Snapshot A 7-day-old neonate presents with difficulty in sucking, facial grimacing, and frequent muscle spasm over the past 48 hours. There was no history of immunization during pregnancy, and the home birth was attended to by a local midwife. Birth weight was estimated to be 3000g. Patient is afebrile. Physical exam reveals a neonate in opisthotonus, with flexion of the arms and extension of the legs. Palpation of the extremities elicit muscle spasms. The umbilical stump is foul smelling and erythematous. You immediately administer diazepam and phenobarbital followed by hyperimmune human globulin. Wound swab of the umbilical stump was taken for culture and the patient monitored in a quiet dark room with minimal handling and airway suction. Introduction Classification bacteria (anaerobic) gram-positive bacilli spore-forming Clostridium C. tetani Presentation Rare in the United States Incidence higher in developing countries Tetanic (spastic) paralysis risus sardonicus trismus (lockjaw) opisthotonus Caused by tetanospasmin toxin exotoxin which cleaves SNARE protein prevents release of inhibitory neurotransmitters glycine and GABA in the spinal cord travels to CNS by retrograde axonal transport Evaluation Diagnosis is clinical on the basis of history and physical exam organism is not usually isolated Differential Seizure disorders Meningitis Drug-induced dystonias Trismus secondary to dental infection Malignant neuroleptic syndrome Strychnine poisoning(perfectly mimics symptoms) Stiff person syndrome Treatment Post-exposure prophylaxis vaccination (Td, Tdap, TT) clean wound and vaccination history out of date or unknown. hyperimmune human globulin (TIG) neutralizes toxin contaminated wound and no vaccination history metronidazole or penicillin also given spasmolytic drugs treat symptoms (e.g. diazepam) Prevention, Prognosis, and Complications Prevention vaccine made of tetanus toxoid formaldehyde-inactivated one dose of Tdap,Td or TT during the third trimester prevents neonatal tetanus 5 doses of DTap starting at 2 months of age Td booster every 10 years in adulthood Tetanus prophylaxis for burns open fractures Prognosis worse if generalized tetanus elderly neonates better if there is access to intensive medical care Complications laryngospasm fracture pneumonia pulmonary embolism death due to respiratory failure