Tetanus

Question 1

Clostridium tetani

Answer 1

Clostridium tetani is an obligate anaerobic, gram-positive bacillus with terminal round spore (drum stick appearance).
It is ubiquitous in nature, widely distributed in soil, hospital environment and in the intestine of man and animals.

Question 2

Virulence factors of tetanus

Answer 2

1. Tetanolysin: hemolysin
 no role in pathogenesis  
2. Tetanospasmin (or tetanus toxin):
• neurotoxin responsible for disease
•„ antigenic and is specifically neutralized by its antitoxin„ 
• plasmid coded
Toxoid:„
 It gets toxoided spontaneously or by formaldehyde(antigenic, but not virulent) ➡️ used for vaccine preparation

Question 3

Mechanism of Action of Tetanus Toxin

Answer 3

1. Tetanus toxin binds to receptors (polysialogangliosides) present on motor nerve terminals
2. Toxin internalization.
   3.‰ Transported in retrograde way to the GABA and glycine
   ‰4. It prevents the presynaptic release of inhibitory neurotransmitters
3. Spastic muscle contraction.

Question 4

Tetanus

mode of transmission

Answer 4

1. Injury (superficial abrasions, punctured wounds,…)
   ™2. Surgery done without proper asepsis
   ™3. Neonates:
   Following abortion/delivery, due to unhygienic practices
   ™4. Otitis media (otogenic tetanus)
   It is non-infectious: No person-to-person spread

Question 5

Tetanus

clinical manifestations

Answer 5

1. First symptom: 🔼 masseter tone ➡️ lockjaw
2. Muscle pain and stiffness, back pain, and dysphagia
   📝 Difficulty in feeding is the initial presentation in 👶
3. Painful muscle spasm develops which may be:
   •„ Localized: Involves the affected limb
   •„ Generalized painful muscle spasm ➡️ descending spastic paralysis (except 💪,🦵). Deep tendon reflexes exaggerated
   4.™ Autonomic disturbance is maximal during the 2nd week:
   🔽 or 🔼 bp, tachycardia, intestinal stasis, sweating, 🔼 tracheal secretions and acute renal failure.

Question 6

Tetanus

complication

Answer 6

1. Risus sardonicus:
   abnormal, sustained spasm of the facial muscles that appears to produce grinning
2. Opisthotonos position:
   due to generalized spastic contraction of the extensor muscles
   ™3. Respiratory muscles spasm:
   airway obstruction

Question 7

Tetanus is more common in developing countries including India, which is attributed various risk factors such as

Answer 7

1. Warm climate
2. Rural area with fertile soil
3. Unhygienic surgeries or deliveries.

Question 8

Tetanus lab diagnosis

specimen and methods

Answer 8

Specimen:
Excised tissue bits from the necrotic depths of wounds are more reliable than wound swabs.
1. Gram staining:
gram-positive bacilli with terminal and round spores (drum stick appearance)
2. Culture: more reliable
3. Toxigenicity test:
In vivo mouse 🐁 inoculation

Question 9

Tetanus

gram staining as lab diagnosis

Answer 9

• Gram staining reveals gram-positive bacilli with terminal and round spores (drum stick appearance)
• ™ However, microscopy alone is unreliable as it cannot distinguish C. tetani from morphologically similar non-pathogenic clostridia like C. tetanomorphum and C. sphenoides.

Question 10

Tetanus

culture as lab diagnosis

Answer 10

Culture is more reliable than microscopy.
1.™ Robertson cooked meat broth:
C. tetani, being proteolytic turns the meat particles black and produces foul odor
™2. Blood agar with polymyxin B:
The plates are incubated at 37°C for 24–48 hours under anaerobic condition.
C. tetani produces characteristic swarming growth

Question 11

Toxigenicity test for tetanus lab diagnosis

Answer 11

As pathogenesis of tetanus is toxin mediated, the association of the isolated organism can only be established when its toxin production is demonstrated.
Toxin assay can be performed by in vivo mouse inoculation test on specimens such as serum and urine

Question 12

Treatment of tetanus

Answer 12

1. Passive immunization
2. Combined Immunization
3. Antibiotic
4. Symptomatic treatment:
   (i) Endotracheal intubation and early tracheostomy
   (ii) anti-spasmodic
   (iii) Beta-blockers
   5.‰ Surgical debridement: Entry wound should be identified, cleaned and debrided of necrotic material, so as to remove the anaerobic foci of infection
   ‰6. Patient should be isolated in a separate room as any noxious stimulus (e.g. light) can aggravate the spasm

Question 13

Passive Immunisation of tetanus

Answer 13

It is the treatment of choice for tetanus.
‰ Two preparations are available:
1. HTIG (Human tetanus immunoglobulin), SII, Pune
2. ATS (Antitetanus serum, equine derived)
‰Dosage: 250 IU of HTIG or 1,500 IU of ATS single IM dose. Intrathecal route is more effective
‰Duration of protection:
HTIG 30 days
ATS 7–10 days
📝:‰ HTIG is preferred over ATS as the latter is associated with side effects such as serum sickness and anaphylactoid reactions.

Question 14

Combined Immunisation for tetanus

Answer 14

In nonvaccinated person, it is ideal to immunize with

1. First dose of tetanus toxoid (TT) vaccine in one arm along with administration of
2. ATS or HTIG in another arm, followed by
3. Complete course of TT vaccine

Question 15

When are antibiotics useful against tetanus

Which antibiotics are preferred

Answer 15

Antibiotics play only a minor role as they cannot neutralize the toxins which are already released.
‰ However, they are useful:
1. In early infection, before expression of the toxin (<6 hours)
2. To prevent further release of toxin ‰ Metronidazole is the drug of choice; given for 7–10 days.
Penicillin or doxycycline can be given alternatively

Question 16

Tetanus prevention

Answer 16

1. Active immunisation:
 tetanus toxoid
 Monovalent
 Combined: DPT, Td, Pentavalent 
2. Prevention of tetanus after injury
 All types of wounds need surgical toilet followed by immunization which depends on the wound type and immunization status of the individual
3. Prevention of neonatal tetanus

Question 17

Types of tetanus toxoid vaccine

Answer 17

1. Monovalent vaccine: Tetanus toxoid is (TT) is prepared by incubating toxin with formalin to become toxoid
   „2. Combined vaccine:
   • DPT vaccine (diphtheria toxoid,
   pertussis whole cell killed preparation and tetanus toxoid)
   • Td vaccine (tetanus toxoid and adult diphtheria toxoid)
   • Pentavalent vaccine (DPT, hepatitis B and Hib)

Question 18

Primary immunization of children against tetanus

Answer 18

Tetanus toxoid is given under National Immunization Schedule of India.
7 doses are given:
1.„ Three doses of pentavalent vaccine at 6, 10 and 14 weeks
2.„ Two booster doses of DPT at 16–24 weeks and 5 years
3.„ Two additional doses of Td at 10 years and 16 years

Question 19

Tetanus vaccine

site, protective titre and for adults

Answer 19

If primary immunization is
not administered in childhood, then adults can be immunized with Td (tetanus and adult diphtheria toxoid)
™Site:
deep IM in anterolateral aspect of thigh (children) and in deltoid (adults)
™Protective titer: ≥0.01 IU/mL

Question 20

Tetanus prone wound

Answer 20

Tetanus-prone wound includes:

1. Age of wound > 6 hours
2. Penetrating wound (missiles, crush, burn, bite)
3. Depth of wound >1 cm
4. Presence of devitalized tissue and contaminants (dirt, saliva, etc.)

Question 21

Recommendation for prevention of tetanus after injury.

Answer 21

If complete course of vaccine is
1. Taken within 5 years:
 Nothing is required for all
2. Taken within >5 to <10 year:
 Td 1 dose
3. Taken >10 years back:
 Td 1 dose w/o HTIG depending on wound type
4. Unknown/ incomplete immunization:
 Td complete dose w/o HTIG depending on wound type

Question 22

Neonatal tetanus

Answer 22

Neonatal tetanus is defined by WHO as ‘an illness occurring in a child who loses ability to suck and cry between day 3 and 28 of life and becomes rigid and has spasms’.

It is also known as “8th day disease” as the symptoms usually start after 1 week of birth

Question 23

Causes for neonatal tetanus

seasonal change

Answer 23

1. Unhygienic practices during deliveries such as infected umbilical stumps due to application of cow dung
2. Rarely by circumcision or by ear piercing
   Neonatal tetanus is seasonal—more common in July, August and September months

Question 24

Prevention of neonatal tetanus

Answer 24

1. Discouraging home deliveries and promoting hospital or attended deliveries
2. Following aseptic clean practices are followed during deliveries—clean hand, surface, blade for cutting cord, cord tie, cord stump, towel and water
3. Td (2 doses) are given to all 🤰during 2nd trimester at 1 month gap.