What are the symptoms and treatment of tetanus?

Tetanus: Clinical Symptoms and Treatment

Primary Clinical Symptoms

Tetanus presents with characteristic muscle rigidity beginning in the jaw (trismus or "lockjaw") and progressing to generalized muscle spasms, with 75% of patients presenting with trismus as the initial symptom. 1, 2

Initial Presentation

• Trismus (lockjaw) is the hallmark initial symptom, occurring in 75% of patients as the first manifestation 2
• Muscle stiffness initially involves the jaw and neck, then becomes generalized 3
• Dysphagia (difficulty swallowing) commonly accompanies early symptoms 4
• The incubation period ranges from 3 to 21 days (median: 7 days), though extremes of 1 day to several months can occur 1

Disease Progression

• Reflex spasms develop in 70% of patients and characterize disease severity 2
• Tonic spasms of skeletal muscles are followed by paroxysmal contractions 3
• Progressive descending paralysis can occur in severe cases requiring ventilatory support 5
• Shorter incubation periods correlate with more severe disease and poorer prognosis 1

Critical Complications

• Respiratory failure from respiratory muscle involvement occurs early and requires aggressive airway management 2
• Autonomic instability (sympathetic nervous system overactivity) typically develops during the second and third weeks 5
• Cardiovascular instability is among the most common complications 5

Treatment Algorithm

Immediate Interventions (First 24 Hours)

Treatment must focus on four simultaneous goals: neutralizing unbound toxin, eliminating the organism, controlling muscle spasms, and providing intensive supportive care. 3, 2

1. Toxin Neutralization

• Administer tetanus immunoglobulin (TIG) 5000 units intramuscularly immediately to neutralize circulating toxin before it binds irreversibly to neural tissue 5, 6
• Give tetanus toxoid 0.5 mL intramuscularly at a different site 5
• This must be done urgently because tetanospasmin binds irreversibly with neural tissue, making early neutralization critical 6

2. Antibiotic Therapy

• Administer procaine penicillin G or metronidazole to eliminate Clostridium tetani and interrupt toxin production 4, 3
• Erythromycin is an alternative for penicillin-allergic patients 5

3. Muscle Spasm Control

• Diazepam is the first-line agent for controlling rigidity and spasms in all cases 4, 2, 5
• Mild cases may be managed with diazepam alone 2
• Severe cases require addition of nondepolarizing neuromuscular blocking agents (e.g., pancuronium bromide) plus mechanical ventilation 2, 5
• Adjunctive agents include chlorpromazine and morphine for sedation, muscle relaxation, and analgesia 5

Supportive Care Requirements

Environmental Management

• Place patient in a semidark, quiet room to minimize stimuli that trigger reflex spasms 5
• Isolation unit placement is recommended 4

Intensive Monitoring and Support

• The disease course is usually intense for ≥4 weeks before subsiding, requiring prolonged intensive care 1
• Ventilatory support is essential for patients with respiratory muscle involvement 2, 5
• Ranitidine for stress ulcer prophylaxis 5
• Heparin for deep-vein thrombosis prevention 5
• Nutritional support (peripheral-vein or enteral nutrition) 5

Autonomic Dysfunction Management

• Monitor for sympathetic nervous system overactivity during weeks 2-3 5
• Treat with alpha and beta blockade when autonomic instability occurs 2

Wound Management

• Debride necrotic tissue to eliminate anaerobic conditions that allow C. tetani germination 6, 3
• Appropriate wound care is essential for both treatment and prevention 3

Critical Prognostic Factors

Mortality Risk

• Without high-quality medical care, mortality approaches 100% 1, 6
• With modern intensive care, case-fatality rates range from 10-20% (most recent U.S. data shows 8.0% for 2001-2016) 1, 7
• Highest mortality occurs in infants and elderly patients 1, 6
• Shorter incubation periods predict worse outcomes 1

Long-Term Sequelae

• The convalescent period is protracted 1
• Long-term neurologic sequelae and intellectual/behavioral abnormalities may follow recovery 1

Post-Recovery Immunization

Tetanus does not confer natural immunity, so patients must complete a full primary immunization series after recovery 1. This is a critical pitfall—surviving tetanus does not protect against future infection because naturally acquired immunity does not occur 8.

Prevention Context

• Tetanus occurs almost exclusively among unvaccinated or inadequately vaccinated persons 8, 1
• A completed primary vaccination series substantially reduces disease risk, and protection lasts at least 10 years 8
• High mortality rates may result from delays in diagnosis and lack of familiarity with treatment 2