Lecturer : Dr.

Aidaruus A/llaahi Muhudin

 INTRODUCTION

 A nervous system disorder characterized by painful muscle

spasms.

 Caused by Clostridium tetani obligate intracellular spore

forming anaerobe.

 Spores found in soil, house dust, animal intestine.

 Enter normal tissues and persist for several months.

 Germinate under anaerobic conditions and produce toxin

C. tetani: key characteristics
Large, spore-forming, motile, obligate anaerobic
bacillus (see below).
Ferments: proteins or amino acids.
Produces: acetic acid, fatty acids, NH3, CO2, H2, and a
strong exotoxin.
Tetanospasmin, a powerful neurotoxin.
Sporulated Vegetative
 TETANOSPASMIN
 Inhibits release of neurotransmitters (GABA, Glycine).

 Reaches nerve end plates through blood and lymphatic.

 Centripetal spread to neurons.

 Increased muscle tone and reflex spasms.

 Once fixed cannot be removed.

 Recovery depends on sprouting of new nerve terminals.

Incubation Period
Varies from 1 day to several months.
It is defined as the time from injury to the first
symptom.
Period of onset
It is the time from first symptoms to the reflex
spasm.

An incubation period of 4 days or less

or
A period of onset of less than 48 hr is associated
with the development of severe tetanus.
pathogenesis
1. C. tetani enters body 2. Stays in sporulated
form until anaerobic
from through wound.
conditions are presented.

3. Germinates under 4. Tetnospasmin spreads

using blood and lymphatic
anaerobic conditions and
system, and binds to motor
begins to multiply and neurons.
produce tetnospasmin.

6. Binds to sites responsible for

5. Travels along the axons inhibiting skeletal muscle
to the spinal cord. contraction.
CLINICAL FEATURES
Tetanus is an acute, potentially deadly, systemic
infection characterized by painful involuntary
contraction of skeletal muscles.
Other symptoms include

• Febrile (feverish), irritability, heavy

sweating
• A stiff neck, a tight jaw (lockjaw)
• Facial muscle spasms (risus sardonicus)
and difficulty swallowing
 CLINICAL FEATURES
In advanced stages, tetanus spasms can break bones.
Respiratory complications are common and death rates
high, especially in children and elderly persons.

Opisthotonos
Risus sardonicus
(spastic paralysis of the back)
CLINICAL FEATURES
Incubation period:1-3 days to several months.

Signs and symptoms progress for 2 weeks after

onset.
Trismus or lockjaw
Tonic muscle contraction.
Painful tetanic contractions or spasms.
Apnea
Dysphagia
Autonomic over activity

No impairment of consciousness.

>270,000 cases worldwide per year
CLINICAL CLASSIFICATION

 Local: Tonic spasms in one extremity or body region

 Cephalic: seen with head injuries. Initial involvement of

cranial nerves .

 Neonatal: Infants within 14 days of birth. Due to poor

immunization of mother and infection of umbilical
stump.

 Generalized: involvement of entire body musculature

Signs and Symptoms
Other symptoms include:
 Drooling
 Excessive sweating
 Fever
 Hand or foot spasms
 Irritability
 Swallowing difficulty
 Uncontrolled urination or defecation
 CLASSIFICATION (SEVERITY)
 Grade 1(Mild): Mild trismus, generalized
spasticity.
 No resp. embarrassment or dysphagia.

 Grade 2(Moderate):Well marked rigidity,

moderate trismus, short lasting spasms.

 Grade 3 (Severe): Gen. spasticity, severe

trismus, reflex or spontaneous prolonged
spasms, resp. distress apnea, dysphagia.

 Grade 4 (Very Severe): Grade 3 plus violent

autonomic disturbances, labile blood pressure,
heart rate, profuse sweating.
 Diagnosis
 There are currently no blood tests that can be
used to diagnose tetanus.
 Diagnosis is done clinically.
 The patient’s history may indicate inadequate
immunization.
The Spatula Test
This simple test involves touching the oropharynx
with a spatula or tongue blade.
Usually, this test causes a gag reflex with the patient,
and the patient tries to expel the spatula. (This means
they have tested negative.)
In tetanus, patients develop a reflex spasm of the
masseters and bite the spatula (a positive test).
Differential Diagnosis
 Hypoglycemia
 Meningitis
 Malaria
 Epileptic
 Masseter muscle spasm due to dental abscess
 Rabies
 Hysteria
Principle of Treatment
1. Neutralization of unbound toxin with Human
tetanus immunoglobulin
2. Prevention of further toxin production by
-Wound debridement
-Antibiotics (Metronidazole) and (Penicillin G )
-Diazepam ; Most commonly used drug for
treatment of tetanic spasms and tetanic seizures.
 3. Control of spasm
- Nursing in quiet environment
- avoid unnecessary stimuli
- Protecting the airway
 4. Supportive care
- Adequate hydration
- Nutrition
- Treatment of secondary infection
- prevention of bed sores.
-NG tube for feeding
Complications
Long bone fractures
Glenohumeral and temporomandibular joint
dislocations
Adverse effects of autonomic instability, such as
cardiac dysrhythmias and hypertension
Malnutrition
Coma, neuropathies, and psychological after
effects
Thanks