Case Study on Tetanus

Patient Profile:
Name: -
Age: 38 years
Sex: Male
Occupation: Construction worker
Medical History: Generally healthy, no significant comorbidities,
no known allergies, received his primary tetanus series in childhood, and
his last booster was definitely more than 10 years ago
Presenting Complaint: jaw discomfort and inability to open his
mouth fully for 3 days, following a deep puncture wound sustained while
attempting to fix his lawn mower seven days ago

 Description:
Tetanus is a serious bacterial infection caused by Clostridium tetani,
a gram-positive bacterium commonly found in soil, dust, and animal feces.
When the spores of this bacterium enter the body through surgery,
intravenous drug
abuse, the neonate’s umbilicus, bites, burns, body piercing, puncture
wounds, and ear infections, they can produce a potent neurotoxin called
tetanospasmin, which affects the nervous system, leading to muscle
rigidity, spasms, and other severe complications.

The disease typically manifests after a period of incubation that can

range from 3 to 21 days (with an average of about 8 days) following
exposure to the bacteria. The disease often progresses in stages, with
early symptoms involving localized muscle stiffness and spasms, and
more severe symptoms such as generalized muscle rigidity, difficulty
swallowing, and respiratory distress in advanced cases.

 Signs and Symptoms:

Incubation Period: Symptoms typically appear between 3 to 21
days after infection. The average is 8 days.
Initial Symptoms:
Painful muscle stiffness around the site of infection, often in the jaw
(trismus), which leads to difficulty opening the mouth.
Neck stiffness and discomfort.
Dysphagia (difficulty swallowing) due to muscle rigidity.
General Symptoms:
Muscle spasms that may begin in the jaw and neck, and
progressively involve other muscles such as those of the back, abdomen,
and limbs. These spasms can be triggered by minor stimuli (light, sound,
touch).
Opisthotonus (spinal arching) may occur in severe cases.
Autonomic dysfunction like sweating, fever, high blood pressure,
and tachycardia.
Severe spasms can lead to respiratory distress, which is potentially
fatal if not treated.
Severe Cases:
 Muscle spasms affecting respiratory muscles can cause difficulty
breathing.
Lockjaw (trismus) makes it difficult for the patient to open their
mouth, resulting in an inability to eat or drink.
Rhabdomyolysis (breakdown of muscle tissue) may occur due to
prolonged muscle contractions.

 Diagnosis:
The diagnosis of tetanus is primarily clinical and based on the
patient’s history and characteristic signs and symptoms. A specific
diagnostic test is not usually necessary, but the following are involved:

History and Presentation:

Presence of a wound or injury (e.g., puncture wound, animal bite,

burn, or surgery).
Lack of recent tetanus immunization or incomplete vaccination.

Clinical Examination:

Signs of muscle rigidity, trismus (lockjaw), and spastic paralysis.

History of recent trauma or injury that could have been the portal of
entry for C. tetani spores.

Laboratory Tests:

No specific test for C. tetani infection itself, but tests to rule out
other conditions like rabies or botulism may be conducted.
Blood cultures or wound cultures may be obtained, though they are
often not helpful in diagnosing tetanus because the bacteria is difficult to
grow in a laboratory setting.

Differential Diagnosis:

Meningitis, rabies, botulism, seizures, and other causes of muscle

spasms or neurological deficits.

 Prognosis:

Without Treatment: Tetanus is often fatal without proper

treatment due to complications such as respiratory failure, cardiac
arrhythmias, or aspiration pneumonia.
With Treatment: Early diagnosis and intervention can significantly
improve the prognosis. However, the disease can still be fatal in severe
cases, especially in older individuals, those with comorbidities, or those
who have delayed access to care.
Recovery: The recovery period can be prolonged. Muscle weakness
and fatigue may persist even after acute symptoms resolve. Full recovery
may take months, and some patients may experience residual
neurological deficits.
The mortality rate for tetanus has decreased significantly in
developed countries due to vaccination and improved medical care but
remains high in areas without access to vaccines and proper healthcare.

 Treatment:

Immediate Care:

Wound management: Cleaning and debridement of the wound to

remove as much dirt and bacteria as possible.
Tetanus immune globulin (TIG): This is given to neutralize the
tetanospasmin toxin circulating in the blood. It is administered as soon as
possible following injury in unvaccinated or under-vaccinated patients.
Tetanus vaccination: The patient may receive a dose of tetanus
toxoid as part of their treatment if they are not fully vaccinated.

Supportive Care:

Muscle Relaxants: Medications such as benzodiazepines (e.g.,

diazepam) are used to manage muscle spasms and rigidity.
Sedation: In severe cases, continuous sedation may be required to
control muscle spasms.
Antibiotics: Though not effective in neutralizing the toxin,
antibiotics (e.g., metronidazole) may be administered to control the
bacterial infection in the wound.
Ventilatory Support: If respiratory failure occurs, mechanical
ventilation may be necessary.
Nutritional Support: Feeding tubes may be required in patients
unable to swallow.

Other Measures:

Pain Management: Analgesics such as opioids may be necessary

to control severe pain from muscle spasms.
Intensive Care: In severe cases, intensive care unit (ICU)
admission may be required to monitor respiratory function, provide
ventilation, and manage autonomic dysfunction.

 Transmission:

Tetanus is not contagious from person to person. The infection

occurs through direct contact with spores of Clostridium tetani that enter
the body through breaks in the skin or mucous membranes. Common
methods of transmission include:

Puncture wounds: From nails, needles, or other sharp objects

contaminated with soil or feces.
 Burns: Contact with contaminated materials can cause infection.
Animal bites: Though rare, bites can introduce the bacteria into
the body.
Surgical procedures: Inadequate sterilization of instruments can
lead to tetanus.
Unhygienic practices: Non-sterile tattooing or piercings can
introduce the bacteria into the body.

 Prevention:
Vaccination: The best prevention for tetanus is vaccination. The
tetanus vaccine (often combined with diphtheria and pertussis in DTaP or
Tdap vaccines) provides long-lasting protection. A booster shot is
recommended every 10 years.
Proper Wound Care: Immediate and thorough cleaning of wounds,
especially if they are deep or contaminated.
Adequate Immunization: Ensuring individuals receive full tetanus
vaccinations, especially those at higher risk (e.g., construction workers,
farmers, or those in contact with animals).

Conclusion:
Tetanus is a preventable, but potentially fatal, disease caused by
Clostridium tetani. Prompt treatment with tetanus immune globulin,
wound care, and supportive measures can greatly improve outcomes, but
the disease still carries a significant risk of morbidity and mortality in
severe cases. Prevention through vaccination and proper wound care is
crucial to reduce the incidence of this condition.

References:

Levin, M., & Adegbola, R. A. (2017). Tetanus and its prevention: An update on vaccination
and treatment. Lancet Infectious Diseases, 17(1), 35-47. https://doi.org/10.1016/S1473-
3099(16)30455-2

Merrill, R. M., & Walson, J. D. (2018). Tetanus and its management: Pathogenesis and
clinical manifestations. Infectious Disease Clinics of North America, 32(4), 799-812.
https://doi.org/10.1016/j.idc.2018.08.002

Pau, A., & Brown, J. (2019). Clinical presentation and management of tetanus. British
Medical Journal, 364, l319. https://doi.org/10.1136/bmj.l319

Centers for Disease Control and Prevention (CDC). (n.d.). Tetanus. Centers for Disease
Control and Prevention. Retrieved November 18, 2024, from
https://www.cdc.gov/tetanus/index.html

Mayo Clinic. (n.d.). Tetanus: Symptoms, causes, and treatment. Mayo Clinic. Retrieved
November 18, 2024, from
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National Institutes of Health (NIH). (n.d.). Tetanus. National Institute of Neurological
Disorders and Stroke. Retrieved November 18, 2024, from https://www.ninds.nih.gov/health-
information/disorders/tetanus

Raia, P. (n.d.). Tetanus: A Case Study. https://www.jabfm.org/content/jabfp/14/3/223.full.pdf

World Health Organization (WHO). (n.d.). Tetanus. World Health Organization. Retrieved
November 18, 2024, from https://www.who.int/news-room/fact-sheets/detail/tetanus