An 11-year-old male came to clinic for his health maintenance examination. He and his father had no concerns. The pertinent physical exam revealed normal vital signs and growth parameters were in the 10-25%. His examination was normal.
The diagnosis of a healthy male was made. As the pediatrician was discussing the vaccines he needed he asked, “Is it true you can get tetanus from stepping on a rusty nail?” The pediatrician said usually no, but anything that possibly has germs on it if it gets into your body can cause problems. “That’s why anytime you have a wound you should always clean it with soap and water and watch it to see if it gets red or causes pain. If it does you need to tell your parents and maybe come see me,” she told him. She went on “You need a tetanus shot at least every 10 years, so we tell people to get them on their “0” birthdays like when you are 20, 30, or 40 years old. That way you are always up to date.”
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. The spores are hardy and can persist in a variety of environments. 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 grow in low oxygen environments and produces a potential neurotoxin which blocks the myoneural junction. Incubation period is 3-21 days, averaging 10 days. Neonatal tetanus generally start with crying and feeding problems 3-7 days after birth (can be up to 28 days) with progression to spasms. Tetanus symptoms occur gradually over 1-7 days and can progress to opisthotonus. These spasms are often provoked by external stimuli. Death can occur because of diaphragmatic spasm and laryngospasm. The spasms persist for about 1 week and then subside over a period of weeks in those who recover. Death can occur because of diaphragmatic spasm and laryngospasm. It is fatal without treatment and even with treatment has a death rate of 10-20%.
With immunization tetanus is almost 100% preventable. Tetanus is not transmitted person to person and herd immunity cannot help prevent the disease. Parents must be educated and advised of the seriousness of the disease. Immunity is not lifelong. Everyone should receive a primary series, and at least a booster shot every 10 years. Boosters may be necessary more often however.
Tetanus spores can contaminate any break in the skin but are more likely in:
- Contaminated wounds with feces, dirt or even saliva
- Puncture wounds
- Crush injuries
- Injuries with devitalized tissue – hence wound debridement is important
Rusty nails by themselves do not cause tetanus. Rusty nails are the quintessential image of what causes tetanus, and most likely someone used this image to convey the problem of contamination with tetanus spores. However it is the potential contamination of the nail with tetanus spores that is the problem not the rust itself. Nails though, are a perfect instrument to deliver whatever contamination could be on them. They cause deep wounds that are difficult to clean, and which can provide the low oxygen environment for tetanus spores to start growing bacteria in.
There is a 2020 case report of a rusty nail that had been thrown up by a lawnmower and lodged in the lung which required removal. The patient did not acquire tetanus.
Questions for Further Discussion
1. Where can you find the recommended vaccinations for locations around the world?
2. How are deep puncture wounds treated?
3. What organisms commonly contaminate deep puncture wounds?
- Disease: Tetanus | Childhood Immunization
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Emergency Medicine | Infectious Diseases
- 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 and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Tetanus and Tetanus, Diphtheria, and Pertussis Vaccines.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Rhinesmith E, Fu L. Tetanus Disease, Treatment, Management. Pediatrics in Review. 2018;39(8):430-432. doi:10.1542/pir.2017-0238
Saplakoglu Y, Mar 18 2019. Do Rusty Nails Really Give You Tetanus? livescience.com. Accessed April 27, 2021. https://www.livescience.com/65007-do-rusty-nails-cause-tetanus.html
Kawamoto N, Okita R, Furukawa M, et al. Penetrating pulmonary injury due to a thrown rusty nail while using a lawn mower: a case report. AME Case Reports. 2020;4(0). doi:10.21037/acr-20-87
Centers for Disease Control, Tetanus Causes and Transmission, Published April 7, 2021. Accessed April 27, 2021. https://www.cdc.gov/tetanus/about/causes-transmission.html
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa