Unique among the vaccine-preventable diseases, tetanus is not transmissible from person to person (Wassilak et al., 2008). The disease is caused by the gram-positive spore forming bacillus Clostridium tetani, which is widespread throughout the environment, particularly in the soil (Wassilak et al., 2008). C. tetani spores are introduced into the body through direct contact with compromised tissues, where they germinate and produce a plasmid-encoded exotoxin that binds to gangliosides at the myoneural junction of skeletal muscle and on neuronal membranes in the spinal cord, blocking inhibitory impulses to motor neurons (AAP, 2009; Wassilak et al., 2008). “The action of tetanus toxin on the brain and sympathetic nervous system is less well documented” (AAP, 2009).
The incubation period for tetanus can range from 1 day to several months but generally lasts 3 to 21 days (Weinstein, 1973). Shorter incubation periods are associated with more severe disease, while incubation periods of 10 or more days generally result in milder disease (Adams, 1968; Bruce, 1920; Garcia-Palmieri and Ramirez, 1957; LaForce et al., 1969).
There are three clinical descriptions of C. tetani infection: generalized, localized, and cephalic. Generalized tetanus occurs in more than 80 percent of all tetanus cases (Wassilak et al., 2008). Trismus (lockjaw) caused by spasm of the facial muscles is the most common manifestation of generalized tetanus (Newton-John, 1984; Pratt, 1945; Weinstein, 1973). Trismus may be followed by muscle spasms in other parts of the body including the neck, back, and abdomen (Wassilak et al., 2008). Tetanospasm, also known as generalized tonic tetanic seizure-like activity, is a sudden contraction of all the muscle groups and can occur in the presence of mild external stimuli such as sudden noise (Wassilak et al., 2008). In addition to these spasms, those with severe tetanus are at risk of developing severe autonomic nervous system abnormalities including diaphoresis, high or low blood pressure, flushing, and cardiac complications (Hollow and Clarke, 1975; Kanarek et al., 1973; Kerr et al., 1968). Tetanus neonatorum is the most common manifestation of generalized tetanus and occurs when the bacterium infects the umbilical stump (Wassilak et al., 2008). Typically manifesting 3 to 14 days after birth, tetanus neonatorum begins with excessive crying and decreased sucking capability, and is followed by trismus, difficulty swallowing, and tetanic spasm (Wassilak et al., 2008). Infants who survive this disease may experience neurologic damage and may also develop intellectual and behavioral abnormalities (Anlar et al., 1989; Barlow et al., 2001; Okan et al., 1997; Teknetzi et al., 1983). Localized tetanus is rare in humans and involves muscle spasms confined to areas. These spasms may last several months before subsiding or developing to generalized tetanus (Millard, 1954). Cephalic tetanus is associated with lesions on the head or