Clostridium tetani

Background

• Ubiquitous soil organism
• Acquired either by direct inoculation or via umbilical stump in neonates

Pathophysiology

• Toxin blocks inhibitory interneurons in the spinal cord and autonomic nervous system

Clinical Manifestations

• Incubation period of 3 to 21 days
• Followed by generalized tetanus, with tetanic spasms with even minimal external stimulus
• Lockjaw, risus sardonicus, opisthotonus, abdominal rigidity, and eventually apnea

Prognosis and Complications

• 30% mortality
• Can cause bony fractures, asphyxia, hematomas, and rhabdomyolysis

Diagnosis

• Baseline IgG serology; if positive, then they are tetanus-immune and it rules out the diagnosis
• Send wound swab or tissue for culture or PCR

Management

• Supportive care
  • Early intubation for airway protection
  • Benzodiazepines to manage muscle spasms
    • Rarely, need to escalate to neuromuscular blockage
  • May need α- or β-adrenergic blockade with labetalol to manage autonomic dysfunction
    • Avoid unopposed α effect, which can cause severe hypertension
  • Increased nutritional support, given the high metabolic demands of the illness
• Immunization
  • Tetanus antitoxin, tetanus immune globulin (TIg), or IVIg can shorten the duration of illness. Administer as early as possible and within 24 hours.
  • Vaccination with toxoid vaccine, within 24 hours, into a different limb.
• Metronidazole may improve outcomes compared to penicillin
• Wound care with debridement as indicated, though it does not alter the course of the disease