Week 8 Flashcards
Tetanus Microbiology
C tetani, anaerobic Gram positive bacterium, terminal spores ‘drumstick’ highly resistant. Found in the environment throughout the world. Pore-forming toxin ‘tetanolysin’ and a collagenase are needed for growth and toxin production. Only toxigenic C tetani causes tetanus
Tetanus Pathophysiology
At the site of inoculation, tetanus spores enter the body and germinate in the wound. Germination needs particular anaerobic conditions, such as dead and devitalized tissue that has low oxidation-reduction potential. After germination, they release tetanospasmin into the bloodstream. This toxin enters the presynaptic terminals in the neuromuscular endplate of motor neurons and destroys a vesicular synaptic membrane protein resulting in the inactivation of inhibitory neurotransmission that usually suppresses motor neuron and muscle activity. This paralyzes muscle fibres. Subsequently, this toxin, via retrograde axonal transport, travels to neurons in the central nervous system, where it also inhibits neurotransmitter release; this occurs approximately 2 to 14 days after inoculation. Since glycine and GABA are major inhibitory neurotransmitters, cells fail to inhibit the motor reflex response to sensory stimulation, causing a tetanic spasm. This can cause such powerful unopposed muscle activity and contraction that bone fractures and muscle tears can occur.
Tetanus Clinical features
Incubation period: Symptoms, Stiffness. Period of onset: Stiffness, spasms, autonomic dysfunction
Tetanus Neonatal prognosis
Significantly improved with ventilation. Paralysis stops the spasms which stops much of the morbidity and mortality
Tetanus Autonomic dysfunction
Difficult to differentiate from acute cardiac events in comorbid patients
Tetanus Modified Ablett Score
Grade 1 No spasm. Grade 2 Mild short-lived spasms not interfering with respiration. Grade 3 More prolonged muscle spasm interfering with respiration. Grade 4 Grade 3 but autonomic nervous system dysfunction
Tetanus Things you won’t read in the textbooks
Voice change, Spasms (can be mild in elderly patients, but beware), cardiovascular instability is early, pyrexia (can cause irreversible heat-shock), Cardiac events are common in elderly patients
Tetanus Management
Remove toxin (debride, ANTIBIOTICS, ANTITOXIN), Support (control spasms, prevent cardiovascular complications), promote recovery, vaccinate
Tetanus Antibiotic
Metronidazole for 7-10d (Penicillin potentiates GABA)
Tetanus Antitoxin treatment
IM Safe, no large improvement by intrathecal administration (but much more expensive). No difference in mechanical ventilation, autonomic dysfunction, ICU stay or hospital stay between two administration methods Human half life 28d, Equine half life 2w.
Tetanus Antitoxin prevention
Incomplete primary course: all wounds give booster, if dirty/high risk give passive immunisation. Incomplete vaccination all wounds give booster, if high risk give passive immunisation. Complete vaccination: no booster or passive immunisation required
Tetanus Supportive
Airway (tracheostomy), Spasm control (Beno, MgSO4 may help reduce requirement for muscle relaxants but not mechanical ventilation), Autonomic disturbance (use short-acting drugs as the swings are huge, Mg may reduce catecholamine response), Gastrointestinal, Hospital acquired infection
Tetanus Recovery
Important to remember QOL, critical illness in ICU for 3-4w and suffer longterm problems as other patients with prolonged ICU. Early rehab (use relatives in absence of physio) in low resource setting
Tetanus Prevention
Prevention is a much more economical option in LMIC and the cost is borne by patients in low resource settings. Vaccination is cheap (challenges: remote communities, multiple doses [5] needed, and no herd immunity). Important to keep the programs running. Unvaccinated are vulnerable (natural disasters, unintended impact, vaccine hesitancy). If you can’t vaccinate people, prevent neonatal tetanus by clean delivery/wound management
Tetanus Key messages
A toxin mediated disease with no herd immunity. Clinical course is relatively predictable at presentation. Specific therapies have limited impact on outcome and supportive management is the mainstay of treatment. Prevention is and will remain a priority.
Mpox Virology
Zoonotic orthopox, multiple animal reservoirs (primarily rodents).
Mpox Clinical features
Acute febrile illness. Incubation 1-2w, invasion period 0-5d (fever, headache, fatigue, LN), 1-2 into fever -> skin eruption - a few to several thousand lesions appear and evolve simultaneously. Centrifugal vs centripetal distribution. Often quite painful. Macules -> papules -> vesicles -> pustules then scab
Mpox Clades
1 Predominantly West Africa. 2 Central Africa
Mpox Epidemiology
Initially in small jungle villages from zoonotic jumps - rural and rare disease, but as time goes on spreading into other areas. Increased over 1970-2019 associated with urbanisation, increased populations. Smallpox vaccination ended in the 1980s, and worldwide waning immunity has likely contributed to increasing susceptibility. 2018-2022 imported cases, associated with animals in quarantine
Mpox Clade 2b
May to October 2022. Sexual health clinic presentation with blistering lesions, systemic illness. 85,000 cases in non-endemic areas over 110 countries. UK epi - Clade 2b mpox - community engagement through Grndr. WHO PHEIC 2022. 25% of those infected living with HIV, 98% GBMSM aged 20-40. Prevention - immunisation, change in behaviour, infection-associated immunity
Mpox Epi study
Used condoms collected - scavengers (brothels, public spaces) - tested for Mpox DNA found 1% had evidence of Mpox, looked for cooccurrence of other STIs - great example of lateral thinking and creativity
Mpox Clade 1a
Geographically limited to DRC and other West African countries. Zoonotic, less person-person transmission. CFR 4.6%
Mpox Clade 1b
Increasing incidence in DRC, ascertainment bias, initially CFR 4% (likely over estimated as the mild cases do not present, difficult to access testing, and if diagnosed may be asked to isolate which adds to stigma, and inability to go to work and support yourself/family) Retrospective review of HSV/VZV swab negative tests in Burundi - wide distribution M=F, children>adults - likely represents spread in childhood. WHO declares PHEIC 08/2024 - spread through DRC, Burundi, Rwanda, Kenya, Uganda, -> Sweden, Thailand, India, Germany, UK, Zambia, Zimbabwe. Epi: predominantly high-contact sexual networks. CFR 0.38%
Mpox Key messages
Waning immunity to poxviruses. Global outbreak clade 2b controlled (mostly gay, bisexual and MSM). Clade 1 continues to occur with increasing geographic spread. Some sexual transmission clade 1. We don’t have much good data for clade 1 as diagnostics lacking