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TETANUS

Tetanus is an acute disease caused


by an exotoxin produced by
Clostridium tetani.
It is characterized by generalized
rigidity and convulsive spasms of
skeletal
muscles.
The
muscle
stiffness usually involves the jaw and
neck and then becomes generalized.

TETANUS
Infection generally occurs through wound
contamination and often involves a cut or
deep puncture wound.

How serious is tetanus?


Tetanus has a high fatality rate: about 10%
of reported cases result in death.

TETANUS
C. tetani is an anaerobic gram-positive

bacillus
( spore-forming bacteria)
Spores found in soil, dust, animal feces;
may persist for months to years
Tetanus is not spread from person to person
Spores are introduced into tissues after a
penetrating injury.

Neurotoxins in tetanus
Clostridium tetani produces two exotoxins:
1.tetanolysin
(the function is not known)
2.tetanospasmin
(a neurotoxin which causes the clinical
manifestations)

Tetanus
Tetanus toxin blocks inhibitory
nerve impulses, by preventing the
release of inhibitory
neurotransmitters GABA (gammaaminobutyric acid) and glycine.

http://www.bilkent.edu.tr/~bilheal/aykonu/ay2005/mart05/tetanoz.htm

Pathogenesis
Tetanus toxin produced in a wound can
spread centrally via intra-axonal transport
along motor nerves to the spinal cord;
it may also spread hematogenously.
Toxin binds in central nervous system and
interferes with neurotransmitter release to
block inhibitor impulses

TETANUS
Tetanus - is rare in industrialized countries
because of the widespread use of active
immunization.
In the United States, fewer than 50 cases are
reported annually; at least 87% occur in
inadequately immunized persons, and 35% occur
in persons older than 60 years, which emphasizes
the need to maintain immunity in older adults.

TETANUS
Tetanus may also occur in association with:
-pregnancy (postpartum and postabortion tetanus),
-surgery (postoperative tetanus),
-burns, vaccination, intramuscular injections, gangrene,
chronic skin ulcers, dog bites, penetrating eye injuries, and
narcotics addiction
-umbilical stump infection in newborns (neonatal tetanus)

In 10% to 20% of patients with tetanus, there is no history


of injury or evidence of an infected lesion

Pathogenesis
The incubation period between injury and onset of
symptoms ranges from 1 to 55 days. In more than
80% of patients, symptoms begin within 14 days.
The length of the incubation period is a valuable
prognostic sign in patients younger than 50 years:
- mortality is almost 100% when this period is
only 1 or 2 days but 35% to 40% when it is more
than 10 days.

Tetanus
Terms describing the initial stages of

tetanus include the incubation period (time


fran inoculation to the first symptoms) and
the period of onset (time from the first
symptom to the first generalized spasm)

The shorter these periods are, the higher the


risk of death is.

Tetanus Clinical Forms

1)
2)
3)

Clinical forms:
local (not common),
cephalic (rare),
generalized (most common, representing
80% of cases)
4) neonatal tetanus

Generalized tetanus
The usual presenting symptoms are:
- restlessness;
- pain caused by muscle spasm;
- stiffness of the back, neck, thighs and abdomen.
- difficulty in opening the mouth (trismus, or lockjawmasseter rigidity), the hallmark of tetanus; this is the
first symptom in more than 50% of patient
- risus sardonicus (facial spasm / sneering expression)

Generalized tetanus
The generalized spasm consists of
opisthotonic posturing with flexion of the
arms and extension of the legs.

During the spasm, the upper airway can be


obstructed, or the diaphragm may
participate in general muscular contraction.

Opisthotonus

TETANUS

TETANUS

Generalized tetanus
Sudden stimuli (e.g., bright light or noise)

can precipitate tonic seizure, accompanied


by diaphragmatic, intercostal, glottal, or
laryngeal spasm, and result in hypoxia and
respiratory arrest
Spasms may occur frequently and last for
several minutes.
Spasms continue for 34 weeks.

Generalized tetanus
Labile hypertension, tachycardia,
arrhythmias, profuse sweating, marked
intermittent vasoconstriction, tachypnea,
and hypotension may occur singly or in
varying combinations.

Generalized tetanus
The complications of tetanus are
respiratory arrest secondary to tetanic spasms,
pneumonia secondary to aspiration, pulmonary
emboli,
cardiac problems related to sympathetic
overactivity or to cardiomyopathy,
fractures of thoracic vertebrae caused by
violent spasms.

Cephalic tetanus
Is a rare form 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
Localized tetanus is characterized by intermittent

painful spasms of muscles in the same anatomic


area as the injury
The stiffness and spasms may persist for weeks in
the local area and then gradually abate.

Local tetanus may precede the onset of

generalized tetanus, but is generally milder.


Only about 1% of cases are fatal.

Neonatal tetanus
Generalized tetanus in newborns
It occurs through infection of unhealed
umbilical stump if mothers are inadequately
immunized.

Tetanus
Tetanus is diagnosed by clinical
observation. There are currently no blood
test that can be used to diagnose tetanus.

Laboratory findings
Blood counts, blood chemistries, and CSF
values are normal.
C. tetani is isolated from the wound in only
30% of cases, probably because of the
fastidious anaerobic requirements of the
organism.

Differential Diagnosis
Trismus may also be present in patients with
encephalitis, but in contrast to those with tetanus,
these patients are not fully conscious.
Acute strychnine poisoning is the only disease that
resembles tetanus.
Hepatic encephalopathy is sometimes associated
with prominent muscular stiffness and rigidity.

Treatment of tetanus
Treatment of tetanus is aimed at prevention
of muscle spasms and respiratory
complications, neutralization of circulating
toxin, and elimination of the source of the
toxin.

Tetanus antitoxin
Human tetanus immune globulin (HTIG) is
recommended for persons with tetanus.
TIG can only help remove unbound tetanus toxin.
It cannot affect toxin bound to nerve endings.
A single intramuscular dose of 5000 units is
generally recommended for children and adults,
with part of the dose infiltrated around the wound
if it can be identified.

Control of muscular spasms and


rigidity
Sedation requires prevent respiratory
depression
Diazepam is the drug of choice produces a
sedative effect without inducing depression
Magnesium intravenous infusion prevents
muscule spasm.

Control of sympathetic
overactivity
Propranolol and labetalol are examples of
beta-adrenergic blocking agents that have
been used in patients with tetanus to treat
marked sympathetic overactivity, including
hypertension, tachycardia, and profuse
sweating.

Antibiotic treatment

Metronidazole, in a 500 mg I.V. dose every 6


hours

Immunization
Infants should receive diphtheria-pertussistetanus (DPT) vaccine at 2 months of age.
Two additional doses are given at 4 and 6
months of age. A booster injection of DPT is
given at 18 months and 4-6 years
At 16 years of age, a booster dose of
combined adult-type tetanus and diphtheria
toxoids is administered.

Immunization
Teatanus-diphteria
vaccine is given
to adolescents and
adults as a booster
shot every 10 years.

Immunization
In the event of tetanus prone-injury a
booster dose of vaccine should be given if
more than 5 years have elapsed since last
dose.

Immunization
Adults who have not been immunized should

receive two doses of alum-precipitated tetanus


toxoid intramuscularly, 1 month apart, followed by
a booster dose after 6 months.
Patients with wounds that are contained with dirt or
feces and who have not received adequate active
immunization in the past 5 years or in whom
immunodeficiency is suspected should receive
passive immunization with HTIG (250-500 units,
intramusculary) in addition to active immunization.

Adult with classic signs of


tetanus

Child has painful muscle


contractions from tetanus

Baby has neonatal tetanus


with complete rigidity

Tetanus in a 46-year-old
man, Manila

Adult with tetanus

Baby has neonatal tetanus

Routine DTaP Primary


Vaccination Schedule
Dose
Primary 1
Primary 2
Primary 3
Primary 4

Age
2 months
4 months
6 months
15-18 months

Interval
--4 wks
4 wks
6 mos