What is Tetanus (Clostridium tetani Infection) ?
Tetanus is a disease caused by a bacteria called Clostridium tetani. This type of bacteria, including ones that produce toxic substances, are everywhere in the environment and have been causing issues for a long time. Thankfully, vaccines have helped to nearly wipe it out worldwide. Nonetheless, tetanus remains a significant problem in areas where public health resources are limited. On the other hand, in areas where vaccines are easily available, tetanus is rare. Because of this rarity, doctors in such areas may fail to quickly recognize and treat it in patients who seek medical help.
Therefore, it’s important for people to know the risk factors, be able to identify typical symptoms, and understand the immediate treatment methods for a tetanus infection. Tetanus is a severe condition marked by painful muscle spasms, increased muscle tension, and problems with the automatic nervous system (this system controls body functions like heart rate and digestion). Even with widespread vaccination efforts in the US, cases of tetanus still occur.
Tetanus is divided into four categories:
- Generalized
- Localized
- Cephalic (related to the head)
- Neonatal (affecting newborns)
Death rates from tetanus are usually highest in very young and very old individuals, where a weakened immune system and the presence of other health conditions is common. Ideally, tetanus patients should be treated by a team of different types of doctors specializing in critical care. However, the ideal treatment facilities are often not available in regions where they’re most needed for tetanus patients. Especially in areas with fewer resources, tetanus in newborns is associated with higher death rates.
Doctors rely on experience and reported cases to treat tetanus. Since cases of tetanus are relatively low and the disease can be deadly, there haven’t been large research studies comparing different treatment methods. However, the common approach for managing tetanus has been well established through case reports and smaller research studies.
What Causes Tetanus (Clostridium tetani Infection) ?
C tetani is a type of bacteria that needs an area without oxygen to survive and can be found everywhere, such as the soil, the waste of animals and humans, dust, and even in our digestive system. They form defensive structures called spores which can be seen under a microscope and are shaped like tennis or squash rackets. These spores are very stable and can survive harsh conditions like disinfectants, boiling, and freezing. They can be destroyed by things like iodine, hydrogen peroxide, glutaraldehyde (a strong disinfectant), and being put under high pressure and temperature (autoclaving).
These spores can become bacteria when they enter a wound. Even though they are present everywhere, it is difficult to detect them in culture tests. So, positive culture tests can be misleading as other strains of C tetani that are not harmful may also be present, and people who have been vaccinated can also show positive cultures of C tetani without having the disease.
Most cases of tetanus, the disease caused by the C tetani bacterium, occur when the bacteria enter the body through a wound, burn injury, post-surgical abscesses (a swollen area with pus), through unsafe drug use, circumcision, or gangrene (dead tissues due to lack of blood flow). Sometimes, the source of infection is not known. Not having a full course of vaccination or no vaccination at all is usually linked with tetanus cases.
Newborns might be affected by tetanus, often due to unsanitary ways of cutting the umbilical cord, especially during home deliveries. Immunity from the tetanus vaccine usually decreases over time for most people, so additional doses of the vaccine or booster shots are necessary for prevention.
Risk Factors and Frequency for Tetanus (Clostridium tetani Infection)
Tetanus mainly occurs in developing countries, particularly in regions suffering from natural disasters, where access to immunity-boosting vaccinations can be limited. At-risk groups in wealthier countries include those who haven’t been vaccinated or have had their vaccine protection reduce over time, with individuals who inject drugs or have insulin-dependent diabetes being especially vulnerable.
Tetanus spores are found everywhere in the environment, regardless of location, typically in the soil, and can enter the body through open skin wounds. All age groups can be affected but the risk is highest when wounds contain dead tissue. Without good medical care, tetanus can be deadly, with death rates potentially reaching 100%. With quality care, the death rate ranges between 10% and 20%.
Babies, or neonates, are at an increased risk of tetanus infection in poorer regions due to unhygienic birthing practices, nonsterile tools used to cut the umbilical cord, or the application of contaminated dressings to the umbilical stump. According to World Health Organization estimates, neonatal tetanus caused about 34,000 deaths in 2015.
Fortunately, tetanus can be prevented via a vaccine and it’s part of the routine childhood vaccination schedule globally. From 2001 to 2008, there were very few cases of tetanus in the US – roughly 0.01 per 100,000 people annually. Between 2009 and 2015, the US saw 197 reported tetanus cases and 16 related deaths. Amongst the highest risk groups are newborns and older individuals.
The first tetanus vaccine was distributed in 1924 and extensively used amongst soldiers during World War II. Today, the most common childhood vaccine worldwide is the pentavalent vaccine, which provides protection against diphtheria, tetanus, pertussis, Hib, and hepatitis B. It’s essential to be vaccinated, as getting infected by tetanus does not provide immunity and the disease isn’t communicated from one person to another.
Signs and Symptoms of Tetanus (Clostridium tetani Infection)
Tetanus is a disease that usually occurs due to a deep wound infection. However, other causes, such as minor injuries, post-surgery infection, drug injections, certain fractures, bedsores, or even a lack of an identifiable cause can also lead to tetanus. Among newborns, particularly those born to unvaccinated mothers, tetanus can develop if the umbilical stump gets contaminated.
Once a person gets a tetanus infection, the disease may develop from as short as one day to several months. The severity of the disease often depends on the size of the infection and how soon the infection reaches the nerves. The typical duration of tetanus is approximately 2 weeks, but full recovery can take several months, as the nerves require time to regenerate.
- Generalized tetanus is the most common version of the disease.
- It usually starts with lockjaw and stiff facial muscles, leading to a fixed grin-like expression.
- Afterwards, painful muscle contractions spread throughout the body.
- People may have trouble swallowing due to throat muscle spasms.
- In some cases, spasms in the neck muscles and diaphragm cause difficulty breathing.
- These spasms can last for weeks as the toxins remain within the nerves.
- Even simple activities or loud noises can trigger the spasms.
- Unstable blood pressure and irregular heart rhythm may also occur.
- Despite all these symptoms, the patient’s consciousness usually remains intact unless there’s other brain dysfunction.
Localized tetanus is a less common form that usually affects the body part where the initial injury occurred, such as an arm or leg. This form may progress into generalized tetanus. If the tetanus infection starts in the face or scalp, it can lead to cephalic tetanus, which involves the muscles controlled by the cranial nerves and can mimic stroke symptoms.
Neonatal tetanus in infants can result from infection of the umbilical stump, especially in babies born to unvaccinated mothers. Affected infants show symptoms such as inability to suckle, followed by body stiffness, and severe reactions. Infant mortality is high due to complications like stopping breathing and blood poisoning.
Testing for Tetanus (Clostridium tetani Infection)
Tetanus is mainly diagnosed through clinical observations and evaluations, which means your doctor will take into account your symptoms and how they present. Relying on methods like imaging scans, blood tests, chemical tests, and analyzing samples under a microscope often doesn’t provide a clear confirmation of this condition. One of the crucial pieces of information for diagnosing tetanus is your vaccination history and whether you’ve recently had any injuries or wounds. However, sometimes this information can be difficult to obtain.
In cases of newborns getting tetanus, what’s also important is the vaccination status of the mother and whether there may have been unclean conditions during the baby’s birth.
Treatment Options for Tetanus (Clostridium tetani Infection)
Treating acute tetanus demands a combined effort between doctors specializing in infectious diseases and intensive care. The focus is on managing symptoms and minimizing the spread of the tetanus toxin in the body. When a person has a wound likely to develop tetanus, immediate cleaning and removal of dead or damaged tissue is crucial. This helps to get rid of bacterial spores and stop the spread of toxins from the wound to the bloodstream.
Patients showing signs of tetanus should be closely watched, ideally in an intensive care unit (ICU). In this setting, efforts should be made to reduce noise, bright light, and physical contact to avoid triggering spasms. It’s also important to constantly monitor the patient’s airways and prepare for the possibility of needing to insert a tube in their throat (intubation) to help them breathe.
In terms of medication, a drug known as human tetanus immune globulin (HTIG) is recommended as soon as tetanus is suspected. This is a form of passive immunization, where antibodies against the toxin are injected to help the body fight the disease. Studies have shown that HTIG can shorten the duration and reduce the severity of tetanus.
If HTIG is not available, such as in poorer countries, equine antitetanus serum can be used instead. This is given through an intravenous drip into a vein. However, it can sometimes cause severe allergic reactions, so skin testing should be done before using this treatment. If both human and equine antitetanus treatments aren’t available, pooled human immunoglobulin should be given.
Drugs to reduce anxiety and relax muscles, called benzodiazepines, are key in managing tetanus. Other drugs that block nerve impulses to muscles, such as vecuronium, may be used in severe cases of tetanus. These are only used if benzodiazepines haven’t worked.
There’s limited information on the use of a drug called magnesium sulfate for treating tetanus, but it’s thought to potentially help with managing muscle spasms and rapid heart rate. Another drug, intrathecal baclofen, has been used to control muscle spasms due to tetanus. This has to be administered in an ICU setting because it can cause slow breathing or irregular heartbeats.
Patients with tetanus are often prescribed antibiotics, such as metronidazole or penicillin, for one to two weeks. This helps to eliminate the tetanus bacteria from the wound, but won’t change the muscle spasms or autonomic nervous system dysfunction. In cases where the wound is infected with a mix of bacteria, additional antibiotics may be used. Comparisons between metronidazole and penicillin have not definitively shown if one antibiotic is better than the other for treating wounds associated with tetanus.
What else can Tetanus (Clostridium tetani Infection) be?
Tetanus can be tricky to diagnose due to its rarity, which could lead to delayed or even missed diagnosis with serious consequences. When looking at symptoms similar to tetanus, doctors should also consider the following potential conditions:
- Oropharyngeal abscess: This is a throat abscess that could cause difficulty swallowing and inability to open the mouth wide.
- Stroke: Blood clots or bleeds in the brain can cause facial muscle weakness.
- Meningitis: This inflammation of the brain and spinal cord coverings can cause muscle stiffness but not the spasms characteristic of tetanus. Neck stiffness is often an early sign.
- Strychnine poisoning: This can cause similar muscle spasms as tetanus, but without the automatic nervous system issues. It can also happen due to intentional or accidental poisoning with substances like cocaine or heroin.
- Botulism: This serious neurological condition caused by a toxin leads to difficulty swallowing, facial muscle weakness, and limp muscles, rather than the muscle spasms seen in tetanus.
- Hypocalcemia: Though low calcium levels can cause muscle spasms, these spasms will not exhibit the automatic nervous system abnormalities characteristic of tetanus.
- Neuroleptic malignant syndrome: This medication-induced condition presents with high body temperature, changes in mental state, and stiff muscles. It can be differentiated from tetanus based on a patient’s clinical history.
Each of these has distinct characteristics that can help healthcare professionals rule out tetanus and arrive at the correct diagnosis.
What to expect with Tetanus (Clostridium tetani Infection)
The outcome after contracting tetanus, a severe bacterial infection, often depends on the time it took for symptoms to appear, also known as the incubation period. Usually, if symptoms appear quickly, it means that the illness may be more severe. Risk factors that could lead to a worse prognosis include a short incubation period of less than 48 hours, drug addiction, generalized tetanus (which affects the whole body), a high fever above 104°F, getting tetanus from operations, burns, use of intravenous drugs, or in the case of septic abortion (an abortion followed by a bacterial infection).
Two specific types of tetanus, cephalic (affecting the head and neck) and neonatal (in infants), are often associated with worse outcomes.
However, if tetanus is localized or contained to a particular area in the body, the mortality and disease indices are much lower. The recovery process, though slow, typically extends over several months or even years until full recovery. It’s important for survivors to get vaccinated against tetanus, because unlike some diseases, surviving tetanus does not automatically protect you from future infections.
Possible Complications When Diagnosed with Tetanus (Clostridium tetani Infection)
The main issues that can occur with tetanus and contribute to its severe effects or even death are problems with breathing. This can happen when a person’s airway becomes obstructed, something gets aspirated, or certain medications lead to suppressed respiratory functions. Other common problems include irregular heart rhythms, unsteady blood pressure, and extreme sweating because of overactive sympathetic activity. These problems can present more management challenges when accompanied by extreme physical exhaustion due to widespread muscle spasms. Also, complications related to extended hospital stays often add further complexity to managing and treating tetanus.
Common Complications of Tetanus:
- Difficulty with breathing due to blocked airway, aspiration, or medication effects
- Irregular heart rhythms
- Fluctuating blood pressure
- Excessive Sweating due to increased sympathetic activity
- Physical exhaustion because of broad muscle spasms
- Complications arising from prolonged hospital stays
Preventing Tetanus (Clostridium tetani Infection)
The best way to get rid of tetanus all over the world is to ensure that everyone has access to the tetanus shot, also known as the tetanus toxoid vaccine. To do this, we need smart and creative public health campaigns.
It’s also critical to teach people about the importance of keeping up with their tetanus shot schedule and getting medical help if they get a wound that could lead to tetanus.
However, there’s no agreement on whether adults who have had their childhood tetanus shots should get routine booster shots. While the World Health Organization doesn’t recommend routine booster shots for these adults, for adults living in the U.S., it’s recommended they get a tetanus booster every 10 years.
