Tetanus
Encyclopedia
Tetanus is a medical condition characterized by a prolonged contraction of skeletal muscle
fibers. The primary symptoms are caused by tetanospasmin
, a neurotoxin
produced by the Gram-positive
, rod-shaped
, obligate anaerobic bacterium
Clostridium tetani
. Infection generally occurs through wound contamination and often involves a cut or deep puncture wound. As the infection progresses, muscle spasm
s develop in the jaw (thus the name "lockjaw") and elsewhere in the body. Infection can be prevented by proper immunization and by post-exposure prophylaxis
.
Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems.
Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups. This is called tetany. These episodes can cause fractures and muscle tears.
Other symptoms include:
• Drooling
• Excessive sweating
• Fever
• Hand or foot spasms
• Irritability
• Swallowing difficulty
• Uncontrolled urination or defecation
Tetanus affects skeletal muscle
, a type of striated muscle
used in voluntary movement. The other type of striated muscle, cardiac or heart muscle, cannot be tetanized because of its intrinsic electrical properties. Mortality rates reported vary from 48% to 73%. In recent years, approximately 11% of reported tetanus cases have been fatal
. The highest mortality rate
s are in unvaccinated people and people over 60 years of age.
The incubation period of tetanus may be up to several months but is usually about 8 days. In general, the further the injury site is from the central nervous system
, the longer the incubation period. The shorter the incubation period, the more severe the symptoms. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, four different forms of tetanus have been described.
Generalized tetanus is the most common type of tetanus, representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is trismus
, or lockjaw, and the facial spasms called risus sardonicus
, followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf
muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure
, and episodic rapid heart rate. Spasm
s may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. Spasms continue for up to 4 weeks, and complete recovery may take months.
Neonatal tetanus is 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. Neonatal tetanus is common in many developing countries and is responsible for about 14% (215,000) of all neonatal deaths, but is very rare in developed countries.
Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus.
Cephalic tetanus is a rare form of the disease, occasionally occurring with otitis media
(ear infections) in which C. tetani is present in the flora of the middle ear, or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area.
, especially rusty nails, but this concept is somewhat misleading. Objects that accumulate rust are often found outdoors, or in places that harbor anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more C. tetani bacteria. The rough surface of rusty metal merely provides a prime habitat for a C. tetani endospore to reside, and the nail affords a means to puncture skin and deliver endospore into the wound. An endospore
is a non-metabolizing survival structure that begins to metabolize and cause infection once in an adequate environment. Because C. tetani is an anaerobic bacterium, it and its endospores survive well in an environment that lacks oxygen
. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic) environment is provided by the same object that causes a puncture wound, delivering endospores to a suitable environment for growth.
s of Clostridium tetani
enter damaged tissue. The spores transform into rod-shaped bacteria and produce the neurotoxin tetanospasmin
(also known as tetanus toxin). This toxin is inactive inside the bacteria, but, when the bacteria die, the toxin is released and activated by protease
s. Active tetanospasmin enters at neuromuscular junction
s of motor neurons and is carried by retrograde axonal transport to cell bodies in the spinal cord
and brain stem
where it binds irreversibly to receptors at these sites. It cleaves membrane proteins involved in neuroexocytosis
, which in turn blocks neurotransmission
. This ultimately produces the symptoms of the disease. Damaged upper motor neuron
s can no longer inhibit lower motor neuron
s (see Renshaw cell
s). Plus, they cannot control reflex
responses to afferent sensory stimuli. Both mechanisms produce the hallmark muscle rigidity and spasm
s. Likewise, a lack of neural control of the adrenal gland
s results in release of catecholamine
s, thus producing a hypersympathetic
state and widespread autonomic
instability.
C. tetani also produces tetanolysin
, another toxin whose role in tetanus is unknown.
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. A short report in The American Journal of Tropical Medicine and Hygiene states that, in a patient research study, the spatula test had a high specificity (zero false-positive test results) and a high sensitivity (94% of infected patients produced a positive test result).
to tetanus. This is due to the extreme potency of the tetanospasmin toxin; even a lethal dose of tetanospasmin is insufficient to provoke an immune response.
Tetanus can be prevented by vaccination
with tetanus toxoid
. The CDC
recommends that adults receive a booster vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than three lifetime doses of the vaccine. The booster may not prevent a potentially fatal case of tetanus from the current wound, however, as it can take up to two weeks for tetanus antibodies to form. In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, DPT/DTaP vaccine
, which also includes vaccines against diphtheria
and pertussis
. For adults and children over seven, the Td vaccine (tetanus and diphtheria) or Tdap (tetanus, diphtheria, and acellular pertussis) is commonly used.
The WHO certifies countries as having eliminated maternal or neonatal tetanus. Certification requires at least two years of rates < 1 case per 1000 live borns. In 1998 in Uganda, 3,433 tetanus cases were recorded in new-born babies; of these, 2,403 died. After a major public health effort Uganda in 2011 was certified as having eliminated tetanus.
. Administration of the antibiotic metronidazole
decreases the number of bacteria
but has no effect on the bacterial toxin. Penicillin
was once used to treat tetanus, but is no longer the treatment of choice, owing to a theoretical risk of increased spasms. However, its use is recommended if metronidazole is not available. Passive immunization with human anti-tetanospasmin
immunoglobulin or tetanus immunoglobulin is crucial. If specific anti-tetanospasmin immunoglobulin is not available, then normal human immunoglobulin may be given instead. All tetanus victims should be vaccinated against the disease or offered a booster shot.
Drugs such as diazepam
or other muscle relaxant
s can be given to control the muscle spasms. In extreme cases it may be necessary to paralyze the patient with curare
-like drugs and use a mechanical ventilator.
In order to survive a tetanus infection, the maintenance of an airway and proper nutrition
are required. An intake of 3500-4000 calories, and at least 150 g of protein per day, is often given in liquid form through a tube directly into the stomach (Percutaneous endoscopic gastrostomy
), or through a drip into a vein (Total parenteral nutrition
). This high-caloric diet maintenance is required because of the increased metabolic strain brought on by the increased muscle activity. Full recovery takes 4 to 6 weeks because the body must regenerate destroyed nerve axon
terminals.
Tetanus is an international health problem, as C. tetani spores are ubiquitous. The disease occurs almost exclusively in persons unvaccinated or inadequately immunized. Tetanus occurs worldwide but is more common in hot, damp climates with soil 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. Spores can be introduced into the body through puncture wounds. In agricultural areas, a significant number of human adults may harbor the organism. The spores can also be found on skin surfaces and in contaminated heroin. Heroin users, particularly those that inject the drug, appear to be at high risk for tetanus.
Tetanus – in particular, the neonatal form – remains a significant public health problem in non-industrialized countries. The World Health Organization
estimates that 59,000 newborns worldwide died in 2008 as a result of neonatal tetanus. In the United States, 50-100 people become infected with tetanus each year. Nearly all of the cases in the United States occur in unimmunized individuals or individuals who have allowed their inoculation
s to lapse.
Tetanus is the only vaccine-preventable disease that is infectious
but is not contagious
.
-like toxin of tetanus from free-living, anaerobic soil bacteria. The etiology of the disease was further elucidated in 1884 by Antonio Carle and Giorgio Rattone, who demonstrated the transmissibility of tetanus for the first time. They produced tetanus in rabbits by injecting pus from a patient with fatal tetanus into their sciatic nerves. In 1889, C. tetani
was isolated from a human victim by Kitasato Shibasaburō
, who later showed that the organism could produce disease when injected into animals, and that the toxin could be neutralized by specific antibodies. In 1897, Edmond Nocard
showed that tetanus antitoxin induced passive immunity
in humans, and could be used for prophylaxis 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
.
Skeletal muscle
Skeletal muscle is a form of striated muscle tissue existing under control of the somatic nervous system- i.e. it is voluntarily controlled. It is one of three major muscle types, the others being cardiac and smooth muscle...
fibers. The primary symptoms are caused by tetanospasmin
Tetanospasmin
Tetanus toxin is an extremely potent neurotoxin produced by the vegetative cell of Clostridium tetani in anaerobic conditions, causing tetanus. It has no known function for clostridia in the soil environment where they are normally encountered. It is also called spasmogenic toxin, tetanospasmin or...
, a neurotoxin
Neurotoxin
A neurotoxin is a toxin that acts specifically on nerve cells , usually by interacting with membrane proteins such as ion channels. Some sources are more general, and define the effect of neurotoxins as occurring at nerve tissue...
produced by the Gram-positive
Gram-positive
Gram-positive bacteria are those that are stained dark blue or violet by Gram staining. This is in contrast to Gram-negative bacteria, which cannot retain the crystal violet stain, instead taking up the counterstain and appearing red or pink...
, rod-shaped
Bacillus
Bacillus is a genus of Gram-positive, rod-shaped bacteria and a member of the division Firmicutes. Bacillus species can be obligate aerobes or facultative anaerobes, and test positive for the enzyme catalase. Ubiquitous in nature, Bacillus includes both free-living and pathogenic species...
, obligate anaerobic bacterium
Anaerobic organism
An anaerobic organism or anaerobe is any organism that does not require oxygen for growth. It could possibly react negatively and may even die if oxygen is present...
Clostridium tetani
Clostridium tetani
Clostridium tetani is a rod-shaped, anaerobic bacterium of the genus Clostridium. Like other Clostridium species, it is Gram-positive, and its appearance on a gram stain resembles tennis rackets or drumsticks. C. tetani is found as spores in soil or in the gastrointestinal tract of animals. C...
. Infection generally occurs through wound contamination and often involves a cut or deep puncture wound. As the infection progresses, muscle spasm
Spasm
In medicine a spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after a few minutes...
s develop in the jaw (thus the name "lockjaw") and elsewhere in the body. Infection can be prevented by proper immunization and by post-exposure prophylaxis
Post-exposure prophylaxis
Post-exposure prophylaxis is any prophylactic treatment started immediately after exposure to a pathogen , in order to prevent infection by the pathogen and the development of disease.-Rabies:...
.
Signs and symptoms
Tetanus often begins with mild spasms in the jaw muscles (lockjaw). The spasms can also affect the chest, neck, back, and abdominal muscles. Back muscle spasms often cause arching, called opisthotonos.Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems.
Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups. This is called tetany. These episodes can cause fractures and muscle tears.
Other symptoms include:
• Drooling
• Excessive sweating
• Fever
• Hand or foot spasms
• Irritability
• Swallowing difficulty
• Uncontrolled urination or defecation
Skeletal muscle
Skeletal muscle is a form of striated muscle tissue existing under control of the somatic nervous system- i.e. it is voluntarily controlled. It is one of three major muscle types, the others being cardiac and smooth muscle...
, a type of striated muscle
Striated muscle
Striated muscle tissue is a form of fibers that are combined into parallel fibers. More specifically, it can refer to:* Cardiac muscle .* Skeletal muscle* Branchiomeric muscles...
used in voluntary movement. The other type of striated muscle, cardiac or heart muscle, cannot be tetanized because of its intrinsic electrical properties. Mortality rates reported vary from 48% to 73%. In recent years, approximately 11% of reported tetanus cases have been fatal
Death
Death is the permanent termination of the biological functions that sustain a living organism. Phenomena which commonly bring about death include old age, predation, malnutrition, disease, and accidents or trauma resulting in terminal injury....
. The highest mortality rate
Mortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
s are in unvaccinated people and people over 60 years of age.
The incubation period of tetanus may be up to several months but is usually about 8 days. In general, the further the injury site is from the central nervous system
Central nervous system
The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...
, the longer the incubation period. The shorter the incubation period, the more severe the symptoms. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, four different forms of tetanus have been described.
Generalized tetanus is the most common type of tetanus, representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is trismus
Trismus
-Common causes:*Pericoronitis is the most common cause of trismus.*Inflammation of muscles of mastication. It is a frequent sequel to surgical removal of mandibular third molars . The condition is usually resolved on its own in 10–14 days, during which time eating and oral hygiene are compromised...
, or lockjaw, and the facial spasms called risus sardonicus
Risus sardonicus
Risus sardonicus is a highly characteristic, abnormal, sustained spasm of the facial muscles that appears to produce grinning.The name of the condition derives from the appearance of raised eyebrows and an open "grin" - which can appear malevolent to the lay observer - displayed by those suffering...
, followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf
Calf (anatomy)
In human anatomy the calf is the back portion of the lower leg . In terms of muscle systems, the calf corresponds to the posterior compartment of the leg. Within the posterior compartment, the two largest muscles are known together as the calf muscle and attach to the heel via the Achilles tendon...
muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
, and episodic rapid heart rate. Spasm
Spasm
In medicine a spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after a few minutes...
s may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. Spasms continue for up to 4 weeks, and complete recovery may take months.
Neonatal tetanus is a form of generalized tetanus that occurs in newborns. Infants who have not acquired passive immunity
Immunity (medical)
Immunity is a biological term that describes a state of having sufficient biological defenses to avoid infection, disease, or other unwanted biological invasion. Immunity involves both specific and non-specific components. The non-specific components act either as barriers or as eliminators of wide...
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. Neonatal tetanus is common in many developing countries and is responsible for about 14% (215,000) of all neonatal deaths, but is very rare in developed countries.
Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus.
Cephalic tetanus is a rare form of the disease, occasionally occurring with otitis media
Otitis media
Otitis media is inflammation of the middle ear, or a middle ear infection.It occurs in the area between the tympanic membrane and the inner ear, including a duct known as the eustachian tube. It is one of the two categories of ear inflammation that can underlie what is commonly called an earache,...
(ear infections) in which C. tetani is present in the flora of the middle ear, or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area.
Cause
It is caused by the tatanus bacterium Clostridium tetani. Tetanus is often associated with rustRust
Rust is a general term for a series of iron oxides. In colloquial usage, the term is applied to red oxides, formed by the reaction of iron and oxygen in the presence of water or air moisture...
, especially rusty nails, but this concept is somewhat misleading. Objects that accumulate rust are often found outdoors, or in places that harbor anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more C. tetani bacteria. The rough surface of rusty metal merely provides a prime habitat for a C. tetani endospore to reside, and the nail affords a means to puncture skin and deliver endospore into the wound. An endospore
Endospore
An endospore is a dormant, tough, and temporarily non-reproductive structure produced by certain bacteria from the Firmicute phylum. The name "endospore" is suggestive of a spore or seed-like form , but it is not a true spore . It is a stripped-down, dormant form to which the bacterium can reduce...
is a non-metabolizing survival structure that begins to metabolize and cause infection once in an adequate environment. Because C. tetani is an anaerobic bacterium, it and its endospores survive well in an environment that lacks oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic) environment is provided by the same object that causes a puncture wound, delivering endospores to a suitable environment for growth.
Pathophysiology
Tetanus begins when endosporeEndospore
An endospore is a dormant, tough, and temporarily non-reproductive structure produced by certain bacteria from the Firmicute phylum. The name "endospore" is suggestive of a spore or seed-like form , but it is not a true spore . It is a stripped-down, dormant form to which the bacterium can reduce...
s of Clostridium tetani
Clostridium tetani
Clostridium tetani is a rod-shaped, anaerobic bacterium of the genus Clostridium. Like other Clostridium species, it is Gram-positive, and its appearance on a gram stain resembles tennis rackets or drumsticks. C. tetani is found as spores in soil or in the gastrointestinal tract of animals. C...
enter damaged tissue. The spores transform into rod-shaped bacteria and produce the neurotoxin tetanospasmin
Tetanospasmin
Tetanus toxin is an extremely potent neurotoxin produced by the vegetative cell of Clostridium tetani in anaerobic conditions, causing tetanus. It has no known function for clostridia in the soil environment where they are normally encountered. It is also called spasmogenic toxin, tetanospasmin or...
(also known as tetanus toxin). This toxin is inactive inside the bacteria, but, when the bacteria die, the toxin is released and activated by protease
Protease
A protease is any enzyme that conducts proteolysis, that is, begins protein catabolism by hydrolysis of the peptide bonds that link amino acids together in the polypeptide chain forming the protein....
s. Active tetanospasmin enters at neuromuscular junction
Neuromuscular junction
A neuromuscular junction is the synapse or junction of the axon terminal of a motor neuron with the motor end plate, the highly-excitable region of muscle fiber plasma membrane responsible for initiation of action potentials across the muscle's surface, ultimately causing the muscle to contract...
s of motor neurons and is carried by retrograde axonal transport to cell bodies in the spinal cord
Spinal cord
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain . The brain and spinal cord together make up the central nervous system...
and brain stem
Brain stem
In vertebrate anatomy the brainstem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. The brain stem provides the main motor and sensory innervation to the face and neck via the cranial nerves...
where it binds irreversibly to receptors at these sites. It cleaves membrane proteins involved in neuroexocytosis
Exocytosis
Exocytosis , also known as 'The peni-cytosis', is the durable process by which a cell directs the contents of secretory vesicles out of the cell membrane...
, which in turn blocks neurotransmission
Neurotransmission
Neurotransmission , also called synaptic transmission, is the process by which signaling molecules called neurotransmitters are released by a neuron , and bind to and activate the receptors of another neuron...
. This ultimately produces the symptoms of the disease. Damaged upper motor neuron
Upper motor neuron
Upper motor neurons are motor neurons that originate in the motor region of the cerebral cortex or the brain stem and carry motor information down to the final common pathway, that is, any motor neurons that are not directly responsible for stimulating the target muscle...
s can no longer inhibit lower motor neuron
Motor neuron
In vertebrates, the term motor neuron classically applies to neurons located in the central nervous system that project their axons outside the CNS and directly or indirectly control muscles...
s (see Renshaw cell
Renshaw cell
Renshaw cells are inhibitory interneurons found in the gray matter of the spinal cord, and are associated in two ways with an alpha motor neuron....
s). Plus, they cannot control reflex
Reflex
A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc; this does not apply to casual uses of the term 'reflex'.-See also:...
responses to afferent sensory stimuli. Both mechanisms produce the hallmark muscle rigidity and spasm
Spasm
In medicine a spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after a few minutes...
s. Likewise, a lack of neural control of the adrenal gland
Adrenal gland
In mammals, the adrenal glands are endocrine glands that sit atop the kidneys; in humans, the right suprarenal gland is triangular shaped, while the left suprarenal gland is semilunar shaped...
s results in release of catecholamine
Catecholamine
Catecholamines are molecules that have a catechol nucleus consisting of benzene with two hydroxyl side groups and a side-chain amine. They include dopamine, as well as the "fight-or-flight" hormones adrenaline and noradrenaline released by the adrenal medulla of the adrenal glands in response to...
s, thus producing a hypersympathetic
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
state and widespread autonomic
Autonomic nervous system
The autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...
instability.
C. tetani also produces tetanolysin
Tetanolysin
Tetanolysin is a toxin produced by Clostridium tetani bacteria. Its function is unknown but it is believed to contribute to the pathogenesis of tetanus.The other C. tetani toxin, tetanospasmin, is more definitively linked to tetanus....
, another toxin whose role in tetanus is unknown.
Diagnosis
There are currently no blood tests that can be used to diagnose tetanus. The diagnosis is based on the presentation of tetanus symptoms and does not depend upon isolation of the bacteria, which is recovered from the wound in only 30% of cases and can be isolated from patients without tetanus. Laboratory identification of C. tetani can be demonstrated only by production of tetanospasmin in mice.The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal
Pharynx
The human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...
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
Gag reflex
The pharyngeal reflex or gag reflex is a reflex contraction of the back of the throat, evoked by touching the soft palate or sometimes the back of the tongue. It prevents something from entering the throat except as part of normal swallowing and helps prevent choking...
attempting to expel the foreign object. A short report in The American Journal of Tropical Medicine and Hygiene states that, in a patient research study, the spatula test had a high specificity (zero false-positive test results) and a high sensitivity (94% of infected patients produced a positive test result).
Prevention
Unlike many infectious diseases, recovery from naturally acquired tetanus does not usually result in immunityImmunity (medical)
Immunity is a biological term that describes a state of having sufficient biological defenses to avoid infection, disease, or other unwanted biological invasion. Immunity involves both specific and non-specific components. The non-specific components act either as barriers or as eliminators of wide...
to tetanus. This is due to the extreme potency of the tetanospasmin toxin; even a lethal dose of tetanospasmin is insufficient to provoke an immune response.
Tetanus can be prevented by vaccination
Vaccination
Vaccination is the administration of antigenic material to stimulate the immune system of an individual to develop adaptive immunity to a disease. Vaccines can prevent or ameliorate the effects of infection by many pathogens...
with tetanus toxoid
Tetanus vaccine
Tetanus vaccine is a vaccine used against Clostridium tetani, the agent that causes tetanus.The vaccine is composed of tetanus toxoid, tetanus toxin inactivated with formaldehyde, which is immunogenic but not pathogenic. It is a component of the DPT vaccine.The tetanus vaccine is required again...
. The CDC
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
recommends that adults receive a booster vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than three lifetime doses of the vaccine. The booster may not prevent a potentially fatal case of tetanus from the current wound, however, as it can take up to two weeks for tetanus antibodies to form. In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, DPT/DTaP vaccine
DPT vaccine
DPT refers to a class of combination vaccines against three infectious diseases in humans: diphtheria, pertussis and tetanus...
, which also includes vaccines against diphtheria
Diphtheria
Diphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram-positive bacterium. It is characterized by sore throat, low fever, and an adherent membrane on the tonsils, pharynx, and/or nasal cavity...
and pertussis
Pertussis
Pertussis, also known as whooping cough , is a highly contagious bacterial disease caused by Bordetella pertussis. Symptoms are initially mild, and then develop into severe coughing fits, which produce the namesake high-pitched "whoop" sound in infected babies and children when they inhale air...
. For adults and children over seven, the Td vaccine (tetanus and diphtheria) or Tdap (tetanus, diphtheria, and acellular pertussis) is commonly used.
The WHO certifies countries as having eliminated maternal or neonatal tetanus. Certification requires at least two years of rates < 1 case per 1000 live borns. In 1998 in Uganda, 3,433 tetanus cases were recorded in new-born babies; of these, 2,403 died. After a major public health effort Uganda in 2011 was certified as having eliminated tetanus.
Treatment
The wound must be cleaned. Dead and infected tissue should be removed by surgical debridementDebridement
Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...
. Administration of the antibiotic metronidazole
Metronidazole
Metronidazole is a nitroimidazole antibiotic medication used particularly for anaerobic bacteria and protozoa. Metronidazole is an antibiotic, amebicide, and antiprotozoal....
decreases the number of bacteria
Bacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
but has no effect on the bacterial toxin. Penicillin
Penicillin
Penicillin is a group of antibiotics derived from Penicillium fungi. They include penicillin G, procaine penicillin, benzathine penicillin, and penicillin V....
was once used to treat tetanus, but is no longer the treatment of choice, owing to a theoretical risk of increased spasms. However, its use is recommended if metronidazole is not available. Passive immunization with human anti-tetanospasmin
Tetanospasmin
Tetanus toxin is an extremely potent neurotoxin produced by the vegetative cell of Clostridium tetani in anaerobic conditions, causing tetanus. It has no known function for clostridia in the soil environment where they are normally encountered. It is also called spasmogenic toxin, tetanospasmin or...
immunoglobulin or tetanus immunoglobulin is crucial. If specific anti-tetanospasmin immunoglobulin is not available, then normal human immunoglobulin may be given instead. All tetanus victims should be vaccinated against the disease or offered a booster shot.
Mild tetanus
Mild cases of tetanus can be treated with:- Tetanus immunoglobulin IVIntravenous therapyIntravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
or IMIntramuscular injectionIntramuscular injection is the injection of a substance directly into a muscle. In medicine, it is one of several alternative methods for the administration of medications . It is used for particular forms of medication that are administered in small amounts... - metronidazoleMetronidazoleMetronidazole is a nitroimidazole antibiotic medication used particularly for anaerobic bacteria and protozoa. Metronidazole is an antibiotic, amebicide, and antiprotozoal....
IVIntravenous therapyIntravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
for 10 days - DiazepamDiazepamDiazepam , first marketed as Valium by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms , restless legs syndrome, alcohol withdrawal,...
Severe tetanus
Severe cases will require admission to intensive care. In addition to the measures listed above for mild tetanus:- human tetanus immunoglobulin injected intrathecalIntrathecalIntrathecal is an adjective that refers to something introduced into or occurring in the space under the arachnoid membrane of the brain or spinal cord...
ly (increases clinical improvement from 4% to 35%) - tracheotomyTracheotomyAmong the oldest described surgical procedures, tracheotomy consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea...
and mechanical ventilationMechanical ventilationIn medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...
for 3 to 4 weeks - magnesiumMagnesiumMagnesium is a chemical element with the symbol Mg, atomic number 12, and common oxidation number +2. It is an alkaline earth metal and the eighth most abundant element in the Earth's crust and ninth in the known universe as a whole...
, as an intravenous (IV) infusion, to prevent muscle spasm - diazepamDiazepamDiazepam , first marketed as Valium by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms , restless legs syndrome, alcohol withdrawal,...
as a continuous IV infusion - the autonomicAutonomic nervous systemThe autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...
effects of tetanus can be difficult to manage (alternating hyper- and hypotensionHypotensionIn physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
hyperpyrexia/hypothermiaHypothermiaHypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as . Body temperature is usually maintained near a constant level of through biologic homeostasis or thermoregulation...
) and may require IV labetalolLabetalolLabetalol is a mixed alpha/beta adrenergic antagonist, which is used to treat high blood pressure.-Indications:...
, magnesium, clonidineClonidineClonidine is a sympatholytic medication used to treat medical conditions, such as high blood pressure, some pain conditions, ADHD and anxiety/panic disorder...
, or nifedipineNifedipineNifedipine is a dihydropyridine calcium channel blocker...
.
Drugs such as diazepam
Diazepam
Diazepam , first marketed as Valium by Hoffmann-La Roche is a benzodiazepine drug. Diazepam is also marketed in Australia as Antenex. It is commonly used for treating anxiety, insomnia, seizures including status epilepticus, muscle spasms , restless legs syndrome, alcohol withdrawal,...
or other muscle relaxant
Muscle relaxant
A muscle relaxant is a drug which affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeutic groups: neuromuscular blockers and spasmolytics...
s can be given to control the muscle spasms. In extreme cases it may be necessary to paralyze the patient with curare
Curare
Curare is a common name for various arrow poisons originating from South America. The three main types of curare are:* tubocurare...
-like drugs and use a mechanical ventilator.
In order to survive a tetanus infection, the maintenance of an airway and proper nutrition
Nutrition
Nutrition is the provision, to cells and organisms, of the materials necessary to support life. Many common health problems can be prevented or alleviated with a healthy diet....
are required. An intake of 3500-4000 calories, and at least 150 g of protein per day, is often given in liquid form through a tube directly into the stomach (Percutaneous endoscopic gastrostomy
Percutaneous endoscopic gastrostomy
Percutaneous endoscopic gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. The procedure is an alternative to surgical gastrostomy insertion, and...
), or through a drip into a vein (Total parenteral nutrition
Total parenteral nutrition
Parenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulae that contain nutrients such as glucose, amino acids, lipids and added vitamins and dietary minerals...
). This high-caloric diet maintenance is required because of the increased metabolic strain brought on by the increased muscle activity. Full recovery takes 4 to 6 weeks because the body must regenerate destroyed nerve axon
Axon
An axon is a long, slender projection of a nerve cell, or neuron, that conducts electrical impulses away from the neuron's cell body or soma....
terminals.
Epidemiology
Manure
Manure is organic matter used as organic fertilizer in agriculture. Manures contribute to the fertility of the soil by adding organic matter and nutrients, such as nitrogen, that are trapped by bacteria in the soil...
-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. Spores can be introduced into the body through puncture wounds. In agricultural areas, a significant number of human adults may harbor the organism. The spores can also be found on skin surfaces and in contaminated heroin. Heroin users, particularly those that inject the drug, appear to be at high risk for tetanus.
Tetanus – in particular, the neonatal form – remains a significant public health problem in non-industrialized countries. The World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
estimates that 59,000 newborns worldwide died in 2008 as a result of neonatal tetanus. In the United States, 50-100 people become infected with tetanus each year. Nearly all of the cases in the United States occur in unimmunized individuals or individuals who have allowed their inoculation
Inoculation
Inoculation is the placement of something that will grow or reproduce, and is most commonly used in respect of the introduction of a serum, vaccine, or antigenic substance into the body of a human or animal, especially to produce or boost immunity to a specific disease...
s to lapse.
Tetanus is the only vaccine-preventable disease that is infectious
Infectious disease
Infectious diseases, also known as communicable diseases, contagious diseases or transmissible diseases comprise clinically evident illness resulting from the infection, presence and growth of pathogenic biological agents in an individual host organism...
but is not contagious
Contagious disease
A contagious disease is a subset category of infectious diseases , which are easily transmitted by physical contact with the person suffering the disease, or by their secretions or objects touched by them....
.
History
Tetanus was well known to ancient people who recognized the relationship between wounds and fatal muscle spasms. In 1884, Arthur Nicolaier isolated the strychnineStrychnine
Strychnine is a highly toxic , colorless crystalline alkaloid used as a pesticide, particularly for killing small vertebrates such as birds and rodents. Strychnine causes muscular convulsions and eventually death through asphyxia or sheer exhaustion...
-like toxin of tetanus from free-living, anaerobic soil bacteria. The etiology of the disease was further elucidated in 1884 by Antonio Carle and Giorgio Rattone, who demonstrated the transmissibility of tetanus for the first time. They produced tetanus in rabbits by injecting pus from a patient with fatal tetanus into their sciatic nerves. In 1889, C. tetani
Clostridium tetani
Clostridium tetani is a rod-shaped, anaerobic bacterium of the genus Clostridium. Like other Clostridium species, it is Gram-positive, and its appearance on a gram stain resembles tennis rackets or drumsticks. C. tetani is found as spores in soil or in the gastrointestinal tract of animals. C...
was isolated from a human victim by Kitasato Shibasaburō
Kitasato Shibasaburō
Baron was a Japanese physician and bacteriologist. He is remembered as the co-discoverer of the infectious agent of bubonic plague in Hong Kong in 1894, almost simultaneously with Alexandre Yersin.-Biography:...
, who later showed that the organism could produce disease when injected into animals, and that the toxin could be neutralized by specific antibodies. In 1897, Edmond Nocard
Edmond Nocard
Edmond Isidore Etienne Nocard , was a French veterinarian and microbiologist, born in Provins ....
showed that tetanus antitoxin induced passive immunity
Passive immunity
Passive immunity is the transfer of active humoral immunity in the form of readymade antibodies, from one individual to another. Passive immunity can occur naturally, when maternal antibodies are transferred to the fetus through the placenta, and can also be induced artificially, when high levels...
in humans, and could be used for prophylaxis and treatment. Tetanus toxoid vaccine
Vaccine
A vaccine is a biological preparation that improves immunity to a particular disease. A vaccine typically contains an agent that resembles a disease-causing microorganism, and is often made from weakened or killed forms of the microbe or its toxins...
was developed by P. Descombey in 1924, and was widely used to prevent tetanus induced by battle wounds during World War II
World War II
World War II, or the Second World War , was a global conflict lasting from 1939 to 1945, involving most of the world's nations—including all of the great powers—eventually forming two opposing military alliances: the Allies and the Axis...
.
Notable victims
- Tom ButlerTom Butler (footballer)Thomas "Tom" Butler was an English footballer who played as an inside-left. He played 60 league games in the Football League, scoring 23 goals. He played for non-league Willenhall, before spending the 1921–22 season at Walsall. He joined Port Vale via Darlaston in December 1922...
– English footballerFootball (soccer)Association football, more commonly known as football or soccer, is a sport played between two teams of eleven players with a spherical ball...
; contracted after suffering a badly broken arm. - George HoggGeorge Hogg (adventurer)George Aylwin Hogg was an English adventurer. He was a graduate of Oxford University in economics. He is known as a hero in China for saving 60 orphaned boys during the Second Sino-Japanese War, including leading them through dangerous mountain passes, escaping the approaching Japanese secret...
– English adventurer who rescued war orphans in China; died in 1945 from an infection resulting from a foot injury. - Joe Hill LouisJoe Hill LouisJoe Hill Louis , born Lester Hill, was an American singer, guitarist, harmonica player and one-man band...
– MemphisMemphis, TennesseeMemphis is a city in the southwestern corner of the U.S. state of Tennessee, and the county seat of Shelby County. The city is located on the 4th Chickasaw Bluff, south of the confluence of the Wolf and Mississippi rivers....
bluesBluesBlues is the name given to both a musical form and a music genre that originated in African-American communities of primarily the "Deep South" of the United States at the end of the 19th century from spirituals, work songs, field hollers, shouts and chants, and rhymed simple narrative ballads...
musician; died in 1957 as a result of an infected wound to his thumb. - George Montagu – English ornithologist; contracted tetanus when he stepped on a nail.
- Joe PowellJoe PowellJoseph Joshua "Joe" Powell was an English footballer who was captain of Woolwich Arsenal in their first season of League football. He is also notable for being one of the few footballers to die as a result of an injury incurred whilst playing.Born in Bristol, Powell had joined the Army as a young...
– English footballerFootball (soccer)Association football, more commonly known as football or soccer, is a sport played between two teams of eleven players with a spherical ball...
; contracted following amputationAmputationAmputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for...
of a badly broken arm. - John A. RoeblingJohn A. RoeblingJohn Augustus Roebling was a German-born American civil engineer. He is famous for his wire rope suspension bridge designs, in particular, the design of the Brooklyn Bridge.-Early life:...
– Civil EngineerCivil engineerA civil engineer is a person who practices civil engineering; the application of planning, designing, constructing, maintaining, and operating infrastructures while protecting the public and environmental health, as well as improving existing infrastructures that have been neglected.Originally, a...
and ArchitectArchitectAn architect is a person trained in the planning, design and oversight of the construction of buildings. To practice architecture means to offer or render services in connection with the design and construction of a building, or group of buildings and the space within the site surrounding the...
famous for his bridgeSuspension bridgeA suspension bridge is a type of bridge in which the deck is hung below suspension cables on vertical suspenders. Outside Tibet and Bhutan, where the first examples of this type of bridge were built in the 15th century, this type of bridge dates from the early 19th century...
designs, particularly the Brooklyn BridgeBrooklyn BridgeThe Brooklyn Bridge is one of the oldest suspension bridges in the United States. Completed in 1883, it connects the New York City boroughs of Manhattan and Brooklyn by spanning the East River...
; contracted tetanus following amputation of his foot due to an injury caused by a ferryFerryA ferry is a form of transportation, usually a boat, but sometimes a ship, used to carry primarily passengers, and sometimes vehicles and cargo as well, across a body of water. Most ferries operate on regular, frequent, return services...
when it crashed into a wharfWharfA wharf or quay is a structure on the shore of a harbor where ships may dock to load and unload cargo or passengers.Such a structure includes one or more berths , and may also include piers, warehouses, or other facilities necessary for handling the ships.A wharf commonly comprises a fixed...
. - George Crockett StrongGeorge Crockett StrongGeorge Crockett Strong was a Union brigadier general in the American Civil War.-Biography:Strong was born in Stockbridge, Vermont, and attended Williston Seminary but left after 1851. He attended Union College, but left for the U.S. Military Academy, from which he graduated in 1857...
– UnionUnion (American Civil War)During the American Civil War, the Union was a name used to refer to the federal government of the United States, which was supported by the twenty free states and five border slave states. It was opposed by 11 southern slave states that had declared a secession to join together to form the...
brigadier generalBrigadier GeneralBrigadier general is a senior rank in the armed forces. It is the lowest ranking general officer in some countries, usually sitting between the ranks of colonel and major general. When appointed to a field command, a brigadier general is typically in command of a brigade consisting of around 4,000...
in the American Civil WarAmerican Civil WarThe American Civil War was a civil war fought in the United States of America. In response to the election of Abraham Lincoln as President of the United States, 11 southern slave states declared their secession from the United States and formed the Confederate States of America ; the other 25...
; from wounds sustained in the assault against Fort WagnerFort WagnerFort Wagner was a beachhead fortification on Morris Island, South Carolina, that covered the southern approach to Charleston harbor...
on Morris IslandMorris IslandMorris Island is an 840 acre uninhabited island in Charleston Harbor in South Carolina, accessible only by boat. The island lies in the outer reaches of the harbor and was thus a strategic location in the American Civil War.-History:...
, South CarolinaSouth CarolinaSouth Carolina is a state in the Deep South of the United States that borders Georgia to the south, North Carolina to the north, and the Atlantic Ocean to the east. Originally part of the Province of Carolina, the Province of South Carolina was one of the 13 colonies that declared independence...
. - Fred ThomsonFred ThomsonFrederick Clifton Thomson was an American silent film cowboy who rivaled Tom Mix in popularity before dying at age 38 of tetanus.-Birth and athletic achievement:...
– silent filmSilent filmA silent film is a film with no synchronized recorded sound, especially with no spoken dialogue. In silent films for entertainment the dialogue is transmitted through muted gestures, pantomime and title cards...
actor; stepped on a nail. - John Thoreau (brother of Henry David ThoreauHenry David ThoreauHenry David Thoreau was an American author, poet, philosopher, abolitionist, naturalist, tax resister, development critic, surveyor, historian, and leading transcendentalist...
); nicked himself with a razor while shaving. - Johann Tserclaes, Count of Tilly; wounded by a cannonCannonA cannon is any piece of artillery that uses gunpowder or other usually explosive-based propellents to launch a projectile. Cannon vary in caliber, range, mobility, rate of fire, angle of fire, and firepower; different forms of cannon combine and balance these attributes in varying degrees,...
ball in the Battle of RainBattle of RainThe Battle of Rain was fought on April 15, 1632, as part of the Thirty Years' War. The forces involved in this conflict were 40,000 Swedish troops under Gustavus Adolphus and 25,000 Catholic League troops under Count Johan Tzerclaes of Tilly...
. - TravellerTraveller (horse)Traveller was Confederate General Robert E. Lee's most famous horse during the American Civil War.-Birth and war service:...
– General Robert E. LeeRobert E. LeeRobert Edward Lee was a career military officer who is best known for having commanded the Confederate Army of Northern Virginia in the American Civil War....
's favorite horseHorseThe horse is one of two extant subspecies of Equus ferus, or the wild horse. It is a single-hooved mammal belonging to the taxonomic family Equidae. The horse has evolved over the past 45 to 55 million years from a small multi-toed creature into the large, single-toed animal of today...
; stepped on a nail.
External links
- Tetanus Symptoms
- Tetanus Information from Medline Plus
- Tetanus Surveillance -- United States, 1998-2000 (Data and Analysis)