Tetanus: Tetanus is an acute, often fatal disease that is characterized by generalized increased rigidity and convulsive spasms of skeletal

muscles. Tetanus is caused by the spore-forming bacterium Clostridium tetani History: First described by Hippocrates as a timeless human misery. The etiology of Tetanus was discovered in 1884 by Antonio Carle and Giorgio Rattone, who demonstrated the transibility of the disease for the first time. They produced Tetanus in rabbits by injecting their sciatic nerves (largest nerve fiber running from the lower back through buttocks to the lower limb) with pus from a fatal patient with Tetanus. In 1889, Dr. Shibasaburo Kitasato isolated C. tetani (a type of anaerobic bacterium) from a human victim which showed that it could produce disease when injected into animals. He reported that the toxin could be neutralized by specific antibodies. In 1897, Edmond Nocard demonstrated that tetanus antitoxin induced passive immunity in humans and could be used for prophylaxis (medical procedure to prevent rather that cure a disease) and treatment. Tetanus toxoid vaccine was developed by P. Descombey in 1924, and was widely used to prevent tetanus induced by battle wounds during World War II. How Disease Was Contracted: Tetanus is a worldwide health problem since C. tetani spores are found everywhere. A person can contract tetanus through contaminated wounds or tissue injury. Spores can be introduced into the body through contaminated wounds or tissue injury. The spores can also be found on the surfaces of the skin. C. tetani spores (the dormant form of the organism) are found in soil and in animal and human feces. The spores enter the body through breaks in the skin, and germinate under low-oxygen conditions. Puncture wounds and wounds with a significant amount of tissue injury are more likely to promote germination. The vegetative organisms excrete the potent toxin tetanospasmin into the bloodstream. The toxin then reaches the nervous system, causing painful and often violent muscular contractions Acts at several sites: Central nervous system Spinal cord Brain Sympathetic nervous system

It occurs most commonly in densely populated regions and hot and damp climate rich in organic matter. This is particularly true with manure-treated soils, as the spores are widely distributed in the intestines and feces of many non-human animals such as horses, sheep, cattle, dogs, cats, rats, guinea pigs, and chickens. . In agricultural areas, a significant number of human adults may harbor the organism. Contraction of Tetanus peaks during the summer or wet season. It is not contagious from person to person. It is the only vaccine-preventable disease that is infectious but not contagious. Symptoms: Four clinical forms: Localized (uncommon) Cephalic (rare) Generalized (most common) Neonatal

Localized tetanus -Unusual presentation Persistent contraction of muscle in same anatomic area as the injury Contractions may persist for many weeks before subsiding May precede the onset of generalized tetanus Only 1% of cases are fatal Cephalic tetanus (rare) Rare presentation Special form of localized disease affecting the cranial nerve musculature Occurs after injury to scalp, eyes, face, ear or neck, conjunctiva Clinical manifestations 1-2 days after injury : Facial palsy Dysphagia Paralysis of extraocular muscles Outcome is variable Generalized tetanus -Most commonly recogized form

 Masseter muscle rigidity - trismus (lockjaw) Risus sardonicus ( increased tone in orbicularis oris muscle) Stiffness of neck Difficulty swallowing Abdominal muscle rigidity Neonatal - A form of generalized tetanus that occurs in newborns. Infants who have not acquired passive immunity because the mother has never been immunized are at risk. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument Generalized spasms resembles decorticate posturing- opisthotonic posturing with flexion of arms and extension of legs Patient does not lose consciousness and experiences severe pain during each spasm Spasms triggered by sensory stimuli Spasms continue for 2-3 weeks; (time required to complete transport of toxin already intraaxonal) after antitoxin is given If antitoxin not given, complete recovery take months (until cessation of production/ binding of tetanospasmin and formation of new neuromuscular junctions) Diagnosis:

The diagnosis is almost always made clinically. The disease is characterized by painful muscular contractions, primarily of the masseter and neck muscles, secondarily of trunk muscles. A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, though rigidity is sometimes confined to the region of injury. Generalized spasms occur, frequently induced by sensory stimuli; typical features of the tetanic spasm are the position of opisthotonos and the facial expression known as risus sardonicus. History of an injury or apparent portal of entry may be lacking. The organism is rarely recovered from the site of infection, and usually there is no detectable antibody response.

The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the involuntary

contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a gag reflex attempting to expel the foreign object

Treatment or Cure/Prevention: The tetanus vaccine can prevent tetanus, but its protection does not last forever. Adults should get a tetanus shot, or booster, every 10 years.

Three goals of management : Neutralize the toxin Eradicate C. tetani Provide supportive care and maintain adequate airway and nutrition Numerous formulations of tetanus toxoidcontaining vaccines are available in the United States. Tetanus and diphtheria toxoids and acellular pertussis (DTaP) and diphtheria and tetanus toxoids (DT) are licensed for infants and children younger than 7 years of age; and tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) are licensed for children 7 years of age and older and adults.

Tetanus disease does not confer immunity because of very small amount of toxin required to produce illness Patients recovering from tetanus should begin or complete active immunization with tetanus toxoid during period of recovery. Prevention of Tetanus Wound management Routine immunization

Mortality Rate:
Mortality and incidence rates of tetanus reported in the United States, 1900 to 2005.

In the United States, the reported mortality due to tetanus has declined at a constant rate since the early 1900s, and documented tetanus incidence has declined since the mid- to late 1940s, when national reporting of tetanus cases began Tetanus death statistics by worldwide region:

About 84,000 deaths from tetanus in Africa 2002 (The World Health Report, WHO, 2004) About 82,000 deaths from tetanus in South East Asia 2002 (The World Health Report, WHO, 2004) About 36,000 deaths from tetanus in Eastern Mediterranean 2002 (The World Health Report, WHO, 2004) About 11,000 deaths from tetanus in Western Pacific 2002 (The World Health Report, WHO, 2004)

Source: Centers for Disease Control and Prevention

Prognosis (Recovery Chances): Localized tetanus can be mild or progress to generalized tetanus which is dangerous and can be fatal.

Without treatment, one out of four infected people die. The death rate for newborns with untreated tetanus is even higher. With proper treatment, less than 10% of infected patients die. Wounds on the head or face seem to be more dangerous than those on other parts of the body. If the person survives the acute illness, recovery is generally complete. Uncorrected episodes of hypoxia (lack of oxygen) caused by muscle spasms in the throat may lead to irreversible brain damage.

Organizations:
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National Center for Immunization and Respiratory Diseases [http://www.cdc.gov/vaccines/](Centers for Disease Control and Prevention) National Institute of Allergy and Infectious Diseases [http://www.niaid.nih.gov/Pages/default.aspx] Return to top [http://www.nlm.nih.gov/medlineplus/tetanus.html#skip]