This document presents a case report of a 50-year-old male farmer who was admitted to the hospital with symptoms of tetanus. He had sustained a deep cut on his right calf while working in his field one week prior that had been sutured at a local health center. On admission, he exhibited stiffness of the neck muscles and inability to open his mouth. He was diagnosed with tetanus and admitted to the intensive care unit for management. Treatment included wound debridement, antibiotics, tetanus immunoglobulin, sedation and muscle relaxants. Tetanus is a vaccine-preventable neurological disease caused by Clostridium tetani spores entering the body through wounds. It causes painful muscle

1. Tetanus : Case Presentation
Anupam Ghimire
GP/EM Resident
PAHS

2. Patient Details
Name: Motilal Tamang
Age/sex: 50yr/M
Address: Ramechap
Occupation : Farmer
Date of Admisson : 2075- 1- 15

3. Chief complain
• Cut Injury over Right leg 7 days back
HOPI
• Cut injury over Right calf region while he was
ploughing field, active bleed and muscles were
exposed
• Due to pain , he couldnot walk
• No swelling , injury to other areas

4. • At Local Health center, suturing was done . No
history of TT vaccination
• Pus discharge was present- yellowish , non
foul smelling
• Arrived in Hospital , kathmandu , suture was
removed and dressing done
• No history of fever, headache, Shortness of
breathe or altered bowel/bladder habits

5. • Past history – Not significant
• Family history – Not significant
• Personal history
- Consumes alcohol occassionally
- Non- smoker

6. Physical Examination
• GC : Fair
• No PILCCOD
• Vitals – Stable
• Systemic Examination : Grossly normal

7. Local examination
• Cut injury of 15x10 cm over left calf, vertically
oriented with sharp margin and yellowish non
foulsmelling discharge
• Brownish slough were present at margin of
wound
• Local temp. raised , Tender
• DNVS intact
• ROM : Painful on ankle movement

9. Investigation
• TLC : 22500
• N90L10
• Hb: 11.2
• Platelet: 560000
• RFT – Normal

10. Management
• Dressing and posterior slab application
• IV antibiotics , Analgesic
• Debridement
• On 3rd day :
- Stifness of neck muscles
- Unable to open mouth

11. • Tetanus Diagnosed  ICU admisson
• Managed with
- Minimised sensory stimulation
- Inj. HTIG 4000 I.U IM stat
- Inj. Durataz, Vancomycin , enoxaparin
- Intubated  diazepam, propofol infusion,
vecuronium
- Daily dressing and wound care

12. Introduction: Tetanus
• Tetanos – a greek word – to strech
• Neurological disease characterized by an acute
onset of hypertonia, painful muscular
contractions and generalized muscle spasms
• Only vaccine preventable disease that is
infectious but not contagious

13. • Caused by Clostridium Tetani
• Anaerobic, Motile, Gram positive bacilli
• Oval, colourless, terminal spores – tennis
racket or drumstick shape.
• It is found worldwide in soil, in inanimate
environment, in animal faeces & occasionally
human faeces.

14. Epidemiology
• International health problem, as spores are
ubiquitous.
• Occurs almost exclusively in persons who are
unvaccinated or inadequately immunized.
• Tetanus occurs worldwide but is more
common in hot, damp climates with soil rich
in organic matter

15. Risk Factors
• Age : Active age (5-40 years),
• Sex : Higher incidence in males
• Occupation : Agricultural workers are at higher
risk
• Immunity : Herd immunity does not protect
the individual
• Environmental and social factors: Unhygienic
habits, Unhygienic delivery practices

16. Tetanus prone wound
• A wound sustained more than 6 hr before
surgical treatment
• A wound sustained at any interval after injury
which is puncture type or shows much
devitalised tissue or is septic or is
contaminated with soil or manure

17. Pathogenesis
• Spores gain entry  persist in normal tissue
for months to years under anaerobic
conditions.
• When the oxygen levels in the surrounding
tissue is sufficiently low  the implanted C.
tetani spore then germinates into a new,
active vegetative cell  grows and multiplies
and produces tetanus toxin - tetanospasmin
and tetanolysin.

18. • Tetanolysin is not believed to be of any
significance in the clinical course of tetanus
• Tetanospasmin is a neurotoxin and causes the
clinical manifestations of tetanus

19. • Toxin migrates across the synapse  binds to
presynaptic nerve terminals  inhibits release
of certain inhibitory neurotransmitters
(glycine and gamma-amino butyric acid)
• Loss of inhibition of preganglionic sym
neurons – sympathetic hyperactivity

20. • Neurons, which release gammaaminobutyric
acid (GABA) and glycine, the major inhibitory
neurotransmitters, are particularly sensitive to
tetanospasmin, leading to failure of inhibition
of motor reflex responses to sensory
stimulation.

21. • Once the toxin becomes fixed to neurons, it
cannot be neutralized with antitoxin
• Recovery of nerve function from tetanus
toxins requires sprouting of new nerve
terminals and formation of new synapses.

22. Clinical Features
• IP : Ranges from 3-21 days
• In general the further the injury site is from
the central nervous system, the longer the
incubation period
• The shorter the incubation period, the higher
the chance of death

23. • Triad of muscle rigidity, spasms & autonomic
dysfunction
• Early symptoms are neck stiffness, sore throat
and poor mouth opening.
• Patients with generalized tetanus present with
trismus (ie, lockjaw) in 75% of cases.
• Other presenting complaints include stiffness,
neck rigidity, dysphagia, restlessness, and reflex
spasms.
• Spasms usually continue for 3-4 weeks.

24. • Subsequently, muscle rigidity becomes the
major manifestation. Rigid Abdomen.
• Muscle rigidity spreads in a descending
pattern from the jaw and facial muscles over
the next 24-48 hours to the extensor muscles
of the limbs – stiff proximal limb muscles &
relatively sparing hand & feet.

25. • Risus sardonicus: Sustained contraction of
facial musculature at the angle of mouth and
frontalis
• Trismus (Lock Jaw): Spasm of Masseter
muscles
• Opisthotonus: Spasm of extensor of the neck,
back and legs to form a backward curvature

26. Sequence of events

27. Diagnosis
• No blood tests that can be used to diagnose
tetanus
• Diagnosis is done clinically
• Laboratory studies may demonstrate a moderate
peripheral leukocytosis
• Cerebrospinal fluid (CSF) study findings are
usually within normal limits.

28. Principle of treatment
1. Neutralization of unbound toxin
2. Prevention of further toxin production
- Wound debridement & antibiotics
3. Antibiotics
4. Control of spasm
- Anticonvulsants, Sedatives, Muscle relaxants
5. Management of autonomic dysfunction
- MgSO4, Betablockers
6. Supportive care
- Physiotherapy, Nutrition, Thromboembolism
prophylaxis

29. Management
• Admit patients to the intensive care unit (ICU).
• Because of the risk of reflex spasms, maintain
a dark and quiet environment for the patient.
• Avoid unnecessary procedures and
manipulations.
• Attempting endotracheal intubation may
induce severe reflex laryngospasm; prepare
for emergency tracheostomy

30. Immunogloulin
• A single intramuscular dose of 3000-5000
units is generally recommended for children
and adults, with part of the dose infiltrated
around the wound if it can be identified.
• The WHO recommends TIG 500 units by IM/IV
(depending on the available preparation) as
soon as possible; in addition, administer TT-
containing vaccine , 0.5 cc by intramuscular
injection at separate site with HTIG.

31. • TIG can only help remove unbound tetanus
toxin, but it cannot affect toxin bound to
nerve endings.

32. Prevention of further toxin production
• Debridement of Wound to remove organisms
and to create an aerobic environment
• Current recommendation is to excise at least 2
cm of normal viable-appearing tissue around
the wound margins
• Incise and drain abscesses.

33. Antibiotics
• Penicillin G aqueous : (10-12 MU IV in 2-4
divided doses- 2-4 MU IV every 4 to 6 hrs)
- 10- to 14-d course of treatment is
recommended
• Metronidazole: (5oomg 6 hrly or 1gm 12 hrly)

34. Summary
• Tetanus : Vaccine preventable
• Diagnosis clinically
• High index of suspicion
• Significant mortality and morbidity

35. • Harrison’s PRINCIPLES OF INTERNAL MEDICINE
: Eighteenth Edition
• UpToDate (http://www.uptodate.com)
• Current recommendations for treatment of
tetanus during humanitarian emergencies :
WHO Technical note

36. THANK YOU