Patient Presentation
An 11-year-old female came to the emergency room with increasing muscle spasms over the past 3 days. She initially complained of neck soreness which progressed to her back. Drinking and swallowing became more difficult. These episodes increased to spasms with relaxation of the muscles in between. The spasms became worse in the morning involving her arms and legs and became more frequent. She lived on a farm and was well-known not to wear shoes often. The past medical history revealed that she was unimmunized.
The pertinent physical exam upon arrival in the emergency room showed her to have an episode where her entire body went rigid with severe back arching and a scared expression on her face. This occurred for about 10 seconds and then she became relaxed, still appeared scared and indicated general pain. A puncture wound on her left heel showed mild induration. She had several more opisthotonic episodes while in the emergency room. The pertinent laboratory evaluation included negative drug testing, and an electroencephalogram showed no seizure activity. The diagnosis of tetanus was made. The patient’s clinical course at 24 hours showed that she had been given tetanus immune globulin and was mechanically ventilated. Her puncture wound had been surgically debrided and she was receiving antibiotics. At one week she was slowly improving.
Figure 90 – Painting by Sir Charles Bell in 1809 showing opisthotonus. Dr. Bell was a surgeon and anatomist most well known for Bell’s palsy.
Discussion
Clostridium tetani is a gram-positive bacillus that is anaerobic and spore forming. Tetanus spores are found universally worldwide in the soil and the stool of animals and people. Contamination through the skin in wounds (especially deep puncture wounds) and the umbilicus are the primary entry points. It is not unusual for the organism not to grow in cultures. The bacteria grows in dead tissues and produces a potential neurotoxin which blocks the myoneural junction. Symptoms occur gradually over 1-7 days and progress to opisthotonus. These spasms are often provoked by external stimuli. The spasms persist for about 1 week and then subside over a period of weeks in those who recover.
Opisthotonus can also be caused by other diseases such as Sandifer syndrome, and phenothiazines and strychnine.
Tetanus is not transmitted person to person and herd immunity cannot help prevent the disease. Primary immunization series for tetanus in the U.S. is at 2, 4,and 6 months of age, with the 4th dose 6-12 months after the 3rd dose, and the 5th dose at ages 4-6 years with DTaP. Pre-teens and teenagers with no history of tetanus vaccination are recommended to receive 3 vaccinations, preferably with Tdap, followed by Td after 4 weeks, and then third dose 6-2 months after the earlier Td dose. Tdap can be substituted for another dose in the series though.
Treatment for tetanus includes:
- Tetanus immune globulin given IM in one injection
- Metronidazole for 10-14 days to decease the number of vegetative forms
- Debridement of the wound
- Supportive treatment for tetanic spasms and respiratory failure
Learning Point
Primary immunization and improved obstetrical/neonatal care has significantly decreased the cases and deaths worldwide caused by tetanus. However, in 2008, ~61,000 children (about 1% of children) still died from tetanus. Most of these were neonates. A trend graph shows the number of tetanus cases/year markedly decreasing as the immunization rate also increases. Low immunization rates (under 50%) are seen most often in India and Africa
In the United States in 2008, 18 cases of tetanus were reported with no deaths. From 2005-2009, 133 cases of tetanus were reported in the U.S. There is clear evidence that tetanus disease occurs because of parental objection to vaccination. As there is no method for prevention of tetanus other than immunization, parents must be educated and advised of the seriousness of the disease. Herd immunity which some parents wish to rely on for other diseases (such as pertussis) does not apply for tetanus.
Questions for Further Discussion
1. How do you educate parents about the risks of vaccine preventable diseases?
2. What are medical contraindications to tetanus vaccine?
3. What are the barriers to vaccination in your local community?
4. In what circumstances would no vaccination or undervaccination be considered child neglect?
Related Cases
- Disease: Tetanus
- Symptom/Presentation: Neck Stiffness
- Specialty: Critical Care | Emergency Medicine | Infectious Diseases | Neurology / Neurosurgery | Preventive Medicine and Health Maintenance
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tetanus
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1006-07.
American Academy of Pediatrics. Tetanus, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;665-660.
Summary of recommendations for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) and tetanus and diphtheria toxoids (Td) use among adolescents aged 11–18 years. MMWR. March 24, 2006 / 55(RR03);37-38. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5503a4.htm (cited 9/20/10).
World Health Organization. Tetanus. Available from the Internet at http://www.who.int/immunization_monitoring/diseases/tetanus/en/index.html (rev. 3/26/2010, cited 9/20/10).
World Health Organization. Maternal and Neonatal Tetanus (MNT) elimination. Available from the Internet at http://www.who.int/immunization_monitoring/diseases/MNTE_initiative/en/index2.html (rev. 7/5/10, cited 9/20/10).
Notifiable Diseases and Mortality Tables. MMWR. June 4, 2010 / 59(21);662-675. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5921md.htm#tab3 (cited 9/20/10).
Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. World Health Organization and UNICEF. Lancet. 2010 Jun 5;375(9730):1969-87. Available from the Internet at http://www.who.int/immunization_monitoring/diseases/Lancet_2010_withAppendix.pdf (cited 9/20/10).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 
