Updated: 10/4/2021

Tetanus

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Snapshot
  • A 4-day-old girl presents to the pediatric emergency room for inability to suck or cry. The mom reports that since birth, she has been feeding, sucking, and crying normally until this morning. She also reports that she herself had not had any of the recommended vaccines as she grew up in a family that had refused vaccines. On physical exam, the baby girl is stiff and fails to cry during exam. She is also in opisthotonos. When given a pacifier, she also fails to suck. She is given a benzodiazepine for the spasm and appropriate treatment. She is admitted for further management.
Introduction
  • Classification
    • Clostridium tetani
      • anaerobic gram + rod
      • produces tetanospasmin toxin
    • transmission
      • direct contact in contaminated soil
  • Epidemiology
    • demographics
      • rare in the US
      • more common in developing countries due to low rates of vaccination
    • risk factors
      • lack of vaccination
      • trauma
      • chronic wounds
      • lack of immunity in mothers
  • Pathogenesis
    • forms spores that are resistant to heat and chemicals
    • produces tetanospasmin, an exotoxin
      • a protease that cleaves SNARE proteins, which blocks the release of inhibitory neurotransmitters (glycine and GABA)
      • causes paralysis
  • Associated conditions
    • tetanus
    • neonatal tetanus
      • neonate who are born to unvaccinated mothers
      • inability to suck or cry after day 2 of life
      • infection of the umbilical stump
  • Prevention
    • DTap vaccine
      • vaccine against diphtheria, tetanus, and pertussis
      • 5 doses before school-age, completed by 4-6 years of age
    • Tdap vaccine
      • booster vaccine at 11-12 years of age
      • indicated at least once in adults who have never previously received a dose of Tdap
    • Td vaccine
      • tetanus and diphtheria toxoid vaccine at 10-year intervals
  • Prognosis
    • spasms last for ~ 1 month
    • mortality can be high if not treated
Presentation
  • Symptoms
    • spastic paralysis
      • muscle stiffness
      • spasms
    • fever
  • Physical exam
    • trismus
      • lockjaw
    • risus sardonicus
      • raised eyebrows
      • grin
    • opisthotonos
      • spinal muscle spasms
      • causes backward arching of head and spine
    • rigid abdominal muscles
    • neonates
      • foul-smelling and erythematous umbilical stump
      • failure or weakness of suck or cry
Studies
  • Serology or culture
    • rarely used due to low sensitivity and specificity
  • Making the diagnosis
    • most cases are clinically diagnosed
Differential
  • Bacterial meningitis
    • distinguishing factor
      • nuchal rigidity without other signs of spastic paralysis
Treatment
  • Management approach
    • stop toxin production
    • neutralize circulating toxin
    • active immunization
    • symptomatic and supportive care
  • Conservative
    • wound debridement
      • indication
        • all patients
  • Medical
    • tetanus immune globulin
      • indication
        • when diagnosis of tetanus is considered
    • metronidazole 
      • indication
        • universally recommended
    • active immunization
      • indication
        • all patients with tetanus should receive full vaccine series at diagnosis
    • benzodiazepine
      • indications
        • muscle spasms
  • Prophylaxis
    • indicated for wounds for the prevention of tetanus
    • booster vaccine 
      • indication
        • clean and minor wounds
          • patients with <3 prior doses or unknown vaccination history
          • patients with ≥3 prior doses but ≥10 years since last dose 
        • all other wounds, including dirty, contaminated, and/or severe
          • patients with <3 prior doses or unknown vaccination history
          • patients with ≥3 prior doses but ≥5 years since last dose  
    • tetanus immune globulin
      • indication
        • dirty, contaminated, and/or severe wounds and <3 prior doses of tetanus toxoid-containing vaccine or unknown vaccination history
Complications
  • Respiratory compromise from spasm of respiratory muscles
  • Aspiration pneumonia
  • Contractures

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Questions (6)
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(M2.ID.16.4684) A 43-year-old construction worker presents to the emergency department two hours after sustaining a deep laceration to his left forearm by a piece of soiled and rusted sheet metal. His vital signs are stable, there is no active bleeding, his pain is well controlled, and a hand surgeon has been notified about damage to his forearm tendons. He does not recall receiving any vaccinations in the last 30 years and does not know if he was vaccinated as a child. What is the appropriate post-exposure prophylaxis?

QID: 107349
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IV metronidazole only

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Anthrax vaccine

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Tetanus vaccine booster only

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Tetanus immunglobulin only

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Tetanus vaccine + immunoglobulin

100%

(2/2)

M 7 D

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