tetanus

dr. Rohmania Setiarini

Tetanus is an acute,often fatal,disease caused by
an exotoxin produced by the bacterium Clostridium
tetani. But prevented by immunization with tetanus
toxoid.
It is characterized by generalized rigidity and
convulsive spasms of skeletal muscles.
epidemiology
Tetanus is an international health problem, as spores are
ubiquitous. The disease occurs almost exclusively in persons
who are unvaccinated or inadequately immunized.

Tetanus occurs worldwide but is more common in hot,
damp climates with soil rich in organic matter.
More common in developing countries.
Clostridium tetani
Cl.tetani is widely
distributed in soil & in
intestine of human
beings & animals.
They cause tetanus in
both man & animal.
Morphology
Gram-positive, 4-
8m0.5m bacillus.
Anaerob
Has straight axis, parallel
sides & rounded ends.
Occurs singly &
occasionally in chains.
sensitive to heat and cannot
survive in the presence of
oxygen
Resistance
Spore resistance to heat show strain variation.
Majority are killed by boiling for 15min.
Some withstand boiling for 3hr & dry heat at
160C for 1hr.
Spores can survive in soil for years & are resistant
to most antiseptics.
Not destroyed by 5% phenol or 0.1% HgCl
2

solution in 2 weeks or more.
Susceptibility
Autoclaving at 121C for 15min kills the spores
readily.
Iodine(1% aqueous soon) and H
2
O
2
kills spores
within few hours.
Toxins
All types produce same toxins which are
pharmacologically & antigenically
identical.
Plasmid mediated.
1.Tetanolysin
2.Tetanospasmin
Tetanolysin
Heat & O
2
labile hemolysin.
Cause red cell lysis.
Pathogenic role not clear.
.

Tetanospasmin
O
2
stable & heat labile neurotoxin.
Good antigen & specifically neutralised by
antitoxin.
Similar to botulinum toxin
Incubation Period
Varies from 1 day to several months.
It is defined as the time from injury to the
first symptom.
Period of onset
A period of onset of less than 48 hr is
associated with the development of severe
tetanus.
pathogenesis
1. C. tetani enters body
from through wound.
3. Germinates under
anaerobic conditions and
begins to multiply and
produce tetnospasmin.
2. Stays in sporulated
form until anaerobic
conditions are presented.
4. Tetnospasmin spreads using
blood and lymphatic system,
and binds to motor neurons.
5. Travels along the axons
to the spinal cord.
6. Binds to sites responsible for
inhibiting skeletal muscle
contraction.

the toxin acts :

Blocks the release of inhibitory
neurotransmitters (glycine and gamma-amino
butyric acid) across the synaptic cleft, which is
required to check the nervous impulse.

If nervous impulses cannot be checked by
normal inhibitory mechanisms, it leads to
unopposed muscular contraction and spasms
that are characteristic of tetanus.
Local tetanus
Persistent spasm of musculature at site of primary
infection (injury site).
Contractions persist for weeks before subsiding.
Its generally milder, 1% cases are fatal but may
precede the generalised tetanus.
Cephalic tetanus
Primary site of infection is head injury or otitis
media.
Associated with disfunction of 1 or more cranial
nerves, most commonly facial nerve.
Poor prognosis.
Generalised tetanus
Most common form(80% of cases).
Presents with a descending pattern.
1
st
sign is trismus(lockjaw) -due to
spasm of masseter muscles.
Followed by stiffness of the neck,
difficulty in swallowing, rigidity of
abdominal muscles.


Tetanus neonatorum
It is the generalised tetanus
that occurs in newborn
infants.
Occurs in infants of non-
immunised mothers.
Tetanus neonatorum
Occurs from infection of
un-healed umbilical stump
particularly when stump is
cut with non-sterile
instrument.
Very poor prognosis
Clinical features
Risus sardonicus: Contraction of the muscles at the angle
of mouth and frontalis
Trismus (Lock Jaw): Spasm of Masseter muscles.
Opisthotonus: Spasm of extensor of the neck, back and
legs to form a backward curvature.
Muscle spasticity
Prolonged muscular action causes sudden, powerful,
and painful contractions of muscle groups. This is
called tetany. These episodes can cause fractures and
muscle tears.

If respiratory muscle is involved apnoea.
Other symptoms include:
Excessive sweating
Fever
Hand or foot spasms
Irritability
Swallowing difficulty

Risus sardonicus
Characteristic sardonic
smile in tetanus
Results from sustained
contraction of facial
muscles.
Opthisthotonus
Back spasm seen in
tetanus
Diagnosis
There are currently no blood tests that can
be used to diagnose tetanus. Diagnosis is
done clinically.
Principle of Treatment
1. Neutralization of unbound toxin with
Human tetanus immunoglobulin
2. Prevention of further toxin production by
-Wound debridement
-Antibiotics
3. Control of spasm
- Nursing in quiet environment
- avoid unnecessary stimuli
- Protecting the airway
4. Supportive care
- Adequate hydration
- Nutrition
- Treatment of secondary infection