Pediatric Tetanus Clinical Presentation

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jan 9, 2012
 

History

The etiologic agent of tetanus, C tetani, is an anaerobic, motile, gram-positive rod that forms an oval, colorless, terminal spore and assumes a shape that resembles a tennis racket or a drumstick. The organism is found worldwide. The spores may survive for years in some environments and are resistant to disinfectants and to boiling for 20 minutes. Vegetative cells are easily inactivated and are susceptible to several antibiotics. Patients sometimes remember an injury, but, many times, the injury goes unnoticed.

Generalized tetanus

Generalized tetanus is the most commonly found form of tetanus in the United States, accounting for 85-90% of cases. The extent of the trauma varies from trivial injury to contaminated crush injury. The incubation period is 7-21 days, largely depending on the distance of the injury site from the CNS. Trismus is the presenting symptom in 75% of cases; a dentist or an oral surgeon often initially sees the patient. Other early features include irritability, restlessness, diaphoresis, and dysphagia with hydrophobia, drooling, and spasm of the back muscles. These early manifestations reflect involvement of bulbar and paraspinal muscles, possibly because they are innervated by the shortest axons. The condition may progress for 2 weeks despite antitoxin therapy because of the time needed for intra-axonal antitoxin transport.

Localized tetanus

Localized tetanus involves an extremity with a contaminated wound and widely varies in severity. This is an unusual form of tetanus and the prognosis for survival is excellent.

Cephalic tetanus

Cephalic tetanus generally follows head injury or develops with infection of the middle ear. Symptoms consist of isolated or combined dysfunction of the cranial motor nerves (most frequently the seventh cranial nerve). It may remain localized or progress to generalized tetanus. This is an unusual form of tetanus with an incubation period of 1-2 days. The prognosis for survival is usually poor.

Tetanus neonatorum

This is generalized tetanus that results from infection of a neonate. It primarily occurs in underdeveloped countries and accounts for up to one half of all neonatal deaths. The usual cause is the use of contaminated materials to sever or dress the umbilical cord in newborns of unimmunized mothers. The usual incubation period after birth is 3-10 days, which is why it is sometimes referred to as the disease of the seventh day. The newborn usually exhibits irritability, poor feeding, rigidity, facial grimacing, and severe spasms with touch. The mortality rate exceeds 70%.

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Physical

Generalized tetanus

Sustained trismus may result in the characteristic sardonic smile (risus sardonicus) and persistent spasm of the back musculature may cause opisthotonus. Waves of opisthotonus are highly characteristic of the disease. With progression, the extremities become involved in episodes of painful flexion and adduction of the arms, clenched fists, and extension of the legs. Noise or tactile stimuli may precipitate spasms and generalized convulsions. Involvement of the autonomic nervous system may result in severe arrhythmias, oscillation of the blood pressure, profound diaphoresis, hyperthermia, rhabdomyolysis, laryngeal spasm, and urinary retention. In most cases, the patient remains lucid.

Localized tetanus

In mild cases, patients may have weakness of the involved extremity, presumably due to partial immunity. In more severe cases, intense painful spasms occur and usually progress to generalized tetanus.

Cephalic tetanus

Cranial nerve findings and rapid progression are typical. This form may remain localized or progress to generalized tetanus.

Tetanus neonatorum

Physical examination findings are similar to generalized tetanus findings.

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Causes

Causes of tetanus include underimmunization and the use of contaminated materials in newborn care.

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Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Specialty Editor Board

Rosemary Johann-Liang, MD  Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Leslie L Barton, MD  Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sonali Ray, MD, to the development and writing of this article.

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Table. Guide to Tetanus Prophylaxis in Wound Management
History of Absorbed



Tetanus Toxoid



Clean Minor WoundsAll Other Wounds
Tetanus-diphtheria-acellular pertussisTIGTdapTIG
Unknown or < 3 dosesYesNoYesYes
3 or more dosesNoNoNoNo
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