"Stretching": Unraveling the Mystery of Tetanus. By Louis J. Tesoro, MD, FAAP The Pediatric Group, P.A., Princeton

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All of us have heard our parents warn, "Don't touch any rusty metal. You might get lockjaw." Every teen knows to expect their "tetanus booster" at 15 years. So tetanus or "lockjaw" is a fairly common word in our vocabulary. But what is this strange disease and how can we prevent it? Below are some FAQ's about the disease, and some answers in plain English.

First, what is tetanus and why does it have such a peculiar name?
The word "tetanus" comes from the Greek tetanos, which is derived from the term teinein, meaning to stretch. As is described below, the muscular contraction and posturing that can accompany tetanus infection makes this name quite apropos. Medically speaking, tetanus is an infection cause by a bacterium know as Clostridium tetani. The organism gains passage to the inner body through cuts, scrape or abrasions following contact with dirt or the surfaces of contaminated objects such as thorns, splinters, metal and other sharp surfaces. Although small wounds can be complicated by tetanus infection, the larger, more serious the injury, the greater the risk of infection.

What does infection with tetanus look like?
The wound, infected with tetanus, that causes the symptoms that comprise the tetanus syndrome, often doesn't look different from other cuts. It may not be red, produce pus or have a foul odor. The signs of tetanus relate to the neurologic effects of the toxin produced by tetanus germs. Some patients with tetanus present with local signs-persistent rigidity in the muscle group close to the injury site. This form of tetanus, as one might guess, is less serious, and full recovery is the rule. Many patients present with generalized tetanus, a more severe form of tetanus that often starts with trismus, tightening of the jaw muscles. Neck stiffness, trouble swallowing and sore throat also are early complaints. The facial muscle involvement commonly gives rise to a risus sardonicus or ironic smile of tetanus. As the disease progresses, patients have generalized muscle rigidity with intermittent reflex spasms in response to stimuli (i.e., noise, touch). Muscle spasms called tonic contractions give rise to opisthotonus, an involuntary arching of the back, bending of the arms, clenching of the fists, and straightening of the lower extremities. During these episodes, patients are awake and feel severe pain. The spasms can cause fractures, tendon ruptures, and acute respiratory failure.

A third form of the disease, neonatal tetanus, is a major cause of infant mortality in underdeveloped countries, but rare in the United States. Infection results from umbilical cord contamination during unsanitary delivery conditions, coupled with a lack of maternal immunization. At the end of the first week of life, infected infants become irritable, feed poorly, and develop rigidity with spasms. This form of tetanus has a very poor prognosis for survival.

How common is tetanus?
Worldwide, tetanus is extremely common, estimated to affect nearly one million individuals annually, particularly in underdeveloped nations. In the United States annually because of good sanitation, hygiene and vaccination, approximately 50 cases are identified. The mortality rate overall is thirty percent, but drops to 13% in individuals under sixty years of age. U.S. children rarely succumb to tetanus because of compulsory immunization. Internationally, the numbers are much gloomier, with mortality rates approaching fifty percent in developing nations.

How can we treat tetanus and how can it be prevented?
As with all vaccine-preventable diseases, the best treatment is prevention. An effective vaccine termed tetanus toxoid has been available for many years. Tetanus toxoid in combination with diphtheria toxoid and acellular pertussis vaccine (DTaP) should be administered to all children at ages 2 months, 4 months, 6-7 months, 12-18 months, and between 4-6 years. A booster dose of tetanus and diphtheria toxoids should be administered every 10 years thereafter throughout adulthood. Immunity to tetanus from vaccination wanes over time. Therefore, vaccination in adults is important, particularly to prevent disease in the elderly. Once infected, treatment usually involves hospitalization. The first step is thorough cleaning of the wounds and removing non-viable tissue. Next, passively immunizing with tetanus immune globulin shortens the course of the illness and lessens severity. Instituting supportive care, such as artificial respiration or pharmacologic agents to treat muscle spasm, rigidity and seizures can ease the pain associated with tetanus infection. While valium is the mainstay, agents that cause muscle paralysis are sometimes tried. Finally, administering antibiotics, particularly flagyl and penicillin, can be effective at reducing the number of organisms present and thus shortening the course of the illness.

We are fortunate to have a vaccine program that protects us from this ancient scourge, though it remains a modern day horror in many parts of the world. Remember, vaccinate your children! And while you're at it, don't forget to get yourself protected against this very unpleasant disorder.

Dr. Louis J. Tesoro

Dr. Tesoro has been a member of the staff at The Pediatric Group since 1988. Dr. Tesoro is Attending Pediatrician, Medical Center at Princeton, 1988 to present. He has served on several Departmental and hospital committees and was Chairman, Department of Pediatrics, Medical Center at Princeton from 1996 - 2000. He has lectured at the Universiy of Pennsylvania and has published original articles both while at The Children's Hospital of Philadelphia and at The Pediatric Group.

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