 patients (86%) were admitted to the Intensive Care
Unit, 21 required invasive ventilation and 2 patients died.

Discussion
The incidence of tetanus was low but most of cases were severe. Mortality
was slightly higher than previously reported. Interestingly, the deceased
patients were old-women, consistent with previously reported research in
high-income-regions, while mortality in low-income-countries
concentrates in middle-aged men.

Resumen

Introducción
El tétanos es causado por Clostridium tetani, bacteria anaerobia, ubicada en
el suelo. Este microorganismo penetra a través de heridas y libera
neurotoxinas que bloquean la función inhibitoria, produciendo
espasticidad y fracaso respiratorio. Es una enfermedad grave,
especialmente en regiones empobrecidas.

Métodos
Serie de casos realizada en dos hospitales vigueses (área 600.000
habitantes). Los casos fueron identificados mediante los sistemas de
codificación entre 1995-2019. Los datos asistenciales se obtuvieron de la
historia clínica.

Resultados
Se identificaron 33 casos, mediana de edad, 67 años, la mayoría mujeres (n
= 16, 55,2%). El tétanos generalizado fue la forma clínica predominante, la
rigidez cervical el síntoma más común. Un total de 25 pacientes
requirieron ingreso en UCI, 21 ventilación mecánica, dos fallecieron.

Discusión
El número de casos fue bajo, pero la mayoría graves. La mortalidad fue
ligeramente superior a la informada previamente. La mortalidad se
concentró en mujeres ancianas, concordante con otros países
desarrollados, mientras que la mortalidad en regiones no-desarrolladas se
agrupa en varones de mediana edad.

Introduction
Tetanus is an infectious disease caused by Clostridium tetani, a spore-
forming obligate anaerobe, found in the soil, dust and manure. C. tetani
gains access to the human body through damaged tissues, such as skin
wounds.1 After inoculation, this pathogen produces a metalloprotease
toxin, tetanospasmin, which reaches the spinal cord and brainstem
through retrograde axonal transport, blocking neurotransmission and
causing the inactivation of inhibitory neurotransmission.1 The loss of
inhibition results in increased muscle tone, autonomic instability, and
severe spasms. The lack of autonomic control increases the release of
catecholamines driving to tachycardia and hypertension. Moreover, the
loss of muscle control may produce painful spasm and respiratory failure.
The incidence of tetanus is very low in resource-rich countries due to
vaccination programs. Between the years 2005 and 2015, a total of 136
cases were reported in Spain (25 were fatal). Incidence in 2015 was
estimated as 0.02 per 100,000 inhabitants and 8 cases were declared, 2 of
them in Galicia.2 On the other hand, tetanus remains endemic in
resource-limited countries, especially in Africa. According to a global
survey, an estimated between 48,200 and 80,000 deaths occurred from
tetanus worldwide in 2015.3

Since C. tetani cannot grow in healthy tissues, some predisposing factors

must be present in order to develop tetanus disease. Penetrating injuries
and insertion of a foreign body are the most common predisposing
factors. In addition, neonates, obstetric patients, injected drugs users
(IDU) and diabetic patients exhibit a higher risk for developing tetanus
disease.1 However, in almost 25% patients no cause can be identified.

The most frequent clinical presentation is generalized tetanus. Trismus,

also called lockjaw, is the most common symptom, and it is caused by
spasm of the muscles of mastication. Tonic contraction may affect several
other muscle groups, including face, thorax, and abdomen. Several
patients may develop intense tetanic spams, arching their back and
extending their legs. This phenomenon is named opisthotonos and may
be associated with apnea. Contraction of thoracic or pharyngeal muscles
may induce severe apnea and/or dysphagia. Other forms of clinical
presentation are local tetanus, affecting only the limb where the injury
occurred, cephalic tetanus in which the cranial nerves are affected. Both
forms can progress to generalized disease. Finally, neonatal tetanus
typically occurs in children 5–7 days following birth, due to contaminated
instruments or inadequate umbilical stump management.1

Diagnosis is established on clinical findings. Tetanus should be suspected

in the presence of predisposing wounds, especially in unvaccinated
patients. Treatment is based on halting the toxin production, passive
immunization with human tetanus immune globulin (HTIG) and airway
management. Suspicious wounds must be treated to eradicate spores,
necrotic tissue and antibiotics such as penicillin should be prescribed for
7–10 days. Moreover, active immunization is necessary since tetanus
disease does not confer immunity following recovery from acute illness.

Mortality is lower in resource rich countries, due to supportive care

availability, while case-fatality rate increases in resource-limited
countries.

Research of tetanus is lacking in most of high-income countries, due to

the low incidence of the disease. Despite, the most of Western health
systems report the number of cases of tetanus and mortality, there is not
information about clinical course. The aim of this current study is to
describe clinical, therapeutical and prognosis of tetanus cases from two
hospitals in Spain.

Section snippets

Study design
This retrospective case-series study was performed in Álvaro Cunqueiro
and Ribera Povisa Hospitals. Both are third-level hospitals of Vigo,
Northwest-Spain, comprising around 600,000 inhabitants. Tetanus cases
between the years 1995 and 2019 were searched in the discharge database
of both hospitals using the International Statistical Classification of
Diseases and Related Health Problems (ICD) code A35. Epidemiological
and clinical data were obtained from the patients’ medical records and
four…

Results
A total of 33 cases were identified and four were excluded because lack of
information in the medical records. Finally, 29 patients were analyzed.
Median age was 67 years (IQR, 38.5). Sixteen patients (55.2%) were female.
Baseline characteristics of study population are summarized in Table 1.

Most of cases were diagnosed in patients who lived in rural areas (n = 19,
65.5%). Vigo (n = 12), Salceda (n = 3) and Tui (n = 3) were the counties with
more cases (Fig. 1). Regarding the source of infection, 25…

Discussion
Tetanus is a rare disease in countries with high-economic resources, since
vaccination with tetanus toxoid is included in the vaccination schedule
and reaches practically 100% of the population, including Spain.2 The
most recent official data estimates an incidence of tetanus in Spain
around 0.02 cases per 100,000 inhabitants. In 2015, 8 cases were notified,
including 2 cases in Galicia.2 In our study, cumulative incidence was
0.01% during the period 1995–2018.

In our case-series, women were…

Conclusions
Incidence rate of tetanus is very low in our health area. The most
common clinical presentation was generalized tetanus and none neonatal
case was reported. A suspicious wound was identified in most of patients
and HTIG plus penicillin was the most prescribed treatment. Despite
ICU admission and IMV rates were very high, mortality remained low,
focused on elderly women.…

Authors’ contributions
APG: conceived and designed the analysis and wrote the paper; IFC and
AAA: collected the data; JAO and AO: contributed data or analysis tools;
JF: supervised the project.…

Ethical considerations
Ethical approval for this study was obtained from the Pontevedra-Vigo-
Ourense ethics committee with reference number 2021/420, signed on
23rd November 2021 and followed the Declaration of Helsinki Ethical
Principles for Medical Research Involving Human Subjects. Informed
consent was waived for the present study because of the retrospective
study design.…

Funding
This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors. Alexandre Pérez,
principal investigator, is hired under a Río Hortega contract financed by
Instituto de Investigación Carlos III (ISCIII) with reference number
CM20/00243.…

Conflict of interest
The author(s) declare(s) that there is no conflict of interest.…

References (10)

L.M. Yen et al.

Tetanus
Lancet (2019)

Grupo de trabajo recomendaciones Td 2017. Ponencia de Programa y Registro de

Vacunaciones. Recomendaciones de...

H.H. Kyu et al.

Mortality from tetanus between 1990 and 2015: findings from the global
burden of disease study 2015
BMC Public Health (2017)

R.R. Redfield et al.

(2018)

A.v Ganesh Kumar et al.

Benzathine penicillin, metronidazole and benzyl penicillin in the treatment
of tetanus: a randomized, controlled trial
Ann Trop Med Parasitol (2004)

There are more references available in the full text version of this article.

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