Tetanus (patient information)

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Overview
Tetanus is a serious illness caused by tetanus bacteria. The bacteria live in soil, saliva, dust and manure. The bacteria usually enter the body through a deep cut, like those you might get from cutting yourself with a knife or stepping on a nail.

What are the symptoms?
The infection causes painful tightening of the muscles, usually all over the body. It can lead to "locking" of the jaw, which makes it impossible to open your mouth or swallow. If this happens, you could die of suffocation.
 * Trismus, or lockjaw
 * Facial spasms called risus sardonicus
 * Stiffness of the neck
 * Difficulty in swallowing
 * Rigidity of pectoral and calf muscles.
 * Elevated temperature
 * Sweating
 * Elevated blood pressure
 * Episodic rapid heart rate.
 * Spasms may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. Spasms continue for up to 4 weeks, and complete recovery may take months.
 * Neonatal tetanus is a form of generalized tetanus that occurs in newborns.

What are the causes?
Tetanus is often associated with rust, especially rusty nails, but this concept is somewhat misleading. Objects that accumulate rust are often found outdoors, or in places that harbor anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more C. tetani bacteria. The rough surface of rusty metal merely provides a prime habitat for a C. tetani endospore to reside, and the nail affords a means to puncture skin and deliver endospore into the wound. An endospore is a non-metabolizing survival structure that begins to metabolize and cause infection once in an adequate environment. Because C. tetani is an anaerobic bacterium, it and its endospores survive well in an environment that lacks oxygen. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic) environment is provided by the same object which causes a puncture wound, delivering endospores to a suitable environment for growth.

Who is at highest risk?
People in developing countries are more at risk because of lack of vaccination

When to seek urgent medical care?
The wound should be taken care as soon as possible

Diagnosis

 * Diagnosis is done on the basis of clinical presentation.
 * The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a gag reflex attempting to expel the foreign object.

Treatment options

 * The wound must be cleaned.
 * Dead and infected tissue should be removed by surgical debridement.
 * Administration of the antibiotic metronidazole decreases the number of bacteria but has no effect on the bacterial toxin.
 * Penicillin was once used to treat tetanus, but is no longer the treatment of choice, owing to a theoretical risk of increased spasms.
 * Passive immunization with human anti-tetanospasmin immunoglobulin or tetanus immunoglobulin is crucial.
 * Normal human immunoglobulin may be given instead.
 * All tetanus victims should be vaccinated against the disease or offered a booster shot.

Mild cases of tetanus can be treated with: Severe tetanus
 * Tetanus immunoglobulin IV or IM
 * metronidazole IV for 10 days* Diazepam
 * human tetanus immunoglobulin injected intrathecally (increases clinical improvement from 4% to 35%)
 * tracheotomy and mechanical ventilation for 3 to 4 weeks
 * magnesium, as an intravenous (IV) infusion, to prevent muscle spasm
 * diazepam as a continuous IV infusion
 * the autonomic effects of tetanus can be difficult to manage (alternating hyper- and hypotension hyperpyrexia/hypothermia) and may require IV labetalol, magnesium, clonidine, or nifedipine.
 * Drugs such as diazepam or other muscle relaxants can be given to control the muscle spasms.
 * In extreme cases it may be necessary to paralyze the patient with curare-like drugs and use a mechanical ventilator.
 * The maintenance of an airway and proper nutrition are required. An intake of 3500-4000 calories, and at least 150 g of protein per day, is often given in liquid form through a tube directly into the stomach (Percutaneous endoscopic gastrostomy), or through a drip into a vein (Total parenteral nutrition). This high-caloric diet maintenance is required because of the increased metabolic strain brought on by the increased muscle activity. Full recovery takes 4 to 6 weeks because the body must regenerate destroyed nerve axon terminals.

What to expect (Outlook/Prognosis)?
If you get tetanus, there is usually a long course of treatment. The tetanus vaccine can prevent tetanus but its protection does not last forever. Adults should get a tetanus shot, or booster, every 10 years. If you get a bad cut or burn, see your doctor--you may need a booster.

Possible complications
Sepsis, death