Tetanus is caused by the bacterium Clostridium tetani (C. tetani), an anerobic, gram-positive organism capable of forming spores. These spores are found in soil, manure, and the digestive tracts of animals and humans, and have also been identified in contaminated heroin and on skin surfaces(1).
C. tetani produces two exotoxins: tetanolysin, whose function is not yet well understood, and tetanospasmin, a neurotoxin directly implicated in the clinical symptoms of tetanus.(2).
These bacteria do not survive in oxygen-rich environments, but they resist many chemicals and high temperatures(3). Lightly bleeding and tissue-covered wounds can offer the ideal anaerobic environment for the proliferation of these bacteria(4).
After entering the body, the spores can germinate under anaerobic conditions, producing toxins that spread throughout the body. The incubation period varies from three days to three weeks(5). Initial symptoms include muscle stiffness of the jaw and neck, headache, seizures, changes in heart rate and blood pressure, fever and chills. Complications can be severe, including fractures, vocal cord spasms, breathing difficulties, pulmonary embolism, pneumonia, nosocomial infections, and death(6).
There are four forms of tetanus: the most common is generalized tetanus, which makes up about 80% of cases and often begins with muscle spasms of the jaw and are known as "lockjaw." It can also present with spasms involving other parts of the body(7). Localized tetanus causes spasms near the wound and is generally milder, often in previously vaccinated individuals, but can progress to generalized tetanus. Cephalic tetanus, associated with ear infections or head injuries, is rare but serious and can lead to cranial nerve palsies. Neonatal tetanus, which has almost disappeared in the USA, remains a threat in developing countries and occurs in infants born in unsanitary conditions (8).
Treatment includes immediate hospitalization and application of human tetanus immunoglobulin (TIG), along with wound care, antispasmodic drugs, respiratory support, and antibiotics (9). Healing can take months(9).
There are no laboratory findings to confirm tetanus, and the diagnosis is based on clinical symptoms. In addition, only about 30% of the wounds of patients diagnosed with tetanus test positive for the tetanus bacterium.(10)
Tetanus has been a notifiable disease since 1955 (11) and in 2018, 92 cases were reported in the EU/EEA, of which 48 were confirmed(12).
