Tetanus and neonatal tetanus. Its symptoms,diagnosis,prevention,vaccination and treatment.

1. TETANUS
(LOCKJAW)
BY; DR YUSUF IMRAN
DEPT. OF PEDIATRICS
J.N MEDICAL COLLEGE
AMU-INDIA

2. ETIOLOGY
• TETANUS, HISTORICALLY CALLED LOCKJAW, IS AN ACUTE, SPASTIC
PARALYTIC ILLNESS CAUSED BY TETANUS TOXIN
• AGENT- CLOSTRIDIUM TETANI, A MOTILE, GRAM-POSITIVE,
SPORE-FORMING, OBLIGATE ANAEROBE IS NOT A TISSUE-INVASIVE
ORGANISM
• TETANUS TOXIN (TETANOSPASMIN)- NEUROTOXIN PRODUCED BY
IT CAUSES DISEASE MANIFESTATIONS
• IT IS THE SECOND MOST POISONOUS SUBSTANCE KNOWN (AFTER
BOTULINUM TOXIN )
• TETANOLYSIN- A HEMOLYTIC TOXIN ,POTENTIATE INFECTION BUT
DOESNOT CONTRIBUTE TO DISEASE PROCESS

3. EPIDEMIOLOGY.
• TETANUS OCCURS WORLDWIDE AND IS ENDEMIC IN 90
DEVELOPING COUNTRIES
• MOST COMMON FORM, NEONATAL (UMBILICAL) TETANUS,
KILLS APPROXIMATELY 500,000 INFANTS EACH YEAR (ABOUT
80% DEATHS INVOLVING 12 TROPICAL COUNTRIES)
• AN ESTIMATED 15,000-30,000 UNIMMUNIZED WOMEN
WORLDWIDE DIE EACH YEAR OF MATERNAL TETANUS THAT
RESULTS FROM POSTPARTUM, POSTABORTAL, OR
POSTSURGICAL WOUND INFECTION WITH C. TETANI

4. • MOST NON-NEONATAL CASES OF TETANUS ARE ASSO. WITH A
TRAUMATIC INJURY, FOR EXAMPLE-
1) A PENETRATING WOUND INFLICTED BY A DIRTY OBJECT, SUCH
AS A NAIL, SPLINTER, FRAGMENT OF GLASS
2) AFTER ILLICIT DRUG INJECTION, IN ADDICTS
3) UNCOMMON SETTINGS INCLUDE ANIMAL BITES, ABSCESSES
(INCLUDING DENTAL ABSCESSES), EAR PIERCING, BURNS,
COMPOUND FRACTURES, FROSTBITE, GANGRENE, INTESTINAL
SURGERY, RITUAL SCARIFICATION, INFECTED INSECT BITES
4) THE USE OF CONTAMINATED SUTURE MATERIAL OR AFTER
INTRAMUSCULAR INJECTION

5. PATHOGENESIS
SPORES GERMINATE, MULTIPLY, AND
PRODUCE TETANUS TOXIN IN THE INFECTED
INJURY SITE
TOXIN IS RELEASED WITH VEGETATIVE
BACTERIAL CELL DEATH AND SUBSEQUENT
LYSIS
TETANUS TOXIN BINDS AT THE
NEUROMUSCULAR JUNCTION AND ENTERS

6. UNDERGOES RETROGRADE AXONAL TRANSPORT TO THE
CYTOPLASM OF THE ALPHA-MOTOR NEURON
TOXIN EXITS THE MOTOR NEURON IN THE SPINAL CORD
AND NEXT ENTERS ADJACENT SPINAL INHIBITORY INTERNEURONS
BLOCKS THE NORMAL INHIBITION OF ANTAGONISTIC MUSCLES
AFFECTED MUSCLES SUSTAIN MAXIMAL CONTRACTION RESULTING
IN TETANUS

7. CLINICAL MANIFESTATIONS
• THE INCUBATION PERIOD TYPICALLY IS 2-14 DAYS (USUALLY
ABOUT 8 DAYS)
• VARIOUS TYPES OF TETANUS ARE:
• GENERALIZED TETANUS- TRISMUS (MASSETER MUSCLE SPASM,
OR LOCKJAW) MAY BE THE PRESENTING SYMPTOM
• HEADACHE, RESTLESSNESS, AND IRRITABILITY ARE EARLY
SYMPTOMS
• STIFFNESS, DIFFICULTY CHEWING, DYSPHAGIA, AND NECK
MUSCLE SPASM FOLLOW LATER

8. • OPISTHOTONOS-PATIENT MAY ASSUME AN ARCHED POSTURE
OF EXTREME HYPEREXTENSION OF THE BODY
• SARDONIC SMILE (RISUS SARDONICUS) RESULTS FROM
INTRACTABLE SPASM OF FACIAL AND BUCCAL MUSCLES
• LARYNGEAL AND RESPIRATORY MUSCLE SPASM CAN LEAD TO
AIRWAY OBSTRUCTION AND ASPHYXIATION
• AS TETANUS TOXIN DOES NOT AFFECT SENSORY NERVES OR
CORTICAL FUNCTION, THE PATIENT REMAINS CONSCIOUS, IN
EXTREME PAIN, AND IN FEARFUL ANTICIPATION

9. • NEONATAL TETANUS (TETANUS NEONATORUM)- INFANTILE
FORM OF GENERALIZED TETANUS, TYPICALLY MANIFESTS
WITHIN 3-12 DAYS OF BIRTH AS PROGRESSIVE DIFFICULTY IN
FEEDING
• LOCALIZED TETANUS- RESULTS IN PAINFUL SPASMS OF THE
MUSCLES ADJACENT TO THE WOUND SITE AND MAY PRECEDE
GENERALIZED TETANUS
• CEPHALIC TETANUS- RARE FORM OF LOCALIZED TETANUS
INVOLVING THE BULBAR MUSCULATURE THAT OCCURS WITH
WOUNDS OR FOREIGN BODIES IN THE HEAD, NOSTRILS, OR
FACE(ASSO. WITH CHRONIC OTITIS MEDIA)

10. DIFFERENTIAL DIAGNOSIS (OF
LOCKJAW)
• PARAPHARYNGEAL, RETROPHARYNGEAL, OR DENTAL
ABSCESSES RESULTING IN TRISMUS
• RABIES MAY PRESENT AS TRISMUS WITH SEIZURES
• STRYCHNINE POISONING MAY RESULT IN TONIC MUSCLE
SPASMS
• HYPOCALCEMIA MAY PRODUCE TETANY, CHARACT. BY
LARYNGEAL AND CARPOPEDAL SPASMS
• OCCASIONALLY, EPILEPTIC SEIZURES, NARCOTIC WITHDRAWAL,
OR OTHER DRUG REACTIONS MAY SUGGEST TETANUS

11. MANAGEMENT
• GENERAL - SURGICAL WOUND EXCISION AND DEBRIDEMENT IS OFTEN
NEEDED
• PATIENT SHOULD BE SEDATED AND PROTECTED FROM ALL UNNECESSARY
SOUNDS, SIGHTS, AND TOUCH
• CAREFUL NURSING ATTENTION TO MOUTH, SKIN, BLADDER, AND BOWEL
FUNCTION IS NEEDED
• MUSCLE RELAXANTS- DIAZEPAM PROVIDES BOTH
RELAXATION AND SEIZURE CONTROL (INITIAL DOSE OF 0.1-0.2MG/KG Q 3-
6 HR)
• MAGNESIUM SULFATE, OTHER BENZODIAZEPINES (E.G., MIDAZOLAM),
CHLORPROMAZINE,DANTROLENE, AND BACLOFEN ARE ALSO USED

12. • SPECIFIC TREATMENT
• HUMAN TETANUS IMMUNOGLOBULIN(TIG ) IS GIVEN AS SOON
AS POSSIBLE TO NEUTRALIZE TOXIN BEFORE IT CAN BIND AT
DISTANT MUSCLE GROUPS
• A SINGLE INTRAMUSCULAR INJECTION OF 500 U OF TIG IS
SUFFICIENT , BUT TOTAL DOSES AS HIGH AS 3,000-6,000 U
ARE ALSO RECOMMENDED
• ANTIBIOTIC- PENICILLIN G (100,000 U/KG/24 HR DIVIDED Q
4-6 HR IV FOR 10-14 DAYS) REMAINS THE ANTIBIOTIC OF
CHOICE
• METRONIDAZOLE ,ERYTHROMYCIN AND TETRACYCLINE ARE

13. COMPLICATIONS
• ASPIRATION OF SECRETIONS AND PNEUMONIA
• SEIZURES MAY RESULT IN :
1. LACERATIONS OF THE MOUTH OR TONGUE,
2. INTRAMUSCULAR HEMATOMAS OR RHABDOMYOLYSIS WITH
MYOGLOBINURIA AND RENAL FAILURE
3. LONG BONE OR SPINAL FRACTURES
• VENOUS THROMBOSIS, PULMONARY EMBOLISM, GASTRIC
ULCERATION, PARALYTIC ILEUS, AND DECUBITUS ULCERATION
ARE CONSTANT HAZARDS
• MAINTAINING AIRWAY PATENCY OFTEN MANDATES
ENDOTRACHEAL INTUBATION AND MECHANICAL VENTILATION

14. PREVENTION
• TETANUS IS AN ENTIRELY PREVENTABLE DISEASE; A SERUM
ANTIBODY TITER OF ≥0.01 U/ML IS CONSIDERED PROTECTIVE
• ACTIVE IMMUNIZATION SHOULD BEGIN IN EARLY INFANCY
WITH COMBINED DPT VACCINE AT 2, 4, AND 6 MO OF AGE, F/B
A BOOSTER AT 15MTH AND 4-6 YR OF AGE (DT) & AT 10-YR
INTERVALS THEREAFTER WITH (TD) TOXOIDS
• IMMUNIZATION OF WOMEN WITH TETANUS TOXOID PREVENTS
NEONATAL TETANUS