2ND M.B.

BS

TRAVANCORE MEDICAL COLLEGE, KOLLAM KERALA

MORPHOLOGY
Relatively large, Gram-positive, slender bacillus with straight axis, parallel sides & rounded ends. Occurs singly, occasionally in chains Spores are spherical, terminal & bulgingdrumstick- appearance Non-capsulated and motile by peritrichate flagella Found in soil, especially heavily-manured soils, and in the intestinal tracts and feces of various animals Strictly fermentative mode of metabolism.

CULTURAL CHARACTERISTICS
Obligate anaerobe; 37 degrees C and pH 7.4 Grows on ordinary media Surface colonies swarming over surface of agar. If water of condensation at the bottom of a slope of nutrient agar is inoculated with mixed cell culture, after incubation for 24h, subcultures from the top of tube will yield a pure growth of the bacillus. (Fildes technique) Deep agar shake culturesspherical fluffy ball colonies Gelatin stab culturesfir tree type of growth Grows well in RCM Blood agar-alpha followed by beta hemolysis (tetanolysin)

VIRULENCE AND PATHOGENICITY

Not pathogenic to humans and animals by invasive infection but by the production of a potent protein toxin

 tetanus toxin or tetanospasmin The second exotoxin produced is tetanolysinfunction not known. Produced when spores germinate and vegetative cells grow after gaining access to wounds. The organism multiplies locally and symptoms appear remote from the infection site. Estimated lethal human dose of Tetanospamin = 2.5 Nano grams/kg body The toxin has a specific affinity for nervous tissue, it is referred to as a neurotoxin Initially binds to peripheral nerve terminals Transported within the axon and across synaptic junctions until it reaches the central nervous system. Becomes rapidly fixed to gangliosides at the presynaptic inhibitory motor nerve endings, then taken up into the axon by endocytosis. Blocks the release of inhibitory neurotransmitters (glycine and gamma-amino butyric acid) across the synaptic cleft, which is required to check the nervous impulse. If nervous impulses cannot be checked by normal inhibitory mechanisms, it leads to unopposed muscular contraction and spasms that are characteristic of tetanus.

METHODS OF TRANSMISSION
C. tetani can live for years as spores in animal feces and soil. As soon as it enters the human body through a major or minor wound and the conditions are anaerobic, the spores germinate and release the toxins. Tetanus may follow burns, deep puncture wounds, ear or dental infections, animal bites, abortion. Only the growing bacteria can produce the toxin. It is the only vaccine-preventable disease that is infectious but not contagious from person to person.

SYMPTOMS
Tetanic seizures (painful, powerful bursts of muscle contraction) if the muscle spasms affect the larynx or chest wall, they may cause asphyxiation stiffness of jaw (also called lockjaw) stiffness of abdominal and back muscles contraction of facial muscles, fast pulse, fever, sweating

TYPES OF TETANUS
Incubation period: 3-21 days, average 8 days.

Local tetanus: persistent muscle contractions in the same anatomic area as the injury, which will however subside after many weeks; very rarely fatal; milder than generalized tetanus, although it could precede it. Cephalic tetanus: occurs with ear infections or following injuries of the head; facial muscles contractions

Most common types:

Generalized tetanus
Descending pattern: lockjaw (trismus) stiffness of neck difficulty swallowing rigidity of abdominal and back muscles. (Opisthotonus) Spasms continue for 3-4 weeks, and recovery can last for months Death occurs when spasms interfere with respiration.

Neonatal tetanus:
Form of generalized tetanus that occurs in newborn infants born without protective passive immunity because the mother is not immune. Usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with an unsterile instrument.

LAB DIAGNOSIS
Based on the patients account and physical findings that are characteristic of the disease. Diagnostic studies generally are of little value, as cultures of the wound site are negative for C. tetani two-thirds of the time. When the culture is positive, it confirms the diagnosis of tetanus Tests that may be performed include the following: Culture of the wound site (may be negative even if tetanus is present) Tetanus antibody test Other tests may be used to rule out meningitis, rabies, strychnine poisoning, or other diseases with similar symptoms.

PROPHYLAXIS
1. Surgical attention 2. Antibiotics

3. Immunization-Active, Passive, Combined

Surgical- removal of foreign bodies, necrotic tissue & blood clots Antibiotics-destroy or inhibit the bacilli in wounds so that toxin production is prevented. Long acting penicillin inj or erythromycin (500mg b.d for 5 days). To be started before wound toilet. Neomycin or bacitracin may also be applied locally

Passive immunization-ATS from hyper immune horses-1500U s/c or i/m in nonimmune persons
soon after receiving any tetanus prone injury. (Risk of hypersensitivity) TIG-250U, has a longer half-life

Active immunization-most effective

Achieved by spaced inj of formal toxoid (plain/adsorbed). The tetanus toxoid is given either alone or along with diphtheria toxoid and pertussis vaccine (DPT/ triple vaccine) 3 doses of TT i/m, with an interval of 4-6 wks between the first two inj and the 3rd dose 6 months later. A full course of immunization confers immunity for a period of at least 10 yrs

Combined immunization
TIG inj at one site, along with 1st dose of TT at the contralateral site, followed by 2nd & 3rd doses of toxoid (adsorbed) at monthly intervals

TREATMENT
Isolate pt from noise and light (may provoke convulsions) Control spasms using muscle relaxants Maintain airway by tracheostomy with intermittent positive pressure respiration & attention to feeding Human TIG 10,000U suitably dilutedgiven IV Antibacterial therapy-penicillin or metronidazole Patients recovering from tetanus should receive a full course of active immunization

Answering a question is an art, which has to be perfected. Our student in Microbiology writes the article on Clostridium tetani as part of problem solving question in Applied Microbiology. The answer is well-scripted and expressing solutions with a scientific spirit. If this methodology is followed every one can score the best.

The article is published as part empowering the Students