Tetanus

By Dr. Haile Onado.(MD,pediatrics resident)

Tetanus
• An acute, spastic paralytic illness caused by
tetanus toxin (tetanospasmin), the neurotoxin
produced by Clostridium tetani
Etiology
• C. tetani, a motile gram + spore forming
obligate anaerobe whose natural habitat is
soil, dust & alimentary tract of animals
• Can survive boiling
Epidemiology
• Endemic in 90 developing countries
• Most common form – neonatal (umbilical) tetanus,
killing ~500,000 infants each year
• ~80% of deaths occur in just 12 tropical Asian &
African countries
• Additionally, 15,000 – 30,000 Unimmunized
mothers die each year from:
 maternal tetanus result from post-partum, post-abortal
& post-surgical wound infection
• Most non-neonatal cases associated with traumatic
injury by a dirty object
Pathogenesis
Corticospinal N
Descending SN

Inhibitory Interneuron

Alpha motoneuron

Adrenal
Medulla
muscle
NMJ
Pathogenesis
• Introduced spores germinate, multiply &
produce tetanospasmin and tetanolysin at an
infected injury site
 Tetanolysin damages viable tissue increasing the
volume of tissue for multiplication of the organism
• Tetanus toxin binds at neuromuscular
junction ➞ retrograde axonal transport to
cytoplasm of alpha motoneuron cells (3.4 mm/hr)
Pathogenesis
• Exit alpha motoneuron & enter adjacent
inhibitory interneuron ➞ blocks normal
inhibition of agonist and antagonistic muscles
➞ tetanic spasms
• It can block also inhibition of the
intermediolateral neurons that control
adrenal medulla ➞ autonomic disturbances
Clinical Manifestation
• Incubation period – 2 to 14 days commonly;
but can be as long as months after the injury
• Can be divided in to two:
• Generalized tetanus –
 Trismus or lock jaw (masseter muscle spasm) is
presenting symptom in about 50%
 Headache, restlessness, and irritability are early
symptoms often followed by stiffness, dysphagia and
neck muscle spasm
Clinical manifes…..
 Opisthotonus – arched posture due to involvement of
abdominal, lumbar, hip and thigh muscles (“board” like
rigidity in which the back of the head and heals touch
ground)
 Laryngeal and respiratory muscle spasm can lead to
airway obstruction and asphyxiation
 Risus Sardonicus (sardonic smile) results from
intractable spasm of facial and buccal muscles
 Patient remains conscious in extreme pain and
anticipation of next tetanic seizure
 Tetanic spasm may be triggered by the smallest
disturbance (sight, sound or touch)
Clinical manifes….

• High grade fever – due to a catabolic state

 Autonomic NS manifestations: tachycardia, arrhythmias,
labile hypertension, diaphoresis and cutaneous
vasoconstriction
 Tetanic paralysis become more intense in the first week
after onset, and stabilizes over the ensuing one to four
weeks
• Neonatal tetanus (Tetanus Neonatrum):
 Infantile type of generalized tetanus
 Typically manifests with in 3 – 12 days of birth
 Difficulty in feeding, crying, paralysis, stiffness to touch
with or without opisthotonus are characteristics
Clinical…
• Localized tetanus
Painful spasm of muscles adjacent to the wound site
May precede generalized tetanus
• Cephalic tetanus:
A rare form of localized tetanus involving the bulbar
musculature
Follow wounds or foreign bodies in the head, nostrils
or face, and occasionally chronic otitis media
Characterized by retracted eye lids, deviated gaze,
trismus, risus sardonicus and spastic paralysis of the
tongue
Diagnosis

• No diagnostic lab test

• Based on Hx and clinical finding
• Differential diagnosis:
Strychnine poisoning
Meningitis
Peritonitis
Rabies
Dental abscess
Hypocalcemic tetany
Treatment
• Principles
Eradication of C. tetani and wound
environment conducive for its multiplication
Neutralization of all accessible tetanus toxin
Control of spasms
Provision of meticulous supportive care
Prevention of recurrences