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Tetanus in the United States is decidedly rare, and most of us will not see a case of it during our careers. Given its lethality, it is a disease about which one must be aware. Be willing to consider it as a diagnosis, no matter the immunization status of the patient, if clinical signs and symptoms warrant. To emphasize this point, the authors present a case of an otherwise healthy 41-year-old man who sustained electrical burns when he fell from a ladder and struck a power line on his way to the ground. He developed a compartment syndrome of his left leg at the exit site and subsequently underwent fasciotomies. When he later began to exhibit signs and symptoms of sepsis, his wound was debrided, and most of his anterior compartment was resected. Despite this, his condition worsened, and his clinical picture was suggestive of tetanus, including the classic findings of trismus, risus sardonicus, and opisthotonus. Using mechanical ventilation, paralysis, narcotics, and muscle-relaxing sedatives, the authors supported him until his tetany subsided. He survived and was discharged to home when complete coverage of his burns and left leg anterior compartment was obtained. The authors discuss the presentation, diagnosis, and treatment of tetanus, as well as its incidence in the general population and in the previously immunized patient.

Tetanus remains a leading cause of maternal and neonatal morbidity and mortality in developing countries. It is caused by the release of two toxins produced by Clostridium tetani, a noninvasive gram-positive anaerobic bacillus. Tetanospasmin is taken up by the neuronal end plates and prevents neurotransmitter release at the synaptic junction. This leads to spasms and is irreversible. Recovery requires the formation of new neurons and may take months. Generalized muscle spasm, respiratory compromise, and autonomic dysfunction are all common clinical manifestations. Diagnosis is based mainly on history and clinical examination. The management of the pregnant woman is similar to the nonpregnant individual. The main objectives are prompt prevention of further toxin absorption, wound debridement, antibiotic therapy, and aggressive supportive care. Primary and secondary prevention protocols are important worldwide because tetanus is a preventable disease. The tetanus toxoid vaccine can be given in pregnancy.

Electrophysiological studies of stimulus sensitive myoclonus in a man with generalised tetanus revealed features characteristic of hyperekplexia or brainstem myoclonus., (Copyright 2003 Movement Disorder Society)

The medical records of ten pediatric patients with a clinical diagnosis of tetanus were reviewed retrospectively. The heart rate and blood pressure of all tetanus patients were measured noninvasively every hour during the first two weeks of hospitalization. Six of ten tetanus patients presented clinical evidence of sympathetic hyperactivity (group A) and were compared with a control group consisting of four children who required mechanical ventilation for diseases other than tetanus (group B). Heart rate and blood pressure simultaneously and progressively increased to a maximum by day 7. The increase over baseline was 43.70 +/- 11.77 bpm (mean +/- SD) for heart rate (P<0.01) and 38.60 +/- 26.40 mmHg for blood pressure (P<0.01). These values were higher and significantly different from those of the control group (group B) at day 6, which had an average heart rate increase over baseline of 19.35 +/- 12.26 bpm (P<0.05) and blood pressure of 10.24 +/- 13.30 mmHg (P<0.05). By the end of the second week of hospitalization, in group A the increase of systolic blood pressure over baseline had diminished to 9.60 +/- 15.37 mmHg (P<0.05), but the heart rate continued to be elevated (27.80 +/- 33.92 bpm, P = NS), when compared to day 7 maximal values. The dissociation of these two cardiovascular variables at the end of the second week of hospitalization suggests the presence of asymmetric cardiac and vascular sympathetic control. One possible explanation for these observations is a selective and delayed action of tetanus toxin on the inhibitory neurons which control sympathetic outflow to the heart.

Introduction: Tetanus is medical disease with a high mortality rate, even in high tech centres and in Intensive Care Units (ICU). AIMS. To analyse the appearance and evolution of tetanus in the ICU at our hospital., Patients and Methods: This retrospective descriptive study, made up of 26 patients admitted to hospital with tetanus in the ICU at the Hospital Escuela during the period between January 1995 and December 2001, examined the clinico epidemiological of the disease and the clinical evolution of the patients., Results: Of the cases reviewed (n= 26), 34.6% were females and 65.4% males. The main clinical manifestations were: trismus (88%), dysphagia (77%) and cervical rigidity (69%). The incubation period varies from 3 days to 4 weeks. Most cases resulted from cut wounds (54%), to a lesser extent from excoriations (15%), and one case was associated with gynaecological surgery. The entry sites of the injuries were mainly on the upper (42%) and lower limbs (34.6%). Three patients had been vaccinated and 17 had not. Six cases were not recorded. The chief complications that developed were: dysautonomia (73%) and pneumonia (42%). The mortality rate was 69%., Conclusion: In spite of having suitable equipment available with which to treat tetanus, mortality is high, mainly because of dysautonomias. Prevention is therefore the most effective way of controlling this disease

The World Health Organization was committed to eliminating neonatal tetanus by 1995. Three years after this date, the infection killed over 400,000 babies a year, even though a safe, effective vaccine had been available for most of this century. The frequency of tetanus in the developing world epitomizes the healthcare disparity between the developed and the developing world. Consequently, the priority of the medical profession must be prevention, with the development of simpler immunization schedules with longer protection. Consequently, the purpose of this collective review is to provide an overview to the management of tetanus as well as to review the immunization strategy that will prevent this potentially deadly illness. Tetanus is caused by Cloistridium tetani, which is an obligate anaerobic, gram-positive rod that is motile and readily forms endospores. Although C. tetani is located everywhere, the disease is encountered largely in underdeveloped, overcrowded, and economically disadvantaged countries. C. tetani is widespread in the feces of domestic animals and humans, while spores of C. tetani are abundant in soil and in the environment surrounding the habitation of humans and animals. Tetanus usually follows deep penetrating wounds where anaerobic bacterial growth is facilitated. Three basic forms of tetanus may be distinguished: local, cephalic, and generalized. At least 80% of the cases are the generalized form. In the adult patient, the most characteristic sign of generalized tetanus is lockjaw, or trismus. The diagnosis of tetanus is most frequently made on clinical manifestations, rather than on bacteriologic findings. The three objectives of management of tetanus are: (1) to provide supportive care until the tetanospasmin that is fixed in tissue has been metabolized; (2) to neutralize circulating toxin; and (3) to remove the source of tetanospasmin. Because there is essentially no immunity to tetanus toxoid, the only effective way to control tetanus is by prophylactic immunization.

Tetanus is considered a major health problem in the developing and under-developed countries, with approximately 1 million new cases occurring each year. We have evaluated the tetanus patients and their presenting complaints, the clinical findings and their relations to the head and neck region along with the frequency of otolaryngological findings and their correlation to the prognosis of this highly mortal disease. There were a total of 37 patients with generalized tetanus diagnosed and treated between 1991 and 2001. There were 25 women and 12 men with a mean age of 55+/-15.6 years. The most common presenting symptom was trismus, followed by neck pain, dysphagia, generalized pain and facial muscular contractions. Wound evaluation revealed that 72.9% of the patients had tetanus-prone wounds, and 27% had either no obvious wounds or a wound considered to be trivial by the patient. Only 62% percent of the patients had sought medical attention immediately after being injured. Three patients in our series were admitted to the otolaryngology clinic with upper aerodigestive tract symptoms. A comparison of complaints with clinical findings revealed a significant lack of correlation, emphasizing that complete physical examination must be performed when evaluating patients with trismus, dysphagia and neck pain. Tracheotomy was performed in 21 cases. There was a direct correlation between the clinical stage and the requirement of tracheotomy. Wound debridment was performed, and antibiotherapy, tetanus toxoid vaccine and immunoglobulin were administered. The mortality rate was 59.4% (22/37). Shorter incubation periods and periods of onset and a higher grade of disease were significantly related to high mortality rates ( P=0.001). It is important to realize the fact that instead of looking for tetanus-prone wounds, one should be on the lookout for tetanus-prone patients. Consequently, on the part of the otolaryngologist, there should always be a high index of suspicion, and concerning patients with trismus or subacute progressive dysphagia, the possibility of tetanus must be borne in mind.

Tetanus is a potentially life threatening disease affecting nearly 50,000 to 1 million people world wide every year. Four major clinical forms of tetanus are described i.e. generalized, cephalic, localized and neonatal. Neonatal tetanus is particularly common in developing countries, due to unhygienic child birth practices, social taboos and improper immunization of pregnant mothers. Management of this disorder involves a team approach and aims at eradicating focus of infection, neutralizing the toxin, controlling spasms and dysautonomia and providing adequate ventilatory and supportive care. Metronidazole may be the preferred antibiotic although penicillin is still used frequently. Adequate wound debridement is necessary to prevent spore germination. Spasms are usually managed by sedatives like diazepam and neuromuscular blocking agents. Magnesium sulphate is an attractive substitute and may be tried if ventilatory facilities are unavailable. Use of baclofen is potentially advantageous but cannot be routinely prescribed. Dysautonomia is difficult to manage and requires therapy with benzodiazepines, morphine, magnesium sulphate, adrenergic blockers and recently tried baclofen therapy. Supportive care including ventilatory assistance are highly essential for successful outcome of the patients. It is imperative that complications are diagnosed early and managed appropriately. Immunization is extremely effective and is the key to prevention. Adequate steps and measures should be taken to increase awareness of this potentially preventable disease.

Despite diligent efforts by the World Health Organization and the governments of developing world countries, tetanus persists as a global health problem. This retrospective study was undertaken to assess the outcome for victims of tetanus presenting to the Baptist Medical Centre in Ogbomoso, Nigeria and to develop better management techniques for future patients. Sixty patients (46 males, 14 females) with nonneonatal tetanus were seen over a 5-year period (1995-1999). The mean age was 26 years, and 74% were 30 years or younger. All patients were treated with antitetanus serum, antibiotics, wound débridement (when a wound was identified), and antispasmodics. No patients underwent tracheostomy or gastrostomy. The mortality rate was 44%. Factors significant for predicting mortality were age greater than 14 years, occupation as a farmer, short incubation period, short symptom duration, high degree of severity on presentation, and high temperature during hospital care. The best hope for improvement in the treatment of tetanus in our institution is more conscientious titration of antispasmodics to control spasms without causing significant respiratory depression. The only real hope for reducing the global mortality for tetanus, however, lies in renewed immunization efforts by all health care providers in developing world countries, not just community health workers.

Introduction: Tetanus is still a significant health hazard in developing countries, with high associated mortality., Objective: Describe the management of patients with severe tetanus in intensive care units (ICUs), in two different periods., Setting: ICUs of two general hospitals., Design: Concurrent cohort study., Methods: Follow-up of all patients hospitalized with the diagnosis of severe tetanus in the ICUs from October 1981 to March 2001. We collected data prospectively, regarding the site of injury, clinical features, frequent clinical and infectious complications, concomitant illnesses, and mortality. The patients were divided into two groups according to the treatment protocol used; before 1993 and after 1993., Results: There were 126 patients in group 1 (93 males) with a mean age of 39.0 +/- 18.8 years. There were 110 patients in group 2 (95 males) with a mean age of 48.4+/-17.8 years. Incubation period, onset period, and symptomatic period were higher in group 2 ( P < or = 0.02). The duration of neuromuscular junction blockade, benzodiazepine administration, mechanical ventilation, and ICU stay were longer in group 2, P < 0.001. Infectious complications were more frequent in group 2 ( P < 0.001). The mortality rate in group 1 was 36.5% and in group 2, 18.0% ( P = 0.002). Mortality was directly associated with symptomatic period, acute renal failure cardiac arrest and hypotension, and inversely associated with onset period in the multivariate analyses., Conclusions: The reduced mortality in severe accidental tetanus patients in group 2 is probably related to advances in ICU management, despite the higher incidence of infectious complications, which are probably related to the longer ICU stay.

Tetanus is uncommon in Korea due to the introduction of vaccination programs and advances in public health. A case of maternal tetanus occurred on the 9 day postpartum in a 29-yr-old woman, who had not received a 10-yr-booster of tetanus-diphtheria toxoid after receiving the primary series of tetanus-toxoid-containing vaccine. There has hitherto been no reports on maternal tetanus in Korea. This case illustrates that tetanus remains a medical problem, principally among non- and under-immunized adults. The only way to fully prevent this disease is to ensure adequate immunization in all adults.

With adequate immunization, tetanus caused by the gram-positive anaerobic cocci, clostridium tetani, is a preventable disease. In treating C. tetani infection, Metronidazole as an antibiotic is more effective than Penicillin G since it is a GABA antagonist. Agents used to control spasm and rigidity should have little effect on the level of consciousness, respiration and blood pressure. The drug of choice for treating spasm and rigidity is benzodiazepine, a GABA agonists. Large doses of benzodiazepines may be required to overcome the spasm and are safe. Baclofen is another GABA agonist, which has been tried as an alternative to benzodiazepine with moderate success. Clinical experience with dantrolene sodium is limited. Magnesium with its unique properties on the neuromuscular junction and sympathetic system has been used to treat both spasms and autonomic dysfunction with limited success. Neuromuscular blocking drugs are indicated depending on the severity of spasms. Neuromuscular blocking drugs with steroid molecule should be avoided in view of prolonged weakness. No drug has consistently proven to be effective in the treatment of autonomic dysfunction. Beta-blockers, variation of and beta blockers, opioids, clonidine, magnesium, spinal and epidural anaesthesia have been tried with varying success. Beta-blockers should be used with caution as they have been implicated in the deaths of some patients with autonomic dysfunction.

Despite the availability of effective immunization to prevent tetanus, there are still up to one million cases per year worldwide. Although the majority of tetanus cases occur in third world countries, there are still significant numbers of cases occurring in countries such as the United States, where preventive immunization is easily accessible. The Emergency Physician has the opportunity to contribute to the decline of the incidence of tetanus through knowledge of those at greatest risk for inadequate immunization and through providing proper wound care and immunization prophylaxis.

Abnormalities of the silent period (SP) and blink reflexes occur in diseases that interfere with inhibitory pathways, such as tetanus and stiff-person syndrome (SPS). The SP is abnormal in tetanus but not in SPS. Studies of the blink reflex in tetanus are limited. In this report, a patient with generalized tetanus is described. The masseteric-and mixed-nerve SP was absent or truncated. In contrast to SPS, blink reflex studies revealed no bilateral R1 component, and a discrete R3 was only present ipsilateral to right supraorbital stimulation. This reflects the distinct inhibitory pathways underlying these disorders., (Copyright 2000 John Wiley & Sons, Inc.)

The treatment of severe tetanus generally requires prolonged mechanical ventilation. We describe two cases managed with continuous intrathecal infusion of baclofen via a subcutaneous tunnelled spinal catheter and an abdominal injection port. Baclofen, by diminishing spasms and spasticity, allowed reduced sedation and paralysis requirements. This potentially decreases the time and resources required for intensive care management. Complications include sedation, hypotension and CSF infection. After appropriate dose adjustment, baclofen improves the management of severe tetanus.

Background: Tetanus as a topic illness is underlined on the basis of the increased cases as well as the appearance of new populations at risk of infection. The tetanospasmins of mechanism action is stressed in order to evaluate the etiopathogenetic role of common therapies as well as the new ones. Ten cases of serious infection personally observed are analysed., Methods: The case records of ten tetanus patients treated in our Intensive Care Unit between 1986 and 1997 have been retrospectively analysed. The prognosis correlated to the seriousness of the case. The most common clinical symptoms on admission were trismus and dysphagia (100% of patients). In 70% of cases, the illness was considered serious enough to warrant the use of neuro-muscular blockers and controlled ventilation. Among the complications observed pulmonary problems had the highest incidence (90%), followed by cardio-vascular ones (80%). Respiratory infections were the most frequently observed (9 patients). Autonomic dysfunction was a constant feature in patients with severe forms of the illness., Results: The observed mortality rate was 30%. It was higher in males at the extremes of the age range., Conclusions: In the light of the survival results as well as the most recent literature data, guidelines for the approach of serious tetanic patients are outline. It is underlined that therapy effectiveness is higher when from being a symptom therapy it becomes an etiopathogenetic therapy.

The cortical silent period has not previously been studied in tetanus. Transcranial magnetic brain stimulation in a patient with generalized tetanus revealed enlarged electromyographic (EMG) responses and absence or reduction of the late phase of EMG silence following the motor evoked potential in sternomastoid and biceps brachii muscles. Following clinical recovery, the silent period returned to normal. This observation is interpreted as evidence of impaired inhibitory mechanisms at multiple levels of the nervous system, including the cortex, in generalized tetanus., (Copyright 1999 John Wiley & Sons, Inc.)

Objective: To determine the efficacy and safety of epidural bupivacaine and sufentanil for the management of sympathetic overactivity in tetanus., Design: Retrospective case review., Setting: Sixteen-bed surgical intensive care unit in a tertiary care centre., Patients: All patients referred to the unit during a 63-month period with the diagnosis of tetanus were included in the study., Measurements and Main Results: All patients (n = 11) had severe tetanus and developed sympathetic overactivity, which was managed by epidural blockade. Three patients died, but there were no fatalities directly attributable to sympathetic overactivity. Before epidural blockade, the average difference between the mean maximum and mean minimum systolic blood pressures was 78 +/- 28 (so) mm Hg. After blockade, this difference was reduced to 38 +/- 15 (so) mm Hg (p < .0001). Similar significant reductions in diastolic blood pressure and heart rate were observed. The mean hourly infusion doses of bupivacaine and sufentanil were 17 mg and 21 microg, respectively. Midazolam was the principal adjunctive sedative agent and was used in all patients (mean dose, 9 mg/hr). Additional pharmacologic agents were necessary in two patients in whom epidural blockade alone was insufficient to control sympathetic overactivity. One patient developed renal failure and there were no instances of pneumothorax. One patient developed an epidural abscess of probable hematogenous origin, which was successfully treated without neurologic sequelae., Conclusions: Epidural blockade is effective in controlling sympathetic overactivity and the associated complications (renal failure, cardiac injury, and sudden death). Although a serious complication occurred in one patient, the efficacy of the technique deserves further validation.

We report a case of non-fluminent and mildly affected tetanus patient who showed afterdischarges following F waves in the affected extremity. The afterdischarges occurred following F waves and showed different configuration respond to each stimuli. Diazepam was also effective for spasms of our patient. This finding disappeared after treatment and showed a good correlation to clinical symptoms. These observations suggest that afterdischarges following F waves are induced by tetanus toxin which puts most of the motor neuron pool in a hyperactive state through its own action to the motor nerve including the spinal motor neuron.

In the United States today, tetanus is a rare disease. However, when it occurs, it can be a highly challenging situation for all members of the healthcare team. The majority of care during the course of the disease is supportive. The availability of personnel trained in managing cardiorespiratory emergencies and sustained mechanical ventilation in the ICU environment can have a beneficial effect on patients' outcomes. An awareness of the potential complications of tetanus can hasten recovery and maintain the patient's preexisting quality of life.

The patient described had generalized tetanus and required anesthetic care during debridement of a lower extremity wound. Despite widespread vaccination, which limits the incidence of the disease in the United States, tetanus remains a major health problem in developing countries. The pathophysiology of tetanus, its clinical manifestations, and current treatment options are discussed, and the anesthetic implications of the disease are reviewed.

Our aims were to itemize the clinical features and the outcome of tetanus in the elderly, as well as any age and sex differences in its acquisition. Therefore, we compared the demographic and clinical data of 12 elderly (group 1) cases of tetanus with 69 middle-aged patients (group 2) and 12 children (group 3) suffering from the same disease. There was no significant difference between the site of entry and incubation period or in the clinical and paraclinical findings among the three groups of patients. Acute respiratory failure was found more commonly in group 1 than in groups 2 and 3 (p = 0.0167 and p = 0.0006, respectively). It was also more common in group 2 than in group 3 (p = 0.0140). A mild form of tetanus was more often detected in children than in middle-aged and elderly cases (p = 0.0213 and p = 0.0013, respectively). Severe tetanus was seen more often in group 1 than in groups 2 and 3 (p = 0.0167 and p = 0.0006, respectively). Despite this, the mortality rate was not statistically different among the three groups of patients. Females were affected much less frequently than males with a female:male ratio of 1:3 in all three age groups. Our results suggest that elderly patients are at higher risk of acquiring a more severe form of tetanus and the subsequent development of acute respiratory failure. In addition, the disease is more common in males of all age groups, and age and sex have no apparent effect on the outcome of patients with tetanus.

Objective: To review the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of tetanus and its complications., Data Sources: MEDLINE and Iowa Drug Information Services databases were searched for literature pertaining to tetanus. Additional literature was obtained from the references of selected articles identified in the search. Information from all articles was considered for inclusion in the manuscript., Study Selection and Data Extraction: Articles selected were those considered by the authors to assist in providing the reader an understanding of the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of tetanus., Data Synthesis: While the number of tetanus cases has decreased markedly since data reporting for the disease began in 1947, mortality among those who acquire the disease remains high. Elderly patients are particularly susceptible to tetanus and its complications. Prevention of tetanus focuses on primary immunization and scheduled boosters. Management of tetanus involves initial stabilization of the patient and protection of the airway, prevention of tetanospasmin absorption by administration of human tetanus immune globulin 3000-6000 IU, and eradication of Clostridium tetani with antimicrobial therapy (metronidazole 500 mg q8h). Supportive measures include the administration of neuromuscular blocking agents such as pancuronium in patients requiring artificial ventilation, as well as benzodiazepines (midazolam 5-15 mg/h) for sedation and muscle relaxation. Autonomic dysfunction should be managed with beta-adrenergic blockers such as propranolol or labetalol., Conclusions: Despite the relative infrequency of tetanus cases, mortality among untreated patients remains significantly high. Clinicians should become knowledgeable in the pathophysiology, clinical manifestations, and management of this potentially fatal disease.

To assess the mechanisms related to tetanus-induced acute renal failure (ARF), 30 patients with tetanus had their renal function prospectively studied and factors possibly related to renal changes were evaluated during four weeks of hospitalization. Fifty percent of these patients had a glomerular filtration rate (GFR) < or = 50 ml/min in the first or second week of hospitalization (Group I) and 50% had a GFR > 50 ml/min throughout the entire hospitalization period (Group II). Age, gender, tetanus incubation time and tetanus onset time, hospitalization time, use of nephrotoxic drugs, need for mechanical ventilation with intermittent positive pressure, and presence of systemic infection were similar in both groups. None of the patients presented with oliguria. Autonomic nervous system (ANS) overactivity, characterized by intense variations in systolic and diastolic blood pressure, by increased heart rate and elevated urinary metanephrine excretion, was higher in Group I compared with Group II. Plasma renin activity, serum creatinephosphokinase levels, and myoglobinuria were not significantly different between the two groups. These results strongly suggest that tetanus-induced ARF has a high prevalence, is characterized by early onset, and is probably related to ANS overactivity.

Changes in sensitivity of the alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) subtype of glutamate receptors following the induction of long-term potentiation (LTP) were investigated in rat hippocampal slices. AMPA was ejected into the stratum radiatum of the hippocampal CA1 region by pressure ejection and the response recorded intracellularly. Responses to AMPA exhibited a fast increase (2-3 min) following LTP induction: the time course of this increase paralleled the potentiation of the excitatory postsynaptic current (EPSC). In cases where there was no increase in the slope of intracellularly recorded EPSC following tetanization, no increase of the AMPA responses was observed. These results suggest that increases in postsynaptic AMPA sensitivity can underlie short-term potentiation (STP) and thus, support a postsynaptic locus for both STP and LTP.

Tetanus (TeNT) neurotoxin and botulinum (BoNT, serotypes A-G) neurotoxins are di-chain bacterial proteins of MW-150 kDa which are also termed as clostridial neurotoxins. They are the only causative agents of two severe neuroparalytic diseases, namely tetanus and botulism. The peripheral muscle spasms which characterise tetanus are due to a blockade of inhibitory (GABAergic and glycinergic) synapses in the central nervous system leading to a motor neurones desinhibition. In contrast, botulism symptoms are only peripheral. They are consequent to a near irreversible and highly selective inhibition of acetyl-choline release at the motor nerve endings innervating skeletal muscles. During the past decade, the cellular and molecular modes of action of clostridial neurotoxins has been near completely elucidated. After a binding step of the neurotoxins to specific membrane acceptors located only on nerve terminals, BoNTs and TeNT are internalized into neurons. Inside their target neurones, the intracellularly active moiety (their light chain) is translocated from the endosomal compartment to the cytosol. The neurotoxins' light chains are zinc-dependent (endopeptidases which are specific for one among three synaptic proteins (VAMP/synaptobrevin, syntaxin or SNAP-25) implicated in neurotransmitter exocytosis. The presence of distinct targets for BoNTs and TeNT correlates well with the observed quantal alterations of neurotransmitter release which characterize certain toxin serotypes. In addition, evidence for a second, non-proteolytic, inhibitory mechanism of action has been provided recently. Most likely, this additional blocking action involves the activation of neurone transglutaminases. Due to their specific action on key proteins of the exocytosis apparatus, clostridial neurotoxins are now widely used as molecular tools to study exocytosis.

The three main basic concepts in the understanding and management of tetanus: (1) Tetanus is polysystemic in terms of pathology and management. Most body organs, as well as the nervous system, are severely affected by tetanus toxins. (2) Prevention is not only by immunization, but also by specific treatment. Since the toxin cannot be therapeutically eradicated from the body, therapy is directed towards preventing continued spread of the toxins and the consequences of intoxication. (3) Variability in terms of prevalence and prognosis. The natural incidence and severity of tetanus varies greatly with social environment, season, climate and soil. Prognosis is influenced by age, source of infection and delay in treatment.

In developing countries tetanus is still a real problem because of its high incidence and mortality. In all countries with high medical standards it has become rare. For this reason many clinicians are no longer familiar with the disease and its diagnosis. Until now no laboratory test has been readily available to confirm or rule out tetanus. However, the diagnosis can be performed by a simple and readily available electromyogram (EMG). We performed EMGs in 13 patients in whom tetanus was suspected but whose case history or clinical findings left some doubt. In 7 cases the EMG was typical for tetanus, showing spontaneous activity of motor units which could not be suppressed voluntarily and with shortening or absence of the silent period after a stretch reflex or after electrical stimulation of the nerve. In 2 cases we found one of the two diagnostic features. In all these 9 cases the diagnosis of tetanus was confirmed by the further development of the disease. In the remaining 4 patients the EMG was normal and in the course it was confirmed that they were not suffering from tetanus. Therefore, we consider electromyography a very useful and reliable tool either to confirm or rule out the diagnosis of tetanus.