Tetanus- Dr.M.A.Aleem Siddiqui

Tetanus is an acute disease induced by the endotoxin of Clostridium tetani. It is clinically characterized by muscular rigidity which persists through out illness punctuated by painful paroxysmal spasms of the voluntary muscles. Especially the masseters (trismus or lock jaw),the facial muscles (risus sardonicus), the muscles of the back and neck (opisthotonus) and those of the lower limbs and abdomen.

What is Tetanus?

The word tetanus is derived from Greek words -“tetanos and teinein”, meaning rigid and stretched, which describe the condition of the muscles affected by the toxin, tetanospasmin, produced by Clostridium tetani .

Agent factors

Clostridium tetani is a gram positive, anaerobic, spore bearing organism, the spores are terminal and give the organism a drum stick appearance.

Spores germinate under anaerobic conditions and produce a potent exotoxin tetanospasmin.

Mode of transmission

• Infection is acquired by contamination of wounds with tetanus spores.

• The range of injuries and accidents which may lead to tetanus comprise a trivial pin prick, skin abrasion, puncture wounds, burns, human bites, animal bites and sting, unsterile surgery, unsterile division of umbilical cord, compound fractures etc….

Incubation Period• It is defined as the time from injury to the first

symptom.• The incubation period is usually 6 to 10 days.• However, it may be as short as one day or as long as

several months.• Long incubation is probably explained by the spores

lying dormant in the wounds. Incubation is also prolonged by prophylaxis

Types of tetanus• TRAUMATIC • PUERPERAL• OTOGENIC • IDIOPATHIC• TETANUS NEONATORUM

Complications of tetanus

• Laryngospasm• Fractures• Hypertension• Nosocomial infections• Pulmonary embolism• Aspiration• Death

Pathogenesis

1. C. tetani enters body through wound.

2. Stays in sporulated form until anaerobic conditions

develop.

3. Germinates under anaerobic conditions and

begins to multiply and produce tetnospasmin.

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.

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 muscles are involved, apnoea may occur.

Signs and SymptomsOther symptoms include:

Drooling Excessive sweating Fever Hand or foot spasms Irritability Swallowing difficulty Uncontrolled urination or defecation

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 (Metronidazole)

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.

Prevention Tetanus is completely preventable

by active tetanus immunization.

Immunization is thought to provide protection for 10 years.

Begins in infancy with the DTP series of shots. The DTP vaccine is a "3-in-1" vaccine that protects against diphtheria, pertussis, and tetanus.

Prevention Can be achieved by active immunization by tetanus

toxoid (5 doses – 0 day, 1 month, 6 month, 1 year, 1 year).

Older teenagers and adults who have sustained injuries, especially puncture-type wounds, should receive booster immunization for tetanus if more than 10 years have passed since the last booster.

Clinical tetanus does not produce immunity to further attacks. Therefore, even after recovery, patients must receive a full course of tetanus toxoid.

Case Presentation Name of the patient: Khushi Father’s name: Maruthi Age: 3 yrs. Sex: Male Address: Bidar Dist., Karnataka.

Chief complaints

Unable to open mouth since 4 days. Stiffing of left side of the neck since 2 days. Spasm of both hands and both leg muscles since 2

days.

History of present illness Patient was asymptomatic 20 days back, then he got

injury on his left leg. He was given first aid. But 4 days back, the parents noticed that the child

was feeling difficulty in swallowing followed by difficulty in opening mouth and stiffening of muscles of left side of the neck.

Then he was taken to Bidar institute of medical sciences in Bidar, from where he was referred to Sir Ronald Ross institute for tropical and communicable diseases, Hyderabad.

Past medical history Patient had normally achieved his developmental

milestones. No H/O koch’s disease No H/O similar conditions

Family History Both the parents are healthy and alive. He has two sisters, one elder and one younger, and

both are healthy and alive.

Differential Diagnosis

• Strychnine poisoning is the only condition that truly mimics tetanus. However, a number of conditions (eg, dental or other local infections, hysteria, neoplasms, and encephalitis) may cause trismus, and these must be differentiated these conditions from tetanus

Final Diagnosis

Tetanus.

Treatment Tetanus Immunoglobulin I.P. (Human) 2000 I.U. Metronidozole 100ml i.v. I.V. fluids Inj. Diazepam (slow i.v.)