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By Dr Lara Goldstein, MBBCh, MMED (Emergency Medicine), FCEM (SA), Cert. Critical Care (SA)
The sporeof Clostridium tetani is pervasive in the environment and leads to tetanus - an illness characterised by the acute onset of painful muscle spasm seemingly without cause. The global mortality rate of tetanus is estimated to be 30-50% but no one who has completed a primary immunisation series has ever died. The vaccine for tetanus is nearly 100% effective. Tetanus is a notifiable disease.
Clostridium tetani spores may be found in soil, manure, dust, skin, clothing and in the gastrointestinal tract in 10-25% of people. The spores release 2 toxins when they germinate viz. tetanospasmin (major toxin which enters the nervous system) and tetanolysin (non-toxic but causes damage to tissues).
Symptoms usually occur one week post-infection but can occur between 3 days and 3 weeks after exposure.
There are 4 forms of tetanus: generalised, local, cephalic and neonatal.
Generalised tetanus is the most common form featuring risus sardonicus and trismus. There may be involvement of the laryngeal muscles and the diaphragm which may compromise airway protection and ventilation. Subsequent autonomic instability is also a cause of mortality.
Local tetanus just causes muscle rigidity at the site of the wound inoculation. It may persist for months but usually resolves without negative sequelae. It may precede the generalised form.
Cephalic tetanus is a form of local tetanus due to a head wound. It can lead to cranial nerve palsies and be confused with a Bell’s palsy.
Neonatal tetanus occurs due to umbilical cord stump infection in neonates whose mothers were not previously immunised. Application of traditional poultices including cow dung also play a role in infection. Death occurs in up to 50% of tetanus cases in neonates in developing countries.
Tetanus is a clinical diagnosis. There is no benefit to laboratory or radiological tests unless an alternate diagnosis is considered more likely.
Pre-exposure prophylaxis should be administered according to local immunisation schedule guidelines.
Refer to the attached flow chart for guidance regarding tetanus vaccination and immunoglobulin administration.
Surgical debridement has no benefit for tetanus. The wound responsible is commonly healed/healing at presentation. If debridement is indicated, it should be undertaken after the patient has been stabilised.
Dr Lara N Goldstein is a Speaker at the Emergency Medicine Conference at the 2018 Africa Health Exhibition & Congress scheduled to be held from 29th to 31st May in Johannesburg, South Africa.
Dr Lara N Goldstein is a Specialist Emergency Physician and Intensivist at Netcare Mulbarton Hospital ICU, Division of Emergency Medicine, University of the Witwatersrand Johannesburg, South Africa