Pankaj Satapathy(1), Kounaina K(2), Huded SP(2), Aishwarya T Devi(3), Avinash MG(4), Shubha Gopal(4), Nagendra Prasad MN(3), Sudarshan S(1), Sunil S More(1), Ravish H(5), Farhan Zameer(1)
Generalized tetanus
This is a predominant type representing about 80% of cases and is the most widely spread. The generalized form usually shows a downward pattern. The major sign is trismus or lock jaw and the facial tremors called risus sardonicus, followed by neck stiffness, trouble in swallowing and rigidity of pectoral and calf muscles. Other symptoms are high temperature, perspiring, high blood pressure and episodic rapid heart rate. Spasms occurs in a characteristic form known as opisthotonos (a state of severe hyper extension and spasticity in which an individual’s neck and spinal column enter into a complete bridging position). These symptoms may occur regularly and last for several minutes depending upon the body shape. Seizures last for up to four weeks and comprehensive healing may take months.

Figure 1: Types of tetanus based on their host and clinical symptoms.
Tetanus Types

Neonatal tetanus
It’s a type of tetanus that occurs in newborns, this happens to the kids born to unvaccinated mothers. Under maternal vaccination care, the offspring is protected via passive immunity. Many a times, due no socio-economical status and/or pre/post operative surgical devices are known to be the major culprits of infection (specially, umbilical stump cut with non sterile instrument). As per the statistics in 1998 about 14% (215,000) were suffering from neonatal tetanus were reported in developing countries. Due to public health campaign the death toll got decreased during the year 1990 and 2010 by 90%. The disease was eliminated in 25 countries and was rare in developed countries by 2013. [3]. However the disease still persists in under developed nations which lack the basic facility of mass vaccination.

Local tetanus
This is uncommon in nature and occurs due to persistent contraction of muscle in a particular muscle area as a result of injury. The contraction prolongs for many weeks and gradually subsides. This is considered as the milder form of tetanus and reported cases are about 1%.

Cephalic tetanus
This is the rarest form of the disease (0.9-3% of cases) [4] and is limited to muscles and nerves present in the head. The main cause is trauma to the head area [5], which includes skull breakage, cut [6], eye wound [5], dental removal [7] and otitis media [8], nevertheless it is also linked with injuries to other parts of the body [9]. Frequent implication is done for paralysis of the facial nerve [7, 10] which leads to lockjaw, facial palsy or ptosis, this may affect other cranial nerves as well. Cephalic tetanus may lead to more generalized form [4, 10]. Rarity of disease brings unfamiliarity among clinicians [5] and might not even suspicious tetanus as disease. Symptoms may be complex [6] and may relate with initial injuries. Its fatal than other types of tetanus with a progression of 15-30% cases [4, 6, 10] to generalized tetanus.

The diagnosis is related to the incubation period, it starts from the spore inoculation to the initial symptom and further leading to the first titanic spasm. The following can be concluded (a). Shorter intermissions directly relates to severe tetanus and a poorer diagnosis. (b). Patients usually survive tetanus and get back to their original state of health. (c). Slow recovery usually over 2-4 months. (d). Clinical tetanus does not produce immunity; active immunization is needed to prevent reoccurrence. A high risk of mortality is related with the following: short incubation time, early onset of convulsions, delay in action and contaminated lesions of the head and the face.

A rating scale has been established to assess the severity of tetanus and shaping the diagnosis [15]. On this scale, 1 point is given for each of the following: Incubation period < 7 days, Period of onset < 48 hours, tetanus which are attained from injuries like burns, surgical wounds, compound fractures, septic abortion, umbilical stump, or intramuscular injection, narcotic addiction, generalized tetanus, temperature > 104°F (40°C), tachycardia > 120 beats/min (150 beats/min in neonates). The disease diversity and the severity is mentioned in the rating scale mentioned in the table no.1.

Table - 1: Rating scale for severity of disease
Scale 0-1 2-3 3-4 5-6
Type of tetanus Mild Moderate Severe Very Severe
Motality % <10% 10-20% 20-40% >50%

Incubation period
Incubation period may range up to several months but commonly about ten days [16, 17]. The incubation period also depends upon the distance of the damage to the central nervous system; greater distance is related to longer incubation time. Shorter incubation has extra severity of symptoms [18]. In case of neonatal tetanus the signs appear from 4 to 14 days after birth and the average is about 7 days. Based on clinical outcomes, four diverse forms of tetanus have been defined [2] as discussed above (Fig 1).

Tetanus spores are resistant to harsh environments, disinfectant and also for boiling temperature up to 20 min which makes their survival easier for some years. Though vegetative cells can be deactivated and are susceptible to numerous antibiotics. Tetanus can be developed in both outdoor and indoor environment. The major basis of infection is wound (approx 65%), often is slight (wood, metal or thorns) generally no initial medical attention is sought. Prolonged skin ulcer is a source in case of approx 5% of the cases. In other cases, the obvious source cannot be documented. Tetanus also advances as a problem for chronic conditions like blisters and gangrene. Tetanus possibly infects tissue damage by burns, frostbite, middle ear infection, dental or surgical procedures, abortion, childbirth and intravenous (IV) or subcutaneous drug use. Important cause of tetanus is lack of immunization it disturbs non-immunized, partly immunized or full vaccinated persons due to lack of maintenance of periodic booster doses. Universal perils for neonatal tetanus comprise the following: unvaccinated mother, home delivery and unhygienic condition for delivery, past history of tetanus in previous child is a risk for successive child, infectious substance attached to umbilical cord and vulnerability to tetanus increases with age.

Tetanus Tetanus 09/04/2018
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