Tetanus

 

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Original Editors - Natalie Gutmann from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

 Tetanus is an acute disease caused by the anaerobic (without oxygen), gram positive, non-capsulated spore forming bacteria Clostridium tetani. C. tetani can resist very high temperatures and is not spread from person to person. Tetanus is a rare and often fatal neurological disease that causes increased tone and muscle spasms due to the bacteria.^1,2 The most common way the bacterium enters the body is through wounds which are susceptible to infection if they are: “contaminated with soil, feces, or saliva, puncture wounds including unsterile injection sites, devitalized tissue including burns, avulsions and degloving injuries”.³
The disease tetanus extends all the way back to the fifth century BC. However, it was not untill the late 1800s that the discovery of the toxins that caused tetanus had the ability to infect several species and that protection could be provided by passive transfer of an antitoxin.² In 1924, the immunization to protect people against tetanus was developed and by 1940 the tetanus immunization has become a routine in children’s vaccinations.¹

Prevalence

 In the United States, from 2000-2007 there has been an “average of 31 reported cases per year with the majority of them being over the age of 40.”⁴ In recent years the percent of people who contracted the bacteria to those that die from it has decreased from 30% to 10%. Since 1989 there has only been 2 reported cases of tetanus in the neonatal population.⁴ It is estimated that about 800,000 to one million people die of tetanus every year worldwide.¹ The majority of the cases are found in underdeveloped countries with children and neonates representing most of the cases due to inadequate immunizations and unhealthy medical procedure especially during childbirth.³ The prevalence of Tetanus has been identified in males over the age of 50, women without formal education, African American of south. Recently immigrants and intravenous drug users have had a higher prevalence for contracting Tetanus. Anyone over the age of 60 are at an increases risk for contracting tetanus due to the face that they may not have received the protective immunity.¹

Characteristics/Clinical Presentation

There are four different forms of tetanus: generalized tetanus, local tetanus, cehalic tetanus, and neonatal tetanus

Generalizes tetanus
This is the most common form of tetanus resulting in about 80% of the cases.⁴ In generalized tetanus the tetanospsmin attacks and inhibits mostly the motor neurons of the CNS and later the neurons of the ANS as well. As a result a person experiences uncontrollable intense muscle contractions.³ The first muscles affected are the facial muscles and the jaw (commonly referred to as lock jaw or trismus) because of their short nerve pathways. As the disease progresses the person will experience stiffness of the neck, difficulty swallowing, and stiffness of the abdominal muscles.^3,4 Spasms can be produced by a stimulus such as light, noise, touch, or unexpectedly with no specific cause.3 Spasms are extremely painful and can occur frequently and can last for several minutes. ^3,4 In generalized tetanus “ spasms continue for 3-4 weeks and complete recovery may take months.”⁴ After several days the ANS will be affected showing others sings such as fever, sweating, elevated blood pressure, and increased or rapid heart rate.^3,4

Local tetanus
Local tetanus can occur before generalized tetanus but this is a much milder form with a decreased amount of associated toxin.³ Local tetanus is rare there is a better prognosis with only about 1% of the cases resulting in death. ⁴ The presentation of local tetanus is muscle rigidity and continuous contractions close to the site to injury.^3,4

Cehalic tetanus
Cehalic tetanus is also rare and shows a combination of both generalized and local tetanus.³ The characteristics of this type of tetanus are facial spasms and paralysis as a result of involvement of the cranial nerves. Head wounds are the main cause with occasional occurrence found with ear infections (otitis media) associated with a head wound.^2,3,4 Cehalic tetanus can progress to generalized tetanus and can be associated with a high fatality rate.³

Neonatal tetnus
In neonatal tetanus is a form of generalized tetanus found in newborn babies with a high fatality rate.³ The symptoms usually “appear 4-14 days after birth”⁴ and occurs due to non immune mothers and poor hygiene during the delivery process.³ Most of the cases of infected infants is a result of infection of the unhealed stump of the umbilical cord especially if the cord has been cut with unsterile instruments. Neonatal tetanus is common in third world countries.⁴

Associated Co-morbidities

• Laryngospasm: Spasms in the muscles of respiration can interfere with breathing⁴
• Fractures: As a result of spasms, most frequently affected the spine and long bones⁴
• Hypertension or abnormal heart rhythem: Hyperactivity of the ANS⁴
• Nosocomial infections: Due to prolonged hospitalization⁴
• Pulmonary Embolism: Mostly seen in the elderly and drug users⁴
• Aspiration pneumonia: Found in the elderly and late stages of tetanus⁴

Medications

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Diagnostic Tests/Lab Tests/Lab Values

There are no specific laboratory or diagnostic tests used to diagnosis tetanus. The diagnosis is made based on clinical signs and symptoms and not on the confirmation of the bacteria C. tetani in the body. 4,5 “C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus.”4

Etiology/Causes

Once the bacteria C. tetani enters the body the spores multiply and germinate due to the anaerobic environment. In the body two toxins are released tetanospamin and tetenolysis.1,5 It is not certain the exact role that tetanolysin but it is believed that it works with the toxin tetanospamin.1,4 Tetanospamin reaches the peripheral nerves by retrograde neuronal transport through the blood or lymphatic system.1,5 “The length of the peripheral nerves determines how long it takes for the neurotoxins to reach the central nervous system (CNS) and cause systems. The toxin tetanospamin disrupts the release of the inhibitory neurotransmitters glycine and GABA throughout the CNS but most commonly at the motor end plates, spinal cord, brain, and sympathetic nervous system”.1 “The disinhibition allows for unopposed muscular contraction followed by muscular rigidity and spasms”.1 Once the bacteria has entered the body the incubation period may range from days to months. The average incubation period is around 4-14 days the incubation period is shorter the closer the injury site is to the CNS.1,2,4 A shorter incubation period usually correlates with poor prognosis due to a more severe disease.2

Systemic Involvement

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Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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