tetanus
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Etiology
- most cases follow acute injury
- complications of chronic conditions
- other conditions
- burns
- frost bite
- middle ear infection
- surgery
- abortion
- childbirth
- drug abuse 'skin popping'
- predisposing conditions
Epidemiology
- occurs largely in inadequately immunized individuals
- most common in warm climates & during summer months
- occurs more commonly in males
- in countries without immunization program, tetanus occurs largely in infants & young children
- in USA, 60 cases of tetanus reported to CDC 1991-94; 37 cases in 2001[3]; 21 cases in California 2008-2014[5]
Pathology
- contamination of wounds with spores of C. tetani is probably common
- germination & toxin production takes place in wound with low redox potential
- C tetani does not evoke inflammation
- tetanus toxin released by autolysis of vegetative organisms binds to peripheral motor neuron terminals, is internalized, retrogradely transported to nerve cell bodies in spinal cord & brain stem, then migrates across synapse to presynaptic terminals of inhibitory neurons
- tetanus toxin inhibits release of glycine & GABA from inhibitory neurons thus increasing the resting firing rate of alpha motor neurons
- loss of inhibition may also affect preganglionic sympathetic neurons in the lateral gray matter of the spinal cord, resulting in increased adrenergic tone
- tetanus toxin may also inhibit neurotransmitter release at neuromuscular junction
- recovery requires sprouting of new nerve terminals
- in localized disease, only the nerves supplying the affected muscle are involved
- in generalized disease, the toxin enters the lymphatics & blood stream & is spread to distant nerve terminals
- tetanus toxin does not cross the blood brain barrier
Clinical manifestations
- onset 3-14 days after injury (median 7 days)
- increased tone in masseter muscle (trismus, lockjaw)
- dysphagia
- neck, shoulder, & back pain
- rigid abdomen
- stiff proximal muscles
- hands & feet relatively spared
- sustained contraction of the face
- sustained contraction of the back muscles (opisthotonos)
- painful generalized muscle contractions
- respiratory failure
- fever
- autonomic dysfunction
Laboratory
- wound cultures
- Clostridium tetani may be isolated from wounds of patients without tetanus
- Clostridium tetani may not be recovered from wounds of patients with tetanus
- leukocytosis
- cerebrospinal fluid is normal
- see ARUP consult[4]
Diagnostic procedures
Complications
- pneumonia
- muscle rupture
- rhabdomyolysis
- thrombophlebitis
- pulmonary embolus
- decubitus ulcer
- case fatality: 5 of 21 patients in Calfornia 2008-2014[5]
Differential diagnosis
- alveolar abscess (trismus)
- strychnine poisoning
- dystonic drug reactions
- hypercalcemic tetany
- meningitis
- encephalitis
- rabies
- intra-abdominal disorder (rigid abdomen)
Management
- general measures
- quiet room in intensive care unit (ICU)
- cardiopulmonary monitoring
- wound exploration, cleaning, debriding
- prophylaxis
- tetanus toxoid (dT) if patient is > 6 years of age
- immunization status unknown
- human tetanus immune globulin (TIG) 250 units IM
- < 3 immunizations with tetanus toxoid
- no tetanus immunization in last 10 years
- contaminated wound & no tetanus immunization in last 5 year
- immunization status unknown
- a single dose of TdaP should be given to adults age >= 10 years to replace the next diphtheria-tetanus toxoid dT booster[5]
- TdaP is acceptable alternative to dT
- tetanus toxoid (dT) if patient is > 6 years of age
- antibiotics
- penicillin G 10-12 million units QD for 10 days
- clindamycin or erythromycin if allergic to penicillin
- control of muscle spasms
- benzodiazepines (1st line)
- barbiturates (2nd line)
- chlorpromazine (2nd line)
- propofol (Diprivan)
- dantrolene
- baclofen
- airway protection
- autonomic dysfunction
- optimal therapy not defined
- suggested agents
- labetalol (has been associated with sudden death)
- esmolol (may be associated with unopposed alpha activity)
- clonidine
- morphine
- magnesium sulfate
Notes
- immunization status of 21 cases in California 2008-2014 from recall[5]
- no other documentation of immunization status found
More general terms
Additional terms
- Clostridium tetani
- diphtheria toxoid/tetanus toxoid (dT, Td)
- tetanus immune globulin (HyperTet, TIG, tetanus antitoxin)
- tetanus toxin (TeTx); tetanospasmin
- tetanus toxoid
- tetany
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 633-34
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 901-904
- ↑ 3.0 3.1 Journal Watch 24(12):99, 2004 Kruszon-Moran DM, McQuillan GM, Chu SY. Tetanus and diphtheria immunity among females in the United States: are recommendations being followed? Am J Obstet Gynecol. 2004 Apr;190(4):1070-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15118644
- ↑ 4.0 4.1 ARUP Consult: Clostridium tetani - Tetanus deprecated reference
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Yen C, Murray E, Zipprich J et al Missed Opportunities for Tetanus Postexposure Prophylaxis - California, January 2008-March 2014 MMWR Weekly. March 13, 2015 / 64(09);243-246 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6409a2.htm
- ↑ Rhinesmith E, Fu L. Tetanus Disease, Treatment, Management. Pediatr Rev. 2018 Aug;39(8):430-432. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30068747