Snapshot A 20-year-old college student presents to the emergency room after stepping on a piece of a rusted nail outside of his dorm. He reports that he has had all the appropriate childhood vaccinations but has had nothing since his last set of boosters at 10 years of age. His vital signs are within normal limits. Aside from erythema surrounding his left sole at the site of trauma, his physical exam is within normal limits. After cleaning the wound site, he is given the appropriate post-exposure prophylaxis. Introduction Classification Clostridium tetani anaerobic gram + rod produces tetanospasmin toxin transmission direct contact in contaminated soil Epidemiology demographics rare in the US more common in developing countries due to low rates of vaccination risk factors lack of vaccination trauma chronic wounds lack of immunity in mothers Pathogenesis forms spores that are resistant to heat and chemicals produces tetanospasmin, an exotoxin a protease that cleaves SNARE proteins (synaptobrevin 2), which blocks the release of inhibitory neurotransmitters (glycine and GABA) causes paralysis Associated conditions tetanus neonatal tetanus neonates who are born to unvaccinated mothers most effective prevention strategy is Tdap vaccination during each pregnancy inability to suck or cry after day 2 of life colonization of the umbilical stump Prevention DTap vaccine vaccine against diphtheria, tetanus, and pertussis 5 doses before school-age, completed by 4-6 years of age Tdap vaccine booster vaccine at 11-12 years of age Td vaccine tetanus and diphtheria toxoid vaccine at 10-year intervals Prognosis spasms last for ~ 1 month mortality can be high if not treated Presentation Symptoms spastic paralysis muscle stiffness spasms fever Physical exam trismus lockjaw risus sardonicus raised eyebrows grin opisthotonos spinal muscle spasms causes backward arching of head and spine rigid abdominal muscles foul-smelling and erythematous umbilical stump in neonates Studies Serology or culture rarely used due to low sensitivity and specificity Making the diagnosis most cases are clinically diagnosed Differential Bacterial meningitis distinguishing factor nuchal rigidity without other signs of spastic paralysis Treatment Management approach treat all with antitoxin and booster if needed Conservative wound debridement indication all patients Medical tetanus antitoxin indication patients with contaminated or dirty wounds benzodiazepine indications muscle spasms booster vaccine indication patients with > 10 years from last dose patients with < 3 or uncertain number of tetanus vaccine doses Complications Respiratory compromise from spasm of respiratory muscles Aspiration pneumonia Contractures