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Christine Ahn MD
Carl Allen DDS, MSD
Brandon Ayres MD
Howard P. Baden MD
Robert Baran MD
Keira Barr MD
Gregory J. Basura MD, Ph.D
Donald Belsito MD
Jeffrey D. Bernhard MD
Jesse Berry MD
Victor Blanco MD
Benjamin R. Bohaty MD
William Bonnez MD
Sarah Brenner MD
Robert A. Briggaman MD
Robert Brodell MD
Roman Bronfenbrener MD
Walter Brooks MD
William Buckley MD
Philip Bulterys MD, PhD (candidate)
Susan Burgin MD
Sonya Burton MD
Sean P. Bush MD, FACEP
Jeffrey Callen MD
Scott Camazine MD
Michael Cardwell
Shelley D. Cathcart MD
Robert Chalmers MD, MRCP, FRCP
Chia-Yu Chu MD, PhD
Flavio Ciferri MD
Maria Rosa Cordisco MD
Noah Craft MD, PhD
John T. Crissey MD
Harold E. Cross MD, PhD
Charles Crutchfield III MD
Adriana Cruz MD
Donna Culton MD, PhD
Bart J. Currie MBBS, FRACP, DTM&H
Chicky Dadlani MD
Alexander Dane DO
C. Ralph Daniel III MD
Thomas Darling MD, PhD
William Delaney MD
Damian P. DiCostanzo MD
Ncoza Dlova MD
James Earls MD
Libby Edwards MD
Melissa K. Egge MD
Charles N. Ellis MD
Rachel Ellis MD
David Elpern MD
Nancy Esterly MD
Stephen Estes MD
E. Dale Everett MD
Janet Fairley MD
David Feingold MD
Benjamin Fisher MD
Henry Foong MBBS, FRCP
David Foster MD, MPH
Brian D. Foy PhD
Michael Franzblau MD
Vincent Fulginiti MD
Sunir J. Garg MD, FACS
Kevin J. Geary MD
Lowell Goldsmith MD, MPH
Sethuraman Gomathy MD
Bernardo Gontijo MD, PhD
Kenneth Greer MD
Kenneth G. Gross MD
Alan Gruber MD
Nathan D. Gundacker MD
Akshya Gupta MD
Vidal Haddad MSC, PhD, MD
Edward Halperin MD, MA
Ronald Hansen MD
John Harvey
Rizwan Hassan MD
Michael Hawke MD
Jason E. Hawkes MD
Peter W. Heald MD
David G. Hicks MD
Sarah Hocker DO
Ryan J. Hoefen MD, PhD
Li-Yang Hsu MD
William Huang MD
Sanjana Iyengar MD
Alvin H. Jacobs MD
Saagar Jadeja MD
Shahbaz A. Janjua MD
Joshua J. Jarvis MD
Kit Johnson
Robert Kalb MD
A. Paul Kelly MD
Henry Kempe MD
Loren Ketai MD
Sidney Klaus MD
Ashwin Kosambia MD
Jessica A. Kozel MD
Carl Krucke
Mario E. Lacouture MD
Joseph Lam MD
Alfred T. Lane MD
Edith Lederman MD
Nahyoung Grace Lee MD
Pedro Legua MD, PhD
Robert Levin MD
Bethany Lewis MD
Sue Lewis-Jones FRCP, FRCPCH
Taisheng Li MD
Christine Liang MD
Shari Lipner MD, PhD
Adam Lipworth MD
Jason Maguire MD
Mark Malek MD, MPH
Jere Mammino DO
Ricardo Mandojana MD
Lynne Margesson MD
Thomas J. Marrie MD
Maydel Martinez MD
Ralph Massey MD
Patrick McCleskey MD
Karen McKoy MD
Thomas McMeekin MD
Josette McMichael MD
Somchai Meesiri MD
Joseph F. Merola MD
Mary Gail Mercurio MD
Anis Miladi MD
Larry E. Millikan MD
Dan Milner Jr. MD
Zaw Min MD
Stephanie Montero
Alastair Moore MD
Keith Morley MD
Dean Morrell MD
Samuel Moschella MD
Taimor Nawaz MD
Vic Newcomer MD
John Nguyen MD
Matilda Nicholas MD
Thomas P. Nigra MD
Steven Oberlender MD, PhD
Maria Teresa Ochoa MD
Art Papier MD
Lawrence Parish MD
Tanner Parrent MD
Mukesh Patel MD
Lauren Patty-Daskivich MD
David Peng MD, MPH
Robert Penne MD
Nitipong Permpalung MD
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Doug Powell MD
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Angela Restrepo MD, PhD
Bertrand Richert MD, PhD
J. Martin Rodriguez, MD, FACP
Theodore Rosen MD
Misha Rosenbach MD
Scott Schiffman MD
Robert H. Schosser MD
Glynis A. Scott MD
Carlos Seas MD, MSc
Deniz Seçkin MD
Daniel Sexton MD
Paul K. Shitabata MD
Tor Shwayder MD, FAAP, FAAD
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Christye Sisson
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Lawrence B. Stack MD
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Belinda Tan MD, PhD
Robert Tomsick MD
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Lisa Wallin ANP, FCCWS
Douglas Walsh MD
Ryan R. Walsh MD
George Watt MD
Clayton E. Wheeler MD
Sally-Ann Whelan MS, NP, CWOCN
Jan Willems MD, PhD
James Henry Willig MD, MPH
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Vivian Wong MD, PhD
Sook-Bin Woo MS, DMD, MMSc
Jamie Woodcock MD
Stephen J. Xenias MD
Lisa Zaba MD
Vijay Zawar MD
Bonnnie Zhang MD
Carolyn Ziemer MD
Organizations
Am. Journal of Trop. Med & Hygiene
Armed Forces Pest Management Board
Blackwell Publishing
Bugwood Network
Centers For Disease Control and Prevention
Centro Internacional de Entrenamiento e Investigaciones Mèdicas (CIDEIM)
Dermatology Online Journal
East Carolina University (ECU), Division of Dermatology
Generalized
Tetanus is a disease of the nervous system caused by a toxin produced by the bacterium Clostridium tetani.
This bacterium is spore-forming, and spores are widely distributed throughout the world. Disease occurs after the spores are inoculated into a deep puncture wound. The portal of entry may also be a burn wound, infection of the skin or middle ear, or septic abortion. It also might be minor and not readily apparent. Germination leads to the production of an exotoxin, tetanospasmin. This metalloprotease destroys the protein essential for the release from the presynaptic vesicles of the neurotransmitters that prevent the firing of the neurons from the motor and autonomous systems. The retrograde neuronal transport of tetanospasmin and entry in the central nervous system accounts for the clinical manifestations of the disease that are different from those of botulism. Another toxin, tetanolysin, is also produced. The role of this toxin in infection is not known with certainty, but it is suspected that it may cause local tissue damage and thereby optimize the local conditions for bacterial replication.
In developed countries such as the United States, tetanus is rare due to the near-universal vaccination of children. Surveillance of patients who develop the disease reveals that many were inadequately vaccinated or did not receive proper prophylaxis following an injury. In the developing world, tetanus is more common, and outbreaks can be seen following natural disasters. Neonatal tetanus is also much more common in the developing world.
The period from the time of wound inoculation to the onset of symptoms can vary. It is generally about 1 week (range 1-60 days). The incubation period may be somewhat shorter in neonates.
Patients with generalized tetanus (the most common clinical presentation) present with excruciatingly painful muscle spasms, trismus (lockjaw, the common name of tetanus), risus sardonicus (sardonic smile), opisthotonus (spasms and arching of the back), a rigid abdomen, apnea, and dysphagia. Other presentations of tetanus include local tetanus (muscle contractions at the site of spore inoculation) and cephalic tetanus (involving only the cranial nerves and usually manifesting as diplopia or facial paralysis). Both of these presentations can progress to generalized tetanus.
The symptoms of generalized tetanus may last 2-4 weeks, during which time the patient will typically require intensive care. During this time, the patient might experience autonomic dysfunction (especially labile blood pressure and heart rate), which can be life-threatening. After the acute illness, symptoms continue to improve over the following weeks.
An additional clinical pattern is neonatal tetanus. This is caused by contamination of the umbilical stump when a mother has been inadequately vaccinated against tetanus. This severe form of illness has symptoms similar to generalized tetanus and usually presents within the first 2 weeks of life. Mortality is high, and survivors may suffer developmental delay.
In the United States, tetanus is more common in patients with diabetes mellitus and a history of injection drug use.
Codes
ICD10CM: A35 – Other tetanus
SNOMEDCT: 76902006 – Tetanus
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
Strychnine poisoning – Symptoms may mimic tetanus, and serum and urine testing for strychnine should always be performed when tetanus is suspected.
Dystonic reactions – Lateral head turning seen in dystonic reactions is rare in tetanus. Benztropine may be administered to rule out a dystonic reaction.
Dental infection – Dental infection may cause trismus but no other symptoms of tetanus.
