Sign Of Tetanus
Tetanus is also known as lockjaw syndrome. Tetanus is caused by severe toxin reaction from infection by Clostridium tetani. Tetanus is characterized by intermittent tonic spasm and rigidity of voluntary muscle. Mostly the neck and the jaw. Tetanus is an acute disorder with duration of disorder is typically 3- 6 weeks. Tetanus may lead to fatality.
There are four different types of tetanus. These include generalized tetanus, localized tetanus, cephalic tetanus and neonatal tetanus. Generalized tetanus is the most common and severe form of tetanus. Cephalic tetanus affects the cranial nerves with neonatal tetanus affects neonates and carries high mortality rates.
The severity of tetanus is determined by dysfunction of the autonomous system, the presence of opisthotonus and the frequency of the spasm. Neonatal tetanus may present during 6-8 days. The infection may enter the body through the umbilical cord. Neonatal tetanus death can be avoided by providing tetanus toxoid in the second and third trimesters.Neonatal tetanus carries high rate of mortality. Pregnant women are also predispose to tetanus.The infection may enter through the uterus postpartum.
Tetanus is common in male and female. Neonates and people from low income countries are also susceptible to tetanus. The common risk factors of developing tetanus are elderly ( more than 60 years old), IV drug user, multiple piercings, newborn, surgical wound, frostbites, tattooing, poor umbilical hygiene, crush injuries, chronic wound, lack of vaccination, lack of up to date booster, burns, puncture wounds, skin ulcers, exposure of wounds to soils or animal feces, diabetes and wound with low supply of oxygen.
Generally, tetanus is treated with series of treatments. These include decontamination, wound debridement, passive immunization post exposure with tetanus immunoglobulin, antibiotic administration such as erythromycin or penicillin G and active immunization. Tetanus toxoid forms part of the active immunization. These include DTaP ( diphtheria, tetanus toxoid and acellular pertussis) , Tdap ( tetanus, diphtheria and acellular pertussis), Td booster and toxoid immunization for pregnant women.
Clostridium tetani is a gram positive bacteria. It is the forms of anaerobic rod.The spores from Clostridium tetani are resistant to heat. The spores may also survive any contact with antiseptic. Tetanus may spread through the infection of the contaminated wound by the spores. The incubation period is 4- 14 days . Spores under anaerobic condition may germinate and produce two types of toxins. These toxins may spread through the lymphatic and blood system. The toxins are tetanospamin which cause the symptoms of tetanus and tetanolysin which cause hemolysin. Tetanospamin will act at the motor neuron end plates. Tetanospamin may alter the release of neurotransmitter. Tetanospamin may results in unopposed muscle spasm, muscle contraction and seizures. Tetanospamin inhibit the function of inhibitory neuron.
On clinical examination, patient may present with drooling, dysphagia, fixed smell ( Risus sardonicus) , trismus, lockjaw, hyper reflexia, autonomic instability, opisthotonus and painful tonic convulsions. Other symptoms and signs are asphyxia, arrhythmias, nuchal rigidity, muscular spasticity, muscular rigidity, hydrophobia, hyperhidrosis, low grade fever, hyper pyrexia, irritability and laryngeal spasm.
Laboratory investigations may reveal polymononuclear leukocytosis ( full blood count), bradyarrhythmias, tachyarrhythmias (ECG), anti toxin assay (level more than 0.01 - 0.015 IU/ml are safe) and spatula test. In spatula test, oropharynx is touched by tongue blade. A positive spatula test is recorded if the blade is bitten down by the patient because of the masseter reflex spasm. A negative spatula test is recorded if the patient tries to expel the blade and produce gag reflex.
The common differential diagnoses of tetanus are alcohol withdrawal, seizures, rabies, amyotrophic lateral sclerosis, strychine poisoning, meningoencephalitis, neuroleptic malignant syndrome, hypocalemic tetany and peritonsillar abscess.
The treatment may include diazepam to reduce muscle rigidity, provide anxiolytic and sedative effects. Tetanus toxoid is given in patient who is previously immunized. Intrathecal immunoglobulin is also considered as well as metronidazole. Penicillin G is the form of antibiotic given. Clindamycin and doxycyline are considered in case of penicillin allergy. Benzodiazepines is useful as a mainstay for therapy. Phenobarbitone or chlorpromazine is also useful in providing muscle relaxation. Patient requires a lot of rest and prophylaxis against ulcer and deep vein thrombosis. The spasm of the muscle may require attention of the physical therapist.
Patient may need to be monitored for any signs of respiratory failure,autonomic dysfunction and cardiac arrhythmias. Patient may require feeding by using feeding tube or nasogastric tube.
Tetanus carries a poor prognosis. The indicators for poor prognosis are extreme of age,severity of the symptoms, autonomic system dysfunction, the forms of tetanus and the short incubation period.
The complications of tetanus are anorexia, cardiac failure, dehydration, obstruction of the airway, respiratory arrest, pulmonary embolism, fracture of the vertebrae, rhabdomyolysis, constipation, urinary retention, acute renal failure and aspiration pneumonia.
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