Chika Kameda
Melissa Fabry
Bio 240: Microbiology
Research: Tetanus Symtoms, Causes, and Treatment
Spring 2009

Introduction:
Tetanus is also called lockjaw, and is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin. Tetanospasmin is a neurotoxin that is produced by Clostridium tetani, which is gram positive and an obligate anaerobic bacterium. We chose this topic because we want to work in the health care field. We are both Kinesiology majors and since tetanus affects muscles, it interested us right away. Tetanus can be effectively prevented but once someone contracts tetanus, it is difficult to cure. Toxoids, tetanus immune globuline, and even vitamin C have been researched and been found effective for some patients.








Chika Kameda

Tetanus: Symptoms and Causes


Introduction:
· This topic was interesting because I would like to pursue a career in health care.
· It is a musculoskeletal disorder, which is relevant to my field of study.
· Identification of early symptoms is crucial in appropriate care for patients with Tetanus.
· Some causes of Tetanus are preventable and could be avoided.

Research:

What is Tetanus?


~Tetanus is also called lockjaw, and is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin. Tetanospasmin is a neurotoxin that is produced by Clostridium tetani, which is gram positive and an obligate anaerobic bacterium.

Clostridium tetani
  • Gram positive
  • Form endospores
  • Obligate anaerobic bacterium
  • Has flagella
  • C. tetani's spores are resistant to heat and most antiseptics
  • In the presence of anaerobic (low oxygen) conditions, the spores of Clostridium tetani will germinate.

external image Clostridium%20tetani%20fig14.jpg
external image Clostridium%20tetani%20fig14.jpg
History
  • Tetanus was well known to ancient peoples, who recognized the relationship between wounds and fatal muscle spasms.
  • In 1884, Arthur Nicolaier isolated the toxin of tetanus from free-living, anaerobic soil bacteria.
  • The etiology of the disease was further researched in 1884 by Antonio Carle and Giorgio Rattone, who demonstrated the transmissibility of tetanus.
  • Scientists produced tetanus in rabbits by injecting their sciatic nerve with a fatal human tetanus case in 1884.
  • In 1889, C. tetani was isolated from a human victim, by Kitasato Shibasaburo, who later showed that the organism could produce disease when injected into animals, and that the toxin could be neutralized by specific antibodies.

Causes
  • Deep Puncture wounds and cuts by nails and knives (“rusty nail”)
  • Animal bites
  • Tooth infections
    external image RustyNail.jpg
    external image RustyNail.jpg
  • Ear infections
  • Pinprick/scratch
  • Severe burns
  • Not safe tattoos and piercing
  • Tetanus can be found in soil and dust; it can enter through breaks in the skin
  • Tetanus spores are resistant to heat, therefore it survives standard sterilization and antiseptics commonly used to treat wounds.
  • Once Tetanus find a hospitable environment that lacks oxygen, the spores germinate and release bacteria that attack nerves.
  • Clostridium Tetani causes Tetanus

*Tetanus is not spread from person to person*
Symptoms

  • The further the injury site is from the central nervous system, the longer it will take for it to show symptoms.
  • It could take up to three weeks for the first symptoms to appear. (CDC)

  • Headaches, crankiness, spasms of the jaw muscle (therefore Tetanus is also known as “Lock Jaw”)
  • Spasms of the jaw muscle is one of the first symptoms for Tetanus.
  • Bacteria produce toxin which spreads to body, resulting in painful muscle spasms (in neck, arms, legs, stomach etc)
  • Mostly in children, but could occur to adults, the spasms can lead to fractures.
  • Fever
  • Sweating
  • Elevated blood pressure
  • Rapid heart rate
  • Frequent spasms, whcih can last for several minutes
  • Older adults account for 70 percent of reported cases of tetanus. Due to not getting vaccinated. external image tetanus.jpgexternal image tetanus2.gif
























Complications from Tetaus
  • Laryngospasm (spasms of the vocal cords) is a complication that can lead to interfere with breathing
  • Complete recovery, if it occurs, may take months.
  • Bone fractures
  • Hypertension
  • Abnormal Heart Rhythems
  • Secondary Infections (from staying at the hospital for prolonged periods and low immune system)

How is tetanus diagnosed?
  • The diagnosis of tetanus is based on the clinical signs and symptoms only. Laboratory diagnosis is not useful because the C. tetani bacteria often cannot be recovered from the wound of an individual who has tetanus.

How common is tetanus in the United States? (CDC)
  • Tetanus first became a reportable disease in the late 1930s.
  • At that time, there were 500-600 cases reported per year.
  • After the introduction of the tetanus vaccine in 1933, reported cases of tetanus dropped steadily.
  • During 1990-2001, a total of 534 cases of tetanus were reported.
  • Most of these cases occurred among adults age 19-64 years and 38% were among persons age 65 years or older.
  • Almost all cases of tetanus are in people who have never been vaccinated, or who completed their childhood series, but did not have a vaccination in the preceding 10 years. (CDC)


external image slide49.gif
external image slide49.gif

Neonatal tetanus
  • Neonatal tetanus is a form of tetanus that occurs in newborn infants
  • The most common way to get neonatal tetanus is through the use of an unsterile cutting instrument on the unhealed umbilical chord.
  • The babies who get neonatal tetanus usually have no temporary immunity passed on from their mother because their mother hasn't been vaccinated and therefore has no immunity.
  • Neonatal tetanus is very rare in the United States (three cases reported during 1990-2004), but is common in some developing countries.
  • Neonatal tetanus causes more than 215,000 deaths worldwide per year.

Can you get tetanus more than once? external image 300_148527.jpg (CDC)
  • Yes!
  • Tetanus does not create immunity because so little of the potent toxin is required to cause the disease.
  • Persons recovering from tetanus should begin or complete the vaccination series.




Sources (Pictures and Content):

Bardenheier, B, D.R. Prevots, N.Khetsuriani, and M. Wharton. "Tetanus Surveillance- United States, 1995-1997." Pub Med. 47(2)(1998): 1.Database: Interscience
Brody, Jane. "A Dose of Advice: Don't Mess With Tetanus." The New York Times. 19 July 2005. 2 Apr 2009 <http://www.nytime.com/2005/07/19/health/19brod.html>.
Dyce , Orville, James Bruno, Douglas Hong, and Keith Silverstein. "Tongue Piercing...The New "Rusty Nail"?" Case Report. (2000): 1-5. Database: Interscience
"Parent's Guide to Childhood Immunization." The Center of Disease and Control. 2009. Web.15 Apr 2009. <http://www.cdc.gov/vaccines/vdp-vac/tetanus/downloads/pg_why_vacc_tetanus.pdf>.
Peat, S.J., D.R. Potter, and J.M. Hunter. "The Prolonged Use of Atracurium in a Patient with Tetanus." Anaesthesia 43(1988): 962-963. Database: Interscience
Pedrazzi, C, L. Ghio, A. Balloni, and A. Panuccio. "Duration of Immunity to Diphtheria and Tetanus in Young Kindney Transplant Patients." Pediatric Transplantation. 3(1999): 109-114. Database: Interscience
http://www.thaitravelhealth.com/blog/wp-content/uploads/2008/01/tetanus.jpg
https://www.caremark.com/Imagebank/Articles_images/RustyNail.jpg
http://farm1.static.flickr.com/251/518623270_79a4200f60.jpg
http://www.microbelibrary.org/microbelibrary/files/ccImages/Articleimages/Atlas-Gram/Clostridium%20tetani%20fig14.jpg
http://images-cdn01.associatedcontent.com/image/A1485/148527/300_148527.jpg






Melissa Fabry
Due: 5/15/09

Treatment of Tetanus


Abstract:
Before immunization for tetanus became available, millions of people died from stepping on a rusty nail or having an infected wound. In the United States and other developed countries, the majority of residents are immunized against tetanus. In developing countries however, effective treatment for tetanus is important because many do not have access or money to be immunized. As a result, mortality rates from tetanus are high in these areas and research is being done to provide more effective means for treating tetanus. Anti-toxins and toxoids have been the most effective treatments for years and researchers are looking for treatments that are more accessible to the largest number of the population.

Introduction:
Tetanus is a neuromuscular disease is caused by the Clostridium tetani. This bacteria produces toxins that cause tetanus. C. tetani is a gram positive, endospore-forming, obligate anaerobe (Tortora, 2007). I wanted to research tetanus because it affects the nerve and muscle connnectivity and function of our bodies. I want to be a physical therapist and muscles are what I will be working with every minute of every day in my job. I have found what I have learned about muscles fascinating and I was looking forward to learning more. Tetanus can be effectively prevented but once someone contracts tetanus, it is difficult to cure. Treatment of tetanus has been widely researched and research is still being done. Toxoids, tetanus immune globuline, and even vitamin C have been researched and been found effective for some patients (Hemila, 2008).


Discussion:
Tetanus is caused by toxins produced by Clostridium tetani.
clostridium_tetani.gif
(http://www.medical-look.com/Bacterial_infections/Tetanus.html)

Normally, opposing muscles contract one after the other. When someone has tetanus, both opposing muscles contract which causes spasms. This occurs because the relaxation pathway that one of the muscles should be in is blocked by the tetanus neurotoxin. The neurotoxin is what causes both the opposing muscles to be in the contraction pathway. Typically, tetanus begins in the jaw muscles and then progresses to larger muscles. Tetanus can cause death if it reaches the respiratory muscles (including the diaphragm and intracostal muscles).
Vaccines are highly effective in preventing tetanus. Once infected with the bacteria however, tetanus is almost impossible to cure. The first vaccinations for tetanus became available in the 1940s. Throughout the years, vaccination has become more common. Since the 1960s it was part of the DTaP (diphtheria, tetanus, and acellular pertussis) vaccine given to children in United States. 96% of six year olds in the U.S have immunity while only 30% of 70 year olds do.
tetanus-cartoon-300x285.jpg
(http://blogs.courierpostonline.com/veteranvoices/tag/tetanus/)

How the tetanus vaccine works: it is a toxoid, so it is an inactivated toxin that produces antibodies that effectively neutralize the toxin produced by Clostridium tetani. To continue good immunity against tetanus, booster shots are encouraged every ten years but many Americans do not get them. Today, less than 50 cases of tetanus occur in the United States. There are over 1 million cases each year around the world; half of those infected are infants. The mortality rate world-wide is 50 percent and only 25 percent in the U.S.
tetanus.jpg
(http://scienceblogs.com/denialism/2007/06/who_are_the_denialists_part_iv.php)

Once infected, there is not enough time to vaccinate because the antibodies will take to long to produce. Tetanus immune globulin (TIG) can be administered which acts as a temporary immunity. TIG is composed of antibodies from immunized people. If the wound was severe, physicians may administer TIG and the toxoid. They are injected in two separate places so that they do not neutralize each other. If the tetanus toxin has already attached to the body’s nerves, treatment is not very useful.

Tetanus following an abrasion injury:
This study by Blaich found that a superficial injury can cause tetanus if antibodies are below acceptable level and wound is not disinfected. The subject was a 80 year old woman who injured her arm while she was gardening. She began experiencing symptoms 5 days after the incident. She had been vaccinated for tetanus but it had not been for many years. She was admitted to the hospital eight days after the incident. There, her wound was disinfected and she was injected with multiple doses of the tetanus antitoxin and penicillin. She was discharged four weeks later with all of her symptoms gone except for only a slight cramp in her hand.

Quantitation of anti-tetanus and anti-diptheria antibodies by enzymoimmunoassay:
This study by Virella discusses the development of enzymoimmunoassays (EIA) to accumulate antibodies against the tetanus toxoids. Enzymoimmunoassays detect an antibody or antigen in a sample. They are also known as enzyme immunoassays. Being able to quantify the amount of antibodies present in a patient suspected to have tetanus has helped to correctly diagnose tetanus. It also gives doctors a better understanding of how patients will react to different treatments and dossages.

Traditional treatment of 194 cases of tetanus:
Even though this research was conducted in 1974, by Busuttil, it is still relavant today. The research looked retrospectively at cases from 1957-1966. Treatment for all cases were sedation, antitoxin distribution, and antibiotis administered. The study found that antibiotics and antitoxins were most effective which is what is still being said today. The study also talks about performing positive pressure respiration and muscular relaxation as a way to decrease the progression of tetanus in severe cases.

Coverage of recommended vaccines in children at 7-8 years of age in Flanders, Belgium:
This study conducted by Theeten displays the percentages of children that have had DTP administered. 91.4% of children from the study had received their immunization for DTP. 88.3% of this group received the booster at age six. Children in lower socioeconomic status had a higher rate of nonvaccination as to be expected.

Vitamin C for preventing and treating tetanus:
This study, conducted at the University of Helsinki by H. Hemila. The study was conducted because previous studies showed that vitamin C protected rats from acquiring tetanus. In their study on humans, vitamin C was used as a treatment method. 1 g/day of vitamin C was given along with antibodies and anti-toxins. In children from one to twelve years of age, all patients survived (a 100% reduction). In those thirteen to thirty, mortality rate was reduced by 45%. These are very exciting results, however, the study was poorly conducted and the authors urge for more research and trials to be done using vitamin C as a treatment method for tetanus.


Literature Cited
Blaich, A. 2006. Tetanus following an abrasion injury. Deutsche medizinische Wochenschrift 131, 979-981 (2006).
Busuttil, A. 1974. Traditional treatment of 194 cases of tetanus. Published online in Wiley 61, 731-734 (2005).
Hemila, H. 2008. Vitamin C for preventing and treating tetanus. Published online in PUBMED, CD006665
Theeten, H. 2007. Coverage of recommended vaccines in children at 7-8 years of age in Flanders, Belgium. Published online in PUBMED, 19432835
Tortora, G.J. 2007. Microbiology. Pearson Education Inc., CA., 647-648 pps.
Virell, G. 2005. Quantitation of anti-tetanus and anti-diphtheria antibodies by enzymoimmunoassay: Methodology and applications. Published online in Wiley 5, 43-48 (2005).