tetanus

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TETANUS:

TETANUS . Dr.Abhijit Gogoi University of Fiji

TETANUS:

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

Epidemiology:

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

2012 global figures :

2012 global figures   4'649 reported cases        61'000 estimated deaths (2011)        75% reported TT2+ coverage (among pregnant women)

Introduction:

Introduction Primary symptoms by- tetanospasmin, a neurotoxin produced by the Gram-positive, obligate anaerobic bacterium Clostridium tetani. Infection generally occurs through wound contamination, & often involves a cut or deep puncture wound.

Introduction:

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:

Clostridium tetani Cl.tetani is widely distributed in soil & in intestine of human beings & animals. They cause tetanus in both man & animal.

Morphology:

Morphology Gram-positive, 4-8 µm×0.5µm bacillus. Has straight axis, parallel sides & rounded ends. Occurs singly & occasionally in chains.

Morphology:

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

Cultural characteristics:

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

Spore:

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.

Resistance:

Resistance Spore resistance to heat show strain variation. Majority are killed by boiling for 15min. Some withstand boiling for 3hr & dry heat at 160 °C for 1hr. Spores can survive in soil for years & are resistant to most antiseptics. Not destroyed by 5% phenol or 0.1% HgCl 2 solution in 2 weeks or more.

Susceptibility:

Susceptibility Autoclaving at 121 °C for 15min kills the spores readily. Iodine(1% aqueous soon) and H 2 O 2 (10 volume) kills spores within few hours.

Toxins:

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

Tetanolysin:

Tetanolysin Heat & O 2 labile hemolysin. Cause red cell lysis. Pathogenic role not clear. May act as leucocidin.

Tetanospasmin:

Tetanospasmin O 2 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:

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

1.Local tetanus:

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:

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:

3.Generalised tetanus Most common form(80% of cases). Presents with a descending pattern. 1 st 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:

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

Opthisthotonus:

Opthisthotonus Back spasm seen in tetanus

4.Tetanus neonatorum:

4.Tetanus neonatorum It is the generalised tetanus that occurs in newborn infants. Occurs in infants of non-immunised mothers.

Tetanus neonatorum:

Tetanus neonatorum Occurs from infection of un-healed umbilical stump particularly when stump is cut with non-sterile instrument. Very poor prognosis

Laboratory diagnosis:

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:

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

PREVENTION :

PREVENTION

PREVENTION :

PREVENTION ACTIVE IMMUNIZATION. DPT AND TETANUS TOXOID.

Active immunization 1st dose 6wks 2nd dose 10 wks 3rd dose 14 wks 1st booster 18mts 2nd booster 5yrs 3rd booster 10yrs:

Active immunization 1 st dose 6wks 2 nd dose 10 wks 3 rd dose 14 wks 1 st booster 18mts 2 nd booster 5yrs 3 rd booster 10yrs

Antibiotic prophylaxis:

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.

Prophylaxis:

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

Surgical Prophylaxis:

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

Antibiotic prophylaxis:

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:

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

Treatment:

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

Prevention & control:

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 5 yrs. 5.TT boosters at 10 & 16 yrs.

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