Contents
1. Overview
2. Causative agent
3. Symptoms
4. Who is at risk
5. Types of tetanus
6. Diagnosis
7. Pathophysiology
8. Prevention
9. Treatment
10. Case study
I. Introduction
II. Background
III. Incidence of injury
IV. Treatment
V. Observation
VI. Recovery
Overview
Tetanus is a non-infectious bacterial disease that affects the body
through cuts and abrasions. These cuts and abrasions are the
reason why tetanus is closely associated with rusted nails and
metal. The toxins released by the bacterium cause damage to the
interneurons which assist in processes that range from punching
a wall to breathing.
Before widespread vaccination, Tetanus was a major cause of
mortality for newborns and mothers after childbirth. Tetanus killed
hundreds of thousands annually, with estimates of over 300,000
deaths per year in the early 20th century. Modern medicine has
helped reduce the widespread occurrence of Tetanus through
better medical hygiene, combination of vaccines and improved
medical care
Causative agent
Tetanus comes from an ancient Greek word “tetanos” meaning “to stretch”.
Clostridium Tetani bacteria are often found in soil, manure and dead
leaves. They are also found in contaminated heroin. These bacteria are
gram positive, colorless and drumstick shaped.
They are found as endospores, which can survive for many years. When a
person cuts themselves with a rusted metal, it creates uneven, rough
wounds with a lot of deoxygenated dead tissue onto which the tetanus
bacterium can latch onto. The drumstick shaped endospore germinates
inside the body releasing deadly tetanus toxin. This toxin damages the
interneurons causing uncontrollable muscle spasms.
A common misconception is that rust itself is the cause which is not true, as
tetanus infected metals (which are often rusted) is the causative.
Symptoms
Typically, the incubation period from entering of C. Tetani into the
body and showing symptoms is an average period of 7 to 21 days.
Within 7 to 10 days, patients begin to experience general aches,
trouble swallowing and lockjaw (Trismus).
As the toxin spreads, there’s a frightening arching of the back. If left
untreated, within 72 hours, the muscles associated with the chest and
windpipe become affected leading to suffocation, and death.
Other symptoms include
neck rigidity
Restlessness
reflex spasms. The spasms spread in descending fashion starting
from the jaw and facial muscles towards the limb.
The patient also may experience high fever, increased blood pressure
and heart rate, drooling and seizures.
Who is at risk?
C. Tetani bacteria enters the body through trivial injuries, animal/human
bites, burns and even due to parental drug abuse. A wound that is puncture
type or a wound that shows a lot of devitalized tissue, especially if
contaminated with soil or manure is at great risk for tetanus.
1. Newborn babies, female during delivery or abortions: Over
20,000 infants still die of tetanus every year. If mothers are
unvaccinated, C. tetani bacteria can infect their umbilical stump.
2. Agricultural workers, people living in rural areas and
unhygienic conditions are at greater risk due to usual contact
with possibly infected objects.
3. Drug abusers are at a higher risk for tetanus because if the
needles are not sterilized, or if the drug is contaminated with
spores of c. Tetani, then the bacteria can enter the bloodstream.
4. Unvaccinated individuals are more prone to the disease
especially if they have inadequate immunization.
Types of tetanus
1. Generalized tetanus: Most common type of tetanus, affecting the
whole body. Severe cases cause Opisthotonos (arching of the back)
and difficulty in breathing.
Opisthotonos
2. Cephalic tetanus: A rare form of tetanus that affects the head and
neck. Usually associated with head injuries. Often results in localized
paralysis of facial muscles
3. Maternal tetanus: Tetanus occurring during pregnancy or within 6
weeks of any type of pregnancy termination usually resulting due to
septic procedures during delivery.
4. Neonatal tetanus: Children born to inadequately immunized mothers
are prone to the disease after unsterile treatment of umbilical stump.
The newborns show poor feeding, rigid body and spasms.
5. Local Tetanus: Manifestations are confined to the area near the
wound, resulting in restriction of skeletal muscles near the area. The
affected person has a high likelihood of making a full recovery with
minimal impact on their quality of life and functioning. (Excellent
prognosis)
Diagnosis
● There are no blood tests for the diagnosis of tetanus.
Diagnosis is done clinically on the basis of generalized
muscular rigidity, opisthotonos and/or spasms.
● An assay for antitoxin levels are not readily available, however,
a level of 0.01 IU/mL or greater amount of serum indicates the
body is adequately immunized and thus, lesser chance for
tetanus.
Clinical test for tetanus:
➔ Spatula test: the posterior pharyngeal wall is touched with a
soft-tipped instrument and the effects are observed. 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.
Pathophysiology
Inhibitory neurons release neurotransmitters like GABA
(gamma-aminobutyric acid) or glycine. These neurotransmitters function to
inhibit neural activity, promoting muscle relaxation and preventing
excessive excitation.
Tetanus toxin, produced by Clostridium tetani, enters the body through a
wound and is taken up at the neuromuscular junction (motor end plate). It is
then transported to the central nervous system (CNS) via retrograde axonal
transport. Once in the CNS, the toxin acts primarily on inhibitory
interneurons by preventing the release of inhibitory neurotransmitters such
as GABA and glycine from presynaptic terminals. This leads to unopposed
excitatory signals, resulting in muscle stiffness, spasms, and the
characteristic symptoms of tetanus. The toxin does not act on postsynaptic
neurons directly.
Localized tetanus occurs when Tetanus neurotoxin (TeNT) only affects the
muscle groups close to the injury site. There is no CNS involvement, and
the symptoms are usually mild, with localized muscle spasms caused by a
dysfunction in the surrounding neurons.
In Generalized tetanus,
1. TeNT enters the neurons of Peripheral nervous system.
2. From there, it moves to the site of the wound, and then back to
inhibitory neurons in the Central nervous system through the
bloodstream by retrograde transmission.
3. There, it prevents the release of Gamma amino butyric acid (GABA)
and glycine responsible for muscle relaxation, resulting in spasms.
These spasms generally affect the jaw muscles first causing an
inability to open the jaw (lockjaw).
4. As the neurotransmitter is blocked, other muscles are also involved,
causing painful extreme spasms that causes tendons to break and
bones to fracture.
Neonatal tetanus occurs when the umbilical stump of the newborn is
infected with tetanus spores. Neonatal tetanus is a major cause of death in
countries with poor and unsanitary medical conditions.
Prevention
Unlike many infectious diseases, recovery from naturally acquired tetanus
does not usually result in immunity. This is because of the extreme potency
of tetanospasmin toxin. This toxin will become lethal before it induces an
immune response. But we can take the measures to reduce the risk of
tetanus by
1. Taking the tetanus toxoid vaccine: Adults are recommended to
take the vaccine every 10 years. The vaccine is also given to
individuals with a puncture wound who are unsure of the last time
they were vaccinated. In children under the age of seven, the tetanus
vaccine is often administered as a combined vaccine, DPT/DTaP
vaccine, which is a 3 in 1 vaccine against diphtheria, pertussis and
tetanus.
2. Practice good wound care:Seek immediate first aid for cuts and
injuries. Even minor injuries like animal/human bites, blisters and
splinters should be taken care of immediately.
3. Wash your hands to prevent the entering of bacteria through any
wounds.
Treatment
1. Admit patients to ICU
2. Maintain a quiet and peaceful environment for the patient to not
provoke spasms
3. Endotracheal intubation may cause laryngospasms (involuntary
spasms in the throat usually because of tightness in the throat which
blocks the path of airflow). Therefore, emergency tracheostomy
(creating a hole (stoma) in the trachea for the airflow) is done.
FURTHER MEDICAL PROCEDURES:
● TOXIN REMOVAL
WHO recommends 500 units of TIG (tetanus immune globulin) as
soon as possible and in addition, injection of age appropriate TT
vaccine.
● PREVENT FURTHER TOXIN PRODUCTION
Dead tissues (about 2 cm) are removed surrounding the wound in
order to create an aerobic condition where c.tetani bacteria cannot
survive. Abscesses are cut and pus is removed. Wound
manipulations are done after antitoxin injection to prevent the release
of tetanospasmin into the bloodstream.
● ANTIBIOTICS
Penicillin G was preferred as the drug to prevent the growth the
Clostridium tetani, but now metronidazole is used.
● SPASM CONTROL
Environment must be quiet and dark. Sedative hypnotic drugs are the
most reliable for tetanus treatment. Benzodiazepines are the most
effective as they enhance GABA’s action leading to muscle
relaxation. Diazepam depresses all levels of CNS including limbic.
Baclofen is another muscle relaxant which enhances GABAergic
inhibition in the CNS which reduces the muscle spasms.
● SUPPORTIVE CARE
Patients may be immobile in the Intensive Care Unit for prolonged
periods much of which is on mechanical ventilation. Early
tracheostomy is preferred more than endotracheal intubation due to
better tracheal suctioning in the latter.
Nutritional support may be provided through enteral feeding (a tube is
directly providing the nutrients to the digestive tract)
Anticoagulants like heparin should be administered early to prevent
thromboembolism (movement of blood clot which blocks blood flow)
CASE STUDY
Introduction
Tetanus remains a fairly common problem in developing countries
where the people of poverty come in contact with infected metals in
their day to day lives. The diagnosis of Tetanus is fairly easy.
However, its cephalic form is a rare but life threatening condition
caused by Clostridium Tetani, which if untreated could potentially lead
to death.
Background
Sumitha is a 36 year old agricultural farmer from southern India. As
she comes from a poorer background, she is unable to afford clean
water and nutritious food. Her immunization is therefore inadequate.
The incident of injury
Sumitha cut herself on a barbed wire while working on the fields. She
washed her face with water from a pond, unaware that the pond
water was infested with C. tetani bacteria. She treated the wound at
home, thinking it was not that serious.
A week later, Sumitha began to experience mild pain in the jaw, but
she believed that it was due to the fatigue from her work. However,
the pain escalated and within 48 hours, she was unable to open her
mouth to eat food and speak. She started to develop intense spasms
on her neck and jaw, a classic sign of tetanus.
The volunteer doctors from a non-profit healthcare clinic fortunately
reached out to their home. By this time, she had undergone facial
paralysis and distortion.
She was immediately diagnosed with Tetanus and transported to a
nearby hospital. Transportation charges were covered by charity.
Treatment
● She was admitted to the ICU immediately and treated with
Penicillin G
● Tetanus immunoglobulin (TIG) was supplied to neutralize the
circulation of tetanospasmin in the bloodstream
● Emergency tracheostomy was performed to ensure airflow
● Muscle relaxants like benzodiazepines were supplied to
manage the spasms
● Wound is manipulated, debridement is performed to remove
any excess bacteria from the wound area
Observation
When Sumitha was admitted, she was experiencing lockjaw,
hypersensitivity to light and sound and saliva was leaking through the
mouth.
Her CT scan showed no peculiar findings as the changes brought about by
Tetanus is on the nerves and therefore does not change the brain structure
or tissues which can be captured using a CT scan.
Muscle relaxants calmed down the intense spasms of the patient.
Recovery
The recovery process of the patient was gradual. Normally, cephalic and
neonatal tetanus has a poorer prognosis.. She spent a total of a month and
a half in recovery in the ICU, all of the costs covered by the local funding. In
this time, she also underwent physiotherapy to completely overcome the
paralyzation. She and her family were educated on Tetanus by the lead
surgeon. Sumitha is grateful for the medical intervention that saved her life.
Conclusion
Tetanus was, in the past, a terrifying cause of high mortality rate among
women, working men and even infants. Without medical intervention, the
mortality rate of Tetanus is said to be 100 percent.
Many infants still die of tetanus, usually from low income families that
cannot afford medical treatment, village areas that are possibly even
unaware of the disease, and areas where vaccine access is limited.
Vaccines are crucial for preventing deadly diseases like Tetanus,
highlighting the need to expand medical access in developing and rural
areas to save lives.
Afzi A Kalam
XII C2
