Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 33-05: Clostridial Diseases + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ History of wound with possible contamination Jaw muscle stiffness ("lock jaw") then spasms (trismus) Stiffness of the neck and other muscles Dysphagia Irritability Hyperreflexia Finally, painful convulsions precipitated by minimal stimuli +++ General Considerations ++ Caused by the neurotoxin tetanospasmin elaborated by Clostridium tetani Spores of this organism are ubiquitous in soil. When introduced into a wound, spores may germinate Tetanospasmin interferes with neurotransmission at spinal synapses of inhibitory neurons Minor stimuli result in uncontrolled spasms, and reflexes are exaggerated Most cases occur in unvaccinated individuals Persons at risk Elderly Migrant workers Newborns Injection drug users, who may acquire the disease through subcutaneous injections + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ The first symptom may be pain and tingling at the site of inoculation, followed by spasticity of the muscles nearby Other early signs Stiffness of the jaw Neck stiffness Dysphagia Irritability Hyperreflexia develops later, with spasms of the jaw muscles (trismus) or facial muscles and rigidity and spasm of the muscles of the abdomen, neck, and back Painful tonic convulsions precipitated by minor stimuli are common Spasms of the glottis and respiratory muscles may cause acute asphyxia The patient is awake and alert throughout the illness. The sensory examination is normal. The temperature is normal or only slightly elevated Urinary retention and constipation may result from spasm of the sphincters Respiratory arrest and cardiac failure are late, life-threatening events +++ Differential Diagnosis ++ Meningitis Rabies Tetany due to hypocalcemia Strychnine poisoning Neuroleptic malignant syndrome Trismus due to peritonsillar abscess + Diagnosis Download Section PDF Listen +++ ++ Clinical + Treatment Download Section PDF Listen +++ +++ Medications ++ Human tetanus immune globulin, 500 units, is given intramuscularly to those with clinical signs and symptoms of tetanus. Active immunization with tetanus toxoid should be started concurrently Table 33–2 provides a guide to prophylactic management Debridement of wounds should be undertaken if implicated as the source Metronidazole 7.5 mg/kg administered intravenously or orally every 6 hours (maximum 4 g daily) is preferred and should be administered to all patients Penicillin, 20 million units intravenously daily in divided doses, is an alternative ++Table Graphic Jump LocationTable 33–2.Guide to tetanus prophylaxis in wound management.View Table||Download (.pdf) Table 33–2. Guide to tetanus prophylaxis in wound management. History of Absorbed Tetanus Toxoid Clean, Minor Wounds All Other Wounds1 Tdap or Td2 TIG3 Tdap or Td2 TIG3 Unknown or < 3 doses Yes No Yes Yes 3 or more doses No4 No No5 No 1Such as, but not limited to, wounds contaminated with dirt, feces, soil, saliva, etc; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.2Td indicates tetanus toxoid and diphtheria toxoid vaccine, adult form. Tdap indicates tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, which may be substituted as a single dose for Td. Unvaccinated individuals should receive a complete series of three doses, one of which is Tdap.3Human tetanus immune globulin, 250 units intramuscularly.4Yes if more than 10 years have elapsed since last dose.5Yes if more than 5 years have elapsed since last dose. (More frequent boosters are not needed and can enhance side effects.) Tdap has been safely administered within 2 years of Td vaccination, although local reactions to the vaccine may be increased. +++ Therapeutic Procedures ++ Minimal stimuli can provoke spasms, so the patient should be placed at bed rest and monitored under the quietest conditions possible Sedation, paralysis with curare-like agents, and mechanical ventilation are often necessary to control tetanic spasms Enteral nutritional support should be given early + Outcome Download Section PDF Listen +++ +++ Complications ++ Airway obstruction Urinary retention and constipation Respiratory arrest Pneumonia +++ Prevention ++ Tetanus is preventable by active immunization (Table 30–7) For primary immunization of adults Tetanus and diphtheria toxoids are administered as two doses 4–6 weeks apart, with a third dose 6–12 months later Booster Td doses are given at time of major injury if it occurs more than 5 years after a dose Women should receive Tdap with each pregnancy, preferably between 27 and 36 weeks, with immunization at 27–30 weeks associated with the highest antibody concentrations ++Table Graphic Jump LocationTable 30–7.Recommended adult immunization schedule—United States, 2020.View Table||Download (.pdf) Table 30–7. Recommended adult immunization schedule—United States, 2020. +++ Prognosis ++ High mortality rates are associated with A short incubation period Early onset of convulsions Delay in treatment Contaminated lesions about the head and face are more dangerous than wounds on other parts of the body The overall mortality rate is about 40%, but this can be reduced with ventilator management +++ When to Refer ++ For mechanical ventilation, refer to an intensivist or pulmonary specialist +++ When to Admit ++ Any patient in whom there is clinical suspicion of the disease Intensive care unit may be needed + Reference Download Section PDF Listen +++ + +Heal CM et al. Association between third-trimester Tdap immunization and neonatal pertussis antibody concentration. JAMA. 2018 Oct 9;320(14):1464–70. [PubMed: 30304426]