CLINICAL DESCRIPTION

Generalized tetanus is an acute, often fatal neurologic disease characterized by painful skeletal muscular contractions. The toxin blocks signals through nerves that signal muscles not to contract in response to voluntary contractions of opposing muscles. Onset is gradual, occurring over 1 to 7 days. The muscle stiffness usually first involves the jaw (lockjaw) and neck and progresses to severe generalized muscle spasms, which frequently are aggravated by any external stimulus. Severe spasms persist for one week or more and subside over a period of weeks in those who recover. Clostridium tetani is a non-invasive wound contaminant; it causes neither tissue destruction nor an inflammatory response.

Neonatal tetanus, which arises from contamination of the umbilical stump, is a form of generalized tetanus. However, inability to nurse is the most common presenting sign. Localized tetanus is manifested by local muscle spasms in areas contiguous to a wound, although history of an injury or an apparent portal of entry may be lacking. Cephalic tetanus is a rare form of the disease and involves the cranial nerves, especially the facial area. It is associated with infected wounds of the head and neck, including otitis media. Both localized and cephalic tetanus may precede generalized tetanus.

Complications of the disease include laryngospasm (spasm of the vocal cords) and/or spasm of the muscles of respiration, leading to interference with breathing; fractures of the spine or long bones, which may result from sustained contractions and convulsions; and hyperactivity of the autonomic nervous system, which may lead to hypertension and/or an abnormal heart rhythm. Other complications may include increased susceptibility to nosocomial infections, pulmonary embolism (particularly in drug addicts and elderly patients), and aspiration pneumonia. The case-fatality rate ranges from 10% to 90%; it is highest in infants and the elderly and varies inversely with the length of the incubation period and the availability of experienced intensive care unit personnel and resources. Tetanus disease does not confer immunity. Patients who survive the disease should be given a complete series of vaccine.

There are no laboratory findings characteristic of tetanus, and the diagnosis does not depend on bacteriologic confirmation. The diagnosis is entirely clinical by excluding other possibilities, including hypocalcemic tetany, phenothiazine reaction, strychnine poisoning, and hysteria. Clostritium tetani is recovered from the wound in only 30% of cases, and not infrequently, it is isolated from patients who do not have tetanus. Sera collected before TIG is administered can demonstrate susceptibility of a patient to the disease, but the test is not readily available.

CASE CLASSIFICATION

1. CONFIRMED
   
   A clinically compatible case, with or without laboratory isolation, as reported by a healthcare professional.
   
   
2. PROBABLE
   
   Not used.
   
   
3. POSSIBLE
   
   Not used.