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Infectious Diseases

Tetanus

An acute, often fatal disease caused by the neurotoxin (tetanospasmin) produced by Clostridium tetani bacteria. Characterized by muscle rigidity and painful spasms. Spores enter through wounds.

Also known as: Lockjaw

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Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL/ADMISSION to Hospital (H/RR, ideally with ICU capability) for ALL suspected cases of tetanus.

Red flags

  • Trismus ('Lockjaw').
  • Generalized muscle spasms.
  • Risus sardonicus.
  • Opisthotonus.
  • Difficulty breathing / Laryngospasm.

Signs and symptoms

  • Incubation period: few days to weeks (average 7-10 days).
  • Early Signs:
  • - Stiffness of the jaw (Trismus or 'Lockjaw') - often first sign.
  • - Neck stiffness.
  • - Difficulty swallowing.
  • - Restlessness, irritability.
  • Progressive Signs:
  • - Painful, generalized muscle spasms (often triggered by stimuli like noise, light, touch).
  • - Facial muscle spasm causing characteristic grin ('Risus Sardonicus').
  • - Arching of the back (Opisthotonus).
  • - Abdominal rigidity.
  • - Spasms can be severe enough to cause fractures or respiratory compromise.
  • - Laryngeal spasm (can cause acute airway obstruction).
  • - Autonomic dysfunction (later stages): fluctuating BP, tachycardia, arrhythmias, sweating, fever.
  • Patient usually remains fully conscious during spasms.
  • Wound may be trivial or not apparent.

Risk factors

  • Lack of immunization or incomplete immunization series.
  • Contaminated wounds (deep penetrating wounds, puncture wounds, crush injuries, burns, wounds with dead tissue or foreign bodies).
  • Non-sterile procedures (umbilical cord care in neonates, unsafe abortions, traditional surgery/circumcision, IV drug use).
  • Animal bites, human bites.
  • Chronic wounds (ulcers).
  • Recent surgery.

Diagnosis

Clinical assessment

Diagnosis is entirely clinical, based on the characteristic presentation of trismus, generalized muscle rigidity, and reflex spasms in a patient with a potential exposure history. There are no specific lab tests to confirm tetanus.

Differential diagnosis

  • Meningitis / Meningoencephalitis (altered consciousness usually present).
  • Strychnine poisoning (similar spasms).
  • Dystonic reaction (to medications like phenothiazines, metoclopramide).
  • Hypocalcemia (tetany).
  • Seizure disorder (usually associated loss of consciousness).
  • Rabies (hydrophobia, aerophobia, altered mental state).
  • Temporomandibular joint (TMJ) disorder (trismus, but no generalized spasms).

Investigations

  • Investigations mainly to rule out other conditions.
  • Wound culture (rarely grows C. tetani).
  • Serum Calcium (rule out hypocalcemia).

Diagnostic criteria

Clinical diagnosis based on characteristic muscle rigidity and spasms, especially trismus, risus sardonicus, opisthotonus.

Management

Non-pharmacological management

  • Urgent Hospital Admission (preferably ICU if available).
  • Minimize Stimulation: Nurse in quiet, dark, isolated room.
  • Airway Management: Maintain patent airway. High risk of laryngospasm and respiratory arrest. Early intubation/tracheostomy and mechanical ventilation often required for severe spasms or respiratory compromise.
  • Wound Care: Thorough cleaning and surgical debridement of any identified wound to remove source of toxin production.
  • Nutritional Support: High metabolic demands due to spasms. Enteral feeding via Nasogastric Tube (NGT) usually needed.
  • Fluid balance management.
  • Prevent complications (pressure sores, DVT).

Pharmacological treatment

  • Neutralize Unbound Toxin:
  • - Human Tetanus Immunoglobulin (TIG): Give 3000-6000 IU IM (single dose) OR 150 IU/kg IM (as per UCG) into multiple sites, away from TT injection site. Neutralizes circulating toxin, does not affect bound toxin. (LOC: H)
  • - (Equine Antitoxin (ATS) may be used if TIG unavailable, requires sensitivity testing).
  • Eliminate Bacteria:
  • - Metronidazole: 500mg IV/PO Q8H for 7-10 days (Child: 7.5mg/kg Q8H). Preferred antibiotic. (LOC: H)
  • - Alternative: Benzylpenicillin 2-4 MU IV Q6H (Child: 50k-100k IU/kg/dose). (Historically used, may theoretically worsen spasms by GABA antagonism - Metronidazole preferred).
  • Control Muscle Spasms (Sedation):
  • - Benzodiazepines (Mainstay): Diazepam IV/Rectal/NGT. Requires large, frequent doses titrated to control spasms while avoiding excessive sedation/respiratory depression. Start 10mg IV/Rectal, repeat Q1-4H PRN. (Child: 0.2mg/kg IV or 0.5mg/kg rectal, max 10mg/dose). Continuous infusion may be needed in ICU.
  • - Magnesium Sulphate: IV infusion (e.g., 5g load then 2g/hr) can help control spasms and autonomic instability. Monitor reflexes, respiration, BP closely. (LOC: H)
  • - Baclofen (intrathecal - specialist ICU use).
  • - Neuromuscular Blockade + Mechanical Ventilation (for severe, refractory spasms - ICU).
  • Manage Autonomic Instability: (ICU)
  • - Alpha/Beta blockers (Labetalol), Morphine, Magnesium Sulphate.
  • Pain Control: Opioids (Morphine IV), Paracetamol. (LOC: H)
  • Active Immunization: Disease does not confer immunity. Start/complete Tetanus Toxoid (TT) vaccination series concurrently with TIG. (See UCG section 18.1.4). (LOC: H)

Monitoring

Continuous monitoring of: Airway patency, Respiratory function (rate, effort, SpO2, need for ventilation), Muscle spasms (frequency, severity, triggers), Autonomic function (BP, HR), Temperature, Fluid balance. Monitor sedation level. Monitor for complications.

Complications

  • Laryngospasm / Airway obstruction.
  • Respiratory failure / arrest.
  • Aspiration pneumonia.
  • Fractures (vertebral compression fractures due to severe spasms).
  • Rhabdomyolysis -> Acute kidney injury.
  • Autonomic instability (cardiac arrest).
  • Pulmonary embolism.
  • Pressure sores.
  • Nosocomial infections.
  • Death.

Prevention

  • Active Immunization: Universal childhood immunization with DPT/Pentavalent vaccine. Booster doses (Td) every 10 years for adults.
  • Tetanus Prophylaxis for Wounds: Based on wound type (clean/minor vs tetanus-prone) and patient's vaccination history. May involve TT booster +/- TIG.
  • - Tetanus-prone wounds: Contaminated with dirt/faeces/saliva, puncture wounds, avulsions, wounds from missiles, crush injuries, burns, frostbite, wounds with devitalized tissue.
  • - UCG TIG prophylaxis doses: Child <5y: 75 IU IM; 5-10y: 125 IU IM; >10y/Adult: 250 IU IM (double if heavy contamination/>24h delay).
  • Clean delivery practices and umbilical cord care (prevent neonatal tetanus).
  • Safe surgical and injection practices.

Patient education

  • Explanation of tetanus as a serious infection causing muscle spasms.
  • Need for urgent hospitalization and intensive care.
  • Explanation of treatments (TIG, antibiotics, sedation).
  • Importance of completing vaccination series after recovery.
  • Wound care and vaccination for prevention.

Uganda-specific notes

Tetanus still occurs, especially neonatal tetanus (due to cord care practices) and in adults with contaminated wounds and inadequate immunization. Management requires intensive supportive care (airway, sedation) which is challenging. Metronidazole preferred over Penicillin. TIG availability may be limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.1.8, 2.1.8.1 (Neonatal)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 18, Section 18.1.4 (Tetanus Immunization/Prophylaxis)

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