Tetanus

CVAS, BIKANER

Tetanus Overview
The word tetanus comes from the Greek tetanos, which is derived from the term teinein, meaning to stretch. Also known as Lock Jaw disease

Tetanus is a highly infectious disease characterized by a prolonged spasmatic contractions of skeletal muscles, stiffness and immobilization.
Tetanus is the only vaccine-preventable disease that is infectious but is not contagious

History

5th century BC: Hippocrates first described the disease 1884: Carle and Rattone discovered the etiology
(cause/origin of disease)

Produced tetanus by injecting pus from a fatal human case Nicolaier was able to do the same by injecting soil samples

into animals

1889: Kitasato isolated the organism from human victim, showed that it could produce disease when injected into animals. Reported that toxin could be neutralized by specific antibodies.

1897: Nocard demonstrated the protective effect of passively transferred antitoxin used in WWI

1924: Descombey developed tetanus toxoid for active immunization used in WWII

Etiology

Clostridium tetani is the bacterium responsible for the disease. gram-positive, rod-shaped, anaerobic bacterium that is found worldwide in soil. The bacteria are found in two forms: as a spore (dormant) or as a vegetative cell (active) that can multiply. The spores are in soil, dust, and animal waste and can survive there for many years. These spores are resistant to extremes of temperature

Causative agent

Stained pus from a mixed anaerobic infection. At least three different clostridia are apparent.

Electron micrograph of vegetative Clostridium tetani cells.

Virulence & Pathogenicity

Not pathogenic to humans and animals by invasive infection but by the production of a potent protein toxin
tetanus toxin or

tetanospasmin The second exotoxin produced is tetanolysin function not known.

Tetanus toxin
Produced when spores germinate and vegetative cells grow after gaining access to wounds. The organism multiplies locally and symptoms appear remote from the infection site. One of the three most poisonous substances known on a weight basis, the other two being the toxins of botulism and diphtheria.

Tetanus toxin is produced in vitro in amounts up to 5 to

10% of the bacterial weight. Estimated lethal human dose of Tetanospamin = 2.5 nanograms/kg body

Because the toxin has a specific affinity for nervous tissue, it is referred to as a neurotoxin.

Transmission

The disease typically follows an acute injury or trauma that results in a break in the skin. Most cases result from a puncture wound, laceration (cut), or an abrasion (scrape). Other tetanus-prone injuries include the following: frostbite surgery crush wound abscesses childbirth drug users (site of needle injection). Wounds with devitalized (dead) tissue (for example, burns or crush injuries) or foreign bodies (debris in them) are most at risk of developing tetanus

Objects that accumulate rust are often found outdoors, or in places that harbor anaerobic bacteria, but the rust itself does not cause tetanus nor does it contain more C. tetani bacteria. The rough surface of rusty metal merely provides a prime habitat for a C. tetani endospore to reside, and the nail affords a means to puncture skin and deliver endospore into the wound. An endospore is a non-metabolizing survival structure that begins to metabolize and cause infection once in an adequate environment.. Hence, stepping on a nail (rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic) environment is provided by the same object that causes a puncture wound, delivering endospores to a suitable environment for growth.

Epidemiology

Distribution of disease in animals:

The disease is prevalent in all parts of the world. The pathogen which is common habitat of soil and intestinal tract of various animals, has been isolated form feces of pigs , horses, dogs, cattle, goats, and monkeys

Distribution of disease in man:

The disease occurs almost exclusively in persons unvaccinated or inadequately immunized

Tetanus occurs worldwide but is more common in hot, damp climates with soil rich in organic matter.
Tetanus in particular, the neonatal form remains a significant public health problem in nonindustrialized countries. The World Health Organization estimates that 59,000 newborns worldwide died in 2008 as a result of neonatal tetanus.

The spores can also be found on skin surfaces and in contaminated heroin. Heroin users, particularly those that inject the drug, appear to be at high risk for tetanus.

Host range and reservoirs

Horses, monkeys and mice are most susceptible animals Sheep, goat, swine, and cattle are less susceptible. Birds and clod blooded animals are highly resistant

The disease in humans is the result of infection of a wound with the spores of the bacteria Clostridium tetani. These bacteria produce the toxin tetanospasmin, which is responsible for causing tetanus. Tetanospasmin binds to motor nerves that control muscles, enters the axons (filaments that extend from nerve cells), and travels in the axon until it reaches the body of the motor nerve in the spinal cord or brainstem (a process termed retrograde intraneuronal transport).

Pathogenesis

Pathogenesis
Then the toxin migrates into the synapse where it binds to presynaptic nerve terminals and inhibits or stops the release of certain inhibitory neurotransmitters (glycine and gamma-amino butyric acid). Because the motor nerve has no inhibitory signals from other nerves, the chemical signal to the motor nerve of the muscle intensifies, causing the muscle to tighten up in a huge continuous contraction or spasm. If tetanospasmin reaches the bloodstream or lymphatic vessels from the wound site, it can be deposited in many different presynaptic terminals resulting in the same effect on other muscles.

Types of tetanus:
local 2. cephalic 3. generalized 4. Neonatal
1.

Incubation period: 3-21 days, average 8 days

Most common types:

Generalized tetanus: can affect all skeletal muscles. It is the most common as well as the most severe form of the four types. descending pattern: lockjaw stiffness of neck difficulty swallowing rigidity of abdominal and back muscles. Spasms continue for 3-4 weeks, and recovery can last for months Death occurs when spasms interfere with respiration

Neonatal tetanus: it is a form of generalized

tetanus that occurs in newborns Neonates may be irritable and have poor sucking ability or difficulty swallowing.. Infants who have not acquired passive immunity because the mother has never been immunized are at risk. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. Neonatal tetanus is common in many developing countries and is responsible for about 14% (215,000) of all neonatal deaths, but is very rare in developed countries.

Uncommon types

Cephalic tetanus: Cephalic tetanus is a rare

form[citation needed] of the disease, occasionally occurring with otitis media (ear infections) in which C. tetani is present in the flora of the middle ear, or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area.

Localized tetanus: muscle spasms occur at or near

the site of the injury. This condition can progress to generalized tetanus. Local tetanus is generally milder; only about 1% of cases are fatal

Symptoms

Tetanic seizures (painful, powerful bursts of muscle contraction)

if the muscle spasms affect the larynx or chest wall, they may cause asphyxiation stiffness of jaw (also called lockjaw) stiffness of abdominal and back muscles contraction of facial muscles fast pulse fever sweating

A sardonic smile -- medically termed risus sardonicus -is a characteristic feature that results from facial muscle spasms. Muscle spasms are progressive and may include a characteristic arching of the back known as opisthotonus Muscle spasms may be intense enough to cause bones to break and joints to dislocate. Severe cases can involve spasms of the vocal cords or muscles involved in breathing. If this happens, death is likely, unless medical help (mechanical ventilation with a a respirator) is readily available.

The back muscles are more powerful, thus creating the arc backward
Oposthotonus by Sir Charles Bell, 1809.

Baby has neonatal tetanus with complete rigidity

Symptoms

In animals

besides previous symptoms the gait becomes slow and stiff, hyperasthesia and sweating develops. In horses show prolapse of third eye lid in inner canthus of eye followed by locked jaw: stiffness of neck with sensitivity to sound In in sheep and goats stiffness and ophithotonus with moderate bloating occurs.

Diagnosis
Based on the patients account and physical findings that are characteristic of the disease. Diagnostic studies generally are of little value, as cultures of the wound site are negative for C. tetani two-thirds of the time.

When the culture is positive, it confirms the diagnosis

of tetanus

Tests that may be performed include the following:

Culture of the wound site (may be negative even if

tetanus is present) Tetanus antibody test Other tests may be used to rule out meningitis, rabies, strychnine poisoning, or other diseases with similar symptoms.

There are currently no blood tests that can be used to diagnose tetanus. The diagnosis is based on the presentation of tetanus symptoms and does not depend upon isolation of the bacteria, which is recovered from the wound in only 30% of cases and can be isolated from patients without tetanus. Laboratory identification of C. tetani can be demonstrated only by production of tetanospasmin in mice. The diagnosis of generalized tetanus is usually made by observing the clinical presentation and a combination of the following: Incomplete tetanus immunizations

History of a recent injury resulting in skin breakage (but this is not universal; only 70% of cases have an identified injury) Progressive muscle spasms (starting in the facial region, especially lockjaw and progressing outward from the face to include all muscles of the body) Fever, Changes in blood pressure (especially high blood pressure),Irregular heartbeat.

In localized tetanus, pain, cramps, or muscle spasms occur at or near a recent skin injury

Neonates show signs of being generally irritable, muscle spasms, and poor ability to take in liquids (poor sucking response), usually seen in neonates about 7-10 days old. The "spatula test" is a clinical test for tetanus that involves touching the posterior pharyngeal wall with a sterile, soft-tipped instrument, and observing the effect. A positive test result is the involuntary contraction of the jaw (biting down on the "spatula"), and a negative test result would normally be a gag reflex attempting to expel the foreign object.

Prevention
Unlike many infectious diseases, recovery from naturally acquired tetanus does not usually result in immunity to tetanus. This is due to the extreme potency of the tetanospasmin toxin; even a lethal dose of tetanospasmin is insufficient to provoke an immune response. Tetanus can be prevented by vaccination with tetanus toxoid.

A person recovering from tetanus should begin active immunization with tetanus toxoid during convalescence. The tetanus toxoid is a formalin-inactivated toxin, with an efficiency of approx. 100%. The DTaP vaccine includes tetanus, diphtheria and pertuses toxoids; it is routinely given in the US during childhood. After 7 years of age, only Td needs to be administered. Because the antitoxin levels decrease over time, booster immunization shots are needed every 10 years

After the injury or any kind of surgery as precaution anti tetanus serum (ATS) is given. Antitoxin therapy with human tetanus immune globulin; inactivates circulating toxin but does not counteract that which is already bound

Medical treatment
Medical treatment has two aims: limit growth and eventually kill the infecting C. tetani and thus eliminate toxin production; the second aim is to neutralize any toxin that is formed. If the toxin has already affected the patient, the two aims are still important, but supportive measures will be needed for the patient. Wound cleansing to remove any obvious bacteria collections (abscesses) or foreign bodies; if the patient is exhibiting any toxin-related problems

TIG (tetanus immune globulin) is usually administered first and wound care is delayed for a few hours while the TIG neutralizes toxin because infected wounds, when manipulated, may release more toxin. Antibiotics (for example, metronidazole [Flagyl, Flagyl 375, Flagyl ER], penicillin G or doxycycline [Adoxa, Alodox, Avidoxy, Doryx, Monodox, Oracea, Oraxyl, Periostat, Vibramycin, Vibramycin Calcium, Vibramycin Monohydrate, Vibra-Tabs]) to kill the bacteria, tetanus booster shot, if necessary, and occasionally, antitoxin (termed or TIG) to neutralize the toxin

Supportive measures: Pain medicine as needed Sedatives such as diazepam (Valium) to control muscle spasms and muscle relaxants Ventilator support to help with breathing in the event of spasms of the vocal cords or the respiratory muscles IV rehydration because, as muscles spasm constantly, increased metabolic demands are placed on the body