Tetanus

What is Tetanus?

Tetanus is an infection that causes a condition where the muscles in your body become extremely tense & tight. This happens in the form of painful muscle spasms, specifically affecting the jaw and neck. This disease is most often seen in people who haven’t been vaccinated or older adults whose immune response has dwindled with age. Thankfully, due to widespread vaccination efforts, tetanus has become less common worldwide. The muscle spasms caused by tetanus can last anywhere from a few minutes to several weeks. They usually start in the face before moving down to the rest of the body. These symptoms are caused by toxins from a bacterium called Clostridium tetani. There are mainly four types of tetanus:

1. Generalized tetanus
2. Neonatal tetanus
3. Localized tetanus
4. Cerebral tetanus

Diagnosing tetanus is based on the symptoms observed, since there is no specific lab test to confirm it. The treatment includes injecting antitoxin for tetanus, taking antibiotics, using medications to block the nerve signals that are causing muscle spasms, and providing support for breathing problems, control of automatic body functions, and muscle spasms. Even after recovering from a bout of tetanus, it’s important to get fully vaccinated against the disease as there is no lifelong natural immunity developed. Some patients who have survived tetanus have reported long-term health issues.

What Causes Tetanus?

Tetanus results from an infection by the bacterium Clostridium tetani. This bacteria can be found in soil, dust, or animal waste and is often found in areas with warm, moist climates and soil rich in organic matter.

This bacteria can enter your body through different types of wounds like punctures, cuts, or insect bites. It can also be contracted through used needles. Sometimes, infections can occur from seemingly minor wounds such as small cuts from wood, metal splinters, or thorns. If you aren’t vaccinated, use intravenous drugs, or have a compromised immune system, you are at a higher risk. Some people have also got infected from surgical procedures, injections, open fractures, dental infections, and dog bites.

The bacteria’s spores can survive for a long time in certain environments. In many cases, you can become infected from a minor wound. Not being vaccinated or being vaccinated but losing immunity over time can also put you at risk. Tetanus can also be a result of long-term conditions like abscesses (a swollen area within body tissue, containing an accumulation of pus) and gangrene (death of body tissue due to either a lack of blood flow or a bacterial infection). People who have been burned or are having surgery can also get infected.

Tetanus typically affects those who are not vaccinated, only partially vaccinated, or those who have been vaccinated but haven’t had enough booster doses (additional doses of a vaccine needed periodically to ‘boost’ the immune system).

For newborns, the risk factors for tetanus include:

1. If their mother hasn’t been vaccinated.
2. Being born at home.
3. Cutting of the umbilical cord in non-sterile conditions.
4. If an older sibling had neonatal tetanus.
5. Infectious substances like animal waste, mud, or other similar materials being applied to the umbilical stump.

Risk Factors and Frequency for Tetanus

Tetanus is a disease that affects people of all ages, but it’s most common in newborns and young people. The World Health Organization (WHO) reports that death rates from tetanus have improved due to aggressive vaccination campaigns in recent years. However, tetanus is still more prevalent in developing countries where resources are limited. In these countries, death rates from the disease range from 20% to 45%.

In contrast, the chances of getting tetanus have decreased worldwide, especially among newborns, thanks to routine vaccinations. These vaccinations, usually administered in combination with vaccines for pertussis and diphtheria, have resulted in global protection from tetanus for about 84% of children less than 12 months old in 2013.

Meanwhile, in countries with adequate resources like the United States, tetanus usually occurs in individuals who are not vaccinated or in older people whose immunity has weakened over time. People who use intravenous drugs are also at risk because of the use of contaminated needles or drugs.

• Tetanus is a disease that commonly affects people of all ages, but it’s most prevalent in newborns and young individuals.
• Despite improvements in mortality rates from tetanus in recent years, it’s still much more common in developing countries with limited resources.
• The occurrence of tetanus has decreased worldwide due to routine vaccinations.
• In resource-rich countries like the U.S., tetanus typically affects people who haven’t been vaccinated or older adults whose immunity has reduced with age.
• Users of intravenous drugs also face a risk of contracting tetanus.

Signs and Symptoms of Tetanus

Tetanus is a disease that often affects those who haven’t been fully immunized. The time from exposure to showing symptoms can vary, typically between 4 to 14 days. The person may or may not remember getting injured.

Tetanus can cause symptoms such as lockjaw, a facial expression that seems like a forced smile, intense muscle spasms and pain, drooling, and loss of control over the bladder and bowels. It can also cause a dangerous back arching spasm causing difficulties with breathing. The symptoms usually start with lockjaw and progress to spasms in the rest of the body. External factors, like noise, touch, or light can trigger these spasms.

There are four types of tetanus based on their symptoms:

• Generalized tetanus is the most common type, seen in about 80% of the cases. It starts with lockjaw and progresses to stiffness in various muscles, which could last up to 4 weeks. Recovery can take months. Patients may also experience fever, unstable blood pressure, and difficulties with breathing. This form can even be fatal.
• Neonatal tetanus affects newborn babies, usually when the mother hasn’t been immunized, or through an infection from unclean instruments used to cut the umbilical cord. The symptoms include irritability, difficulties with feeding, stiffness, and severe spasms. Survivor babies may suffer from long-lasting consequences like behavioral problems and delays in speech and motor skills.
• Localized tetanus is rare and affects muscles at the injury site for weeks. While it’s not usually fatal, it can progress to generalized tetanus, which is life-threatening.
• Cephalic or cerebral tetanus affects the muscles and nerves of the head. It usually occurs after some type of head trauma, or from a different injury site. It can cause stiffness in the neck, difficulties with swallowing, a forced smile, and issues with eye movement. In severe situations, it can result in complications including breathing difficulties and even paralysis of the respiratory muscles. This type can also progress to generalized tetanus.

Diagnosing tetanus can be difficult as patients’ symptoms can vary. However, a physical examination technique known as the spatula test can provide some clues. If a patient bites down, instead of gagging, when the back of their throat is stimulated, this could suggest tetanus.

Sometimes, patients may show signs like extreme changes in blood pressure or heart rate, and even cardiac arrest. They may also experience tenderness and guarding in the abdomen, which could be mistakenly diagnosed as acute abdomen. In the past, exploratory surgery was carried out before the correct diagnosis was reached.

Though they are rare, cases of cephalic tetanus can present with various nerve issues. The 8th cranial nerve is most commonly affected.

Testing for Tetanus

Diagnosing tetanus, a bacterial infection that causes painful muscle contractions, doesn’t rely on specific lab tests. Instead, it’s primarily based on noticing certain signs and symptoms. Doctors look for sudden muscle contractures and widespread spasms not caused by another medical condition. Some patients can also recall a recent injury, but this is not always the case.

If doctors need to exclude tetanus as a possibility, they may conduct an antitoxin level test. Although this test isn’t widely available, it can be useful. This test measures the antibodies in the blood that combat the tetanus toxin. A high enough level of these antibodies generally indicates protection against tetanus. An antitoxin level of 0.01 IU/mL or higher is considered as protecting against the disease making tetanus unlikely.

A specific test known as the “spatula test” can also aid in diagnosing tetanus. In this test, a doctor gently touches the back of the throat with a soft-tip instrument. If instead of the normal gag reflex, the patient’s jaw contracts involuntarily, it may suggest a positive test for tetanus.

It’s key to remember that tetanus infection can happen in people who don’t have immunity or have low levels of anti-tetanus antibodies in their blood. Serious complications from tetanus are possible, including pneumonia due to aspiration, muscle break down (rhabdomyolysis), upper gastrointestinal bleeding, irregular heartbeats, high blood pressure, kidney failure, and secondary wound infections. The main causes of death from tetanus are respiratory failure and cardiovascular collapse associated with a condition called autonomic dysfunction.

Treatment Options for Tetanus

Tetanus, sometimes known as “lockjaw,” is a bacterial infection that can cause severe muscle stiffness and spasms. Treatment of tetanus depends on the severity of the symptoms but generally involves several steps. However, all patients will aim to achieve these treatment goals:

1. Clean the wound that caused the infection
2. Get the right supportive care
3. Antibiotics to fight the bacteria
4. Injection of medicines to boost the immune system (human tetanus immunoglobulin or HTIG)
5. Medication to reduce muscle stiffness and spasms
6. Control various effects of the disease
7. Handle any complications that arise.

The first line of treatment typically involves an injection of a drug known as HTIG. This drug works by neutralizing a toxin (tetanospasmin) produced by the bacteria which causes symptoms. This drug doesn’t affect toxins that have already bound to the nervous system but can still shorten the course of illness and reduce its severity. Sometimes, particularly in cases of a severe type of the disease known as “generalized tetanus”, larger doses may be required. Cleaning (debridement) of the infected wound is also crucial to control the source of the bacteria and toxin production.

Metronidazole is an antibiotic that’s shown to be effective at slowing the disease’s progression. It’s also been found to decrease the risk of death. In the past, penicillin was used as a treatment, but it’s no longer recommended after it was found to potentially enhance the effects of the toxin.

Certain medicines like benzodiazepines, baclofen, vecuronium, pancuronium, and propofol, can help with muscle stiffness and spasms.

In severe cases of tetanus, patients may need to be admitted to the intensive care unit (ICU). They might require drugs to help relax (sedation) and a machine to assist them with breathing (mechanical ventilation). Sometimes, doctors may need to place a tube into the windpipe (tracheostomy) to help the patient breathe more easily, especially in cases where the spasms are triggered by a standard breathing tube or when the breathing tube is needed for more than 10 days.

One class of drugs, called benzodiazepines, are frequently used to manage muscle stiffness or spasms. These drugs not only relieve anxiety but can also cause muscle relaxation, therefore preventing serious breathing complications.

Throughout the treatment, healthcare providers will ensure the patient receives proper support, particularly for dealing with issues like rapidly fluctuating blood pressure (autonomic instability), fever or low body temperature. High-calorie diets are often provided to compensate for energy expended from muscle contractions.

It’s also worth noting that upon recovery from this infection, a patient does not automatically gain immunity to future tetanus infections, so full vaccination would still be needed.

What else can Tetanus be?

The condition that is most similar to tetanus is strychnine poisoning. A key symptom of tetanus is trismus, or jaw muscle stiffness, which can also occur in many other conditions. Here are some of those:

• Local infections
• Hysteria
• Neoplasms (abnormal tissue growths)
• Malignant hyperthermia (a life-threatening reaction to certain medications used during general anesthesia)
• Use of stimulant drugs
• Acute abdomen (sudden, severe abdominal pain)
• Dystonic drug effects (abnormal muscle tones resulting from medication)
• Serotonin syndrome (an excess of serotonin, a chemical your neurons produce)
• Black widow spider poisoning
• Stiff person syndrome (a rare neurological disorder causing stiffness and rigidity)

What to expect with Tetanus

The outcome after experiencing tetanus depends on how quickly the first symptom progressed to the first spasm. Overall, if the symptoms appeared quickly, the outcome tends to be unfavorable. Recovery from tetanus can be a slow process, sometimes taking months.

Some types of tetanus, for example, neonatal (occurring in a newborn baby) and cephalic (affecting the head) tetanus, often have a poor outcome. Furthermore, some patients may experience hypotonia (a condition where the muscles lose their usual tone or tension), and autonomic dysfunction (where the automatic functions of the body like heartbeat and breathing are affected) lasting for months or even years. Even if a person survives tetanus, they still need to get the tetanus shot because having the infection doesn’t make someone immune to it in the future. While patients usually survive tetanus, recovery can be slow and some may continue to have low muscle tone.

Doctors use a special scale to predict how serious a tetanus infection might get. Different elements are scored with one point each:

• Incubation time (the time from exposure to the bacteria to the appearance of first symptoms) shorter than 7 days,
• Onset of symptoms in less than 48 hours,
• Tetanus caused by burns, surgical wounds, septic abortion (an infection due to an abortion), umbilical stump (a wound remaining after the removal of the umbilical cord), open fractures or intramuscular injection,
• If the person has an addiction to opiates (a group of strong painkillers),
• Generalized tetanus (a type affecting all the body),
• High temperature – more than 104 F (40 C),
• Rapid heart rate – more than 120 beats per minute (150 beats per minute in newborns).

The total score helps doctors estimate the severity of the disease:

• 0-1 – less than 10% chance of dying
• 2-3 – 10-20% chance of dying
• 4 – 20-40% chance of dying
• 5-6 – more than 50% chance of dying.

Possible Complications When Diagnosed with Tetanus

Tetanus can lead to severe complications in the body, such as uncontrollable tightening of the muscles in the respiratory system, vocal cords, and other essential body parts. A major cause of death in critically ill patients with tetanus is hyperactivity of the body’s sympathetic nervous system, which controls the body’s response to emergencies.

The potentially serious complications can further include:

• Paralysis of the vocal cords leading to difficulty in breathing
• Autonomic dysfunction which can cause high blood pressure
• Asphyxia, or severe lack of oxygen
• Long bone fractures
• Paralytic ileus, which is a severe blockage of the intestine
• Dislocation of joints
• Potentially deadly pneumonia due to inhaling food or drink (aspiration pneumonia)
• Pressure sores from being in one position for too long
• Ulcers caused by stress
• Coma, which is a prolonged state of unconsciousness
• Nerve palsy, or loss of muscle function
• Inability to urinate (urine retention)
• Seizures, or sudden, uncontrolled electrical disturbances in the brain

Preventing Tetanus

We should emphasize the crucial role of childhood vaccines and booster shots. In parts of the world that are developing or underdeveloped, midwives and people who help with childbirth should be trained in maintaining a clean, germ-free environment when a baby is born. Everyone should be taught the basics of first aid and how to look after wounds. Being able to quickly recognize the early signs and symptoms of a tetanus infection and seeking medical help right away is particularly important.

Healthcare professionals, like nurses and pharmacists, need to remind people about the importance of getting vaccinated. Getting a tetanus shot is considered a routine vaccination, along with the pneumonia and flu vaccines, especially for older adults. Being vaccinated against tetanus is crucial because our bodies don’t naturally develop resistance to this disease. The toxin produced by tetanus is extremely harmful and can cause death before our body is able to mount an immune response.

Even after recovering from a tetanus infection, patients should get fully vaccinated to ensure they’re immune. Also, if someone has been exposed to tetanus, we can give them a preventative treatment. This could involve a tetanus vaccine, with or without a medicine called tetanus immunoglobulin, given through a needle in a vein or a muscle. This will depend on the nature of the wound that caused the exposure.