TetanusDefinisi : gangguan neurologik yang ditandai dengan meningkatnya tonus otot dan spasme, yang disebabkan oleh tetanospasmin, suatu toksin protein yang kuat yang dihasilkan oleh Clostridium tetani.Clostridium tetani merupakan bakteri gram positif berbentuk batang yang selalu bergerak, dan merupakan bakteri anaerob obligat yang menghasilkan spora.Spora bakteri ini dapat bertahan selama bertahun-tahun pada lingkungan tertentu, tahan terhadap sinar matahari dan bersifat resisten terhadap desinfektan dan pendidihan selama 20 menit.

EpidemiologiTetanus masih merupakan penyakit yang membebani di negara-negara berkembang, misal Brazil, Filipina, Vietnam, Indonesia dan negara-negara lain.Angka mortalitas dari data WHO pada tahun 1992 sebanyak 1.000.000 kasus di seluruh dunia, termasuk di dalamnya 580.000 kematian akibat tetanus neonatorum, 210.000 di Asia Tenggara dan 152.000 di Afrika.Sebagian besar tetanus terjadi akibat trauma akut seperti luka tusuk, laserasi atau abrasi. Selain itu, tetanus juga dapat merupakan komplikasi penyakit kronis seperti ulkus, abses, dan gangren. Tetanus akibat luka bakar, infeksi telinga tengah juga pernah terjadi.

Epidemiology

Tetanus was first described in Egypt over 3000years ago(Edwin smith papyrus). It was again described by HippocratesCarle and Rattone in 1884 who first noticed tetanus in animals by injecting them with pus from a fatal human tetanus case.During the same year,Nicolaier produced tetanus in animals by injecting them with samples of soil.In 1889,Kitasato isolated the organism from a human victim,showed that it produced disease when injected into animals,and reported that the toxin could be neutralized by specific antibodies.Nocard demonstrated the protective effect of passively transferred antitoxin,and passive immunization in humansPassive immunization and prophylaxis for tetanus during World War ITetanus Toxoid was first widely used during world war II

Tetanus - Greek Word -- Tetanos-to ContractTetanus Remains a Major Public Health Problem in the Developing World and Is Still Encountered in the Developed World.There Are Between 800000and 1Million Deaths Due to Tetanus Each Year. Eighty Per Cent of These Deaths Occur in Africa and South East Asia and It Remains Endemic in 90Countries World Wide. 1998 - U.K,USA 7 Cases, 41 Cases Including One Neonate

Acridine orange stain of characteristic C tetani with endospores wider than the characteristic drumstick shape.

Courtesy : Google Image on tetanus

C.tetani is a slender,gram-positive,anaerobic rod that may develop a terminal spore,giving it a drumstick appearance.The organism is sensitive to heat and cannot survive in the presence of oxygen.The spores,in contrast,are very resistant to heat and the usual antiseptics.They can not survive autoclaving at 249.8 F (121 C)for 20 minutes.The spores are also relatively resistant to phenol and other chemical agents.The spores are widely distributed in soil and in the intestines and faeces of horses,sheep,cattle,dogs,cats,rats, guinea pigs,and chickens.Manure-treated soil may contain large numbers of spores.Spores may persist for months to years.

C. tetani produces two exotoxins, tetanolysin and tetanospasmin. The function of tetanolysin is not known with certainty. Tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus.Tetanospasmin estimated Human lethal dose 2.5 ng/kg

PatogenesisDalam keadaan anaerobik yang dijumpai pada jaringan nekrotik dan terinfeksi, basil tetanus mensekresi dua macam toksin: tetanospasmin dan tetanolisin. Tetanospasmin menghasilkan sindroma klinis tetanus.Tetanospamin merupakan suatu polipeptida rantai ganda dengan berat molekul 150 kDa. Rantai berat dan rantai ringan dihubungkan oleh suatu ikatan yang sensitif terhadap protease dan dipecah oleh protease jaringan yang menghasilkan jembatan disulfida yang menghubungkan dua rantai ini.Tetanospasmin dalam jumlah banyak dapat memasuki aliran darah yang kemudian berdifusi untuk terikat pada ujung-ujung saraf di seluruh tubuh.

Toksin menyebar dan ditransportasikan dalam akson dan secara retrograd ke dalam badan sel di batang otak dan saraf spinal.Jika toksin telah masuk ke dalam sel, toksin akan berdifusi keluar dan akan masuk dan mempengaruhi neuron di dekatnya. Apabila interneuron inhibitori spinal terpengaruh, gejala-gejala tetanus akan muncul.

Manifestasi Klinis (1)Riwayat adanya faktor trauma sebelumnya timbul luka yang dapat berkontaminasi dengan tanah, kotoran binatang, logam berkarat.Bentuk yang paling umum tetanus generalisata, ditandai: meningkatnya tonus otot dan spasme generalisata. Masa inkubasi : 3-10 hari.Trias klinik: Rigiditas, spasme otot dan apabila berat akan terjadi disfungsi otonomik.Kaku kuduk, nyeri tenggorokan, dan kesulitan membuka mulut gejala awal tetanus.Spasme otot masseter (trismus), spasme otot-otot wajah (risus sardonicus), hingga meluas ke otot-otot untuk menelan disfagia.Rigiditas tubuh menyebabkan opistotonus dan gangguan respirasi dengan menurunnya kelenturan dinding dada.

Spasme otot bersifat episodik, dapat spontan atau dipicu oleh stimulus berupa sentuhan/taktil, visual, auditori atau emosional. Bila spasme ini terjadi terus menerus, mengakibatkan sianosis dan gagal nafas.Disfungsi otonom yang bisa terjadi : takikardia dan hipertensi berat yang bergantian dengan hipotensi, bradikardia. Selain itu terjadi hipersalivasi dan meningkatnya sekresi bronkial. Adanya hiperpireksia dan keringat berlebihan akibat tonus simpatis yang meningkat.

Manifestasi Klinis (2)Derajat keparahan berdasarkan pada sistem pembagian oleh Ablett :Derajat I (ringan): trismus ringan sampai sedang, spastisitas generalisata, tanpa gangguan pernafasan, tanpa spasme, sedikit atau tanpa disfagia.Derajat II (sedang): trismus sedang, rigiditas jelas, spasme singkat ringan sampai sedang, gangguan pernafasan sedang dengan frekuensi nafas > 30 x/menit, disfagia ringan.Derajat III (berat): trismus berat, spastisitas generalisata, spasme refleks berkepanjangan, frekuensi nafas > 40 kali/ menit, serangan apnea, disfagia berat dan takikardia (nadi > 120 x/menit).Derajat IV (sangat berat): derajat tiga dengan gangguan otonomik berat melibatkan sistem kardiovaskuler. Hipertensi berat dan takikardia terjadi berselingan dengan hipotensi dan bradikardia, salah satunya dapat menetap.

Bentuk-bentuk lain tetanusTetanus neonatorumTetanus lokalTetanus sefalik

Komplikasi tetanus

SistemKomplikasiJalan nafas

Respirasi

Kardiovaskuler

GinjalGastrointestinal

Lain-lainAspirasiLaringospasme/obstruksiObstruksi berkaitan dengan sedatifApneaHipoksiaGagal nafasARDS (acute respiratory distress syndrome)Takikardia, hipertensi, bergantian dengan bradikardia, hipotensiGangguan ritme jantungGagal jantungGagal ginjalStasis gasterIleusDiareTromboemboliSepsis dengan gagal organ mutipel

PenatalaksanaanUmum: penderita ditempatkan pada area yang sedikit/minimal dari berbagai stimulus, gangguan obstruksi jalan nafas harus ditangani, pemantauan kardiopulmoner, luka segera dieksplorasi dan dilakukan debridemen.Netralisasi toksin: TIG (tetanoimunoglobulin), dosis 3000-6000 unit intramuskuler.Mengobati sumber infeksi: - Penisilin 10-12 juta unit selama 10 hari- Metronidazole 4 x 500 mg atau 2 x 1 g- Alergi penisilin, diberikan alternatif: eritromisin, klindamisin, kloramfenikol, tetrasiklin.

Three Objectives of Management of Tetanus (1)To provide supportive care until the tetanospasmin that is fixed in tissue has been metabolized

(2)To neutralize circulating toxin

(3)To remove the source of tetanospasmin.

The rating scale for the severity and the prognosis of tetanus is described below. Score 1 point for each of the following: Incubation period less than 7 days Period of onset less than 48 hours Acquired from burns, surgical wounds, compound fractures, or septic abortion Narcotic addiction Generalized tetanus Temperature greater than 104F (40C) Tachycardia greater than 120 beats per minute (>150 beats per min in neonates)

Total score indicates the severity and the prognosis as follows: Score of 0-1 indicates mild severity with less than a 10% mortality rate. Score of 2-3 indicates moderate severity with a 10-20% mortality rate. Score of 4 indicates severe tetanus with a 20-40% mortality rate. Score of 5-6 indicates very severe tetanus with greater than a 50% mortality rate. (http://www.emedicine.com/ped/topic3038.htm)

Phillips, Dakar,. Udwadia Score

PREVENTION

Spores are extremely stable,although immersion in boiling water for 15 minutes kills most spores. Exposure to saturated steam under 15 lbs.of pressure for 15-20 minutes at 121c is highly effective against spores . Sterilization by dry heat is slower than by moist heat (1 -3 hrs at 160 C),but it is also effective against spores. Ethylene oxide sterilization is also sporocidal.

FumigationSterilization of operation theatre500 ml of formaline, 200gms of Pot.permanganate/30 cu.meters of spaceAll windows and doors are closed except oneFissures between the panels of the doors and windows are closed with adhesive tapeAfter 12 hours the doors and windows are opened and the theatre is aired for 24 hours before decommissioning it

Active ImmunizationPassive ImmunizationActive and passive ImmunizationAntibiotics

Tetanus toxoid was developed by Descombey in 1924,Tetanus toxoid immunizations were used extensively in the armed services during World War II.Tetanus toxoid consists of a formaldehyde-treated toxin.There are two types of toxoid available adsorbed (aluminum salt precipitated)toxoid and fluid toxoid.Although the rates of seroconversion are about equal,the adsorbed toxoid is preferred because the antitoxin response reaches higher titers and is longer lasting than that following the fluid toxoid.

TETANUS TOXOID

Active Immunization1st dose - 6th week2nd dose - 10th week3rd dose - 14th week1st booster - 18th month2nd booster - 6th year3rd booster - 10th year

Passive ImmunizationATS(equine) Ig- 1500 IU/s.c after sensitivity test (or)2. ATS(human) Ig- 250-500 IU, no anaphylactic shock, very safe and costly.

Immunization requires at least three doses of Td. 1st dose should be administered on the First visit 2nd dose 4 8 weeks after the first dose of Td and 3rd dose after 6 months of the second Td. A booster dose of Td should be repeated every 10 years throughout life Persons Seven Years of Age or Older Who Have Not Been Immunized

PREVENTION OF NEONATAL TETANUS2 doses of T.T to all pregnant women between 16 to 36 weeks of pregnancy with an interval of 1 to 2 months between the two doses. The first dose as early as possible & the second dose a month later preferably 3 weeks before delivery.If the pregnant woman is previously immunized, a booster dose is sufficient.If the pregnant woman is not immunized, then the new born should be protected against tetanus by giving tetanus human immunoglobulin 750 IU with in 6 hours of birth.