Tetanus

A clinical review

Juma M. Al-Kaabi, MRCP, DTM&H, Euan M. Scrimgeour, FRACP, DTM&H, Andre Louon, MD,
Bazdawi M. Al-Riyami, FRCP, PhD.

ABSTRACT
Objectives: Although tetanus is now uncommon in presented with severe generalized tetanus. Two patients
Oman (The Expanded Program on Immunization was with traditional cautery marks developed tetanus. A focus
introduced in 1981), patients continue to present from time of infection could not be found in 2 patients. All patients
to time at an average rate of 6 cases per year. Worldwide, had early tracheostomy and assisted ventilation with
the mortality rate for tetanus remains high (ranging from appropriate sedation. One patient required almost 45 gm
15-20% in developed countries). At the Sultan Qaboos of diazepam throughout his Intensive Care Unit stay. One
University Hospital, Muscat, Oman, prolonged Intensive adult patient died on the 6th day of admission following
Care Unit treatment and multi-disciplinary management is myocardial infarction. The neonatal case survived after 35
invariably required for tetanus patients. This study was days care in the Intensive Care Unit. The mortality rate
carried out to evaluate our results over the past decade. for our patients was therefore 10%.
Methods: All tetanus patients admitted to the Sultan
Qaboos University Hospital from 1991 up to the end of Conclusion: Tetanus in Oman remains an infrequent but
1999 were retrospectively reviewed. Patients were important disease requiring costly and prolonged Intensive
diagnosed early, and aggressive treatment in the Intensive Care Unit treatment. We attribute the comparatively low
Care Unit was instituted, with a coordinated mortality rate (10%) in this study, to early diagnosis,
multidisciplinary management. institution of aggressive treatment, good nursing as well as
a well-coordinated multi-disciplinary management.
Results: Ten cases were identified and included in the
review, comprising 9 adults and one infant aged 2 weeks. Keywords: Tetanus, tetanus management, cautery burns,
Adult patients were aged 36-75 years (mean 59 years), and immunization, Risus Sardonicus.
the average Intensive Care Unit stay of the 9 surviving
patients was 5.5 weeks (range 3-7 weeks). All patients Neurosciences 2001; Vol. 6 (4): 220-223

etanus is a potentially preventable disease caused World Health Organization (WHO) Expanded
T by a potent neurotoxin produced by Clostridium
tetani. The disease was first described in the 14th
Program on Immunization (EPI). The overall annual
incidence worldwide is 0.5-1 million cases. It is
century by John of Arderne.1 Tetanospasmin is estimated that there are 140,000 fatal neonatal cases
responsible for its pathogenesis. After the toxin of per annum. The disease is more common in tropical
botulism, it is the most potent neurotoxin known to and developing countries, where immunization is
man, with an estimated lethal dose of 2.5 ng/kg body deficient and opportunities for penetrating
weight.2 Tetanus is one of the target diseases of the contaminated wounds is higher.3 In Oman, tetanus

From the Departments of Medicine (Al-Kaabi, Scrimgeour, Al-Riyami) and Anesthesia (Louon), Sultan Qaboos University Hospital, Muscat, Oman.

Published simultaneously with special permission from Saudi Medical Journal.

Address correspondence and reprint request to: Dr. Juma M. Al-Kaabi, Senior Registrar, Department of Medicine, Sultan Qaboos University Hospital,
PO Box 35, Al-Khod 123, Muscat, Oman. Tel. +968 513355 ext. 3404. Fax. +968 513419. E-mail: [email protected]

220
 Tetanus ... Al-Kaabi et al

toxoid was first included in the EPI in 1981 and calcium, arterial blood gases, urea and electrolytes,
accordingly the majority of adults are not electrocardiogram, chest x-ray and wound cultures.
immunized. Most Omanis live in rural areas and are All the patients received antibiotics, anti-tetanus
involved in subsistence agriculture and livestock toxoid and human tetanus immunoglobulin (TIG).
farming, subsequently, exposure to tetanus is Generalized muscle spasms, which occurred in all
common. Sultan Qaboos University Hospital patients, were well controlled with a combination of
(SQUH) is a tertiary care teaching hospital in Muscat sedative drugs and muscle relaxants. Initially
and patients with tetanus are referred from regional parenteral then enteral nutrition was instituted in all
and district hospitals. patients.

Methods. All patients referred to, or presenting Results. Most patients presented with progressive
at, the SQUH from 1991 to 1999 were included in difficulty in swallowing, back pain and stiffness of
this study. One or more of the authors had treated the back and neck, of 2 days to one-week duration.
each patient. A retrospective evaluation of all the Tetanic spasms were observed in only one patient.
patients was undertaken to determine the results of On admission, all patients were alert, agitated, had
treatment during this time. Medical records were trismus, generalized rigidity associated with
reviewed to collect demographic information, hyperreflexia and exhibited plantar withdrawal, their
circumstances of injury, anatomic site and type of sensorium was otherwise normal. A focus of
injury, treatment and outcomes. Ten cases were infection could not be found in 2 patients. Risus
identified including a neonate, 9 males and one sardonicus and opisthotonos were noted in 2 patients.
female (Table 1). All but one patient, a Bangladeshi, Two patients with traditional cautery burns
were Omanis. All patients had full clinical developed tetanus. One of them was a female patient
examinations, including identification of the focus of with an unreported, infected cautery lesion on her
infection. Severe generalized tetanus was the main scalp, which was found by chance by the nursing
diagnosis in all the cases thus early ventilatory staff when being washed. The other one had multiple
support and tracheostomy together with intensive traditional cautery marks on the neck and the trunk.
nursing care, were instituted. The diagnosis of We obtained only one positive culture out of the 8
tetanus is purely clinical, as there are no specific cases with a known focus of infection and the basic
laboratory tests. However, the basic initial initial investigations were unremarkable. Our
investigations have included full blood count, neonatal case was delivered by an old blind woman
erythrocyte sedimentation rate, serum glucose, serum at home in a remote village (mother Gravida 7, Para
Table 1 - Tetanus cases admitted to the Intensive Care Unit at Sultan Qaboos University Hospital during the period from 1991 to 1999.

Case Patient Year of ICU stay Source of tetanus Incubation Significant Outcome
Number Age/Sex admission (days) infection period (days) complications

1 59/M 1991 41 Unknown NA** Pneumonia, UTI Recovered

2 66/M 1992 6 Left big toe 10 MI, cardiac arrest Died

3 67/M 1992 50 Right thigh 7 2 x pneumonia Recovered

4 63/M 1993 19 Left neck cautery 4 Pneumonia Recovered

5 47/M 1993 31 Unknown NA** Myoclonic epilepsy, Recovered

6 6 days/M 1995 35 Umbilical cord 5 Pneumonia Recovered

7 75/F 1996 51 Small scalp cautery 6 Pneumonia Recovered

8 36/M 1997 52 Left ear 8 DVT, Pneumonia, VT, Recovered

9 68/M 1998 41 Right foot 12 UTI, pneumonia, Recovered

10 52/M 1999 35 Right breast* 15 Pneumonia Recovered

* Two weeks postoperative for abscess ** NA: Not available as the wound or the history of penetrating injury have not been found.
M - Male F - Female ICU - Intensive Care Unit UTI - Urinary Tract Infection MI - Myocardial infarct
DVT - Deep vein thrombosis VT - Ventricular tachycardia SVT - Supraventricular tachycardia

Neurosciences 2001; Vol. 6 (4) 221

6 and sera confirmed non-immunized state). An obtained. A simple bedside test, the "spatula test" (a
unsterile knife cut the umbilical cord. On the 5th day reflex spasm of the masseters on touching the
the baby showed failure of sucking, vomiting and posterior pharyngeal wall leading to biting of the
looked unwell. On the 6th day, he presented to the spatula rather than a gag reflex), was described by
nearest hospital. He was dehydrated, showing tetanic Apte et al. In 400 patients, this test had a sensitivity
spasms, risus sardonicus, opisthotonos with an of 94% and a specificity of 100%.7 Pain and stiffness
infected umbilical cord. As the tetanus diagnosis was of the back are the most common presenting
evident, the neonate was sedated, intubated and symptoms, followed by trismus and dysphagia.
transferred to our hospital. All patients had early Spasms may be precipitated by minimal stimuli such
tracheostomy and assisted ventilation with as noise, light or touch and may last from seconds to
appropriate sedation. It has been noted generally, the minutes. They can be painful or dangerous, causing
further distant the focus of infection from the central apnea, fractures or rhabdomyolysis and thus our
nervous system (CNS) the longer the incubation patients were kept in a quiet room and stimuli kept at
period. The average Intensive Care Unit (ICU) stay a minimum until satisfactory sedation was achieved.
of the 9 surviving patients was lengthy, 5.5 weeks Sera can be analyzed for tetanus antitoxin, the
(range 3-7 weeks). In this small sized sample the presence of more than 0.01 antitoxin unit per ml is
mortality rate of our patients was therefore 10%. The regarded as protective against clinical tetanus,
following major complications were encountered. All although cases have occurred in patients with
patients developed multiple chest infections antibody concentrations at least 10-fold higher than
(pneumonia) and 2 patients contracted urinary tract this. In this study, tetanus serology was only
infections. One patient developed right subclavian performed for the mother of the neonatal case, which
vein thrombosis probably secondary to continuous confirmed her non-immunized state.
diazepam infusion. One patient with severe aortic The major differential diagnoses which were
stenosis (pressure gradient across the aortic valve 70- excluded in our cases are hypocalcemia, meningitis,
80mmHg) was revived from cardiac arrest (asystole) encephalitis, subarachnoid hemorrhage, peritonsilar
and underwent a successful aortic valve replacement abscess, dystonic reactions, rabies, spider
after a full recovery from tetanus. Unsuccessful envenomatoin (widow), strychnine poisoning and
resuscitation of cardiac arrest occurred in a patient hysteria. There are 4 clinical forms of tetanus:
with non-insulin dependent diabetes mellitus who neonatal, localized, cephalic and generalized. All the
sustained myocardial infarction on the 6th day of his adult tetanus cases studied were of the generalized
admission. Myocardial infarction is a rarely observed form. In the literature, the source of infection is from
complication of tetanus.4 All patients showed one or an obvious injury in 58% of cases (8 out of 10 in our
more manifestations of autonomic dysfunction e.g. series). Two patients with traditional cautery remedy
hypertension, hypotension, tachycadia, bradycardia developed tetanus. It is probable, that the source of
and dysrhythmias particularly in the 2nd and the 3rd tetanus in these cases was ash applied by the
week. On discharge there were no major sequele to traditional healer to accelerate the wound healing.
any patient and outpatient follow-up showed no Our treatment followed the recommended
major long-term complications. guidelines: Neutralization of the toxin and
elimination of the source of infection by careful
surgical excision and wound care. As soon as the
Discussion. Tetanus remains an important cause diagnosis of tetanus was made, Human TIG 1000
of morbidity and mortality despite the wide units were given and repeated for an additional 2
implementation of the EPI. The WHO estimated in days in most patients. This at best neutralizes only
1990 that worldwide, there were about 715,000 circulating toxins, but does not affect toxins already
deaths from neonatal tetanus.2 In Oman, tetanus is a fixed to the CNS. Intrathecal administration of
notifiable disease, and there were 2 neonatal and 52 antitetanus toxin has not been used as large meta-
adult cases (on average 6 cases per year) reported analyses reported it to be ineffective in reducing the
over the period from 1991 up to the end of 1999. morbidity and mortality.8 Once the Human TIG has
Tetanus is primarily a disease of the elderly in been given, the infected site should be thoroughly
developed countries. Active immunization and better cleaned and all the necrotic tissue extensively
hygiene, wound care and management of childbirth debribed. Antibiotics destroy tetanus spores. The
have diminished its incidence. Mortality has been favorite choice was Metronidazole 500mg
reduced to 15% with the active employment of intravenously (IV) 8 hourly for 10 days as the drug
intensive care facilities for the treatment of this has a spectrum of activity against anaerobes, it is able
condition.5 Our mortality rate is comparatively low at to penetrate necrotic tissue and has been shown to be
10%. The diagnosis of tetanus is purely clinical, as more effective than penicillin in this situation.9
there are no specific laboratory tests. It has been However, penicillin or a 3rd-generation
estimated that wound cultures are positive in only cephalosporin have also been used in a few patients.
32% of cases.6 Only one positive culture was Natural immunity to tetanus does not occur, tetanus

222 Neurosciences 2001; Vol. 6 (4)

may both relapse and recur, so victims of tetanus to its elimination and loss of life in an easily
must be actively immunized. Immunization with preventable disease is unacceptable. Primary care
tetanus toxoid was given at the time of the diagnoses. and emergency physicians can reduce the morbidity
A 2nd and 3rd toxoid injection were given one and 2 and mortality of tetanus through proper
months later, with planned booster injections one- immunization. As a patient’s tetanus immunization
year later and then 10 yearly intervals. In the case of history is often unreliable in routine wound
a neonate, the mother also was given the vaccine. management, liberal use of tetanus toxoids and
The main aims of treatment are to relieve the appropriate TIG is recommended.3
patient’s distress, controlling the spasms and rigidity In conclusion, tetanus is a potentially preventable
and to maintain adequate respiration. If endotracheal disease. However, it remains a frequent cause of
intubation was necessary, tracheostomy was death and hospitalization in most developing
performed within 10 days. As the endotracheal tube countries. Proper attention, strict adherence to
seems to be a strong stimulus for spasms, in the last 3 immunization schedules and appropriate wound care
patients a tracheostomy was carried out earlier, on will reduce the incidence of this potentially fatal
the 2nd day of ventilation. Benzodiazepines reduce disease. Active immunization is the clear solution.
anxiety, induce amnesia, sedation and muscle Early recognition of tetanus and early use of
relaxation as well as being anticonvulsant.10 These intensive care facilities can reduce the mortality
drugs are Gama-amniobutyric acid A (GABA-A) considerably.
agonists, thereby functioning as indirect antagonists
of the effect of the toxin on inhibitory systems. Acknowledgments. Our sincere thanks go to all those
Diazepam or midazolam by continuous infusion have involved in the management of these unfortunate patients
been used. Diazepam is less expensive compared to stricken by a deadly disease. Their commitment probably saved
other benzodiazepines. The disadvantages of their lives. We also like to thank Dr. Deleu, HoD of
Pharmacology and Consultant Neurologist, for his editorial
diazepam include slow onset, prolonged action, and advice.
irritation to tissues and thrombophlebitis (one patient
developed subclavian vein thrombosis). Most of our
patients received diazepam IV infusions ranging References
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