Tetanus 45831 225818008 2008-07-15T15:26:11Z 12.184.170.5 /* Treatment */ {{DiseaseDisorder infobox | Name = Tetanus | Image = CBell1809.jpg | Caption = Muscular spasms in a patient suffering from tetanus. Painting by [[Sir Charles Bell]], 1809. | Width = 310 | ICD10 = {{ICD10|A|33||a|30}}-{{ICD10|A|35||a|30}} | ICD9 = {{ICD9|037}}, {{ICD9|771.3}} | ICDO = | OMIM = | MedlinePlus = 000615 | eMedicineSubj = emerg | eMedicineTopic = 574 | DiseasesDB = 2829 | }} '''Tetanus''' is a medical condition that is characterized by a prolonged contraction of [[skeletal muscle]] fibres. The primary symptoms are caused by [[tetanospasmin]], a [[neurotoxin]] produced by the [[Gram-positive]], [[Anaerobic organism|obligate anaerobic bacterium]] ''[[Clostridium tetani]]''. Infection generally occurs through wound contamination, and often involves a cut or deep puncture wound. As the infection progresses, muscle [[spasms]] in the jaw develop, hence the common name, '''lockjaw'''. This is followed by difficulty in swallowing and general muscle stiffness and spasms in other parts of the body.<ref name="Baron">{{cite book | author = Wells CL, Wilkins TD | title = Clostridia: Sporeforming Anaerobic Bacilli. ''In:'' Baron's Medical Microbiology ''(Baron S ''et al'', eds.)| edition = 4th ed. | publisher = Univ of Texas Medical Branch | year = 1996 | id = [http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=mmed.section.1099 (via NCBI Bookshelf)] ISBN 0-9631172-1-1 }}</ref> Infection can be prevented by proper immunization and by post-exposure [[prophylaxis]].<ref name="CDC">{{cite web | title=Tetanus | work=CDC Pink Book | url=http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf | accessdate=2007-01-26}}</ref> ==Signs and symptoms== Tetanus affects [[skeletal muscle]], a type of [[striated muscle]]. The other type of striated muscle, cardiac or [[heart muscle]] cannot be tetanized, because of its intrinsic electrical properties. In recent years, approximately 11% of reported tetanus cases have been fatal. The highest mortality rates are in unvaccinated persons and persons over 60 years of age. ''C. tetani'', the bacterium that causes tetanus, is recovered from the initial wound in only about 30% of cases, and can be found in patients who do not have tetanus.<ref name="CDC"/> The incubation period of tetanus ranges from 3 to 21 days, with an average onset of clinical presentation of symptoms in 8 days. In general, the further the injury site is from the [[central nervous system]], the longer the incubation period. The shorter the incubation period, the higher the chance of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, four different forms of tetanus have been described.<ref name="CDC"/> '''Local tetanus''' is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local tetanus is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized tetanus. '''Cephalic tetanus''' is a rare form of the disease, occasionally occurring with [[otitis media]] (ear infections) in which ''C. tetani'' is present in the flora of the middle ear, or following injuries to the head. There is involvement of the [[cranial nerve]]s, especially in the facial area. '''Generalized tetanus''' is the most common type of tetanus, representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is [[trismus]], or lockjaw, and the facial spasms called [[risus sardonicus]], followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf muscles. Other symptoms include elevated temperature, sweating, elevated [[blood pressure]], and episodic rapid heart rate. [[Spasm]]s may occur frequently and last for several minutes with the body shaped into a charcateristic form called [[opisthotonos]]. Spasms continue for 3–4 weeks, and complete recovery may take months. '''Neonatal tetanus''' is a form of generalized tetanus that occurs in newborn infants. It occurs in infants who have not acquired passive [[immunity (medical)|immunity]] because the mother has never been immunized. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. Neonatal tetanus is common in many developing countries and is responsible for about 14% (215,000) of all neonatal deaths, but is very rare in developed countries.<ref name=WHO_2000>{{cite web | title=Maternal and Neonatal Tetanus Elimination by 2005 | author=[[World Health Organization]] | date=2000-11-01 | url=http://www.unicef.org/immunization/files/MNTE_strategy_paper.pdf#search=%22neonatal%20tetanus%20rates%22 | accessdate=2007-01-26}}</ref> ==Spatula test== The "spatula test" for tetanus involves touching the posterior [[Pharynx|pharyngeal]] wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the involuntary contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a [[gag reflex]] attempting to expel the foreign object. A short report in ''The American Journal of Tropical Medicine and Hygiene'' states that in a patient research study, the spatula test had a high specificity (zero false-positive test results) and a high sensitivity (94% of infected patients produced a positive test result).<ref name="AJTMH1995"> {{cite web | url=http://www.ajtmh.org/cgi/content/abstract/53/4/386| title=Short Report: The Spatula Test: A Simple Bedside Test to Diagnose Tetanus |accessdate=2007-10-11 |author=Nitin M. Apte and Dilip R. Karnad |date=1995-10 |work=Am. J. Trop. Med. Hyg. |pages=pp. 386-387}} Also, the ability to open one's mouth widely is often a sign that one does not have lockjaw. </ref> ==Treatment== The wound must be cleaned. Dead and infected tissue should be removed by surgical [[debridement]]. [[Metronidazole]] treatment decreases the number of [[bacteria]] but has no effect on the bacterial toxin. [[Penicillin]] was once used to treat tetanus, but is no longer the treatment of choice, owing to a theoretical risk of increased spasms. However, its use is recommended if metronidazole is not available. [[Passive immunization]] with human anti-[[tetanospasmin]] [[immunoglobulin]] or tetanus immune globulin is crucial. If specific anti-tetanospasmin immunoglobulin is not available, then normal human immunoglobulin may be given instead. All tetanus victims should be vaccinated against the disease or offered a booster shot. [[Image:Neonatal tetanus 6374.jpg|thumb|200px|An infant suffering from neonatal tetanus.]] ===Mild tetanus=== Mild cases of tetanus can be treated with: * Tetanus immune globulin [[Intravenous therapy|IV]] or [[Intramuscular injection|IM]] * [[metronidazole]] [[Intravenous therapy|IV]] for 10 days * [[diazepam]] * tetanus vaccination ===Severe tetanus=== Severe cases will require admission to [[intensive care]]. In addition to the measures listed above for mild tetanus: [[Image:Lock-jaw 2857.jpg|thumb|150px|Lock-jaw in a patient suffering from tetanus.]] * human tetanus immunoglobulin injected [[intrathecal]]ly (increases clinical improvement from 4% to 35%) * [[tracheostomy]] and [[mechanical ventilation]] for 3 to 4 weeks, * [[magnesium]], as an [[intravenous]] (IV) infusion, to prevent muscle spasm, * [[diazepam]] (known under the common name Valium) as a continuous IV infusion, * the [[Autonomic nervous system | autonomic]] effects of tetanus can be difficult to manage (alternating hyper- and [[hypotension]], [[hyperpyrexia]]/[[hypothermia]]) and may require IV [[labetalol]], magnesium, [[clonidine]], or [[nifedipine]]. Drugs such as [[chlorpromazine]] or [[diazepam]], or other [[muscle relaxant]]s can be given to control the muscle spasms. In extreme cases it may be necessary to paralyze the patient with [[curare]]-like drugs and use a mechanical ventilator. In order to survive a tetanus infection, the maintenance of an airway and proper [[nutrition]] are required. An intake of 3500-4000 Calories, and at least 150g of protein per day, is often given in liquid form through a tube directly into the stomach, or through a drip into a vein. This high-caloric diet maintenance is required because of the increased metabolic strain brought on by the increased muscle activity. ==Prevention== Tetanus can be prevented by [[vaccination]].<ref name=MMWR_1991>{{cite journal | author = Hopkins, A.| title = Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory committee (ACIP). | journal = MMWR Recomm Rep | volume = 40 | issue = RR-10 | pages = 1–28 | year = 1991 | pmid = 1865873| doi = 10.1542/peds.2006-0692}}</ref> The [[Centers for Disease Control and Prevention|CDC]] recommends that adults receive a [[Booster shot | booster]] vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than 3 lifetime doses of the vaccine. The booster cannot prevent a potentially fatal case of tetanus from the current wound, however, as it can take up to two weeks for tetanus antibodies to form. In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, [[DPT vaccine|DPT/DTaP vaccine]], which also includes vaccines against [[diphtheria]] and [[pertussis]]. For adults and children over seven, the Td vaccine (tetanus and diphtheria) or Tdap (tetanus, diphtheria, and acellular pertussis) is commonly used.<ref name=MMWR_1991 /> ==Epidemiology== [[Image:Tetanos.png|thumb|320px|Tetanus cases reported worldwide (1990-2004). Ranging from strongly prevalent (in dark red) to very few cases (in light yellow) (gray, no data).]] Tetanus is a global health problem, as ''C. tetani'' spores are ubiquitous. The disease occurs almost exclusively in persons who are unvaccinated or inadequately immunized.<ref name=Baron /> Tetanus occurs worldwide but is more common in hot, damp climates with soil rich in organic matter. This is particularly true with [[manure]]-treated soils, as the spores are widely distributed in the intestines and faeces of many non-human animals such as horses, sheep, cattle, dogs, cats, rats, guinea pigs, and chickens. In agricultural areas, a significant number of human adults may harbour the organism. The spores can also be found on skin surfaces and in contaminated [[heroin]].<ref name= CDC/> Tetanus &ndash; particularly the [[neonatal]] form &ndash; remains a significant public health problem in non-industrialized countries. There are about one million cases of tetanus reported worldwide annually, causing an estimated 300,000 to 500,000 deaths each year.<ref name= CDC/> In the United States, approximately 100 people become infected with tetanus each year, and there are about five deaths from tetanus each year.<ref name=Tetanus7-14-05>{{cite press release | title=Tetanus Cases Prompt Advisory for Missourians to Get Vaccine, Check Booster Status |publisher=Office of Public Information, Missouri Department of Health and Senior Services |url=http://www.dhss.mo.gov/NewsAndPublicNotices/Tetanus7-14-05.html |date=2005-07-14 |accessdate=2006-09-20 }}</ref> Nearly all of the cases in the United States occur in unimmunized individuals or individuals who have allowed their [[inoculation]]s to lapse,<ref name=Tetanus7-14-05/> whereas most cases in developing countries are due to the neonatal form of tetanus. Tetanus is the only vaccine-preventable disease that is [[infectious disease|infectious]] but is not contagious.<ref name=Tetanus7-14-05/><ref name="CDC"/> ==Association with rust== Tetanus is often associated with [[rust]], especially rusty nails, but this concept is somewhat misleading. Objects that accumulate rust are often found outdoors, or in places that harbour anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more ''C. tetani'' bacteria. The rough surface of rusty metal merely provides a prime habitat for a ''C. tetani'' endospore to reside. An [[endospore]] is a non-metabolising survival structure that begins to metabolise and cause infection once in an adequate environment. Because ''C. tetani'' is an anaerobic bacterium, it and its endospores will thrive in an environment that lacks [[oxygen]]. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic) environment of a puncture [[wound]] provides the bacteria with an ideal breeding ground. ==Tetanus Movies== * [http://www.neurology.org/cgi/content/full/70/18/e70/DC1 Generalized tetanus in a 70-year-old woman (Neurology)] * [http://www.youtube.com/watch?v=Fh7rJh3oTCk&amp;feature=related Tetanus in dogs] ==Famous tetanus victims== * [[George Montagu]] &ndash; English [[ornithologist]]; contracted tetanus when he stepped on a nail. * [[Joe Powell]] &ndash; English [[football (soccer)|footballer]]; contracted following [[amputation]] of a badly broken arm. * [[John A. Roebling]] &ndash; [[Civil Engineer]] and [[Architect]] famous for his [[suspension bridge|bridge]] designs, particularly the [[Brooklyn Bridge]]; contracted tetanus following amputation of his foot due to an injury caused by a [[ferry]] when it crashed into a [[wharf]]. * [[George Crockett Strong]] &ndash; [[Union (American Civil War)|Union]] [[brigadier general]] in the [[American Civil War]]; from wounds sustained in the assault against [[Fort Wagner]] on [[Morris Island]], [[South Carolina]]. * [[Fred Thomson]] &ndash; [[silent film]] actor; stepped on a nail. * [[Johann Tserclaes, Count of Tilly]]; wounded by a [[cannon]] ball in the [[Battle of Rain]]. * [[Traveller (horse)|Traveller]] &ndash; General [[Robert E. Lee]]'s favourite [[horse]]; stepped on a nail. * [[John Thoreau Jr.]] &ndash; brother of [[Henry David Thoreau]]. * [[George Hogg (adventurer)|George Hogg]] &ndash; English [[adventurer]] who rescued war orphans in China; died in 1945 from an infection resulting from a foot injury. ==References== <!-- ---------------------------------------------------------- See http://en.wikipedia.org/wiki/Wikipedia:Footnotes for a discussion of different citation methods and how to generate footnotes using the <ref>, </ref> and <reference /> tags ----------------------------------------------------------- --> {{reflist}} ==External links== {{commons|Tetanus}} * [http://www.nlm.nih.gov/medlineplus/ency/article/000615.htm Tetanus Information from Medline Plus] * [http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5203a1.htm Tetanus Surveillance -- United States, 1998-2000 (Data and Analysis)] {{Bacterial diseases}} [[Category:Bacterial diseases]] [[gn:Tétano]] [[bs:Tetanus]] [[ca:Tètanus]] [[cs:Tetanus]] [[cy:Tetanws]] [[da:Stivkrampe]] [[de:Tetanus]] [[et:Teetanus]] [[es:Tétanos]] [[eo:Tetanoso]] [[eu:Tetanos]] [[fr:Tétanos]] [[hr:Tetanus]] [[id:Tetanus]] [[it:Tetano]] [[he:טטנוס]] [[ku:Derdê kopan]] [[la:Tetanus]] [[lt:Stabligė]] [[ms:Kancing gigi]] [[nl:Tetanus]] [[ja:破傷風]] [[no:Stivkrampe]] [[pl:Tężec]] [[pt:Tétano]] [[ru:Столбняк]] [[sq:Tetanosi]] [[sr:Тетанус]] [[fi:Jäykkäkouristus]] [[sv:Stelkramp]] [[th:บาดทะยัก]] [[vi:Bệnh phong đòn gánh]] [[tr:Tetanos]] [[zh:破傷風]]