tetanus

from Wikipedia, the free encyclopedia
Classification according to ICD-10
A33 Tetanus neonatorum
A34 Tetanus during pregnancy, childbirth and the puerperium
A35 Other tetanus
ICD-10 online (WHO version 2019)

The tetanus (from ancient Greek τέτανος tetanos , German , voltage, spasm ' ), and tetanus (and tetanus ), is an often fatal acute infectious disease which affects the muscle-controlling nerve cells of the central nervous system is characterized by a spasmodic muscle rigidity and by the bacterium Clostridium tetani is raised. The resistant spores of the bacterium can be found almost everywhere, also in road dust or in the garden soil. Infection occurs when the spores enter wounds . Only under anaerobic conditions, ie under oxygen absence, the spores germinate, the bacterium multiplies and secretes toxins ( toxins ) from. The proteolytic toxin tetanospasmin damages the muscle-controlling nerve cells and thereby causes the typical muscle cramps . The toxin tetanolysin is heart-damaging.

Opisthotonus in tetanus disease; Painting by Charles Bell , 1809

history

Even in ancient times, the doctor Hippocrates of Kos described the so-called tetanus triad: wound, jaw cramp and death. The Italian researchers Antonio Carle (born May 3, 1854 in Chiusa di Pesio ; † February 23, 1927 in Turin ) and Giorgio Luigi Rattone (born April 25, 1857 in Moncalieri ; † December 20, 1929 in Parma ) were able to detect tetanus in animals in 1884 by inoculating pus from a human tetanus wound on the sciatic nerve of rabbits. This made an infectious disease likely.

Arthur Nicolaier detected the causative agent of tetanus in the soil by inoculating garden soil on test animals. He published this discovery in 1884. Although he was able to breed the pathogens on an artificial culture medium, he did not succeed in isolating the tetanus bacillus in pure culture. However, he observed bacilli that had a head and thus had the typical shape of the Bacillus Clostridium tetani . His colleague Friedrich Julius Rosenbach succeeded in transmitting tetanus from humans to animals. Rosenbach described the shape of the bacillus as a pin or baton in 1885 . The Dane Knud Helge Faber (born August 29, 1862 in Odense , † May 3, 1956 in Copenhagen ) finally succeeded in producing a germ-free tetanus toxin from filtrate in 1889. In the same year, the Japanese microbiologist Kitasato Shibasaburō, researching Robert Koch's Berlin institute, was able to isolate the anaerobically grown tetanus bacillus. Kitasato and Emil von Behring finally succeeded in obtaining an antitoxin in 1890. With this antitoxin production, Behring laid the foundation for "serum therapy" . In 1946, Louis Pillemer (* 1908 in Johannesburg ; † August 31, 1957 in Cleveland Heights ) finally succeeded in obtaining the tetanus toxin in pure form by means of crystalline representation, making a significant contribution to the elucidation of the chemical structure of the poison.

Effect of the toxins

A group of Clostridium tetani

Tetanolysin is hemolytic and cardiotoxic, but insignificant for the typical symptoms of the disease. More important is tetanospasmin , which reaches the central nervous system via peripheral nerve pathways . There it attacks proteins ( SNARE ) that are necessary to release the neurotransmitters ( glycine and GABA ) of the Renshaw cells in the anterior horn of the spinal cord . Tetanospasmin is an endopeptidase . The blockade takes place via an enzymatic inactivation of the Synaptobrevin / Vesicular Associated Membrane Complex, whereby the release of the neurotransmitters is disturbed by exocytosis . This leads to uncontrolled activation of the alpha motor neurons and tonic (persistent) and clonic (twitching) cramps of the striated (voluntary) muscles .

Symptoms

Facial muscle spasms ( risus sardonicus )
Spasms of the back muscles ( opisthotonus )

The incubation period is between three days and three weeks; in rare cases it can last several months, depending on how far the distance between the central nervous system and the entry point is. The shorter the incubation period, the worse the prognosis .

First you experience flu-like symptoms such as headache , dizziness , restlessness, trembling limbs, fatigue, signs of fatigue, muscle aches and sweats . Then the mouth can no longer be opened by a jaw clamp (trismus) , and a facial expression that grins due to cramping of the mimic muscles, the so-called devil's grin (Latin risus sardonicus ) is created. In the further course of the process, the long back muscles become tonic , which often descends from the neck and can lead to painful hyperextension and, if left untreated, even to vertebral fractures. This is followed by tonic and twitching (clonic) muscle spasms in the arms, legs, larynx and diaphragm. The cramps last one to two minutes and are triggered by the smallest external stimuli ( acoustic , optical , mechanical ). If left untreated, death follows by suffocation .

Feeling and consciousness (sensorium) are not impaired, which is why this disease is excruciating if left untreated. A direct infection from person to person is not possible.

to form

Depending on its occurrence, tetanus is distinguished as follows:

  • Neonatal tetanus (neonatal tetanus or tetanus neonatorum ): it affects newborns of insufficiently vaccinated mothers (within 28 days) and occurs almost exclusively in countries with inadequate medical care and poor hygiene; Infection occurs via the umbilical cord. It is the most common form worldwide.
  • Maternal tetanus : If the tetanus occurs during pregnancy or within the last 6 weeks before the end of the pregnancy (birth, miscarriage or termination), it is referred to as maternal tetanus. The WHO has started a program aimed at reducing maternal and neonatal tetanus (MNT).
  • Generalized tetanus : It is the most common form of tetanus in Central Europe , here the entire musculature is affected.
  • Local tetanus : the disease is only limited to the region of the body where the causal contaminated wound is located, for example in the leg. A generalized tetanus can develop from a local tetanus. The prognosis for local tetanus is often positive and occurs predominantly in partially immunized patients.
  • Cephalic tetanus : This is a special form of local tetanus as it typically occurs directly on the head, face or neck after an injury. The incubation period of 1–2 days is relatively short. The symptoms are well known: an ipsilateral Facial Nerve - paresis , especially a trismus and a risus sardonicus .

The literature also mentions:

  • Puerperal tetanus : infections of mothers after births and miscarriages through puerperal wounds (i.e. wounds in the uterus )
  • Postoperative tetanus : here tetanus occurs after surgical interventions because it originates from an infected surgical wound.

Diagnosis

The diagnosis of tetanus is made based on typical clinical findings. Illness is unlikely if the patient has been given a complete primary series and timely booster vaccinations have been given. To confirm the diagnosis, toxin detection can be carried out by means of a neutralization test in animal experiments (mouse) using wound material from the patient. The cultural pathogen detection is usually not successful. In the animal experiment with mice, different amounts of patient serum are inoculated. The proof is positive if the mice die in a so-called "seal position" (rigid convulsions of the hind legs) compared to a control group (patient serum with antitoxin).

distribution

In Germany there is currently a lack of meaningful data on the current frequency of tetanus due to the obligation to report under the Infection Protection Act, which was lifted in 2001 . The overall incidence has fallen sharply in the past few decades, so that fewer than 15 diseases per year have been recorded for a long time. In 1999 and 2000, 8 diseases were reported in accordance with the Federal Disease Act. The mortality rate in Germany is 25%.

In countries with a warm, humid climate and a lower vaccination rate, however, tetanus occurs much more frequently. According to WHO statistics , there were 9,836 incidences worldwide in 2009 .

A particular risk factor is umbilical infection, which occurs when children are born under inadequate hygienic conditions or, as is traditional in some peoples, when earth pastes are applied to the umbilicus for wound care. According to WHO estimates, 180,000 babies worldwide died of newborn tetanus in 2002; in 2002, 11,624 cases were recorded statistically. The numbers are declining worldwide, in 2009 only 4,713 cases were recorded.

treatment

There is no real causal treatment for the disease that has broken out . Because the tetanus toxins spread via the nerve sheaths, high doses of serum (foreign antibodies, passive immunization) via the bloodstream are controversial. A thorough cutting out of the wound, possibly an amputation (focal clean-up), ensures that the tetanus pathogen does not multiply, as further toxin production in the wound must be prevented.

As antibiotic can metronidazole are used. In mild cases, symptomatic treatment based on the symptoms of the disease can avoid the cramps triggered by acoustic and optical stimuli by placing the patient in a darkened and soundproofed room and using strong sedatives. In all severe cases, however, muscular relaxation with medication is required along with mechanical ventilation .

After a sufficient antibody level has been reached, the symptoms subside and mechanical ventilation can be stopped after four to eight weeks. Despite modern intensive care medicine, consequential damage occasionally remains, which requires further treatment. The survived illness does not leave a sufficient antibody titer without additional active vaccination , so that a new illness is possible. This makes preventive vaccination all the more important.

prevention

vaccination

Cases of illness caused by tetanus
(as of September 27, 2006)

A vaccination against tetanus is available and is recommended. Experts from the Standing Vaccination Commission at the Robert Koch Institute (STIKO) recommend preventive immunization against tetanus with a toxoid vaccine , as even small, not particularly deep injuries can lead to the disease. This first immunization can take place after the completion of the second month of life as part of diphtheria - whooping cough - tetanus - combination vaccinations . Complete protection is only available after three vaccinations. Usually a combination vaccination against tetanus and diphtheria is also carried out for adults (re-vaccination after one month, then after one year).

Basic immunization is carried out in infancy, followed by a booster in the fifth and sixth year of life. The complete vaccination protection is effective for at least ten years, after which an active booster vaccination is recommended.

The titer of the protective antibodies produced by vaccination can be measured in the laboratory or with a rapid immunochromatographic test. However, this is not done regularly.

Simultaneous vaccination

After an injury, if there is no or only insufficient vaccination protection, both active and passive , i.e. simultaneous , immunization is necessary. This consists of an injection of a toxin weakened by formol , but immunogenic (toxoid, e.g. tetanol ; there is also a combined tetanus-diphtheria vaccine) and an injection of serum enriched with human antibodies against the tetanus pathogen (tetagam, tetanobulin) . The passively acting serum administration is intended to bridge the time interval until the onset of antibody formation that was stimulated by the active toxoid administration. For the exact indication regarding simultaneous vaccination, see recommendations of the Standing Vaccination Commission.

This is followed by further active repeat vaccinations according to a scheme recognized by the STIKO of the German Medical Association in order to achieve long-term effective protection against tetanus.

Before the development of human antisera, the sequence horse , cattle , mutton applied to the exclusively available animal sera . In this way, a sensitization through foreign protein should be avoided. This recommendation was valid until the last third of the 20th century.

Wound cleansing

Since the pathogens are obligate anaerobes, i.e. they only grow when there is a lack of oxygen, a wound needs to be cleaned even with abrasions . Dead tissue in which the oxygen has been used up should possibly also be surgically removed (see wound treatment ). However, the spores of the bacteria are extremely resistant and can usually not be killed even with medical disinfectants.

Reporting requirement

According to the German Infection Protection Act, tetanus has not been notifiable since 2001. In some German federal states, however, there is an obligation to report or the introduction of one is being discussed. The highest health authorities of the respective federal states can provide information on this. In Mecklenburg-Western Pomerania, for example, there is an obligation to notify under the law on the implementation of the Infection Protection Act, the obligation to notify by name of illness and death from tetanus as well as direct or indirect evidence of Clostridium tetani . In addition, in Thuringia, according to the Thuringian Ordinance on the adjustment of the reporting obligation for infectious diseases, there is a non-named reporting obligation for illness and death from tetanus. According to the law of Saxony, according to the ordinance of the Saxon State Ministry for Social Affairs and Consumer Protection on the extension of the reporting obligation for communicable diseases and pathogens according to the Infection Protection Act, there is a mandatory reporting of illness and death from tetanus.

In Switzerland, tetanus for doctors, hospitals, etc. a notifiable disease and that after the Epidemics Act (EpG) in connection with the epidemic Regulation and Annex 1 of the Regulation of EDI on the reporting of observations of communicable diseases of man . The clinical diagnosis must be reported.

Tetanus in animals

Locked jaws and ears pointing backwards in a cattle suffering from tetanus

Horses

The susceptibility to tetanus infection is particularly high in horses and other solipeds. Horses therefore receive an additional immunization ( booster dose ) after the first vaccination after six to twelve weeks and after twelve months . A refreshment should be done every two years. A typical symptom, in addition to the blocked jaw, is the sawhorse position of sick animals.

Other animals

Ruminants and pigs are also highly receptive. Dogs and cats are only slightly susceptible. Birds are almost completely resistant.

literature

  • W. Lang, Thomas Löscher (Ed.): Tropical medicine in clinic and practice. 3. Edition. Thieme, Stuttgart / New York 2000, pp. 287-290. ISBN 978-3-13-785803-4 .
  • R. Marre, T. Mertens, M. Trautmann, E. Vanek (Eds.): Clinical Infectious Diseases. Urban & Fischer Verlag, Munich / Jena 2000, pp. 235–237. ISBN 978-3-437-21740-1 .
  • German Society for Pediatric Infectious Diseases e. V. (DGPI): Handbook Infections in Children and Adolescents . 4th edition. Futuramed-Verlag, Munich 2003, pp. 665–668. ISBN 3-923599-90-0 .
  • J. Chin (Ed.): Control of Communicable Diseases Manual. American Public Health Association, 2000, pp. 491-496.
  • M. Dietel, J. Dudenhausen, N. Suttorp: Harrison's internal medicine. 15th edition. ABW Wissenschaftsverlag, Berlin, Leiben 2003, pp. 1012-1014. ISBN 978-3-936072-10-5 .
  • Karl Wurm, AM Walter: Infectious Diseases. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 9-223, here: pp. 200-203.
  • RKI: Vaccination recommendations of the Standing Vaccination Commission (STIKO) at the Robert Koch Institute. July 2003. Epid Bull 2003; 32 (PDF; 146 kB): pp. 245–260
  • RKI: Advice for doctors on the need for information on vaccinations / January 2004. Epid Bull 2004; 6 (PDF; 156 kB): pp. 33–52
  • RKI: Vaccine-preventable diseases in Germany up to the year 2000: Tetanus. Epid Bull 2002; 7 : p. 51
  • S1 guidelines for tetanus of the German Society for Neurology (2012). In: AWMF online (as of 2012)

Web links

Wiktionary: Tetanus  - explanations of meanings, word origins, synonyms, translations
Wiktionary: tetanus  - explanations of meanings, word origins, synonyms, translations
Commons : Tetanus  - Album with pictures, videos and audio files
  • Tetanus - information from the Robert Koch Institute
  • Tetanus - impfen-info.de: Comprehensive information from the Federal Center for Health Education (BZgA) on the subject of vaccinations.

Individual evidence

  1. ↑ Verena Nittka, Katrin von Bechtolsheim: Tetanus - Caution: Earth, dust and animal droppings! Techniker Krankenkasse, November 13, 2017, https://www.tk.de/techniker/gesundheit-und-medizin/behandlungen-und-medizin/infektiven/tetanus-achtung-erde-staub-und-tierkot-2022222
  2. ↑ Patrick Guilfoile, Hilary Babcock: tetanus . Infobase Publishing, New York, 2008, ISBN 978-0-7910-9711-3 . P. 26.
  3. ↑ Cf. Emil von Behring : Introduction to the doctrine of combating infectious diseases. Springer, Berlin / Heidelberg 1912, ISBN 9783662345764 , p. 16.
  4. ↑ Karl Wurm, AM Walter: Infectious Diseases. 1961, p. 200.
  5. ↑ http://www.ganino.com/games/Science/Science_1958-1959/root/data/Science%201958-1959/pdf/1958_v127_n3294/1754985.pdf Louis Pillemer, immunochemist (not publicly available)
  6. ↑ BENEFIT DOCUMENTATION OF STANDARD VACCINES: TETANUS. Arznei-Telegram , February 19, 2016, pp. 17-20 , accessed on October 12, 2019 .
  7. ↑ B. Pfausler et al .: S1 guidelines for tetanus. German Society for Neurology , August 31, 2017, accessed December 9, 2019 .
  8. ↑ Tetanus - RKI-Ratgeber. RKI, November 27, 2018, accessed December 9, 2019 .
  9. ↑ Tetanus. WHO, April 29, 2019, accessed December 9, 2019 .
  10. ↑ C. Louise Thwaites et al .: Maternal and neonatal tetanus . In: Lancet (London, England) . tape 385 , no. 9965 , January 24, 2015, p. 362-370 , doi : 10.1016 / S0140-6736 (14) 60236-1 , PMID 25149223 , PMC 5496662 (free full text).
  11. ↑ Maternal and Neonatal Tetanus Elimination (MNTE). WHO, November 8, 2019, accessed December 9, 2019 .
  12. ^ Willibald Pschyrembel: Practical obstetrics and obstetric operations . 14th edition. Walter de Gruyter, 1973, ISBN 978-3-11-150423-0 , p. 696 ( google.com [accessed December 9, 2019]).
  13. ↑ Werner F. List, Peter M. Osswald: Intensive medical practice . Springer-Verlag, 2013, ISBN 978-3-642-77498-0 , p. 640 ( google.com [accessed December 9, 2019]).
  14. ↑ Shayesta Dhalla: Postsurgical tetanus . In: Canadian Journal of Surgery . tape 47 , no. 5 , October 2004, p. 375-379 , PMID 15540694 , PMC 3211939 (free full text).
  15. ↑ a b Arne C. Rodloff: Obligatory anaerobic, spore-forming rods (clostridia) . In: Sebastian Suerbaum, Gerd-Dieter Burchard, Stefan HE Kaufmann, Thomas F. Schulz (eds.): Medical microbiology and infectious diseases . Springer-Verlag, 2016, ISBN 978-3-662-48678-8 , pp. 325 , doi : 10.1007 / 978-3-662-48678-8_39 .
  16. ↑ Case report: Tetanus after injury while gardening . In: Robert Koch Institute (Ed.): Epidemiologisches Bulletin . No. 34 , August 22, 2003, p. 272 ( rki.de [PDF; accessed on November 9, 2019]). - Vaccine-preventable diseases in Germany up to the year 2000 . In: Robert Koch Institute (Ed.): Epidemiologisches Bulletin . No. 7 , February 15, 2002, p. 49–57, here p. 51 ( rki.de [PDF; accessed on November 9, 2019]).
  17. ↑ a b See statistics of the WHO who: Tetanus (total) reported cases ( Memento from March 9, 2013 in the Internet Archive )
  18. ^ A b Immunization, Vaccines and Biologicals: Tetanus. In: who.int. February 13, 2008, accessed January 19, 2015 .
  19. ↑ Professional Association of German Internists : Treatment of Tetanus (undated)
  20. ↑ a b c RKI - Infectious Diseases A – Z - Tetanus. In: rki.de. March 5, 2014, accessed January 19, 2015 .
  21. ↑ Immune Serum - Definition. In: Gesundheit.de. Retrieved January 19, 2015 .
  22. ↑ Andreas Hummel: Drug theory. Vincentz Network GmbH & Co. KG, 2004, ISBN 978-3-878-70482-9 , p. 544 ( limited preview in the Google book search).
  23. ↑ Landtag: Law for the implementation of the Infection Protection Act. (Infection Protection Implementation Act - IfSAG MV). In: landesrecht-mv.de. June 3, 2006, accessed on March 8, 2020 (reference: GVOBl. MV 2006, p. 524, status: last change taken into account: last changed by Article 4 of the law of 16 May 2018 (GVOBl. MV p. 183, 184 )).
  24. ↑ Thuringian Ordinance on the Adjustment of the Reporting Obligation for Infectious Diseases (Thuringian Infectious Disease Reporting Ordinance - ThürIfKrMVO) of February 15, 2003. Reference: GVBl. 2003, 107. (Current version of the complete edition available as of March 9, 2020, status: last change taken into account: last changed by ordinance of February 4, 2015 (GVBl. P. 3)).
  25. ↑ State Minister for Social Affairs: Ordinance of the Saxon State Ministry for Social Affairs and Consumer Protection on the extension of the reporting obligation for communicable diseases and pathogens according to the Infection Protection Act. Full quote: Ordinance of the Saxon State Ministry for Social Affairs and Consumer Protection on the extension of the reporting obligation for communicable diseases and pathogens according to the Infection Protection Act of June 3, 2002 (SächsGVBl. P. 187), last amended by the ordinance of November 9, 2012 (SächsGVBl. P . 698) has been changed. In: revosax.sachsen.de. Retrieved on March 8, 2020 (version valid from: December 16, 2012).
  26. ↑ Notifiable communicable diseases and pathogens. (PDF, 114 kB) Overview of mandatory reporting 2020. Federal Office of Public Health FOPH, Communicable Diseases Department, January 23, 2020, accessed on March 8, 2020 (flyer with tabular overview).
  27. ↑ a b Anton Mayr: Medical microbiology, infection and epidemic theory. Georg Thieme Verlag, 2007, p. 504, ISBN 978-3-830-41060-7 ( limited preview in Google book search).