19 Tetanus

19.2 Clinical features

Tetanus is a clinical diagnosis, and is characterised by muscular rigidity and very painful contraction spasms. When severe it is associated with a characteristic facial grimace (risus sardonicus) and arching of the back (opisthotonus). The patient suffering from tetanus remains alert unless they become severely hypoxic.

The C. tetani toxin reaches the central nervous system via the axons and irreversibly binds to nerve terminals at the neuromuscular junction, blocking the release of inhibitory neurotransmitters and leading to the tetanic muscle spasms.

The incubation period is between 3 and 21 days, commonly about 10 days, but it has been reported to vary from one day to several months. The bacteria need an anaerobic environment in which to grow and this is often found in damaged and necrotic tissue, although the inoculation site may appear insignificant. Initial symptoms include weakness, stiffness or cramps, and difficulty chewing or swallowing food. Reflex muscle spasms usually occur within one to four days of the initial symptoms, the interval being called the onset period. The shorter the incubation and onset periods, the more severe the disease. Even with modern intensive care, tetanus mortality is about 10 percent overall, and much higher in older people.

Neonatal tetanus, from infection of the umbilical stump, is the commonest form of the disease in developing countries.