Tetanus case presentation. Case from Sir Ronald Ross Institute of Tropical and Communicable Diseases, Hyderabad

1. Tetanus
- Dr.M.A.Aleem Siddiqui

2. Tetanus is an acute disease induced by the
endotoxin of Clostridium tetani. It is clinically
characterized by muscular rigidity which persists
through out illness punctuated by painful
paroxysmal spasms of the voluntary muscles.
Especially the masseters (trismus or lock
jaw),the facial muscles (risus sardonicus), the
muscles of the back and neck (opisthotonus)
and those of the lower limbs and abdomen.

3. What is Tetanus?
 The word tetanus is derived from Greek words
-“tetanos and teinein”, meaning rigid and
stretched, which describe the condition of the
muscles affected by the toxin,
tetanospasmin, produced by Clostridium
tetani .

4. Agent factors
 Clostridium tetani is a gram positive, anaerobic, spore
bearing organism, the spores are terminal and give
the organism a drum stick appearance.
 Spores germinate under anaerobic conditions and
produce a potent exotoxin tetanospasmin.

5. Mode of transmission
• Infection is acquired by contamination of wounds
with tetanus spores.
• The range of injuries and accidents which may lead
to tetanus comprise a trivial pin prick, skin abrasion,
puncture wounds, burns, human bites, animal bites
and sting, unsterile surgery, unsterile division of
umbilical cord, compound fractures etc….

6. Incubation Period
• It is defined as the time from injury to the first
symptom.
• The incubation period is usually 6 to 10 days.
• However, it may be as short as one day or as long as
several months.
• Long incubation is probably explained by the spores
lying dormant in the wounds. Incubation is also
prolonged by prophylaxis

7. Types of tetanus
• TRAUMATIC
• PUERPERAL
• OTOGENIC
• IDIOPATHIC
• TETANUS NEONATORUM

8. Complications of tetanus
• Laryngospasm
• Fractures
• Hypertension
• Nosocomial infections
• Pulmonary embolism
• Aspiration
• Death

9. Pathogenesis
1. C. tetani enters body
through wound.
2. Stays in sporulated form
until anaerobic conditions
develop.

10. 3. Germinates under
anaerobic conditions and
begins to multiply and
produce tetnospasmin.
4. Tetnospasmin spreads using
blood and lymphatic system,
and binds to motor neurons.
5. Travels along the axons
to the spinal cord.
6. Binds to sites responsible for
inhibiting skeletal muscle
contraction.

11. Clinical features
 Risus sardonicus: Contraction of the muscles at the angle of
mouth and frontalis
 Trismus (Lock Jaw): Spasm of Masseter muscles.
 Opisthotonus: Spasm of extensor of the neck, back and legs
to form a backward curvature.
 Muscle spasticity
 Prolonged muscular action causes sudden,
powerful, and painful contractions of muscle
groups. This is called tetany. These episodes can
cause fractures and muscle tears.
 If respiratory muscles are involved, apnoea may
occur.

13. Signs and SymptomsOther symptoms include:
 Drooling
 Excessive sweating
 Fever
 Hand or foot spasms
 Irritability
 Swallowing difficulty
 Uncontrolled urination or defecation

14. Diagnosis
 There are currently no blood tests that can be used
to diagnose tetanus. Diagnosis is done clinically.

15. Principle of Treatment
• 1. Neutralization of unbound toxin with Human
tetanus immunoglobulin
• 2. Prevention of further toxin production by
-Wound debridement
-Antibiotics (Metronidazole)

16.  3. Control of spasm
- Nursing in quiet environment
- avoid unnecessary stimuli
- Protecting the airway
 4. Supportive care
- Adequate hydration
- Nutrition
- Treatment of secondary infection
- prevention of bed sores.

17. Prevention
 Tetanus is completely preventable
by active tetanus immunization.
 Immunization is thought to provide
protection for 10 years.
 Begins in infancy with the DTP
series of shots. The DTP vaccine is
a "3-in-1" vaccine that protects
against diphtheria, pertussis, and
tetanus.

18. Prevention
 Can be achieved by active immunization by tetanus
toxoid (5 doses – 0 day, 1 month, 6 month, 1 year, 1
year).
 Older teenagers and adults who have
sustained injuries, especially puncture-type
wounds, should receive booster
immunization for tetanus if more than 10
years have passed since the last booster.
 Clinical tetanus does not produce immunity to further
attacks. Therefore, even after recovery, patients must
receive a full course of tetanus toxoid.

19. Case Presentation
 Name of the patient: Khushi
 Father’s name: Maruthi
 Age: 3 yrs.
 Sex: Male
 Address: Bidar Dist., Karnataka.

20. Chief complaints
 Unable to open mouth since 4 days.
 Stiffing of left side of the neck since 2 days.
 Spasm of both hands and both leg muscles since 2
days.

21. History of present illness
 Patient was asymptomatic 20 days back, then he got
injury on his left leg. He was given first aid.
 But 4 days back, the parents noticed that the child
was feeling difficulty in swallowing followed by
difficulty in opening mouth and stiffening of muscles
of left side of the neck.
 Then he was taken to Bidar institute of medical
sciences in Bidar, from where he was referred to Sir
Ronald Ross institute for tropical and communicable
diseases, Hyderabad.

22. Past medical history
 Patient had normally achieved his developmental
milestones.
 No H/O koch’s disease
 No H/O similar conditions

23. Family History
 Both the parents are healthy and alive.
 He has two sisters, one elder and one younger, and
both are healthy and alive.

24. Differential Diagnosis
• Strychnine poisoning is the only condition that truly
mimics tetanus. However, a number of conditions
(eg, dental or other local infections, hysteria,
neoplasms, and encephalitis) may cause trismus, and
these must be differentiated these conditions from
tetanus

25. Final Diagnosis
 Tetanus.

26. Treatment
 Tetanus Immunoglobulin I.P. (Human) 2000 I.U.
 Metronidozole 100ml i.v.
 I.V. fluids
 Inj. Diazepam (slow i.v.)