j Tetanus This disease results from infection with Clostridium tetani, a commensal in the gut of humans and domestic animals that is found in soil. Infection ent through wounds, )which may be trivial,/It is rare in the UK, occurring mostly in gardeners and farmers, but @ recent increase has been seen in intravenous drug misusers) By contrast, the disease is common in many developing Countries, where dust contains spores derived from animal and human excreta.Unhygieni | r_birth may | Jc infection of the umbilical stump or site of circumcision, causing tetanus neonatorum. Tetanus is still one of the major killers of adults, children and neonates in developing countries, where the mortality rate can be nearly 100% in the newborn and around 40% in others. In circumstances unfavourable to growth of the organism, spores are formed and these may remain dormant for years in the = o_O ane . . Soil. Spores germinate and bacilli multip! conditions that occur in areas of tissue necrosis or if the oxygen tension is lowered by the presence of other organisms, particularly if aerobic.The anterior horn cells are affected after the exotoxin has passed into the blood stream and their involvement results a rigidity and convulsions. Symptoms first appear from 2 several weeks after injury: 16 Shorter the incubation period, = more severe the attack and the worse the prognosis. Clinical features 1 By far the most important early symptom hoon — spasm of the masseter muscles, which causes diffict in opening the mouth and in masticating; hence the name ‘lockjaw’. Lockjaw in tetanus is painl unlike the spasm of the masseters due to dental abscess, septic throat or other caus \ditions that can mimic tetanus include hysteria and phenothiazine overdosage, or overdose in intravenous drug misusers.> 4 In tetanus, (the tonic rigidity spreads to involve the muscles of the face, neck and trunkyContraction of the frontalis and the muscles at the angles of the mouth leads to the so-called ‘risus sardonicus’. There is rigidity of the muscles at the neck and trunk of varying deares{the back is usually slightly arched (‘opisthotonus’) and there is a board-like abdominal wall. In the more severe cases, violent spasms lasting for a few seconds to 3-4 minutes occur spontaneously, or may be induced by stimuli such as movement or noise. These episodes are painful and exhausting, and suggest a grave outlook, especially if they appear soon after the onset of symptoms. They gradually increase in frequency and severity for about 1 week and the patient may die from exhaustion, asphyxia or aspiration pneumonia. In less severe illness, periods of spasm may not commence until a week or so after the first sign of rigidity, and in very mild infections they may never appear. Autonomic involvement may cause cardiovascular complications, such as hypertension. Rarely, the only manifestation of the disease may be ‘local tetanus’ — stiffness or spasm of the muscles near the infected wound - and the prognosis is good if treatment is commenced at this stage. Investigations The diagnosis is made on clinical grounds. It is rarely possible to isolate the infecting organism from the original locus of entry. Management Established disease Management of established disease should begin as soon as possible, as shown in Box 25.71.Prevention Tetanus can be prevented by immunisation and prompt treatment of contaminated wounds by débridement and antibiotics. In patients with a contaminated wound, the immediate danger of tetanus can be greatly reduced by the injection of 1200 mg of penicillin followed by a 7-day course of oral penicillin. For those allergic to penicillin, erythromycin should be used. When the risk of tetanus is judged to be present, an intramuscular injection of 250 IU of human tetanus antitoxin should be given, along with toxoid, which should be repeated 1 month and 6 months later. For those already immunised, only a booster dose of toxoid is required.—] 25.71 Treatment of tetanus Neutralise absorbed toxin © Give IV injection of 3000 IU of human tetanus antitoxin Prevent further toxin production e Débride wound © Give benzylpenicillin 600 mg IV 4 times daily (metronidazole if patient is allergic to penicillin) Control spasms e Nurse in a quiet room e Avoid unnecessary stimuli © Give IV diazepam e If spasms continue, paralyse patient and ventilate General measures ¢ Maintain hydration and nutrition ¢ Treat secondary infections