TETANUS
• In April 2015, WHO included India in the list of
countries which has eliminated neonatal
tetanus.
INTRODUCTION
• Caused by neurotoxin produced by Clostridium tetani.
• Commonly occur in rural areas, in warm climates & during summer.
• Important cause of neonatal death in developing world.
• Only vaccine preventable disease that is infectious but not
contagious fm person to person.
• Disseminated through excreta & found in soil & dust.
• Is a disease characterised by :-
1. Acute onset of hypertonia.
2. Painful muscle contraction(esp jaw &neck muscle).
3. Generalised muscle spasm.
• Clostridium tetani produce :
1. Tetanolysin.
2. Tetanospasmin -> is a neurotoxin.
• Risk factor for infection:-
1. Wound contamination.
2. Unhygienic & improper handling of umbilical cord in
newborns.
3. Aseptic care during & after delivery in women.
4. Suppurative infection.
5. Presence of FB ,trauma or crush injury.
6. Animal bites.
CLINICAL MANIFESTATIONS :-
• I.P – around 10 days (range 3 to 30 days ).
• Types :-
1. Generalized tetanus -> M/C type (80%).
2. Neonatal tetanus -> infantile form of generalized tetanus.
3. Localized tetanus -> may precede generalized tetanus.
4. Cephalic tetanus -> rare form , seen in children with a/w
otitis media.
# Generalized tetanus :
• Usually present with a descending pattern.
• 1st sign : trismus / lockjaw .
• Early symptoms : headache , restlessness,
irritability.
• F/b : neck stiffness , difficulty swallowing ,
rigidity of abdominal muscle .
• Risus sardonicus .
• Opisthotonus posture.
• Laryngeal & respiratory muscle spasm.
• Airway obstruction, asphyxiation.
• Does not affect sensory nerves or cortical function.
• So patient remains conscious, in extreme pain & in fearful
anticipation of next tetanic seizure.
• Urinary retention.
# Neonatal tetanus :-
• Infantile form of generalized tetanus.
• Manifest within 3 -12 days of birth.
• Symptoms – progressive difficulty in feeding.
Paralysis/ diminished movement.
Stiffness & rigidity to touch.
Spasms
With/ without opisthotonus.
• Localized tetanus:-
- Results in painful spasms of the muscles adjacent to wound site.
- May precede generalized tetanus.
• Cephalic tetanus :-
- Rare form .
- Involve bulbar musculature.
- Also occur in a/w chronic otitis media.
• R/fs :- wound / foreign body in head , nostrils or face.
• Characterised by :-
- Retracted eyelids. - Deviated gaze.
- Trismus. - Risus sardonicus.
- Spastic paralysis of tongue & pharyngeal musculature.
DIAGNOSIS:-
• Is clinical.
• Suspected case : unimmunised patient having injury or born
within preceding 2 wks , who presents with trismus , rigid muscles
& clear sensorium.
• Lab : findings normal .
DIFFERENTIAL DIAGNOSIS
1. Parapharyngeal / retropharyngeal / dental abscess.
2. Hypocalcemia.
3. Metabolic alkalosis.
4. 7th nerve palsy.
5. Strychnine poisoning.
6. Rabies ( hydrophobia, marked dysphagia,clonic seizures).
7. Narcotic withdrawal.
MANAGEMENT
• Requires eradication of [Link] .
• Supportive :
- Isolation in a quiet room.
- Maintain fluid, nutrition & electrolytes.
- Oxygen inhalation if required.
- Neutralize circulating toxin before it reaches CNS.
- Surgical wound excision & debridement (after administration of
human TIG & antibiotics).
• TIG shd be given asap to neutralize the toxin that diffuses from the
wound into the circulation before the toxin can bind at distant muscle
groups.
• If TIG unavailable, then human IVIG shd be used.
• Pn G ( 1,00,000 units/kg/day ) iv every 4 to 6 hr for 10 to 14 days.
• Metronidazole ( 500mg ) every 8 hrly .
• Erythromycin & tetracycline ( for > 8 yrs of age ).
• All patients with generalized tetanus need muscle relaxants.
DIAZEPAM 0.1 – 0.2 mg/kg every 3-6 hr iv.
COMPLICATIONS :-
1. Aspiration pneumonia.
2. Pneumothorax.
3. Mediastinal emphysema.
4. Laceration of mouth & tongue.
5. Decubitus ulcer.
6. Paralytic ileus
PREVENTION :-
• Tetanus is an entirely preventable disease.
• Active immunisation shd begin in early infancy with combined
DTaP vaccine at 2, 4, 6 & 15-18 months of age.
• Booster at 4-6 yr (DTaP) & 11-12 yr (Tdap) & 10 yr interval then
throughout adult life with tetanus & reduced diphtheria toxoid(Td).
• Immunization of all pregnant women.
