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Definition Tetanus is a disease caused by the toxin of the bacterium Clostridium tetani that affects the central nervous system, sometimes resulting in death. Alternative Names Lockjaw Causes, incidence, and risk factors Spores of the bacterium Clostridium tetani live in the soil and are found around the world. In the spore form, C. tetani may remain dormant in the soil, and it can remain infectious for more than 40 years. Tetanus causes approximately five deaths per year in the U.S. Internationally, reports show up to 1 million cases annually, mostly in developing countries. Tetanus infections in newborns accounts for about half of tetanus-related deaths in developing countries. Infection begins when the spores are introduced into an injury or wound. The spores germinate, releasing active bacteria that multiply and produce a neurotoxin called tetanospasmin. Tetanospasmin selectively blocks inhibitory nerve transmission from the spinal cord to the muscles, allowing the muscles to go into severe spasm. Spasmodic contractions can be so powerful that they tear the muscles or cause compression fractures of the vertebrae. Tetanus often begins with mild spasms in the jaw muscles (trismus), neck muscles, and facial muscles. Stiffness rapidly develops in the chest, back, abdominal muscles, and sometimes the laryngeal muscles (which then interferes with breathing). Muscular seizures (tetany) cause sudden, powerful, and painful contraction of muscle groups. These episodes can cause fractures and muscle tears. Without treatment, one out of three affected people die. The mortality rate for newborns with untreated tetanus is even higher: two out of three. With proper treatment, less than 10% of infected patients die. The incubation period is 5 days to 15 weeks, with 7 days as the average. About 100 cases of tetanus occur every year in the U.S., the vast majority in un-immunized individuals or those whose last immunization was no longer current. In developing countries, tetanus frequently causes death in newborn infants when the umbilical stump becomes infected. Symptoms * Spasms and tightening of the jaw muscle ("lockjaw") * Stiffness and spasms of various muscle groups o Neck muscles o Chest muscles o Abdominal muscles o Back muscles, often causing arching (opisthotonos) * Tetanic seizures (painful, powerful bursts of muscle contraction) * Irritability * Fever Additional symptoms that may be associated with this disease: * Excessive sweating * Swallowing difficulty * Hand or foot spasms * Drooling * Uncontrolled urination and/or defecation Signs and tests Diagnosis of tetanus is based on the history and physical findings that are characteristic of the disease. Diagnostic studies generally are of little value, as cultures of the wound site are negative for C. tetani two-thirds of the time. When the culture is positive, it confirms the diagnosis of tetanus Tests that may be performed include the following: * Culture of the wound site (may be negative even if tetanus is present) * Tetanus antibody test Other tests may be used to rule out meningitis, rabies, strychnine poisoning, or other diseases with similar symptoms. Treatment * Control and reverse the tetany with antitoxin (tetanus immune globulin). * Give penicillin to kill C. tetani (other antibiotics such as clindamycin, erythromycin, or metronidazole can be used in patients who are allergic to penicillin). * Remove and destroy the source of the toxin through surgical exploration and cleaning of the wound (debridement). * Treat symptoms. Muscle spasms can be treated with muscle relaxants such as diazepam. * Bedrest with a nonstimulating environment (dim light, reduced noise, and stable temperature) may be recommended. * Sedation may be necessary to keep the affected person calm. Respiratory support with oxygen, endotracheal tube, and mechanical ventilation may be necessary. Expectations (prognosis) The death rate is high in children and in the elderly. Wounds on the head or face seem to be more dangerous than those on the body. If the person survives the acute illness, recovery is generally complete. Uncorrected episodes of hypoxia (lack of oxygen) caused by muscle spasms in the throat may lead to irreversible brain damage. Complications * Airway obstruction * Respiratory arrest * Heart failure * Pneumonia * Fractures * Brain damage due to lack of oxygen during spasms