| Tetanus is a serious, potentially fatal disease of the central nervous system caused when a wound becomes infected by the bacteria Clostridium tetani. The disease is characterized by muscle rigidity and numerous muscle spasms. Often, the first sign is stiffness of the jaw muscles, hence the synonym lockjaw. Tetanus has an incubation period of 1 to 55 days, with more than 80% of cases reporting symptoms within 14 days. The shorter the incubation period, the more serious and life-threatening the disease.
Clostridium tetani spores are commonly found in the soil. These bacteria are also found in the intestines of domestic animals. As a result, soil contaminated with manure is especially likely to contain these spores. The spores enter the body through breaks in the skin or wounds, particularly deep puncture wounds. They multiply in wounds where little oxygen is available, producing a poison (neurotoxin) that travels to the central nervous system. There it interferes with the functioning of the nerves that control muscle activity, causing severe muscle spasms. Tetanus has become a rare disease in industrialized countries since the introduction of widespread immunization.
Farmers and other individuals who live in rural areas of the South where they are more likely to come into contact with animal manure are at higher risk. Tetanus is much rarer in cold climates than in warm, humid environments. Intravenous drug use, frostbite, skin ulcers, surgical wounds, traumatic wounds, and burns increase one's risk of contracting tetanus.Risk: Lack of immunization is the highest risk factor in contracting tetanus. In the US, about 87% of cases occur in individuals who have not been adequately immunized. Tetanus affects all age groups, although the very young and those over age 50 are at higher risk. In the US, 70% of cases occur in individuals over age 50 (Zamula).
Men and women are affected equally. About 10% of individuals carry Clostridium tetani bacteria in their intestines. These individuals are at higher risk after abdominal operations or abortion. Incidence and Prevalence: In the US, 40 to 50 cases of tetanus are reported each year, resulting in about 5 deaths. Worldwide, tetanus is predominantly a disease of underdeveloped countries in warm, damp climates. Contributing factors include a very low rate of immunization, poor waste treatment, poor hygiene and wound care, and use of untreated animal manure for fertilizer. Tetanus is one of the target diseases of the World Health Organization Expanded Program on Immunization. Overall annual worldwide incidence is 0.5 million to 1 million cases. Worldwide mortality is about 45%. |
Source: Medical Disability Advisor
| History: The hallmark symptom of tetanus is stiffness of the jaw (trismus or lockjaw), making it difficult or even impossible to open the mouth. Other symptoms include stiff neck, difficulty swallowing (dysphagia), drooling, stiffness in abdominal and back muscles, and contraction of facial muscles into a fixed, excited expression. There may also be a fever, profuse sweating, restlessness, headaches, and painful muscle spasms. Seizures often occur in response to sensory stimuli (noise, light, changes in temperature). Spasms of the respiratory muscles may inhibit normal breathing. Physical exam: The exam may reveal a painful or tender wound. However, a wound may not be apparent in as many as 30% of cases. Muscle rigidity and spasm, increased heart rate (tachycardia), irregular heartbeat (arrhythmia), drooling, irritability, and increased blood pressure (hypertension) may be noted. The individual's color may appear bluish or gray (cyanosis) as a result of inadequate oxygen. The individual remains awake and alert throughout the illness. Tests: Tetanus is diagnosed on the basis of presenting symptoms. No specific laboratory test exists. Although the organism can sometimes be cultured from a wound, false negative cultures occur about one-third of the time. Electromyography (EMG) may be used to analyze the electrical activity of the muscles. Lumbar puncture may be done to eliminate a diagnosis of meningitis. A CT scan may be used to eliminate a diagnosis of brain abnormalities, and a serum calcium level can rule out the diagnosis of hypocalcemia. |
Source: Medical Disability Advisor
| Tetanus infection is serious and life-threatening. Treatment is usually administered in the intensive care unit of a hospital and has four goals: stabilization and support of the patient as symptoms develop, administration of tetanus antitoxin and tetanus immunoglobulin (TIG) to help moderate the effects of the toxin, administration of antibiotics to kill the Clostridium tetani bacteria, and prophylactic immunization to prevent future occurrence.
An open airway must be maintained. Depending on the individual's symptoms, this may be done by different methods. A tube may be inserted into the windpipe (trachea) in a procedure called intubation. In severe cases, an artificial opening in the trachea (tracheostomy) may be required. If the individual is unable to breathe independently, ventilation may be required. Nutritional support may need to be provided through a feeding tube. The wound is cleaned thoroughly. Damaged tissue may need to be surgically removed (débridement). Antibiotics and antitoxins are administered to eradicate the toxin-producing organisms. Anticonvulsants may be necessary to control the seizures. Muscle relaxants may also be prescribed.
Because having tetanus does not grant further immunity against the infection, after recovery the individual should receive the full series of vaccinations. |
Source: Medical Disability Advisor
| Acute respiratory failure is the leading cause of death in tetanus infections. A short incubation period is associated with a particularly grim prognosis. In individuals under age 50, mortality is nearly 100% if symptoms begin within 1 to 2 days. Morbidity is reduced to 35% to 40% if the incubation period is greater than 10 days. The overall mortality rate ranges from less than 10% to as high as 50%. High mortality rates are also associated with early onset of convulsions, individuals who require mechanical ventilation, or delay in treatment. Contaminated wounds located on the head and face are more dangerous than wounds located on other parts of the body. The individual's age and severity of symptoms also affect prognosis. Recovery is complete if the individual survives the infection. |
Source: Medical Disability Advisor
| Complications include inability to breathe (respiratory failure), heart failure, tachycardia, blood clots to the lungs (pulmonary emboli), pulmonary edema, other secondary bacterial infections, dehydration, bone fractures secondary to seizures, airway obstruction, suffocation, urinary retention, kidney failure, constipation, bronchiolitis, destruction of muscle tissue (rhabdomyolysis), coma, and death. |
Source: Medical Disability Advisor
| A leave of absence may be required. Upon returning to work, strenuous activity or work requiring heavy lifting may need to be modified until physical stamina returns. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has diagnosis of tetanus been confirmed?
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Have other conditions such as strychnine poisoning, dental infection, acute drug reaction to phenothiazines, meningoencephalitis, hepatic encephalopathy, rabies, subarachnoid hemorrhage, seizure disorder, alcohol withdrawal, peritonsillar abscess, or hypocalcemic tetany, that cause similar symptoms to tetanus been ruled out?
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Has individual experienced any complications such as respiratory arrest, heart failure, pulmonary emboli, other bacterial infection, dehydration, spinal cord fracture, airway obstruction, suffocation, urinary retention, constipation, pneumonia, destruction of muscle tissue, or coma?
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Does individual have an underlying condition such as advanced age or pre-existing heart disease that may impact recovery?
Regarding treatment:
- Was individual hospitalized?
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Did individual receive prompt administration of tetanus antitoxin or tetanus immune globulin?
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Were antibiotics and antitoxins given to eradicate the toxin-producing organisms?
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Were anticonvulsants and muscle relaxants needed to control the seizures?
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Was intubation, tracheostomy, or mechanical ventilation necessary?
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Did individual experience any complications related to these procedures?
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Was surgical débridement of wound required?
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Is wound now healing adequately? If not, what further procedures may be required?
Regarding prognosis:
- Are any of these risk factors (a short incubation period, early onset of convulsions, need for mechanical ventilation, or delay in treatment) relevant to individual's case?
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Where was the wound located?
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Is individual over 50 years of age?
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Source: Medical Disability Advisor
| Roper, M. H. "Tetanus Prophylaxis in the Emergency Department." Annals of Emergency Medicine 43 3 (2004): 305-314.Zamula, Evelyn. "Adults Need Tetanus Shots, Too." U.S. Food and Drug Administration. 21 Aug. 2006 <http://www.fda.gov/fdac/features/696_tet.html>. |
Source: Medical Disability Advisor
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