Unprotected People Reports: Tetanus
Blindsides by Tetanus: Are You Psychotic, Overdosing, or Did You Just Forget Your Booster Shot?
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|The Immunization Action Coalition (IAC)
publishes articles about people who have suffered or died from
vaccine-preventable diseases and periodically devotes an “IAC Express”
issue to such an article. This is the 59th in our series.
|The article was published in “Discover”
magazine January 2000. It is reprinted with the kind permission of
“Discover,” which holds the copyright. We are grateful to the author, Dr.
Claire Panosian Dunavan, for allowing us to make minor modifications.
|Blindsides by Tetanus: Are You
Psychotic, Overdosing, or Did You Just Forget Your Booster Shot?
By Claire Panosian Dunavan, MD, professor of medicine and infectious
University of California at Los Angeles School of Medicine
Eduardo rubbed his jaw and tried to open his
mouth, wondering about the tight muscles in his face and neck that had
plagued him all day. Then he noticed the flashing lights of a police cruiser
in his rearview mirror. As an illegal [immigrant] in a battered pickup
without cash, driver's license, or friends, Eduardo felt that this was
becoming his worst nightmare.
Charged with weaving across lanes and driving
an unregistered vehicle, Eduardo spent the next two days in a holding cell.
As the hours passed, his cell mates noticed that he grew stiff, grinned
oddly, and ignored his food. Then, one of the guards saw him violently jerk
his neck and torso. The guard thought, "This guy's faking seizures to get
out of jail." But Eduardo's spasms persisted, and other prisoners began
backing away from him. The staff decided to pack him off to the county
hospital's psychiatric unit.
During my years as the sole infectious
diseases specialist at that small county hospital in southern California, I
wasn't called to the psychiatric emergency room often. But when I was, the
cases were never boring, [and this case was no exception].
Eduardo posed a challenge. As I and the
resident both knew--but the police did not--psychosis and [drug] overdose
were not the only conditions that could produce a rigid neck and torso, a
mute smile, and jerking movements. An infection of the central nervous
system was another possibility, and we'd recently seen a few cases of
mosquito-borne encephalitis in the area. "Como esta?" I asked as I
approached the young man lying on a gurney in a curtained cubicle. The
greeting was a courtesy. Eduardo was in no shape to talk. Invisible pulleys
had stretched his mouth into a tight smirk. But his eyes were wide open,
alert, and terrified--no sign of confusion or coma.
"Great--you got here fast!" The resident's
voice rang out as he flung back the curtain.
The sharp sound and sudden motion startled
Eduardo. His head jerked back, his shoulders and trunk arched up, and he
gasped in pain. But he remained conscious throughout the 15-second attack.
That's not consistent with spasms induced by brain disorders. This was no
ordinary seizure. Suddenly the diagnosis dawned on me. Twelve years earlier,
as a medical volunteer in Haiti, I had watched a rigid yet fully conscious
pregnant woman arch her body in just the same way.
She'd had tetanus.
"Get the ICU team here as soon as possible,"
I said to the resident. I spoke softly to avoid startling Eduardo into
another spasm. "The next time this happens, he could stop breathing," I told
the resident. "You make sure he gets an airway. Meanwhile, I'll order up
In the specialty of infectious diseases, few
physical displays are as dramatic as the spasms provoked by tetanus. Its
cause is a protein toxin so potent that many victims require months to
recover from its effects, if they survive at all.
But the toxin is not the ultimate perpetrator
of tetanus. That honor is reserved for the bacillus Clostridium tetani,
which produces the toxin. Excreted in the feces of animals and widely
distributed in soil, mature C. tetani resemble tennis rackets, bulging at
one end with a hardy spore. It doesn't always take an old nail puncturing a
foot to get these into a human host. All the bacteria need is a minor breach
of the skin--a laceration, a burn, or even an insect bite. And if they land
in tissue that receives little oxygen, they will thrive--multiplying and
manufacturing their deadly product.
Once secreted, the toxin molecule sneaks into
the rootlike hairs of nerve fibers, climbs toward the spinal cord, and binds
itself to inhibitory neurons, thus disrupting their function. That takes the
brakes off the peripheral nerve cells, and they start firing faster. The
result is muscle rigidity that typically begins in the head and neck, then
moves to the chest and abdomen, and eventually reaches the extremities.
Lockjaw, or trismus, is an early sign of
tetanus. It means the toxin has affected nerves in the masseters, or chewing
muscles. Another early symptom is risus sardonicus, a term from Roman times
for the tetanus victim's telltale smile, raised eyelids, and wrinkled
forehead. The most vivid hallmark of all is the wrenching spasms, which
result when two opposing muscle groups are simultaneously activated. The
spasms can be triggered by anything from a sudden noise, movement, or draft
of air to such internal stimuli as a full bladder or a cough.
Fortunately, most people in industrialized
countries needn't worry that everyday scratches and scrapes will yield an
internal harvest of tetanus toxin. Because they've received a series of
tetanus vaccines in childhood as well as the occasional tetanus booster,
their bodies have plenty of protective antibodies. Reported tetanus cases in
the United States often number no more than 100 a year.
But people in the developing world are less
likely to receive tetanus vaccines and they suffer the consequences. Tetanus
kills an estimated 300,000 each year; almost all deaths occur in developing
countries. Newborns are particularly vulnerable. During the first few weeks
of life, their only defense against pathogens comes from antibodies imported
from their mothers . . . . Infants born to nonimmunized mothers are tetanus
cases waiting to happen. One dirty knife or soiled bandage on the umbilical
stump is all it takes. Today neonatal tetanus accounts for over half of the
more than 500,000 cases worldwide.
In my quick exam of Eduardo, I hadn't seen a
scratch. I suspected tetanus, but there's no definitive diagnostic test for
the disease because the toxin hides away in the central nervous system. To
confirm my suspicion, I needed to exclude the possibility that another
condition was mimicking tetanus symptoms.
Tests of Eduardo's electrolytes were normal,
which ruled out a low calcium level as the cause of his spastic muscles. And
Eduardo's spinal fluid showed no signs of infection; that ruled out
encephalitis or meningitis. And just in case he was suffering from dystonia--a
movement disorder triggered by certain prescription drugs--he got a dose of
diphenhydramine (Benadryl), the usual antidote. That maneuver proved
fruitless as well. The only remaining tests were blood and urine assays for
strychnine, and those results might not be back for days. Tetanus was the
"We'll start the antitoxin as soon as
pharmacy brings it up," said the ICU chief, taking me aside. "In the
meantime, he's intubated, with diazepam [Valium] by IV. Now what about
Although Eduardo had no visible signs of
infection, at least somewhere in his tissues there must be C. tetani pumping
out toxin. Penicillin was in order. The drug would wipe out the
toxin-producing bacteria. And we hoped the antitoxin--antibodies culled from
horses or humans immunized against tetanus--would intercept the poisons in
his blood and prevent his symptoms from getting worse.
Unfortunately, its effects were far from
Lazarus-like. Eduardo remained in the ICU for a full month, while the toxin
was slowly leached from his spinal cord and brain. I was hoping for a full
recovery, but sometimes tetanus so damages nerves that muscles are left
permanently weakened. Even muscle relaxants, low lights, and tiptoeing
doctors and nurses couldn't prevent Eduardo's spasms, so we paralyzed his
muscles and put him on a ventilator. Thankfully, he made it through.
Several weeks after his discharge from the
hospital, I saw Eduardo at a follow-up visit. He was still thin and leaning
on a cane. When I greeted him in the hall, he seemed to remember me.
"Tetanus vaccine?" he responded laconically
to my first eager question. "I don't remember any vaccines in the village
where I grew up."
I made a mental note to ask our nurse to
vaccinate him. Ironically, so little toxin is released during an infection
that even a full-blown case of tetanus builds no immunity against future
"What about an injury?" I persisted. "Usually
a wound precedes tetanus."
"Ah, the soccer game," he mused. "A few
weekends before I started getting stiff, something sharp went right through
the sole of my shoe. Glass, I think." (This information let me put the
last piece of the puzzle in place: Eduardo’s untreated puncture wound explained
the cause of his tetanus episode. Case closed.)
|10/31/03 • REPORT #59
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