Tetanus

Tetanus is a disorder of neurotransmission associated with infection by

Clostridium tetani. The organism typ- ically becomes established in a wound,
where it elabo- rates a toxin that is transported retrogradely along mo- tor nerves
into the spinal cord or, with wounds to the face or head, the brainstem. The toxin
is also dissemi- nated through the bloodstream to skeletal muscle, where it gains
access to additional motor nerves. In the spinal cord and brainstem, tetanus toxin
interferes with the release of inhibitory neurotransmitters, including glycine and
GABA, resulting in motor nerve hyperac- tivity. Autonomic nerves are also
disinhibited.
After an incubation period of up to 3 weeks, tetanus usually presents with trismus
(lockjaw), difficulty in swallowing, or spasm of the facial muscles that resem- bles
a contorted smile (risus sardonicus). Painful mus- cle spasms and rigidity
progress to involve both axial and limb musculature and may give rise to hyperex-
tended posturing (opisthotonos). Laryngospasm and autonomic instability are
potential life-threatening complications.
Although the diagnosis is usually made on clinical grounds, the presence of
continuous motor unit activ-
ity or absence of the normal silent period in the mas- seter muscle following
elicitation of the jaw-jerk reflex is a helpful electromyographic finding. The serum
CK may be elevated, and myoglobinuria may occur. The organisms can be
cultured from a wound in only a mi- nority of cases.
Tetanus is preventable through immunization with tetanus toxoid. Tetanus toxoid
is usually administered routinely to infants and children in the United States, in
combination with pertussis vaccine and diphtheria toxoids. In children under age 7
years, three doses of tetanus toxoid are administered at intervals of at least 1
month, followed by a booster dose 1 year later. For older children and adults, the
third dose is delayed for at least 6 months after the second, and no fourth dose is
required. Immunization lasts for 510 years.
Debridement of wounds is an important preventive measure. Patients with open
wounds should receive an additional dose of tetanus toxoid if they have not re-
ceived a booster dose within 10 yearsor if the last booster dose was more than 5
years ago and the risk of infection with C tetani is moderate or high. A moderate
likelihood of infection is associated with wounds that penetrate muscle, those
sustained on wood or pave- ment, human bites, and nonabdominal bullet wounds.
High-risk wounds include those acquired in barnyards, near sewers or other
sources of waste material, and ab- dominal bullet wounds. Patients with moderate-
or high-risk wounds should also be given tetanus immune globulin.
The treatment of tetanus includes hospitalization in an intensive care unit to
monitor respiratory and circula- tory function, tetanus immune globulin to
neutralize the toxin, and penicillin or metronidazole for the infection it- self.
Intrathecal administration of tetanus immune globu- lin has been associated with
better clinical progression than intramuscular administration. Diazepam, 1030 mg
intravenously or intramuscularly every 46 hours, and chlorpromazine, 2550 mg
intravenously or intramuscu- larly every 8 hours, are useful for treating painful
spasms and rigidity. Baclofen also has been used, with intrathecal administration.
Neuromuscular blockade with vecuro- nium or pancuronium may be required
when these mea- sures fail; if so, mechanical ventilation must be used.
Fatality rates of 1060% are reported. Lower fatality rates are most likely to be
achieved by early diagnosis, prompt institution of appropriate treatment before the
onset of spasms, and the use of intrathecalin addi- tion to intramuscular
tetanus immune globulin. Among patients who recover, about 95% do so without
long-term sequelae.