tetanus

Definition

Tetanus is a rare but often fatal disease that affects the central nervous system by causing painful muscular contractions. It begins when tetanus bacteria enter the body, usually through a wound or cut exposed to contaminated soil. Tetanus is easily preventable through vaccination.

Description

Tetanus is rare in the United States, with nearly all cases occurring in adults who were not vaccinated as children. About 100 cases are reported each year; 63% of these occur in people over the age of 50. The number of tetanus cases in the United States has steadily decreased since the 1940s (500 to 600 cases per year); the number of reported cases has remained at approximately 50 to 100 cases per year since the mid-1970s. In 1999, however, the lowest number of annual cases to date was reported (33, or 0.02 per 100,000).

Tetanus causes convulsive muscle spasms and rigidity that can lead to respiratory paralysis and death. It is sometimes called "lockjaw" because one of the most common symptoms is a stiff jaw, unable to be opened. Sometimes, tetanus affects only the part of the body where the infection began, but in almost all of reported cases, it spreads to the entire body. The incubation period from the time of the injury until the first symptoms appear ranges from two to 50 days. Symptoms usually occur within five to 10 days. When symptoms occur early, the chance of death is increased. Tetanus is not contagious.

— Lori De Milto

1. An acute, often fatal disease characterized by spasmodic contraction of voluntary muscles, especially those of the neck and jaw, and caused by the toxin of the bacillus Clostridium tetani, which typically infects the body through a deep wound. Also called lockjaw.
2. Physiology. A state of continuous muscular contraction, especially when induced artificially by rapidly repeated stimuli.

[Middle English, from Latin, from Greek tetanos, rigid, tetanus.]

An infectious disease, also known as lockjaw, which is caused by the toxin of Clostridium tetani. The bacterium may be isolated from fertile soil and the intestinal tract or fecal material of humans and other animals. Infection commonly follows dirt contamination of deep wounds or other injured tissues.

The incubation period of tetanus is usually 5–10 days, and the disease is characterized by convulsive tonic contraction of voluntary muscles. Prevention of tetanus rests on the proper, prompt surgical care of contaminated wounds and prophylactic use of antitoxin if the individual has not been protected by active immunization with toxoid. See also Immunology.

Tetanus is perhaps better known through its more dramatic description ‘lockjaw’. This potentially life-threatening condition is characterized by uncontrollable muscular contractions, which can be continuous or spasmodic. The immediate cause of this presentation of a disease state is the presence of a circulating poison (toxin) produced at the site of a wound by spores of the bacterium Clostridium tetani. This bacterium resides normally in human and animal intestines without causing disease, but contact with heavily manured soil or other material containing the spores, which are extremely resistant to heat and other agents, will readily infect those not immunized against such infection. Active immunization by vaccination with tetanus toxoid (an inactivated form of the toxin) is now usual in childhood, along with diphtheria and whooping cough vaccines. Also immediate passive immunization is available for anyone with a wound which could be contaminated, by injection of human immunoglobulin prepared from the plasma of blood donors; this has taken over from the earlier use of antitetanus serum from horses, which sometimes caused adverse reactions.

Insight as to the mode of action of this toxin at the cellular level has interestingly first been gained from research on muscles of the crayfish. In contrast to the single excitatory innervation by motor axons in mammalian skeletal muscle, these invertebrate muscles have a twin innervation, one type of nerve fibre exciting, and the other inhibiting transmission at the neuromuscular junction. This inhibition does not occur through a process directly affecting the muscle fibre or indeed the ‘motor endplate’ of the neuromuscular junction. Instead, it depends on the release of a chemical transmitter ‘GABA’ which acts on the excitatory motor nerve terminals by opening a chemically-gated chloride channel; the effect of this is to reduce the amplitude of the action potential that reaches the terminal, thereby reducing the amount of excitatory transmitter (acetylcholine) released. As human and mammalian muscles lack such a mixed dual action, the muscular contractions must arise centrally in the axons or motor neuron cell bodies within the spinal cord or brain stem. Experiments show that tetanus toxin actually inhibits the release of GABA in the central nervous system. GABA normally damps downs the excitation of motor neurons; the effect of tetanus toxin is therefore to allow a now unchecked excitatory barrage to cause a sustained and uncontrollable discharge of motor neurons; this accounts in turn for the muscular contractions.

Because the muscle spasms may cause airway obstruction, such as by closing the jaw and the larynx, or may render the respiratory muscles functionally useless because contractions are sustained instead of rhythmic, tetanus is potentially fatal, but it can be treated successfully by antibiotic drugs. Meanwhile the patient may need to be sedated or, in more severe intoxication, to be paralysed by muscle relaxant drugs and artificially ventilated.

— Tom Sears

See also immunization; infectious diseases.

In exercise physiology, tetanus refers to a sustained contraction of a muscle block, but most people associate the term with a dreadful disease, lockjaw. A bacterium, Clostridium tetani, is responsible for the disease. It can be found anywhere, but is most common on ground contaminated by animal faeces, such as sports fields used by farm animals. Tetanus is regarded as the most serious type of sports-related infection. The infective organisms usually enter the body through a laceration. In recent years, two Scottish rugby players and one soccer player developed tetanus from lacerations acquired during play. Only one player survived. The others died by exhaustion and asphyxiation. Even when not fatal, the disease is very unpleasant. The bacterium releases a toxin which causes simultaneous contraction of all the muscles, making the body go as rigid as a board. Treatment is usually prolonged and painful. Tetanus is preventable by active immunization. Anyone who exercises out of doors is foolish not to take advantage of this protection. Some sports, including orienteering, insist on participants taking measures to reduce the risk of this fearsome condition.

An acute, potentially fatal infection of the central nervous system caused by tetanospasmin, which is an exotoxin, elaborated by an anaerobic bacillus, Clostridium tetani.

Definition

Tetanus is a rare but often fatal disease that affects the central nervous system by causing painful and often violent muscular contractions. The earliest descriptions of the disease can be found in the medical papyri of ancient Egypt. The disease begins when the tetanus bacterium (Clostridium tetani) enters the body, usually through a wound or cut that has come in contact with the spores of the bacterium. Tetanus spores are commonly found in soil, dust, and animal manure. Tetanus is a noncommunicable disease, meaning that it cannot be passed directly from one person to another.

Description

Tetanus is uncommon in the United States, with nearly all cases occurring in adults who were not vaccinated as children, or in those who have not had a booster vaccination in 10 years.

In the United States, there are between 50 and 100 reported cases of tetanus a year. About 30% of cases are fatal. Most people who die of tetanus infections are over 50 years old.

Tetanus causes convulsive muscle spasms and rigidity that can lead to respiratory paralysis and death. It is sometimes called "lockjaw" because one of the most common symptoms is a stiff jaw that cannot be opened. Sometimes tetanus is localized, that is; it affects only the part of the body where the infection began. However, in almost all reported cases, tetanus spreads to the entire body. The incubation period from the time of the injury until the first symptoms appear ranges from five days to three weeks. Symptoms usually occur within eight to 12 days. The chance of death is increased when symptoms occur early.

Causes & Symptoms

Tetanus is caused by a bacterium called Clostridium tetani, whose spores (the dormant form) are found in soil, street dust, and animal feces. The bacteria enter the body through cuts and abrasions but will multiply only in an environment that is anaerobic, or oxygen-free. Deep puncture wounds and wounds with a lot of dead tissue provide an oxygen-free environment for the bacteria to grow.

As C. tetani grows, it excretes a highly poisonous toxin called tetanospasmin into the bloodstream, spreading it throughout the nervous system. The infection is usually transmitted through deep puncture wounds or through cuts or scratches that are not cleaned well. Many people associate tetanus with rusty nails and other dirty objects, but any wound can be a source. Less common ways of getting tetanus are animal scratches and bites; surgical wounds; dental work; punctures caused by glass, thorns, needles, and splinters; and therapeutic abortion. Rare cases have been reported in people with no known wound or medical condition.

Neonatal tetanus in newborns can be caused by cutting the umbilical cord with an unsterile instrument or by improper care of the umbilical stump. Neonatal tetanus is less common in developed countries.

Tetanus toxin affects the nerve endings, causing a continuous stimulation of the muscles. Initial symptoms may include restlessness, irritability, a stiff neck, and difficulty swallowing. In about half of all cases, the first symptom is a stiff or "locked" jaw, which prevents patients from opening their mouths or swallowing. This symptom is also called trismus and results in a facial expression called risus sardonicus, which is a Latin phrase meaning "sardonic smile." Trismus is often followed by stiffness of the neck and other muscles throughout the body as well as uncontrollable spasms. Sometimes these convulsions, known as opisthotonos, are severe enough to cause broken bones. Other symptoms of tetanus include loss of appetite and drooling. People with localized tetanus experience pain and tingling only at the wound site and spasms in nearby muscles.

In the underdeveloped world, neonatal tetanus accounts for about one-half of tetanus deaths and is related to infection of the umbilical stump in a baby born of an unimmunized mother. In many cases the risk is increased by the mother's giving birth on a floor made of hardpacked soil. Worldwide, 800,000 children die of tetanus each year.

Diagnosis

Tetanus is diagnosed by the clinical symptoms and a medical history that shows no tetanus immunization. Early diagnosis and treatment is crucial for recovery.

In general, the shorter the incubation period, the more severe the disease.

Treatment

As traditional medical treatment revolves around drug therapy, traditional Chinese medicine herbal remedies are the most common alternative treatment for tetanus. Herbs that have sedative effects should be given to reduce the frequency of convulsions, along with herbs to fight the bacteria.

Tetanus and convulsions can be treated with a concoction made from the dried body of a long-nosed pit viper, called this drug Qi She in Mandarin. Chan Tui, or cicada slough (the skin the cicada sheds) is also helpful. Also helpful are the dried root of the Saposhnikovia divaricata, called divaricate saposhnikovia root, and jack-in-the-pulpit tuber, if it is treated to remove toxins.

There are several alternative treatments aimed at prevention of the disease.

Allopathic Treatment

Tetanus is a life-threatening disease. Patients diagnosed with it are usually hospitalized, usually in an intensive care ward. Treatment can take several weeks and includes antibiotics to kill the bacteria and shots of antitoxin to neutralize the toxin. It also includes antianxiety drugs to control muscle spasms or barbiturates for sedation. In severe cases, patients are placed on an artificial respirator. Recovery can take six weeks or more. After recovery, since the levels of circulating toxin are quite low, the patient must still be adequately immunized against this disease.

Expected Results

Full recovery is common in patients who can be kept alive during the most violent portion of the attacks. Yet up to 30% of tetanus victims in the United States die. Early diagnosis and treatment improves the prognosis. Neonatal tetanus, however, has a mortality rate of more than 90%.

Prevention

Castor oil is a natural remedy that can be used to clean out a wound and prevent tetanus. When a wound is sustained, a cotton ball dunked in castor oil should be placed on the wound, and then fixed on the wound with a bandage. Castor oil has tremendous drawing power and can pull out rust and other infectious agents. The dressing should be changed every two hours the first day of treatment and twice a day for the next three days.

Tetanus is easily preventable through vaccination. All children should have a series of five doses of DTaP, a combined vaccine that offers protection against diphtheria, tetanus, and pertussis, before the age of seven. This measure is supported by numerous organizations, including the World Health Organization, the Centers for Disease Control and Prevention, the Advisory Committee on Immunization Practices, the Committee on Infectious Diseases of the American Academy of Pediatrics, and the American Academy of Family Physicians. Children in the United States will not be admitted to school without proof of this and other immunizations.

The DTaP vaccine should be given at ages two months, four months, six months, 15-18 months, and four to six years. DTaP is the preferred vaccine for children up to the age of seven in the United States; it has fewer side effects than DTP and can be used to complete a vaccination schedule begun with DTP. DTaP was first approved by the Food and Drug Administration in September 1996. In December 1996, it was approved for use in infants. Between age 11 and 13, children should have a booster, called Td, for diphtheria and tetanus.

Adults should have a Td booster every 10 years. Statistics from the Centers for Disease Control and Prevention show that fewer than half of Americans aged 60 and older have antibodies against tetanus. The Centers for Disease Control and Prevention suggests that adults be revaccinated at mid-decade birthdays (for example, at 45). Adults who have never been vaccinated against tetanus should get a series of three injections of Td over six to 12 months and then follow the 10-year booster shot schedule.

Side effects of the tetanus vaccine are minor: soreness, redness, or swelling at the site of the injection that appear any time from a few hours to two days after the vaccination and disappear in a day or two. Rare but serious side effects that require immediate treatment by a doctor are serious allergic reactions or deep, aching pain and muscle wasting in the upper arms. These symptoms could start from two days to four weeks after the shot and could continue for months.

For those who are averse to immunizations, tetanus immunity can be boosted naturally by taking vitamin E, according to a study from Tufts University in Medford, Massachusetts. To get the most benefit, 200 mg should be taken daily.

Keeping wounds and scratches clean is important in preventing infection. Since C. tetani grows only in the absence of oxygen, the wounds must be adequately cleaned of dead tissue and foreign substances. Run cool water over the wound and wash it with a mild soap. Dry it with a clean cloth or sterile gauze. To help prevent infection, apply an antibiotic cream or ointment and cover the wound with a bandage. Try the castor oil remedy. The longer a wound takes to heal, the greater the chance of infection. Consult a doctor if the wound doesn't heal, if it is red or warm, or if it drains or swells.

If the wounded individual does not have an adequate history of immunization, a doctor may administer a specific antitoxin (human tetanus immune globulin, TIG) to produce rapid levels of circulating antibody. The antitoxin is given at the same time as a dose of vaccine but at a separate site.

Some persons will report a history of significant allergy to "tetanus shots." In most cases, the reaction occurred in the remote past and was probably caused by antitoxin derived from horse serum. More recently, however, the use of aluminum as an adjuvant, or substance added to a vaccine to increase the body's immune response, has been associated with skin eruptions and swelling in hypersensitive individuals. In some cases, these persons can be safely vaccinated for tetanus with a graduated series of shots. Adverse reactions of any kind to tetanus vaccine should be reported to the Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA).

Resources

Books

Evelyn, Nancy. The Herbal Medicine Chest. Trumansburg, N.Y.: The Crossing Press, 1986.

Magill's Medical Guide, edited by Tracy Irons-Georges. Englewood Cliffs, N.J.: Salem Press, 1998.

Periodicals

Baylor, N. W., W. Egan, and P. Richman. "Aluminum Salts in Vaccines—US Perspective." Vaccine 20 (May 31, 2002)(Supplement 3): S18-S23.

Quddus, A., et al. "Neonatal Tetanus: Mortality Rate and Risk Factors in Loralai District, Pakistan." International Journal of Epidemiology 31 (June 2002): 648-653.

Rennels, M. B., M. A. Deloria, M. E. Pichichero, et al. "Lack of Consistent Relationship Between Quantity of Aluminum in Diphtheria-Tetanus-Acellular Pertussis Vaccines and Rates of Extensive Swelling Reactions." Vaccine 20 (May 31, 2002)(Supplement 3): S44-S47.

Shin, D. H., J. H. Park, P. J. Jung, et al. "A Case of Maternal Tetanus in Korea." Journal of Korean Medical Science 17 (April 2002): 260-262.

Williams, A. N., et al. "Tetanus Immunisation in Hypersensitive Individuals." Journal of the Royal Army Medical Corps 148 (June 2002): 148-150.

Organizations

Food and Drug Administration (FDA), Center for Biologics Evaluation and Research (CBER), 1401 Rockville Pike, Suite 200-N, Rockville, MD 20852. .

Other

Centers for Disease Control and Prevention. "Tetanus & Diphtheria (Td) Vaccine." Healthtouch Online.http://www.healthtouch.com/bin/EContent_HT/showAllLfts.asp.

"Shots for Safety." National Institute on Aging Age Page.www.nih.gov/nia/health/pubpub/shots.htm.

"TCM Herbal Database." China-Med.net.http://www.chinamed.net/herb_search.html.

[Article by: Lisa Frick; Rebecca J. Frey, PhD]

Definition

Tetanus, also called lockjaw, is a serious disease of the nervous system that can cause uncontrolled musclespasms and death. It is caused by toxins (poisons) produced by the bacterium Clostridium tetani.

Description

Tetanus occurs when the body is infected with spores of the bacterium C. tetani. This bacterium is found worldwide in soil and animal manure. The spores can remain alive in the soil for years and are resistant to heating and chemical destruction. They are more common in hot, damp environments than in cold or dry ones.

Once spores enter the body through a break in the skin, they begin producing bacteria. These bacteria multiply in areas where there is little oxygen present and produce a toxin that affects the nervous system. The toxin spreads along the nerves of the body, causing the nerves to fire (react). This results in muscle spasms and convulsions.

Transmission

The bacteria that cause tetanus enter the body through a scrape, cut, or wound, in about 70 percent of cases. The most susceptible wounds are those that are caused by blunt trauma such as crushing or by bites. The bacteria can also enter at the site of a burn, bedsore, or frostbite, or be introduced into the body during surgery. In developing countries, newborns often contract tetanus from contaminated instruments used to tie off the umbilical cord after birth. Often the site where the bacteria enter is insignificant, does not become swollen or red, and does not require medical attention. Any time between two and 50 days later (most commonly between days seven and 21 days), the individual begins to show the signs of tetanus.

The severity of the disease is related to several factors:

• The sooner symptoms appear, the more severe the disease.
• If the point of entry was in the head or face, symptoms are more severe.
• The very young and the very old suffer more severe symptoms and higher death rates.

Demographics

With almost universal vaccination starting in the 1940s, tetanus has become rare in the United States. Fewer than 50 cases have been reported annually since 1995. Worldwide, the disease is common, especially in newborns in developing parts of Asia, Africa, and South America where immunization is not universally available. The disease can affect individuals of any race, age, or gender.

Causes and Symptoms

Since the incubation period can range from several days to many weeks, individuals often do not associate their initial symptoms with wound infection. The first sign of tetanus is a tightening of the jaw muscles that gives the disease its common name, lockjaw. This symptom is followed by waves of back spasms. The spasms then extend to the arms producing clenched fists and to the legs. Any stimulus, such as noise or light, can set off a round of convulsions. Other symptoms include drooling, increase in blood pressure (hypertension), irregular heart beat, inability to open the mouth, high fever, kidney failure, and respiratory failure.

When to Call the Doctor

Tetanus is a medical emergency, and individuals should be taken to the emergency room as soon as symptoms are noticed. About 75 percent of individuals with tetanus are first seen by a dentist or oral surgeon for pain and stiffness in the jaw and mouth region.

Diagnosis

Diagnosis of tetanus is based on presenting symptoms rather than laboratory tests. Less than one-third of the time can the bacteria that causes the disease be cultured from a wound.

Treatment

Treatment begins immediately in the emergency room or intensive care unit of a hospital. There are five aspects of treatment. Initially the patient is placed in a dark, quiet room and given a sedative, usually a drug in the benzodiazepine family, through direct injection into a vein (IV) in an effort to reduce muscle spasms. A tube may be inserted in to the trachea (tracheotomy) in order to keep the airways open.

The second aspect of treatment is to clean and disinfect any wounds and remove any dead flesh.

The third aspect of treatment involves killing the bacteria producing the toxin using antimicrobial drugs given as an injection. The drug of choice is metronidazole (Flagyl), with penicillin the second choice.

Fourth, the toxin already circulating in the blood must be neutralized so that it causes no further damage to the nervous system. This is done with injections of human tetanus immunoglobulin (TIG).

Finally, complications of the disease are managed. This may involve IV fluid replacement, use of a respirator, or kidney dialysis. Contracting tetanus does not provide immunity against future infections, so tetanus immunizations are also given.

Prognosis

Individuals who develop symptoms within a few days of infection have close to a 100 percent mortality rate. The mortality rate for infections originating in the head and in newborns is also very high. The sooner an individual is treated, the more likely he or she is to survive. Overall, the death rate in the United States is 10 percent. Worldwide it is 45 percent. According the United States Centers for Disease Control, the average hospital stay is 16 days. Recovery for those who survive is normally complete after about four weeks.

Prevention

Tetanus is completely preventable by immunization. The recommendation in the United States, as of 2004, is to immunize children against tetanus on the following schedule:

• initial vaccination at two months of age
• repeat at four months of age
• repeat at six months of age
• repeat at 12 to 15 months of age
• repeat at four to six years of age
• booster dose given every 10 years there after, normally at ages 15, 25, 35, etc.

Receiving the complete schedule of multiple vaccinations is necessary to ensure full protection. For children, vaccination against tetanus is normally included in a vaccine called DTaP that protects against diphtheria, tetanus, and whooping cough (acellular pertussis). Many school districts require proof of vaccination before a child may enroll.

Other prevention measures involve prompt cleaning and protection of wounds and hygiene measure such as washing well after exposure to soil containing animal manure. Sterile conditions during surgery also help prevent infection.

Nutritional Concerns

Food is not given by mouth to individuals who are having muscle spasms for fear they will breathe the food into their lungs. During this time, they are fed intravenously.

Parental Concerns

Some parents hesitate to vaccinate their children for religious reasons or because they fear side effects of the vaccination. The bacteria that cause tetanus are so common and the disease is so serious that protection against acquiring tetanus outweighs any risks associated with vaccination.

See also Vaccination.

Resources

Books

Marx, John, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby, 2003.

Parker, James N., et al. Tetanus: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. Boulder, CO: netLibrary, 2004.

Periodicals

Roper, Martha H. "Tetanus Prophylaxis in the Emergency Department." Annals of Emergency Medicine 43, no. 3 (March 2004): 315–17.

Web Sites

Sonali, Ray, and Robert W. Tolan. "Tetanus." eMedicine Medical Library February 24, 2004. Available online at www.emedicine.com/ped/topic3038.htm (accessed October 14, 2004).

[Article by: Tish Davidson, A.M.]

Tetanus, an acute infectious noncontagious disease caused by Clostridium tetani, is characterized by a prolonged illness associated with severe complications, including death. In industrialized countries, tetanus primarily affects elderly adults, while in developing countries, neonatal tetanus predominates and is a substantial major contributor to infant mortality. Elimination of tetanus, especially neonatal tetanus, through vaccination is a global public health priority.

Clinical Description

Tetanus (lockjaw) is an acute neurologic disease that occurs when C. tetani spores infect a site of injury and produce a neurotoxin. Wounds accompanied by tissue injury and necrosis produce the anaerobic conditions necessary for bacterial replication and toxin production. The diagnosis is usually established clinically and supported by the epidemiologic setting. Major symptoms are spasm of the muscles of mastication (trismus or lockjaw) and generalized hyperreflexia, which produces painful and uncontrollable muscular contractions. Generalized spasms can occur, often induced by external sensory stimuli. The incubation period ranges from two days to two months, with an average of ten days. The course of illness may last several weeks (often requiring intubation) and subsides gradually in survivors.

The case fatality rate ranges between 10 and 90 percent. Survival is correlated with longer incubation periods and access to medical care. Shorter incubation periods are usually associated with heavily contaminated wounds, more serious disease, and worse outcomes. A wound history can be established in approximately 80 percent of tetanus patients in the United States; however, absence of a wound does not rule out tetanus. Laboratory confirmation of tetanus is difficult and may not be definitive. Culture of the wound may rarely yield C. tetani; serology is often not helpful because disease can be caused by quantities of toxin insufficient to induce an immune response.

Neonatal tetanus (NT) is caused by unsanitary conditions during childbirth, specifically contamination of the umbilical stump. Neonatal tetanus can be prevented by education about the need for clean deliveries and immunization of women of childbearing age (including pregnant women).

Epidemiology

Clostridium tetani is a normal inhabitant of soil and of animal and human intestines and occurs worldwide. Cases increase during warmer months in temperate climates, most likely because of increased outdoor activity. In the United States, an average of forty-six tetanus cases per year were reported to the Centers for Disease Control and Prevention (CDC) from 1990 to 1999, as compared to an average of sixty-seven cases in the 1980s.

In developing countries, neonatal tetanus is a leading cause of neonatal mortality, accounting for over 250,000 deaths annually. Neonatal tetanus has been called "the silent killer," since infants often die before their birth is recorded.

Control Measures

In the United States, five doses of tetanus toxoid are recommended at 2, 4, 6, and 18 months and between 4 and 6 years of age, most often administered with diphtheria toxoid and acellular pertussis vaccine (DTaP). Subsequent booster shots for tetanus, combined with diphtheria toxoid, are recommended every ten years. Less than one percent of tetanus cases recently reported in the United States were in persons with up-to-date immunizations.

There is no herd immunity for tetanus since C. tetani is not transmitted from person to person. Although tetanus is a highly preventable disease, all individuals remain at risk if they do not acquire and maintain immunity through vaccination and periodic boosters.

(SEE ALSO: Communicable Disease Control; Immunizations)

Bibliography

American Academy of Pediatrics (2000). "Tetanus." In Red Book 2000: Report of the Committee on Infectious Diseases, 25th edition, ed. L. K. Pickering. Elk Grove Village, IL: Author.

American Public Health Association (2000). "Tetanus." In Control of Communicable Diseases Manual, 17th edition, ed. A. S. Benenson. Washington, DC: Author.

Bardenheier, B.; Prevots, D. R.; Khetsuriani, N.; and Wharton, M. (1998). "Tetanus Surveillance: United States, 1995–1997." In Centers for Disease Control Surveillance Summaries 47(SS-2):1–13.

Wassilak, S. G. F.; Orenstein, W. A.; and Sutter, R. W. (1999). "Tetanus Toxoid." In Vaccines, 3rd edition, eds. S. A. Plotkin and W. A. Orenstein. Philadelphia, PA: W. B. Saunders.

— ELIZABETH FAIR; ROLAND SUTTER

For more information on tetanus, visit Britannica.com.

1. lockjaw; a particularly dangerous infection by a bacterium (Clostridiusn tetani), that can result from a laceration. Even when not fatal, this is a most unpleasant condition characterized by muscle stiffness and rigidity requiring prolonged and painful treatment. The infective organism can be found anywhere, but is most common on ground that has been used by animals. It is possible to use anti-tetanus serum, but this carries the risk of allergic reactions; active immunity is better.

2. Sustained contraction of muscle due to fusion of many small contractions (twitches) following one another in rapid succession. Tetanus produces sustained maximal tension and results from high frequency stimulation.

An acute and infectious disease caused by the toxin produced by a kind of bacteria that enters the body through cuts or wounds; also called lockjaw. In tetanus, the muscles of the body, particularly the muscles of the jaw, contract in painful spasms. Tetanus is deadly but can be prevented through immunization (tetanus shots).

A highly fatal disease of all animal species caused by the neurotoxin of Clostridium tetani. The bacterial spores are deposited in tissue, usually by traumatic injury, retained placenta or endometrial injury and under anaerobic conditions vegetate. Clinical features of the disease are remarkably similar in all species but there are differences in susceptibility to the disease. The muscle spasms cause a stiff gait, rigid posture (sometimes called ‘sawhorse stance’), extension or elevation of the tail, protrusion of the third eyelid and trismus (lockjaw). Horses show flaring of the nostrils. In dogs, spasms of facial muscles cause abnormally erect ears and retraction of the lips that resembles the ‘risus sardonicus’ seen in humans with tetanus. Stimulation precipitates generalized muscle contractions and tetanic spasms or convulsions. The disease can be prevented by immunization with tetanus toxoid or the use of antitoxin, but this is done routinely only in humans and horses.

• t. antitoxin — see tetanus antitoxin.
• idiopathic t. — a loosely defined syndrome of outbreaks of tetanus in young cattle without a wound being found; current practice is to refer to such outbreaks as being caused by the ingestion of pre-formed tetanus toxin.
• localized t. — tetany occurs predominantly in one limb, closest to the site of entry of the organism, but then usually spreads to the opposite limb and then the whole body. Seen in dogs and particularly cats.
• t. toxin — see tetanus toxin.
• t. toxoid — see toxoid.

Tetanus
Classification and external resources
Muscular spasms in a patient suffering from tetanus. Painting by Sir Charles Bell, 1809.
ICD-10	A33.-A35.
ICD-9	037, 771.3
DiseasesDB	2829
MedlinePlus	000615
eMedicine	emerg/574
MeSH	D013742

Tetanus, also called lockjaw, 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, 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 spasms develop in the jaw (thus the name "lockjaw") and elsewhere in the body.^[1] Infection can be prevented by proper immunization and by post-exposure prophylaxis.^[2]

Contents 1 Signs and symptoms 2 Pathophysiology 3 Diagnosis 4 Treatment 4.1 Mild tetanus 4.2 Severe tetanus 5 Prevention 6 Epidemiology 7 Association with rust 8 Famous tetanus victims 9 References 10 External links 10.1 Media

Signs and symptoms

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 40% to 78%. In recent years, approximately 11% of reported tetanus cases have been fatal. The highest mortality rates are in unvaccinated persons and persons over 60 years of age.^[2]

The incubation period of tetanus may be up to several months but is usually about 8 days.^[3][4] 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.^[5] 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.^[2]

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. Spasms may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. Spasms continue for 3–4 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.^[6]

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.

Pathophysiology

Tetanus begins when spores 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 dies, it is released and activated by proteases. Active tetanospasmin is carried by retrograde axonal transport^[5][7] to the spinal cord and brain stem where it binds irreversibly to receptors at these sites.^[5] It cleaves membrane proteins involved in neuroexocytosis,^[8] which in turn blocks neurotransmission. Ultimately, this produces the symptoms of the disease. Damaged upper motor neurons can no longer inhibit lower motor neurons, plus they cannot control reflex responses to afferent sensory stimuli.^[5] Both mechanisms produce the hallmark muscle rigidity and spasms. Similarly, a lack of neural control of the adrenal glands results in release of catecholamines, thus producing a hypersympathetic state and widespread autonomic instability.

C. tetani also produces tetanolysin, another toxin whose role in tetanus is unknown.

Diagnosis

There are 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 who do not have tetanus. Laboratory identification of C. tetani can only be demonstrated by production of tetanospasmin in mice.^[2]

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).^[9]

Treatment

The wound must be cleaned. Dead and infected tissue should be removed by surgical debridement. 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 immune globulin 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.

An infant suffering from neonatal tetanus.

Mild tetanus

Mild cases of tetanus can be treated with:

• Tetanus immunoglobulin IV or IM,
• metronidazole IV for 10 days,
• diazepam,
• tetanus vaccination

Severe tetanus

Severe cases will require admission to intensive care. In addition to the measures listed above for mild tetanus:

Lock-jaw in a patient suffering from tetanus.

• human tetanus immunoglobulin injected intrathecally (increases clinical improvement from 4% to 35%)
• tracheostomy and mechanical ventilation for 3 to 4 weeks,
• magnesium, as an intravenous (IV) infusion, to prevent muscle spasm,
• diazepam as a continuous IV infusion,
• the autonomic effects of tetanus can be difficult to manage (alternating hyper- and hypotension, hyperpyrexia/hypothermia) and may require IV labetalol, magnesium, clonidine, or nifedipine.

Drugs such as diazepam or other muscle relaxants 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 150g 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.

Prevention

Unlike many infectious diseases, recovery from naturally acquired tetanus does not usually result in immunity 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.^[10] 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 3 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.^[11] 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.^[10]

Epidemiology

Tetanus cases reported worldwide (1990-2004). Ranging from strongly prevalent (in dark red) to very few cases (in light yellow) (grey, no data).

Tetanus is an international health problem, as C. tetani spores are ubiquitous. The disease occurs almost exclusively in persons who are unvaccinated or inadequately immunized.^[1] 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.^[2] Heroin users, particularly those that inject the drug, appear to be at high risk for tetanus.

Tetanus – particularly the neonatal form – remains a significant public health problem in non-industrialized countries. There are about one million cases of tetanus reported worldwide annually, causing an estimated 300,000 to 500,000 deaths each year.^[2]

In the United States, approximately 100 people become infected with tetanus each year, and there are about five deaths from tetanus each year.^[12] Nearly all of the cases in the United States occur in unimmunized individuals or individuals who have allowed their inoculations to lapse,^[12] whereas most cases in developing countries are due to the neonatal form of tetanus.

Tetanus is the only vaccine-preventable disease that is infectious but is not contagious.^[2][12]

Association with rust

Tetanus is often associated with rust, 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-metabolising survival structure that begins to metabolise 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 which causes a puncture wound, delivering endospores to a suitable environment for growth.

Famous tetanus victims

• Tom Butler – English footballer; contracted after suffering a badly broken arm.
• George Hogg – English adventurer who rescued war orphans in China; died in 1945 from an infection resulting from a foot injury.
• Joe Hill Louis – Memphis blues 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 Powell – English footballer; contracted following amputation of a badly broken arm.
• John A. Roebling – Civil Engineer and Architect famous for his bridge designs, particularly the Brooklyn Bridge; contracted tetanus following amputation of his foot due to an injury caused by a ferry when it crashed into a wharf.
• George Crockett Strong – Union brigadier general in the American Civil War; from wounds sustained in the assault against Fort Wagner on Morris Island, South Carolina.
• Fred Thomson – silent film actor; stepped on a nail.
• Johann Tserclaes, Count of Tilly; wounded by a cannon ball in the Battle of Rain.
• Traveller – General Robert E. Lee's favorite horse; stepped on a nail.
• John Thoreau (brother of Henry David Thoreau); nicked himself with a razor while shaving, contracting lockjaw subsequently.

References

1. ^ ^{a b} Wells CL, Wilkins TD (1996). "Clostridia: Sporeforming Anaerobic Bacilli". in Baron S, et al.. Baron's Medical Microbiology (4th ed.). Univ of Texas Medical Branch. ISBN 0-9631172-1-1. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=mmed.section.1099. 
2. ^ ^{a b c d e f g} "Tetanus". CDC Pink Book. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus-508.pdf. Retrieved 2007-01-26. 
3. ^ Vandelaer J; Birmingham M; Gasse F; Kurian M; Shaw C; Garnier S (28 July 2003). "Tetanus in developing countries: an update on the Maternal and Neonatal Tetanus Elimination Initiative". Vaccine 21 (24): 3442–5. doi:10.1016/S0264-410X(03)00347-5. PMID 12850356. 
4. ^ Brauner JS; Vieira SR; Bleck TP (2002 Jul). "Changes in severe accidental tetanus mortality in the ICU during two decades in Brazil". Intensive Care Medicine 28 (7): 930–5. doi:10.1007/s00134-002-1332-4. PMID 12122532. 
5. ^ ^{a b c d} Farrar JJ; Yen LM; Cook T; Fairweather N; Binh N; Parry J; Parry CM (2000 Sept). "Tetanus". Journal of Neurology, Neurosurgery, and Psychiatry 69 (3): 292–301. PMID 10945801. 
6. ^ World Health Organization (2000-11-01). "Maternal and Neonatal Tetanus Elimination by 2005". http://www.unicef.org/immunization/files/MNTE_strategy_paper.pdf#search=%22neonatal%20tetanus%20rates%22. Retrieved 2007-01-26. 
7. ^ AU Lalli G; Gschmeissner S; Schiavo G (15 Nov 2003). "Myosin Va and microtubule-based motors are required for fast axonal retrograde transport of tetanus toxin in motor neurons". Journal of Cell Science 116 (Pt 22): 4639–50. doi:10.1242/jcs.00727. PMID 14576357. 
8. ^ Schiavo G; Benfenati F; Poulain B; Rossetto O; Polverino de Laureto P; DasGupta BR; Montecucco C (29 Oct 1992). "Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin". Nature 359 (6398): 832–5. doi:10.1038/359832a0. PMID 1331807. 
9. ^ Nitin M. Apte and Dilip R. Karnad (1995-10). "Short Report: The Spatula Test: A Simple Bedside Test to Diagnose Tetanus". Am. J. Trop. Med. Hyg.. pp. 386–387. http://www.ajtmh.org/cgi/content/abstract/53/4/386. Retrieved 2007-10-11. 
10. ^ ^{a b} Hopkins, A. (1991). "Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory committee (ACIP).". MMWR Recomm Rep 40 (RR-10): 1–28. doi:10.1542/peds.2006-0692. PMID 1865873. 
11. ^ Porter JD, Perkin MA, Corbel MJ, Farrington CP, Watkins JT, Begg NT (1992). "Lack of early antitoxin response to tetanus booster". Vaccine 10 (5): 334–6. doi:10.1016/0264-410X(92)90373-R. PMID 1574917. 
12. ^ ^{a b c} Office of Public Information, Missouri Department of Health and Senior Services (2005-07-14). "Tetanus Cases Prompt Advisory for Missourians to Get Vaccine, Check Booster Status". Press release. http://www.dhss.mo.gov/NewsAndPublicNotices/Tetanus7-14-05.html. Retrieved 2006-09-20. 

External links

Wikimedia Commons has media related to: Tetanus

• Tetanus Information from Medline Plus
• Tetanus Surveillance -- United States, 1998-2000 (Data and Analysis)

Media

• Video: Generalized tetanus in a 70-year-old woman (Neurology)
• Video: Tetanus in dogs

v • d • e Infectious diseases · Bacterial diseases: G+ (primarily A00–A79, 001–041, 080–109) Firmicutes/ (low-G+C) Bacilli Lactobacillales (Cat-) Streptococcus Alpha hemolytic optochin susceptible: S. pneumoniae (Pneumococcal infection) optochin resistant: S. viridans (S. mitis, S. mutans, S. oralis, S. sanguinis, S. sobrinus, milleri group) Beta hemolytic A, bacitracin susceptible: S. pyogenes (Scarlet fever, Erysipelas, Rheumatic fever, Streptococcal pharyngitis) B, bacitracin resistant, CAMP test+: S. agalactiae Gamma hemolytic D, BEA+: Streptococcus bovis Enterococcus BEA+: Enterococcus faecalis (Urinary tract infection) · Enterococcus faecium Bacillales (Cat+) Staphylococcus Cg+ S. aureus (Staphylococcal scalded skin syndrome, Toxic shock syndrome, MRSA) Cg- novobiocin susceptible (S. epidermidis) · novobiocin resistant (S. saprophyticus) Bacillus Bacillus anthracis (Anthrax) · Bacillus cereus (Food poisoning) Listeria Listeria monocytogenes (Listeriosis) Clostridia Clostridium (spore-forming) motile: Clostridium difficile (Pseudomembranous colitis) · Clostridium botulinum (Botulism) · Clostridium tetani (Tetanus) nonmotile: Clostridium perfringens (Gas gangrene, Clostridial necrotizing enteritis) Peptostreptococcus (non-spore forming) Peptostreptococcus magnus Mollicutes Mycoplasmataceae Ureaplasma urealyticum (Ureaplasma infection) · Mycoplasma genitalium · Mycoplasma pneumoniae (Mycoplasma pneumonia) Anaeroplasmatales Erysipelothrix rhusiopathiae (Erysipeloid) Actinobacteria/ (high-G+C) Actinomycineae Actinomycetaceae Actinomyces israelii (Actinomycosis) · Tropheryma whipplei (Whipple's disease) Propionibacteriaceae Propionibacterium acnes Corynebacterineae Mycobacteriaceae M. tuberculosis/M. bovis Tuberculosis: Ghon focus/Ghon's complex · Pott disease · brain (Meningitis, Rich focus) · cutaneous (Scrofula, Bazin disease, Lupus vulgaris, Prosector's wart) · Miliary · Tuberculous pericarditis M. leprae Leprosy Nontuberculous R1: M. kansasii · M. marinum R2: M. gordonae R3: M. avium complex (MAA, MAP, MAI, Lady Windermere syndrome) · M. ulcerans (Buruli ulcer) · M. haemophilum R4: M. fortuitum · M. chelonae Nocardiaceae Nocardia asteroides/Nocardia brasiliensis (Nocardiosis) · Rhodococcus equi Corynebacteriaceae Corynebacterium diphtheriae (Diphtheria) · Corynebacterium minutissimum (Erythrasma) · Corynebacterium jeikeium Bifidobacteriaceae Gardnerella vaginalis

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Dansk (Danish)
n. - tetanus, stivkrampe

Nederlands (Dutch)
wondkramp

Français (French)
n. - tétanos

Deutsch (German)
n. - Tetanus

Ελληνική (Greek)
n. - (παθολ.) τέτανος

Italiano (Italian)
tetano

Português (Portuguese)
n. - tétano (m)

Русский (Russian)
(мед.) тетанус, столбняк, (физиолог.) судорога, спазма, длительное сокращение скелетной мышцы

Español (Spanish)
n. - tétano

Svenska (Swedish)
n. - stelkramp, tetanus (med.)

中文（简体）(Chinese (Simplified))
破伤风, 破伤风杆菌

中文（繁體）(Chinese (Traditional))
n. - 破傷風, 破傷風桿菌

한국어 (Korean)
n. - 파상풍, 파상풍균, 강직 경련

日本語 (Japanese)
n. - 破傷風

العربيه (Arabic)
‏(الاسم) مرض تتشنج معه عضلات العنق والفك بخاصه, الكزاز‏

עברית (Hebrew)
n. - ‮צפדת, טטנוס‬

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