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Updated: Jan 11 2022

Clostridium tetani

  • 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
      • 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
1 of 0
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