TETANUS information from definition to treatment

Tetanus , clostridium tetani

1. Tetanus: A Persistent Global Health Threat Understanding the Causes, Risks, and Consequences of Tetanus By Darshan KM Group 20/10

2. Tetanus: A Persistent Global Health Threat Understanding the Causes, Risks, and Consequences of Tetanus Introduction Tetanus is a severe and potentially life-threatening infectious disease caused by the bacterium Clostridium tetani. With its spores found ubiquitous in the environment, tetanus poses a significant risk to individuals worldwide, particularly newborn babies, pregnant women, and adolescent males. Despite significant progress in reducing neonatal tetanus deaths, tetanus remains a pressing public health concern, especially in low-income countries. This presentation aims to provide an in-depth examination of tetanus, including its causes, symptoms, risks, treatment, and prevention strategies .

3. What is Tetanus? Tetanus is an acute infectious disease caused by spores of the bacterium Clostridium tetani. The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/feces of animals and humans, and on the surfaces of skin and rusty tools like nails, needles, barbed wire, etc." Spores are highly resistant to heat and most antiseptics Can survive for years Anyone can get tetanus, but particularly common and serious in: -Newborn babies -Pregnant women who have not been sufficiently immunized -Adolescent and adult males who undergo circumcision due to waning immunity .

4. Global Distribution: - Endemic Areas: Tetanus remains endemic in developing countries and regions with limited healthcare infrastructure. - High Incidence: The highest number of tetanus cases and deaths occur in South Asia, Sub-Saharan Africa, and Southeast Asia. - Low Incidence: In high-income countries (e.g., North America, Europe, Australia), tetanus cases are rare due to widespread vaccination and healthcare interventions. Key Statistics: - Global Deaths: Approximately 30,000 deaths from tetanus occur annually worldwide, with significant deaths in countries such as India and parts of Africa. - Declining Incidence: Globally, tetanus deaths have declined by over 90% since the 1980s due to immunization programs and improved medical care. - Neonatal Tetanus: Neonatal tetanus remains a major issue in areas with poor sanitation, lack of maternal vaccination, and unsterile childbirth practices.

5. Risk Factors : - Unvaccinated Populations: People who have not received tetanus vaccinations, especially in low-resource settings. - Wound Contamination: Deep puncture wounds, burns, or animal bites can introduce the tetanus bacteria   into   the   body. - Poor Hygiene: Inadequate hygiene during childbirth, particularly in rural areas, can lead to neonatal tetanus. - Age: The elderly and infants are more vulnerable to complications due to weakened immunity and insufficient vaccination. - Immune Suppression: People with weakened immune systems or those undergoing immunosuppressive therapy are at higher risk. -Seasonal Variation: Tetanus tends to have a seasonal pattern in some regions, with increased cases during the rainy season when wounds are more likely to become contaminated with soil or bacteria.

6. Transmission of Tetanus - Source of Infection: - Clostridium tetani, the bacterium that causes tetanus, is commonly found in soil, dust, and animal feces. - Entry into the Body: - Tetanus is not transmitted from person to person. - The infection occurs when Clostridium tetani spores enter the body through broken skin or wounds, such as: - Cuts - Puncture wounds (e.g., from stepping on a nail) - Burns - Surgical wounds - Animal bites - Unsterile needles (injection drug use or tattoos) - Contaminated umbilical cord (especially in neonates in unsanitary conditions) Anaerobic Environment: - The bacterium requires a low-oxygen environment to thrive, so it flourishes in deep or poorly oxygenated wounds where the bacteria can produce the toxin tetanospasmin. Not Transmitted by : - Tetanus does not spread through person-to-person contact, like the flu or cold. - Tetanus is not contagious.

7. PATHOPHYSIOLOGY OF TETANUS 1. Entry of the Bacteria: - Infection Source: Clostridium tetani is commonly found in soil, dust, and animal feces. The bacteria enter the body through contaminated wounds, particularly deep puncture wounds, cuts, or burns. - Anaerobic Environment: The bacteria thrive in low-oxygen (anaerobic) environments, such as deep tissue wounds where oxygen circulation is poor. 2. Production of Tetanospasmin: - Toxin Secretion: Once inside the body, Clostridium tetani produces tetanospasmin, a potent neurotoxin. The bacteria multiply locally at the site of infection. - Absorption into Bloodstream: The neurotoxin is absorbed into the bloodstream and then transported throughout the body, particularly targeting the central nervous system (CNS). 3. Neurotoxic   Effects: - Binding to Nervous Tissue: Tetanospasmin binds specifically to the presynaptic membranes of neurons in the spinal cord and brainstem. - Inhibition of Inhibitory Neurotransmitters: Tetanospasmin blocks the release of inhibitory neurotransmitters, specifically gamma-aminobutyric acid (GABA) and glycine. These neurotransmitters normally help control and limit the activity of motor neurons.

8. 4. Disruption of Neurological Signaling: - Excessive Excitation: By preventing the release of inhibitory signals, tetanospasmin causes excessive excitability of motor neurons. - Muscle Spasms: This overactivation leads to uncontrolled muscle contractions, resulting in muscle spasms and rigidity. - The initial symptom often seen is trismus (lockjaw), where the jaw muscles become stiff and the patient is unable to open their mouth. - Opisthotonus (arching of the back) and rigid, painful muscle contractions in other parts of the body are also common. 5. Spinal and Brainstem   Involvement: - Spinal Cord: The toxin primarily affects the spinal cord, causing spastic paralysis. The reflexes become exaggerated, and the muscles are constantly contracted. - Brainstem: The toxin also affects the brainstem, leading to problems with breathing (as respiratory muscles become rigid) and swallowing (as the muscles controlling the throat become paralyzed). - Autonomic Dysfunction: Tetanus can cause autonomic nervous system instability, resulting in high blood pressure (hypertension), tachycardia (increased heart rate), sweating, and fever.

9. 6. Progressive Symptoms: - Facial Muscles: The infection progresses to cause facial spasms, known as risus sardonicus, where the face is pulled back into a grimace-like expression due to constant muscle contraction. - Generalized Rigidity: Spasms spread to the rest of the body, including the limbs and trunk. This results in generalized muscle rigidity, making movement difficult and painful. 7. Complications: - Respiratory Failure: Severe muscle spasms in the chest and diaphragm can lead to respiratory failure, which is a leading cause of death in severe cases   of   tetanus.- Autonomic Instability: The disruption of autonomic functions can lead to arrhythmias (irregular heartbeats), labile blood pressure, and profuse sweating. - Severe cases: Prolonged muscle spasms can cause fractures, muscular injuries, and permanent disability. 8. Recovery: - Neurotoxin Action: The effects of tetanospasmin are not reversible. Recovery depends on the body’s ability to regenerate new nerve endings to bypass the toxin's effects. - Treatment: Early treatment with tetanus immunoglobulin (TIG) and antibiotics (to kill the bacteria) can help limit the spread of the toxin. Muscle relaxants and sedation are also used to control spasms and pain.

10. Clinical Manifestations of Tetanus - Initial Symptoms: - Incubation period: Symptoms appear 3-21 days after infection. - Local pain or tingling near the wound. - Muscle stiffness at the site of infection. Trismus (Lockjaw): - Mild to severe spasms of the jaw muscles. - Difficulty opening the mouth due to muscle rigidity in the lower jaw Risus Sardonicus ("Sardinian Grin"): - A grin caused by facial muscle spasms. - Characterized by a grimace-like facial expression due to muscle contractions. Opisthotonos: - Severe spasms of all muscles in the body. - Often results in the body arching backward, with head and heels touching the surface (rigid body posture).

11. Other main symptoms Affects Only Skeletal Muscles: - Smooth muscle and cardiac function remain unaffected, meaning the heart and organs work normally. Sympathetic Overactivity: - Drooling: Difficulty swallowing leads to saliva buildup. - Excessive sweating : Uncontrolled sweating. - Fever : Elevated body temperature. - Difficulty swallowing : Caused by throat muscle spasms. - Breathing problems: Due to spasms affecting respiratory muscles. - Irregular urination & defecation : Loss of control over bladder   and   bowels.

12. Clinical Forms Of Tetanus 1. Generalized Tetanus: - Most common form. - Muscle stiffness and spasms throughout the body. - Affects jaw muscles (lockjaw), neck, back, and respiratory muscles. - Can lead to respiratory failure and death if untreated. 2. Local Tetanus: - Limited to one area of the body, usually around the site of injury. - Mild muscle spasms and stiffness in the affected area (e.g., near the wound). - Less severe than generalized tetanus, but can still progress. 3. Cephalic Tetanus: - Involves the head and neck area. - Often linked to head wounds, especially from ear infections or cranial trauma. - Facial muscle spasms (like risus sardonicus), and sometimes lockjaw. - Poor prognosis if not treated early. 4. Neonatal Tetanus: - Occurs in newborns, usually due to contaminated umbilical cord or unsanitary birth conditions. - Poor feeding, muscle rigidity, lockjaw, and respiratory problems. - High mortality rate if not treated immediately.

13. 3. Laboratory Tests: - Microbiological Testing: - Culture of wound exudates can be used to detect Clostridium tetani. - However, culturing is not routinely done since the bacteria grow slowly and are difficult to isolate. - Tetanus Toxin Detection: - Toxin testing of the wound or body fluids (such as serum) for tetanospasmin, the neurotoxin produced by Clostridium tetani, is helpful but rarely used in practice due to its cost and difficulty.    4.   Imaging: X-rays or CT scans may be done to rule out other potential causes of symptoms, especially if there’s a suspected head or neck injury. However, imaging is typically not required for diagnosis. 5. Differential Diagnosis: - Tetanus must be distinguished from other conditions that cause muscle spasms or rigidity, such as: - Meningitis or encephalitis - Neuroleptic malignant syndrome - Serotonin syndrome - Hypocalcemia

14. Diagnostics 1. Clinical Diagnosis: - Primary Diagnosis: Tetanus is largely diagnosed based on clinical presentation and symptoms. - Lockjaw (Trismus) - Facial muscle spasms (Risus Sardonicus) - Generalized muscle rigidity and spasms - Opisthotonos (arching of the back) - Difficulty swallowing and breathing problems. 2. History of Injury or Infection: - A detailed medical history is essential, including: - Recent injury or wound (especially a puncture wound or burns). - Unimmunized status (lack of tetanus vaccination). - Poor wound care or unsanitary conditions (e.g., animal bites, contaminated umbilical cord, drug injections).   

15. Treatment of Tetanus Tetanus treatment requires intensive care management, ideally with an anesthesiologist or critical care specialist. 1.Wound management – Immediate wound debridement is necessary to remove spores and necrotic tissue. Antimicrobial therapy – Metronidazole (500 mg IV every 6-8 hours) is preferred over penicillin G due to better outcomes. Other options include cephalosporins, doxycycline, macrolides, and clindamycin. 2. Neutralization of Unbound Toxin Tetanus immune globulin (HTIG) – A single dose of 500 units IM is recommended. Part of the dose should be infiltrated around the wound. Alternative antitoxins – Equine antitoxin can be used if HTIG is unavailable, but requires prior hypersensitivity testing. Intrathecal antitoxin – Generally not recommended due to unclear benefits. 3. Airway Management and Supportive Care Mechanical ventilation – Prolonged ventilation is often required. Early tracheostomy is preferred for better airway management Nutritional support – High energy demands necessitate early enteral feeding. Gastrointestinal protection – Stress ulcer prophylaxis with sucralfate or acid blockers is recommended. Thromboembolism prevention – Early prophylaxis with heparin or low molecular weight heparin is advised. Physical therapy – Essential after recovery to prevent muscle wasting and contractures.

16. 4. Control of Muscle Spasms Benzodiazepines – Diazepam (10-30 mg IV every 1-4 hours) is the first-line treatment. Propofol – Can be used as an alternative sedative. Neuromuscular blockers – Vecuronium is preferred when benzodiazepines are insufficient. Pancuronium should be avoided due to its catecholamine-reuptake inhibition. Baclofen – Intrathecal administration has been effective in controlling spasms, reducing the need for ventilation. 5. Management of Autonomic Dysfunction Magnesium sulfate – Acts as a neuromuscular blocker and catecholamine inhibitor. It has shown benefits in controlling autonomic dysfunction and reducing muscle spasms. Beta-blockers – Labetalol (0.25-1 mg/min) is preferred due to dual alpha- and beta-blocking effects. Propranolol should be avoided due to reports of sudden death. Other agents – Morphine, dexmedetomidine, atropine, clonidine, and epidural bupivacaine can help manage autonomic instability. 6. Active Immunization Since tetanus does not confer immunity, all patients should receive a full series of tetanus and diphtheria toxoid-containing vaccines upon diagnosis. Booster doses should be given every 10 years throughout adulthood

17. Vaccination Types of Tetanus Vaccines: 1. Tetanus Toxoid Vaccine: - Tetanus toxoid is an inactivated form of the tetanus toxin that stimulates the immune system to produce antibodies against the toxin. - Administered as part of routine vaccination schedules. 2. Combined Vaccines: - DTP: A combination vaccine that includes Diphtheria, Tetanus, and Pertussis (Whooping Cough). - DT: A combination vaccine for Diphtheria and Tetanus (for those who cannot receive the pertussis component, such as in the elderly). - Tdap: A booster dose for Diphtheria, Tetanus, and Pertussis recommended for adolescents and adults.

18. Future Directions in Tetanus Treatment Recent advances in medical research and technology are expected to revolutionize the treatment of tetanus. Some potential future developments include: 1. Novel Vaccines: Researchers are working on developing new vaccines that provide longer-lasting immunity and improved protection against tetanus. 2. Immunoglobulin Therapy: Immunoglobulin therapy, which involves administering antibodies against tetanus toxin, may become a more prominent treatment option. 3. Antitoxin Treatments: New antitoxin treatments, such as intrathecal administration of antitoxin, may improve treatment outcomes. 4. Gene Therapy: Gene therapy may be explored as a potential treatment option for tetanus. 5. Personalized Medicine: Advances in personalized medicine may enable tailored treatment approaches based on individual patient characteristics.

19. Myth Buster

20. THANK YOU