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C.L. Thwaites

and Lam Minh Yen



Epidemiology—decline in tetanus incidence rates, particularly neonatal tetanus.

Treatment—additional detail.

Prognosis—additional detail.

Updated on 31 May 2012. The previous version of this content can be found here.
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date: 29 April 2017

Clostridium tetani is a Gram-positive, spore-forming anaerobic bacterium that is ubiquitous, being found throughout the world in human and animal faeces, soil, and street dust. In children and adults, superficial skin wounds are the common entry sites, although in 20% no portal of entry can be found.

Pathophysiology—under favourable anaerobic conditions, clostridial spores germinate and bacteria grow and multiply, producing a pathogenic toxin which—either locally or after circulation in the bloodstream—enters motor nerves, with the eventual effect of preventing discharge of γ‎-aminobutyric acid (GABA) inhibitory interneurons, resulting in unrestricted motor nerve activity, increased muscle tone, and spasms characteristic of tetanus.

Clinical features—after an incubation period of 7 to 14 days the disease presents with symptoms including trismus (‘lockjaw’, 98%), muscle stiffness (95%), back pain (94%), dysphagia (83%), muscle spasms (46%, with ‘risus sardonicus’ due to facial muscle spasm), and difficulty breathing (7%). Life-threatening complications include laryngeal muscle spasms and spasm and hypertonus of the respiratory muscles, and in severe cases there are violent autonomic disturbances. Tetanus continues to be a common cause of death in developing countries.

Diagnosis and treatment—tetanus is a clinical diagnosis: the presence of generalized muscle rigidity with trismus being characteristic, and risus sardonicus virtually pathognomonic. Key elements of treatment are (1) wound toilet and antibiotics, usually metronidazole; (2) antitoxin—most commonly human tetanus immune globulin 100 to 300 IU/kg intramuscularly; (3) spasm control—benzodiazepines are the first-line agents, with chlorpromazine, phenbarbitone, and propafol as alternatives; (4) control of any autonomic disturbance. Many patients require intensive care management and nursing.

Prevention—tetanus has largely been eliminated in countries with good immunization programmes and standards of hygiene. The World Health Organization recommendation is for a primary immunization course of three doses in infancy, followed by boosters aged 4 to 7 years and 12 to 15 years, with a further dose given in adult life. All patients with tetanus require a full course of active immunization as the disease itself does not confer long-lasting immunity.

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