Tetanus including neonatal tetanus

Overview

Tetanus is an acute, often fatal disease caused by a neurotoxin, not by spreading infection. Spores of Clostridium tetani enter a wound, germinate in low-oxygen tissue, and release tetanospasmin, which causes muscle rigidity and violent, painful spasms while the patient stays fully conscious. Neonatal tetanus, from an unclean umbilical stump, kills most affected babies and is entirely preventable by vaccinating mothers and clean delivery. Tetanus is not communicable from person to person.

Organism

• Clostridium tetani: Gram-positive, anaerobic, spore-forming rod; terminal spores give a drumstick shape.
• Spores survive for years in soil, dust and the faeces of animals (and humans); they resist boiling and many disinfectants and are best destroyed by autoclaving.
• Vegetative bacilli are killed by heat and disinfectants and are sensitive to penicillin and metronidazole.
• The organism is not invasive: it stays in the wound and acts only through its toxin.

Pathophysiology

1. Spores enter a wound: deep punctures, dirty or crush wounds, thorn pricks, burns, ear piercing, otitis media, injections with dirty needles; in the newborn, the umbilical stump cut with an unclean instrument or dressed with soil, ash or dung.
2. In anaerobic tissue (dead tissue, foreign body) spores germinate and bacilli release two toxins:
   • Tetanospasmin: the neurotoxin that causes disease.
   • Tetanolysin: enhances the effect.
3. Tetanospasmin binds at motor nerve endings and travels backwards up the axon to the spinal cord and brainstem.
4. There it blocks the release of inhibitory transmitters (glycine and GABA) from inhibitory interneurones, so motor neurones fire unchecked: rigidity with superimposed spasms of opposing muscle groups.
5. The sympathetic system is also disinhibited: tachycardia, labile hypertension, sweating, arrhythmias.
6. Consciousness and sensation are not affected.

• Incubation: usually 2-14 days (Akbar), as short as a day or as long as weeks; Park gives 6-10 days usually.
• A shorter incubation, and a short gap between first symptom and generalised spasms, mean more severe disease.

Clinical features

Forms

Generalised tetanus

• Trismus (lockjaw): spasm of the masseters, difficulty opening the mouth; the presenting feature in about half.
• Risus sardonicus: a fixed grin from spasm of facial muscles.
• Neck stiffness, difficulty swallowing, rigid abdomen.
• Opisthotonos: arching of the back, sometimes so severe that only head and heels touch the bed.
• Spasms are triggered by touch, noise, light, swallowing or handling, and are extremely painful.
• Laryngeal and respiratory muscle spasm: airway obstruction, apnoea, asphyxia.
• Autonomic dysfunction: tachycardia, arrhythmias, labile blood pressure, sweating, vasoconstriction, urinary retention.
• Mind clear throughout; fever may be absent or due to spasms or secondary infection.

Neonatal tetanus

• Usually a baby born at home to an unimmunised mother, with unclean cord care.
• Starts 3-10 days after birth, typically around day 7 (Park notes the local name "8th day disease").
• First sign: failure to suck, then inability to open the mouth (trismus).
• Excessive crying, irritability; then risus sardonicus.
• Within a day, generalised spasms: arms flexed and adducted, fists clenched, legs extended, opisthotonos.
• Spasms set off by touch, noise or light; the baby is conscious.
• Spasms of glottis and respiratory muscles cause apnoea, cyanosis; septic umbilicus, fever and jaundice may be present.
• Symptoms worsen over 3-7 days, plateau in the second week, and subside over 2-6 weeks in survivors.

Differential diagnosis

Meningitis or encephalitis (altered consciousness, abnormal CSF), hypocalcaemic tetany, neonatal seizures, dental abscess or peritonsillar abscess (local trismus), drug reactions (phenothiazine dystonia), rabies, strychnine poisoning.

Diagnosis

• Clinical: history of a wound or unclean delivery, non-immunisation, trismus, spasms and a clear mind.
• Investigations are mostly normal: blood count (occasional leucocytosis from infection or stress), CSF normal, calcium and glucose normal, EEG normal.
• Wound Gram stain or culture is positive in only about a third and is not needed for diagnosis.

Management

Aims (Akbar)

1. Remove the source of toxin (wound care, antibiotics).
2. Neutralise circulating toxin before it binds.
3. Control spasms and support the child until the toxin's effect wears off.

1. Antitoxin

Injecting TIG directly into the wound is unnecessary (Akbar).

2. Wound care and antibiotics

• Clean and debride the wound, remove foreign bodies and dead tissue (removes the anaerobic site). Do not excise the umbilical stump in neonatal tetanus; clean it.
• Crystalline (benzyl) penicillin: 200,000 units/kg/day in four doses for 10-14 days (Akbar).
• Metronidazole is equally effective; erythromycin or (over 8 years) tetracycline for penicillin allergy.

3. Control of spasms

• Diazepam IV 0.1-0.2 mg/kg every 3-6 hours (Akbar), titrated to stop spasms.
• Other options: magnesium sulphate, other benzodiazepines, chlorpromazine, phenobarbitone, baclofen, dantrolene; severe cases need neuromuscular paralysis and ventilation.
• Aim: a child who breathes normally and has only occasional spasms. Over-sedation shows as shallow breathing and loss of tone.

4. Supportive and nursing care

• Quiet, dark room; minimal handling; group procedures together.
• Airway: frequent suction, oxygen, intubation or tracheostomy for laryngeal spasm, ventilation if needed.
• Cardiorespiratory monitoring for apnoea and autonomic storms.
• Nasogastric feeding (expressed breast milk in newborns) once spasms are controlled; IV fluids early.
• Change posture regularly; care of mouth, skin, bladder and bowel.

5. Immunise

Start tetanus toxoid before discharge: the disease leaves no immunity.

Complications

• Aspiration pneumonia and respiratory failure (main causes of death).
• Laryngospasm, apnoea, asphyxia.
• Fractures of vertebrae, tongue and lip lacerations during spasms.
• Autonomic instability: arrhythmias, hypertension, cardiac arrest.
• Pressure sores, malnutrition, hospital infections.

Prognosis

• Akbar: mortality 60% or more in tetanus neonatorum and 20-50% in older children; most deaths in the first week.
• Park quotes up to 80-90% case fatality in neonatal tetanus even with treatment.
• Better prognosis (Akbar): incubation of 8-10 days or more, slow progression (over 60 hours to generalised spasms), absence of fever, localised disease.
• Worse prognosis: incubation under 7 days, less than 3 days from trismus to generalised spasms, high fever, neonatal age.

Wound care and prophylaxis after injury

Principles

• Clean every wound thoroughly with soap and water; remove dirt, foreign bodies and dead tissue.
• Decide on toxoid and TIG from the number of previous doses and the type of wound (Nelson, Table 94-1):

• Akbar's local advice is more cautious: give a toxoid booster if none in the last 5 years, or the last 3 years for a heavily contaminated wound.
• When toxoid and immunoglobulin are given together, use separate syringes and different sites.
• For an unimmunised child, complete the primary course afterwards.
• Park: TIG 250 units IM is the usual prophylactic dose (no serum reactions); antibiotics alone do not replace immunisation.

Prevention

Childhood vaccination

• Tetanus toxoid in DPT, given in Pakistan's EPI as pentavalent vaccine at 6, 10 and 14 weeks; later boosters with DT or Td as per the current national schedule (Federal Directorate of Immunization, EPI Pakistan, checked 8 Nov 2026).
• Tetanus is the one vaccine-preventable disease where herd immunity gives no protection: spores are everywhere in soil, so every individual must be vaccinated.

Neonatal tetanus

• Immunise women: an unimmunised pregnant woman needs two doses of tetanus toxoid (now Td) at least 4 weeks apart, the second at least 3-4 weeks before delivery (Park says 3, Akbar 4); a previously immunised woman needs one booster. Maternal IgG crosses the placenta and protects the baby.
• Never miss a chance: give at least one dose even if the woman is seen late in pregnancy (Park).
• Clean delivery: deliveries in health facilities and trained birth attendants.
• The "three cleans" (Park): clean hands, clean delivery surface, clean cord care (clean blade, clean tie, nothing applied to the stump).
• Report every case of neonatal tetanus; WHO counts elimination as fewer than 1 case per 1,000 live births in every district (WHO tetanus fact sheet, checked 8 Nov 2026).

Quick revision

• C. tetani: anaerobic, spore-forming, Gram-positive drumstick rod; soil and dung; not communicable.
• Tetanospasmin: retrograde axonal transport; blocks inhibitory transmitters; rigidity and spasms; mind clear.
• Trismus, risus sardonicus, opisthotonos; spasms on stimuli; autonomic instability.
• Neonatal: home birth, unimmunised mother, dirty cord; day 3-10; stops sucking, then spasms.
• Investigations normal; diagnosis clinical.
• TIG 3,000-6,000 units IM (or ATS); clean wound; penicillin 10-14 days or metronidazole.
• Diazepam, quiet dark room, suction, NG feeds, ventilation when needed; vaccinate after recovery.
• Prevention: EPI pentavalent, maternal Td, three cleans; wound prophylaxis by doses and wound type.

Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics; Park's Preventive and Social Medicine).

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