Tetanus

Background:
Tetanus is an acute infectious disease caused by toxigenic strains of
the bacterium Clostridium tetani (C. tetani).
The spores of C. tetani are present in the environment irrespective of
geographical location; they enter the body through contaminated
skin wounds or tissue injuries including puncture wounds.
The majority of reported tetanus cases are birth-associated,
occurring in low income countries among insufficiently vaccinated
mothers and their newborn infants, following unhygienic deliveries
and abortions and poor postnatal hygiene and cord care practices.
The disease remains an important public health problem in many
parts of the world where immunization programmes are suboptimal,
particularly in the least developed districts of low income countries.
Epidemiology
In 2013 it caused about 59,000 deaths – down from 356,000 in 1990. Tetanus – in
particular, the neonatal form – remains a significant public health problem in
non-industrialized countries with 59,000 newborns worldwide dying in 2008 as a
result of neonatal tetanus.In the United States, from 2000 through 2007 an
average of 31 cases were reported per year. Nearly all of the cases in the United
States occur in unimmunized individuals or individuals who have allowed their
inoculations to lapse.
Cause
Tetanus is caused by the tetanus bacterium Clostridium tetani. Tetanus is
an international health problem, as C. tetani spores are ubiquitous.
Spores can be introduced into the body through a puncture wound
(penetrating trauma). Due to C. tetani being an anaerobic bacterium, it
and its endospores thrive in environments that lack oxygen, such as a
puncture wound.

The disease occurs almost exclusively in persons inadequately immunized

.It is more common in hot, damp climates with soil rich in organic
matter. Manure-treated soils may contain spores, as they are widely
distributed in the intestines and feces of many animals such as horses,
sheep, cattle, dogs, cats, rats, guinea pigs, and chickens. In agricultural
areas, a significant number of human adults may harbor the organism.
Pathophysiology
Tetanus affects skeletal muscle, a type of striated muscle used in voluntary
movement. The other type of striated muscle, cardiac, or heart muscle, cannot
be tetanized because of its intrinsic electrical properties.

The tetanus toxin initially binds to peripheral nerve terminals. It is transported

within the axon and across synaptic junctions until it reaches the central nervous
system. There it becomes rapidly fixed to gangliosides at the presynaptic
inhibitory motor nerve endings, and is taken up into the axon by endocytosis. The
effect of the toxin is to block the release of inhibitory neurotransmitters glycine
and gamma-aminobutyric acid (GABA) across the synaptic cleft, which is required
to check the nervous impulse. If nervous impulses cannot be checked by normal
inhibitory mechanisms, the generalized muscular spasms characteristic of
tetanus are produced. The toxin appears to act by selective cleavage of a protein
component of synaptic vesicles, synaptobrevin II, and this prevents the release of
neurotransmitters by the cells.
Incubation period :
– In non-neonatal tetanus varies between 3 and 21 days after infection.
– In neonatal tetanus, symptoms usually present 3 to 14 days, averaging
7 days, after birth in 90% of cases.
-Characteristic features of the disease are muscular spasms.
Case-fatality rates vary from 10% to 70% depending on treatment, age
and general health of the patient. Among patients in the youngest and
oldest age groups without intensive care, case-fatality rates approach
100%.
Symptoms and Signs
Tetanus often begins with mild spasms in the jaw muscles—also known as lockjaw
or trismus. The spasms can also affect the facial muscles resulting in an
appearance called risus sardonicus. Chest, neck, back, abdominal muscles, and
buttocks may be affected. Back muscle spasms often cause arching, called
opisthotonos. Sometimes the spasms affect muscles that help with breathing,
which can lead to breathing problems.

Prolonged muscular action causes sudden, powerful, and painful contractions of

muscle groups, which is called "tetany". These episodes can cause fractures and
muscle tears. Other symptoms include drooling, excessive sweating, fever, hand
or foot spasms, irritability, difficulty swallowing, suffocation, heart attack,
breathing problems, irregular heartbeat, and uncontrolled urination or
defecation.

Even with treatment, about 10% of people who contract tetanus die. The
mortality rate is higher in unvaccinated people and people over 60 years .
The spores can also be found on skin surfaces and in contaminated heroin.Heroin
users, particularly those that inject the drug subcutaneously, appear to be at
high risk of contracting tetanus. Rarely, tetanus can be contracted through
surgical procedures, intramuscular injections, compound fractures, and dental
infections. The bite of a dog can transmit tetanus.

Tetanus is often associated with rust, especially rusty nails. Although rust itself
does not cause tetanus, objects that accumulate rust are often found outdoors or
in places that harbour anaerobic bacteria. Additionally, the rough surface of rusty
metal provides a habitat for C. tetani, while a nail affords a means to puncture
skin and deliver endospores deep within the body at the site of the wound. An
endospore is a non-metabolizing survival structure that begins to metabolize and
cause infection once in an adequate environment. Hence, stepping on a nail
(rusty or not) may result in a tetanus infection, as the low-oxygen (anaerobic)
environment may exist under the skin, and the puncturing object can deliver
endospores to a suitable environment for growth.
Diagnosis
There are currently no blood tests for diagnosing tetanus. The diagnosis is
based on the presentation of tetanus symptoms and does not depend upon
isolation of the bacterium, which is recovered from the wound in only 30% of
cases and can be isolated from patients without tetanus. Laboratory
identification of C. tetani can be demonstrated only by production of
tetanospasmin in mice. Having recently experienced head trauma may
indicate cephalic tetanus if no other diagnosis has been made.
The diagnosis of tetanus is primarily based on clinical features and does
not depend on laboratory confirmation.
The "spatula test" is a clinical test for tetanus that involves touching the
posterior pharyngeal wall with a soft-tipped instrument and observing the
effect. 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. A short report in The American
Journal of Tropical Medicine and Hygiene states that, in a patient research
study, the spatula test had a high specificity (zero false-positive test results)
and a high sensitivity (94% of infected patients produced a positive test).
Prevention
Unlike many infectious diseases, recovery from naturally acquired
tetanus does not usually result in immunity to tetanus. This is due to the
extreme potency of the tetanospasmin toxin. Tetanospasmin will likely
be lethal before it will provoke an immune response.

Tetanus can be prevented by vaccination with tetanus toxoid. The CDC

recommends that adults receive a booster vaccine every ten years, and
standard care practice in many places is to give the booster to any
patient with a puncture wound who is uncertain of when he or she was
last vaccinated, or if he or she has had fewer than three lifetime doses
of the vaccine. The booster may not prevent a potentially fatal case of
tetanus from the current wound, however, as it can take up to two
weeks for tetanus antibodies to form.
Post-exposure prophylaxis
Tetanus toxoid can be given in case of a suspected exposure to tetanus. In such cases, it can be
given with or without tetanus immunoglobulin (also called tetanus antibodies or tetanus antitoxin).
It can be given as intravenous therapy or by intramuscular injection.
Treatment
Mild cases of tetanus can be treated with:
-tetanus immunoglobulin (TIG), also called tetanus antibodies or tetanus
antitoxin. It can be given as intravenous therapy or by intramuscular injection.
-metronidazole IV for 10 days
-diazepam oral or IV

Severe cases will require admission to intensive care. In addition to the

measures listed above for mild tetanus:
-Human tetanus immunoglobulin injected intrathecally (increases clinical
improvement from 4% to 35%)
-Tracheotomy and mechanical ventilation for 3 to 4 weeks. Tracheotomy is
recommended for securing the airway because the presence of an endotracheal
tube is a stimulus for spasm
-Magnesium, as an intravenous (IV) infusion, to prevent muscle spasm
-Diazepam as a continuous IV infusion
-The autonomic effects of tetanus can be difficult to manage (alternating hyper-
and hypotension hyperpyrexia/hypothermia) and may require IV labetalol,
magnesium, clonidine, or nifedipine.
Drugs such as diazepam or other muscle relaxants can be given to control
the muscle spasms. In extreme cases it may be necessary to paralyze the
patient with curare-like drugs and use a mechanical ventilator.

In order to survive a tetanus infection, the maintenance of an airway and

proper nutrition are required. An intake of 3,500 to 4,000 calories and at
least 150 g of protein per day is often given in liquid form through a tube
directly into the stomach (percutaneous endoscopic gastrostomy), or
through a drip into a vein (parenteral nutrition). This high-caloric diet
maintenance is required because of the increased metabolic strain
brought on by the increased muscle activity. Full recovery takes 4 to 6
weeks because the body must regenerate destroyed nerve axon
terminals.
Whooping cough
background
Pertussis (whooping cough) is a respiratory tract infection characterized
by a paroxysmal cough. The most common causative organism is
Bordetella pertussis, though Bordetella parapertussis has also been
associated with this condition in humans. Pertussis remains a significant
cause of morbidity and mortality in infants younger than 2 years.
epidemiology
Worldwide, whooping cough affects around 16 million people yearly. One
estimate for 2013 stated it resulted in about 61,000 deaths – down from
138,000 deaths in 1990.Another estimated 195,000 child deaths yearly
from the disease worldwide.This is despite generally high coverage with
the DTP and DTaP vaccines. Pertussis is one of the leading causes of
vaccine-preventable deaths worldwide.About 90% of all cases occur in
developing countries.
 Etiology and Pathophysiology
Humans are the sole reservoir for B pertussis and B parapertussis. B
pertussis, a gram-negative pleomorphic bacillus, is the main causative
organism for pertussis. (B parapertussis is less common than B
pertussis and produces a clinical illness that is similar to, but milder
than, that produced by B pertussis.) B pertussis spreads via
aerosolized droplets produced by the cough of infected individuals,
attaching to and damaging ciliated respiratory epithelium. B pertussis
also multiplies on the respiratory epithelium, starting in the
nasopharynx and ending primarily in the bronchi and bronchioles
Symptoms and Signs
Pertussis is a 6-week disease divided into catarrhal, paroxysmal, and
convalescent stages, each lasting 1-2 weeks.
Stage 1 – Catarrhal phase
The initial (catarrhal) phase is indistinguishable from common upper
respiratory infections. It includes:
Nasal congestion
Rhinorrhea
Sneezing
Low-grade fever
Tearing
Conjunctival suffusion

Pertussis is most infectious when patients are in the catarrhal phase, but
pertussis may remain communicable for 3 or more weeks after the onset
of cough
Stage 2 – Paroxysmal phase
Patients in the second (paroxysmal) phase present with paroxysms of
intense coughing lasting up to several minutes. In older infants and
toddlers, the paroxysms of coughing occasionally are followed by a loud
whoop as inspired air goes through a still partially closed airway. Infants
younger than 6 months do not have the characteristic whoop but may
have apneic episodes and are at risk for exhaustion. Posttussive vomiting
and turning red with coughing are common in affected children.

Stage 3 – Convalescent stage

Chronic cough, which may last for weeks
Diagnosis
The diagnosis of pertussis is made by isolation of B pertussis in culture. A
polymerase chain reaction (PCR) test can also be performed.
The culture specimen should be obtained during the first 2 weeks of
cough by using deep nasopharyngeal aspiration For PCR testing,
nasopharyngeal specimens should be taken at 0-3 weeks following cough
onset
The CDC recommends a combination of culture and PCR assay if a
patient has a cough lasting longer than 3 weeks
Early serial monitoring of white blood cell (WBC) counts is warranted
 Management
Goals of treatment:
- Limit the number of paroxysms
- Observe the severity of cough and provide assistance when necessary
- Maximize nutrition, rest, and recovery
 Pharmacologic therapy
Antimicrobial agents and antibiotics can hasten the eradication of B
pertussis and help prevent spread
 For patients of all ages azithromycin is the preferred agent.
 Erythromycin and clarithromycin are not recommended in infants younger
than 1 month, because their use has been associated with increased risk of
infantile hypertrophic pyloric stenosis (IHPS). Azithromycin is the
recommended agent for the youngest patients, although it also carries some
risk of IHPS. Patients who are aged 2 months or older with hypersensitivity to
macrolides may be treated with trimethoprim-sulfamethoxazole.
A reasonable guideline is to treat people age >1 year within 3 weeks of
cough onset and infants age <1 year and pregnant women within 6 weeks
of cough onset. If the person is diagnosed late, antibiotics will not alter
the course of the illness, and even without antibiotics, they should no
longer be spreading pertussis. Antibiotics when used early decrease the
duration of infectiousness, and thus prevent spread.hort-term antibiotics
(azithromycin for 3–5 days) are as effective as long-term treatment
(erythromycin 10–14 days) in eliminating B. pertussis with fewer and less
severe side effects.
Immunization
Prevention through immunization remains the best defense in the fight
against pertussis. CDC recommendations for vaccination are as follows:
DTaP vaccine: Recommended at the ages of 1.5, 2.5, 3.5, and 15-18
months and at age 4-6 years; it is not recommended for children aged 7
years or older
Tdap vaccine: Recommended for children aged 7-10 years who are not
fully vaccinated; as a single dose for adolescents 11-18 years of age; for
any adult 19 years of age or older; and for pregnant woman regardless of
vaccination history, including repeat vaccinations in subsequent
pregnancies
 Prognosis
 Common complications include pneumonia, bronchitis,
encephalopathy, earache, and seizures. Most healthy older children
and adults fully recover, but those with comorbid conditions have a
higher risk of morbidity and mortality.
 Infection in newborns is particularly severe. Pertussis is fatal in an
estimated 1.6% of hospitalized US infants under one year of age.
First-year infants are also more likely to develop complications, such
as: pneumonia (20%), encephalopathy (0.3%), seizures (1%), failure to
thrive, and death (1%) —perhaps due to the ability of the bacterium to
suppress the immune system. Pertussis can cause severe paroxysm-
induced cerebral hypoxia, and 50% of infants admitted to hospital
suffer apneas. Reported fatalities from pertussis in infants increased
substantially from 1990 to 2010.