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TETANUS

By
GUMILAR GALIH P

TETANUS
Tetanus is a
medical condition
characterised by
prolonged
contraction of
skeletal muscle
fibres.

Introduction
Primary symptoms by-tetanospasmin, a
neurotoxin produced by the Grampositive, obligate anaerobic bacterium

Clostridium tetani.
Infection generally occurs through wound
contamination, & often involves a cut or
deep puncture wound.

Introduction
As the infection progresses, muscle
spasms in the jaw develops, hence the
common name, lockjaw.
This is followed by difficulty swallowing &
general muscle stiffness & spasms in
other parts of the body.
Infection can be prevented by proper
immunisation & by post-exposure
prophylaxis.

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, 48m0.5m bacillus.


Has straight axis, parallel
sides & rounded ends.
Occurs singly &
occasionally in chains.
Young cultures are
strongly Gram positive but
older cells show variable
staining & may be even
Gram negative.

Morphology
It is capsulated & motile with peritrichate
flagella (except typeVI Cl. tetaninonflagellar strain).
Young cultures are strongly Gram positive
but older cells show variable staining &
may be even Gram negative.

Cultural characteristics
It is an obligatory anaerobe (grows only in
absence of oxygen).
Optimum temparature-37C & pH-7.4.
It grows on ordinary media.

Cultural characteristics
1.Robertsons cooked meat medium:
turbidity & some gas formation. The meat
is not digested but turns black on
prolonged incubation.
2.Blood agar: fine translucent film of
growth. hemolysis is produced, which
later develops into hemolysis, due to the
production of hemolysin (tetanolysin)

Cultural characteristics
3.Deep agar shake cultures: spherical
fluffy balls, 1-3mm in diameter, made of
filaments with radial arrangement.
4.Gelatin stab culture: fir tree appearance
with slow liquefaction.

Spore
The spores are
spherical, terminal &
bulging, giving the
bacillus the
characteristic
drumstick
appearance.
Morphology depends
on stage of
development.
Young spore may be
oval rather than
spherical.

Biochemical reactions

Feeble proteolytic but no saccharolytic property.


Forms indole.
MR & VP negative.
H2S is not formed.
Nitrates are not reduced.
Gelatin liquefaction-slow.
Greenish fluorescence produced on media
containing neutral red.

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% HgCl2
solution in 2 weeks or more.

Susceptibility
Autoclaving at 121C for 15min kills the
spores readily.
Iodine(1% aqueous soon) and H2O2 (10
volume) kills spores within few hours.

Toxins
All types produce same toxins which
are pharmacologically &
antigenically identical.
Plasmid mediated.
1.Tetanolysin
2.Tetanospasmin

Tetanolysin

Heat & O2 labile hemolysin.


Cause red cell lysis.
Pathogenic role not clear.
May act as leucocidin.

Tetanospasmin
O2 stable & heat labile neurotoxin.
Good antigen & specifically
neutralised by antitoxin.
Similar to botulinum toxin in str.
Gets toxoided spontaneously or in
presence of formaldehyde.

Pathogenesis
Usual mode of infection-Penetrating
injury.
Germination & toxin production
occurs only in favorable conditionOR potential, devitalised tissues,
foreign bodies, concurrent infection.
Resembles strychnine poisoning

Antigens
All strains share common somatic (O)
antigen.
On basis of flagellar (H) antigen 10 types(
to X) are recognised by agglutination
tests.
Type VI is non-flagellated strain.

1.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.

2.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.

3.Generalised tetanus
Most common form(80%
of cases).
Presents with a
descending pattern.
1st sign is trismus(lockjaw)
-due to spasm of masseter
muscles.
Followed by stiffness of
the neck, difficulty in
swallowing, rigidity of
abdominal muscles.

Risus sardoricus
Characteristic
sardonic smile in
tetanus
Results from
sustained contraction
of facial muscles.

Opthisthotonus
Back spasm seen in
tetanus

4.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

Laboratory diagnosis
Diagnosis made based on
clinical presentation.
Specimen: Wound swab,
exudate or tissue from the
wound.
1.Direct smear & gram
staining
2.Culture
3.Animal inoculation

Direct smear
Show Gram-positive
bacilli with drum-stick
appearance.
Morphologically
indistinguishable from
similar nonpathogenic
bacilli.

Culture
Done in blood agar & aminoglycoside
blood agar under anaerobic condition or in
Robertsons cooked meat medium.
Produces swarming growth after 1-2 days
of incubation.
In contaminated specimen heat at 80C for
10mins before culture to destroy nonsporing organisms.

Animal inoculation
To demonstrate
toxigenicity.
Positive case : test
animal develops stiffness
& spasm of tail &
inoculated hind limb
within 12-24hrs which
spreads to rest of the
body. Death occurs in 1-2
days.

Prophylaxis
1.Surgical attention
2.Antibiotics
3.Immunisation-passive,active or
combined.

Surgical Prophylaxis
Aims at
removal of foreign bodies,
necrotic tissue & blood
clots,
To prevent an anaerobic
envt favourable for the
Clostridium tetanae

Antibiotic prophylaxis
Aims at destroying or inhibiting tetanus
bacilli & pyogenic bacteria in wounds so
that toxin production is prevented.
Long-acting Penicillin is the drug if
choice. Erythromycin is an alternative.
Bacitracin or neomycin can be applied
locally.
Has no action on toxin.

Immunisation
Combined immunisation:
Tetanus
immunoglobulin(TIG) &
tetanus toxoid are given
on different arms.
Provides both passive &
long-lasting immunity.

Treatment
Isolate pt. from noise &
light which may provoke
convulsions.
Followed by supportive
care.
TIG is infused.
Antibacterial therapy
started.

Epidemiology
World wide
distribution- higher
in developing
countries due to
warm climate,
unhygienic practices
& poor medical
services.

Prevention & control


By active immunisation
with tetanus toxoid.
1.TT-2 doses for pregnant
women,
2.DPT at 6, 10, 14 weeks
after birth,
3.DPT booster at 18 months
4.DT at 5yrs.
5.TT boosters at 10 & 16 yrs.

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