TETANUS(LOCKJAW)

BY; DR YUSUF IMRAN

DEPT. OF PEDIATRICS

J.N MEDICAL COLLEGE

AMU-INDIA

ETIOLOGY• TETANUS, HISTORICALLY CALLED LOCKJAW, IS AN ACUTE, SPASTIC

PARALYTIC ILLNESS CAUSED BY TETANUS TOXIN

• AGENT- CLOSTRIDIUM TETANI, A MOTILE, GRAM-POSITIVE,

SPORE-FORMING, OBLIGATE ANAEROBE IS NOT A TISSUE-INVASIVE

ORGANISM

• TETANUS TOXIN (TETANOSPASMIN)- NEUROTOXIN PRODUCED BY

IT CAUSES DISEASE MANIFESTATIONS

• IT IS THE SECOND MOST POISONOUS SUBSTANCE KNOWN (AFTER

BOTULINUM TOXIN )

• TETANOLYSIN- A HEMOLYTIC TOXIN ,POTENTIATE INFECTION BUT

DOESNOT CONTRIBUTE TO DISEASE PROCESS

EPIDEMIOLOGY.• TETANUS OCCURS WORLDWIDE AND IS ENDEMIC IN 90

DEVELOPING COUNTRIES

• MOST COMMON FORM, NEONATAL (UMBILICAL) TETANUS,

KILLS APPROXIMATELY 500,000 INFANTS EACH YEAR (ABOUT

80% DEATHS INVOLVING 12 TROPICAL COUNTRIES)

• AN ESTIMATED 15,000-30,000 UNIMMUNIZED WOMEN

WORLDWIDE DIE EACH YEAR OF MATERNAL TETANUS THAT

RESULTS FROM POSTPARTUM, POSTABORTAL, OR

POSTSURGICAL WOUND INFECTION WITH C. TETANI

• MOST NON-NEONATAL CASES OF TETANUS ARE ASSO. WITH A

TRAUMATIC INJURY, FOR EXAMPLE-

1) A PENETRATING WOUND INFLICTED BY A DIRTY OBJECT, SUCH

AS A NAIL, SPLINTER, FRAGMENT OF GLASS

2) AFTER ILLICIT DRUG INJECTION, IN ADDICTS

3) UNCOMMON SETTINGS INCLUDE ANIMAL BITES, ABSCESSES

(INCLUDING DENTAL ABSCESSES), EAR PIERCING, BURNS,

COMPOUND FRACTURES, FROSTBITE, GANGRENE, INTESTINAL

SURGERY, RITUAL SCARIFICATION, INFECTED INSECT BITES

4) THE USE OF CONTAMINATED SUTURE MATERIAL OR AFTER

INTRAMUSCULAR INJECTION

PATHOGENESIS

SPORES GERMINATE, MULTIPLY, AND

PRODUCE TETANUS TOXIN IN THE INFECTED

INJURY SITE

TOXIN IS RELEASED WITH VEGETATIVE

BACTERIAL CELL DEATH AND SUBSEQUENT

LYSIS

TETANUS TOXIN BINDS AT THE

NEUROMUSCULAR JUNCTION AND ENTERS

THE MOTOR NERVE BY ENDOCYTOSIS

UNDERGOES RETROGRADE AXONAL TRANSPORT TO THE

CYTOPLASM OF THE ALPHA-MOTOR NEURON

TOXIN EXITS THE MOTOR NEURON IN THE SPINAL CORD

AND NEXT ENTERS ADJACENT SPINAL INHIBITORY INTERNEURONS

BLOCKS THE NORMAL INHIBITION OF ANTAGONISTIC MUSCLES

AFFECTED MUSCLES SUSTAIN MAXIMAL CONTRACTION RESULTING

IN TETANUS

CLINICAL MANIFESTATIONS

• THE INCUBATION PERIOD TYPICALLY IS 2-14 DAYS (USUALLY

ABOUT 8 DAYS)

• VARIOUS TYPES OF TETANUS ARE:

• GENERALIZED TETANUS- TRISMUS (MASSETER MUSCLE SPASM,

OR LOCKJAW) MAY BE THE PRESENTING SYMPTOM

• HEADACHE, RESTLESSNESS, AND IRRITABILITY ARE EARLY

SYMPTOMS

• STIFFNESS, DIFFICULTY CHEWING, DYSPHAGIA, AND NECK

MUSCLE SPASM FOLLOW LATER

• OPISTHOTONOS-PATIENT MAY ASSUME AN ARCHED POSTURE

OF EXTREME HYPEREXTENSION OF THE BODY

• SARDONIC SMILE (RISUS SARDONICUS) RESULTS FROM

INTRACTABLE SPASM OF FACIAL AND BUCCAL MUSCLES

• LARYNGEAL AND RESPIRATORY MUSCLE SPASM CAN LEAD TO

AIRWAY OBSTRUCTION AND ASPHYXIATION

• AS TETANUS TOXIN DOES NOT AFFECT SENSORY NERVES OR

CORTICAL FUNCTION, THE PATIENT REMAINS CONSCIOUS, IN

EXTREME PAIN, AND IN FEARFUL ANTICIPATION

• NEONATAL TETANUS (TETANUS NEONATORUM)- INFANTILE

FORM OF GENERALIZED TETANUS, TYPICALLY MANIFESTS

WITHIN 3-12 DAYS OF BIRTH AS PROGRESSIVE DIFFICULTY IN

FEEDING

• LOCALIZED TETANUS- RESULTS IN PAINFUL SPASMS OF THE

MUSCLES ADJACENT TO THE WOUND SITE AND MAY PRECEDE

GENERALIZED TETANUS

• CEPHALIC TETANUS- RARE FORM OF LOCALIZED TETANUS

INVOLVING THE BULBAR MUSCULATURE THAT OCCURS WITH

WOUNDS OR FOREIGN BODIES IN THE HEAD, NOSTRILS, OR

FACE(ASSO. WITH CHRONIC OTITIS MEDIA)

DIFFERENTIAL DIAGNOSIS (OF LOCKJAW)

• PARAPHARYNGEAL, RETROPHARYNGEAL, OR DENTAL

ABSCESSES RESULTING IN TRISMUS

• RABIES MAY PRESENT AS TRISMUS WITH SEIZURES

• STRYCHNINE POISONING MAY RESULT IN TONIC MUSCLE

SPASMS

• HYPOCALCEMIA MAY PRODUCE TETANY, CHARACT. BY

LARYNGEAL AND CARPOPEDAL SPASMS

• OCCASIONALLY, EPILEPTIC SEIZURES, NARCOTIC WITHDRAWAL,

OR OTHER DRUG REACTIONS MAY SUGGEST TETANUS

MANAGEMENT• GENERAL - SURGICAL WOUND EXCISION AND DEBRIDEMENT IS OFTEN

NEEDED

• PATIENT SHOULD BE SEDATED AND PROTECTED FROM ALL UNNECESSARY

SOUNDS, SIGHTS, AND TOUCH

• CAREFUL NURSING ATTENTION TO MOUTH, SKIN, BLADDER, AND BOWEL

FUNCTION IS NEEDED

• MUSCLE RELAXANTS- DIAZEPAM PROVIDES BOTH

RELAXATION AND SEIZURE CONTROL (INITIAL DOSE OF 0.1-0.2MG/KG Q 3-

6 HR)

• MAGNESIUM SULFATE, OTHER BENZODIAZEPINES (E.G., MIDAZOLAM),

CHLORPROMAZINE,DANTROLENE, AND BACLOFEN ARE ALSO USED

• SPECIFIC TREATMENT

• HUMAN TETANUS IMMUNOGLOBULIN(TIG ) IS GIVEN AS SOON

AS POSSIBLE TO NEUTRALIZE TOXIN BEFORE IT CAN BIND AT

DISTANT MUSCLE GROUPS

• A SINGLE INTRAMUSCULAR INJECTION OF 500 U OF TIG IS

SUFFICIENT , BUT TOTAL DOSES AS HIGH AS 3,000-6,000 U

ARE ALSO RECOMMENDED

• ANTIBIOTIC- PENICILLIN G (100,000 U/KG/24 HR DIVIDED Q

4-6 HR IV FOR 10-14 DAYS) REMAINS THE ANTIBIOTIC OF

CHOICE

• METRONIDAZOLE ,ERYTHROMYCIN AND TETRACYCLINE ARE

ALTERNATIVES

COMPLICATIONS• ASPIRATION OF SECRETIONS AND PNEUMONIA

• SEIZURES MAY RESULT IN :

1. LACERATIONS OF THE MOUTH OR TONGUE,

2. INTRAMUSCULAR HEMATOMAS OR RHABDOMYOLYSIS WITH

MYOGLOBINURIA AND RENAL FAILURE

3. LONG BONE OR SPINAL FRACTURES

• VENOUS THROMBOSIS, PULMONARY EMBOLISM, GASTRIC

ULCERATION, PARALYTIC ILEUS, AND DECUBITUS ULCERATION

ARE CONSTANT HAZARDS

• MAINTAINING AIRWAY PATENCY OFTEN MANDATES

ENDOTRACHEAL INTUBATION AND MECHANICAL VENTILATION

PREVENTION

• TETANUS IS AN ENTIRELY PREVENTABLE DISEASE; A SERUM

ANTIBODY TITER OF ≥0.01 U/ML IS CONSIDERED PROTECTIVE

• ACTIVE IMMUNIZATION SHOULD BEGIN IN EARLY INFANCY

WITH COMBINED DPT VACCINE AT 2, 4, AND 6 MO OF AGE, F/B

A BOOSTER AT 15MTH AND 4-6 YR OF AGE (DT) & AT 10-YR

INTERVALS THEREAFTER WITH (TD) TOXOIDS

• IMMUNIZATION OF WOMEN WITH TETANUS TOXOID PREVENTS

NEONATAL TETANUS