[Tetanus: an immunopreventable disease]

Tetanus is an infectious disease caused by a ubiquitous bacterium Clostridium tetani, that synthesizes and releasesa potent neurotoxin under anaerobic conditions, which is responsible for the clinical manifestations. As it is found in soil contaminated with animal and human excreta, it is difficult to eradicate but it may be prevented by immunization. Immunization rate has decreased in the last years, especially during the COVID-19 pandemic. We report two cases of tetanus, attended during 2022. A 39-year-old man whose entry route was a gunshot wound and he was discharged from the intensive care unit (ICU) and a second case of an 83-year-old woman with unknown entry point, who died during her ICU stay. The cases reported highlight that it is a life-threatening disease, its diagnosis is mainly clinical and it should be in the algorithm of differential diagnoses. We emphasize about the prompt treatment administration or consultation to a specialized healthcare center. The importance of this presentation is to show the severity of the disease, whose assessment is mainly clinical and should not escape the algorithm of differential diagnoses, emphasizing that treatment should be instituted early or when in doubt consult a specialized center. In addition to this, it is important to check theimmunization rate in our country, especially during thepandemic, becauseit is a vaccine-preventable disease.

[Tetanus - still a reality in Sweden]

Tetanus (lockjaw) is a potentially life-threatening disease caused by a neurotoxin produced by the spore forming bacterium Clostridium tetani. The incidence has decreased substantially the last decades in most high-income countries, much due to well established vaccination programs. However, although uncommon, tetanus still remains a reality in Sweden. The condition is diagnosed based on clinical parameters and is hard to distinguish from many other more common differential diagnoses. Lack of vaccine induced antibodies is the most important risk factor for developing tetanus. Here we present a patient who developed tetanus two weeks following a puncture wound, but who was initially misdiagnosed with wake-up stroke. The case illustrates the importance of reviewing a patient's tetanus vaccine history, which determines what prophylactic measures are adequate to take, especially following potentially contaminated wounds.

Risk of Clostridium tetani infection in an elderly patient following hemorrhoid ligation

Tetanus after gastrointestinal surgery is an extremely rare but very dangerous disease caused by infection with Clostridium tetani. Tetanus can occur due to bacterial infection during surgery or dressing change, or the bacteria may exist in the patient’s intestines and be discharged with feces. This report describes a 71-year-old woman who developed tetanus 3 days after a hemorrhoidal ligation. Clinicians need to be aware of symptoms of C. tetani infection that might present in patients who have undergone gastrointestinal procedures.

[An unvaccinated man with a painful arm and jaw]

BACKGROUND

Clostridium tetani is a gram-positive spore-forming bacterium that produces toxins and grows under anaerobic conditions. Infections with this bacterium can lead to local or generalised forms of tetanus.

CASE DESCRIPTION

An 83-year-old man presented to the acute cardiac care unit with a painful left arm and jaw. Because the patient had a hypertonic left arm and was unable to open his mouth fully, the neurologist was consulted. The patient had been to the emergency department 9 days earlier for an infected wound after falling in the garden. He had not been actively or passively immunised against tetanus at that time. On inquiry, it appeared that the patient had also not been vaccinated as a child. We made a clinical diagnosis of tetanus. The patient was admitted and treated with tetanus immunoglobulin, metronidazole, diazepam and painkillers. He was also administered tetanus toxoid and the wound was cleaned. After 1 month and 7 months, the patient was again administered tetanus toxoid.

CONCLUSION

Patients with a wound that may have come into contact with road grime, dirt or manure, should always be asked for their vaccination status, especially people from high-risk groups, such as the elderly.

[Tetanus Still Current]

Tetanus is a disease caused by tetanotoxin produced in necrotic wounds by Clostridium tetani. It is a very rare disease in Czechia due to successful and effective population-wide vaccination programme, despite the fact that spores of C. tetani are permanently present in the environment. Groups with the highest risk of clinical tetanus include elderly people, immunocompromised individuals, residents of foreign origin with unclear vaccination history, and unvaccinated children. We present four case studies of severe and mild form of tetanus, wound infection with the presence of C. tetani without the development of clinical tetanus in a fully vaccinated individual, and unexpected risk of tetanus in an unvaccinated child. Due to the rare occurrence of tetanus in Czechia, the clinical awareness of the risk of tetanus decreases as well as the clinical experience with diagnosis of early or mild forms of tetanus. Communication skills during the management of contaminated wounds play a critical role in the decision who should get tetanus anatoxin only and who should get antitetanus immunoglobulin along with the active immunization by tetanus anatoxin. Key words: etanus, Clostridium tetani, vaccination, postexposure prophylaxis, vaccine hesitancy, contaminated wounds.

Forgotten pathogen: tetanus after gastrointestinal surgery

A previously healthy 79-year-old woman underwent an urgent laparotomy and resection of a strangulated loop of small bowel. On the second postoperative day, she developed symptoms suspicious for postoperative tetanus. A transfer to the intensive care unit was necessary for aggressive supportive therapy. The patient required 5 months of intensive physiotherapy and rehabilitation and was successfully discharged home. New cases of tetanus have become rare in developed countries. This potentially lethal disease affects both non-immunised and inadequately immunised patients. The occurrence of tetanus after gastrointestinal surgery is extremely rare. Prevention is key and can be achieved with correct immunoprophylaxis. Older patients are often inadequately immunised. Should tetanus immunoprophylaxis routinely be checked for elderly patients undergoing gastrointestinal surgery? Or can we limit the immunisation to severe cases of ischaemic bowel injury with necrosis and/or soiling of the abdominal cavity?

Tetanus presenting primarily as periocular discomfort in a patient who underwent surgery for sleep apnea: A case report and brief literature review

RATIONALE

Tetanus is caused by a neurotoxin (tetanospasmin) secreted by a spore forming gram-positive, anaerobic rod-shaped motile bacillus, Clostridium tetani. The most common symptoms of tetanus are trismus (100%), dysphagia (70.5%), dysarthria (35.2%), and neck stiffness (29.4%). Respiratory failure, laryngeal spasm, seizure, chest pain, nausea/vomiting, opisthotonus, back pain, and rigid abdominal wall can also be observed during progression of the disease. However, there has been no report of periocular discomfort as an initial manifestation after endoscopic sleep surgery in a patient with tetanus. Here, we report a patient who underwent endoscopic sleep surgery with a concurrent diagnosis of tetanus infection presenting with atypical periocular discomfort as the initial symptom.

PATIENT CONCERNS

A 63-year-old man complaining of sleep apnea, snoring, and daytime sleepiness visited our department. He subsequently underwent sleep surgery (anterior pharyngoplasty with tonsillectomy, septoplasty, microdebrider-assisted inferior turbinoplasty, and an endoscopic sinus surgery) for the treatment of his newly diagnosed obstructive sleep apnea. After 3 weeks of surgery, he visited the outpatient clinic of our department with right side periocular discomfort.

DIAGNOSES

Four days after presenting with periocular discomfort, he was diagnosed with tetanus by presenting trismus, jaw pain, dysphagia, and ptosis at an emergency department of a different hospital.

INTERVENTIONS

Tetanus immunoglobulin and antibiotics were administered.

OUTCOMES

His symptoms then resolved after a month without sequelae.

LESSONS

Although periocular discomfort is atypical and is not uncommon after nasal and oral surgeries, care should be taken when patients present with periocular pain because it could be a rare initial symptom of tetanus.

[Shiga toxin and tetanus toxin as a potential biologic weapon]

Toxins produced by the bacteria are of particular interest as potential cargo combat possible for use in a terrorist attack or war. Shiga toxin is usually produced by shiga toxigenic strains of Escherichia coli (STEC - shigatoxigenic Escherichia coli). To infection occurs mostly after eating contaminated beef. Clinical syndromes associated with Shiga toxin diarrhea, hemorrhagic colitis, hemolytic uremic syndrome (HUS - hemolytic uremic syndrome) or thrombotic thrombocytopenic purpura. Treatment is symptomatic. In HUS, in which mortality during an epidemic reaches 20%, extending the kidney injury dialysis may be necessary. Exposure to tetanus toxin produced by Clostridium tetani, resulting in the most generalized tetanus, characterized by increased muscle tension and painful contractions of individual muscle groups. In the treatment beyond symptomatic behavior (among others spasticity medications, anticonvulsants, muscle relaxants) is used tetanus antitoxin and antibiotics (metronidazole choice). A common complication is acute respiratory failure - then it is necessary to implement mechanical ventilation.

[Tetanus and Clostridium tetani--a brief review]

Tetanus is an acute, often fatal, disease caused by an exotoxin (tetanospasmin) produced by the anaerobic, gram-positive spore-forming bacterium Clostridium tetani. It is characterized by generalized rigidity and convulsive spasms of skeletal muscles. In most industrialized countries, tetanus is a rare disease. However, in many tropical and subtropical countries with low vaccination coverage and poor medical care, it is still widely distributed. This applies in particular for neonatal tetanus. About 50 000 newborns and infants die each year from consequences from this severe illness. Management of tetanus involves neutralization of free circulating toxin, adequate antibacterial and symptomatic therapy as well as intensive care of the patient. For prophylaxis of the disease, active tetanus toxoid vaccination is the method of choice.

Human monoclonal ScFv that inhibits cellular entry and metalloprotease activity of tetanus neurotoxin

Tetanus is a deadly disease of warm blooded animals and humans caused by an exotoxin called tetanospasmin or tetanus neurotoxin (TeNT) produced by anaerobic bacterium named Clostridium tetani TeNT is an A-B toxin; each molecule consists of a heavy chain (HC) containing cellular receptor binding domain and a light chain (LC) with zinc metalloprotease activity. TeNT produced in the infected tissue by the bacteria grown under anaerobic condition binds to ganglioside receptors of peripheral nerve, and endocytosed. The A subunit exits from the endosome and undergoes a retrograde transport via the nerve axon to the spinal cord. This highly toxic enzyme specifically cleaves one of the nerve cell SNARE proteins, i.e., synaptobrevin, resulting in inhibition of the release of neurotransmitters (glycine and GABA) from inhibitory interneuron causing spastic paralysis, the characteristic of tetanus. Current treatment mainstay of human tetanus is by passively administering anti-tetanus toxin produced from animals immunized with adjuvanted tetanus toxoid (TT). There are several obstacles in production and use of the animal derived therapeutic antibody especially the allergic reaction and serum sickness induced by the host immune response to the foreign protein. The animal antibody, mainly IgG, blocks nerve cell entry of the TeNT but does not neutralize the TeNT protease activity per se and cannot reverse the tetanus symptoms. In this study, fully human single chain antibody fragments (HuScFv) were produced from a human antibody phage display library. TT was used as antigen in a single round phage bio-panning to select phage clones that display TT bound-HuScFv from the library. HuScFv from 4 selected huscfv-phagemid transformed E. coli clones inhibited binding of the native TeNT to retinoic acid pulsed human neuroblastoma cells when used at the molecular TeNT:HuScFv ratio of 1:100. HuScFv from one of the 4 clones also inhibited the TeNT mediated cleavage of recombinant synaptobrevin. Further investigation is needed for identification of epitope specificity of these HuScFv and HuScFv effector mechanisms towards the TeNT. Cell penetrating version of the HuScFv that inhibited the TeNT zinc metalloprotease activity should be made. The HuScFv produced in this study either singly or in their suitable combination warrant developing further to a real use in humans as a surrogate of the animal antibody for treatment of tetanus.

Retrospective Study of Tetanus in 20 Dogs: 1988–2004

The case records of 20 dogs that were treated for tetanus between 1988 and 2004 were reviewed. Young, large-breed dogs were most commonly affected. Twelve dogs had a likely source of infection identified. All dogs were treated with intravenous antibiotics and supportive care, such as muscle relaxants and sedation for muscle tremors and rigidity. Sixteen dogs received tetanus antitoxin. The mortality rate was 50%. Complete recovery in survivors required approximately 1 month.

Tetanus in pregnancy

Tetanus remains a leading cause of maternal and neonatal morbidity and mortality in developing countries. It is caused by the release of two toxins produced by Clostridium tetani, a noninvasive gram-positive anaerobic bacillus. Tetanospasmin is taken up by the neuronal end plates and prevents neurotransmitter release at the synaptic junction. This leads to spasms and is irreversible. Recovery requires the formation of new neurons and may take months. Generalized muscle spasm, respiratory compromise, and autonomic dysfunction are all common clinical manifestations. Diagnosis is based mainly on history and clinical examination. The management of the pregnant woman is similar to the nonpregnant individual. The main objectives are prompt prevention of further toxin absorption, wound debridement, antibiotic therapy, and aggressive supportive care. Primary and secondary prevention protocols are important worldwide because tetanus is a preventable disease. The tetanus toxoid vaccine can be given in pregnancy.

Bronchoaspiration as a possible cause in a case of tetanus. A reminder on the importance of adulthood immunizations

Although preventable by immunization tetanus still takes a large death toll, mostly in developing countries, where adult population is often unprotected and opportune medical care unavailable. We present a case of tetanus in an elderly patient with bronchoaspiration pneumonia after a near-drowning incident, in which no objective entry site could be suspected with as much temporal relation as the bronchoaspiration incident. Bronchoaspiration of organic matter and feces provides both a source of the causative agent and an adequate polymicrobial environment for the development of the disease. It is under such conditions that we propose this unusual entry site as the cause of tetanus in our patient. Special emphasis is made on the importance of adulthood immunization programs and how incidents like this one should be taken into account in the overall care provided to the elderly population.

SEROLOGICAL GROUPING OF THE PATHOGENIC CLOSTRIDIA

Ellner, Paul D. (University of Vermont, Burlington), and Stanley S. Green. Serological grouping of the pathogenic clostridia. J. Bacteriol. 86:1098-1100. 1963.-By use of the soluble antigens of ten species of pathogenic clostridia and specific globulins, it has been possible to divide these organisms into a number of groups based upon the presence or absence of precipitin lines in agar gel. A scheme for such a grouping is presented, and the utility of this method is discussed.

ANTIMICROBIAL ACTION OF NITROGEN-CONTAINING STEROIDS

Smith, Rodney F. (University of Maryland, Baltimore), Donald E. Shay, and Norman J. Doorenbos. Antimicrobial action of nitrogen-containing steroids. J. Bacteriol. 85:1295-1299. 1963.-A new group of 16 synthetic nitrogen-containing steroids have been tested against a variety of microorganisms for antimicrobial properties. The gradient plate screening method, serial dilution, and dry weight techniques were used in the studies. The organisms tested consisted of 14 gram-negative bacteria, 10 gram-positive bacteria, 2 actinomycetes, 7 yeasts, and 8 molds. Inhibitory properties were found to be specific and potent in four compounds, with inhibitory concentrations as low as 0.37 mug/ml. Three of the active steroids are 4-aza cholestanes and one is a 4-nor-3,5-secocholestane amide. Sensitivity to the compounds was greatest in the gram-positive bacteria, followed by the yeasts and molds. The gram-negative bacteria were not inhibited. All 16 steroids interfered to some extent with pigmentation in Serratia marcescens but not with pigment production in Pseudomonas aeruginosa. In a few instances, some of the molds were stimulated by the steroids at a concentration of 250 mug/ml.

SEROLOGY OF THE SOLUBLE ANTIGENS OF THE PATHOGENIC CLOSTRIDIA

Ellner, Paul D. (University of Vermont, Burlington), and Stanley S. Green. Serology of the soluble antigens of the pathogenic clostridia. J. Bacteriol. 86:1084-1097. 1963.-Soluble antigens of 42 strains, representing nine species of clostridia commonly occurring in human infections, were prepared by growing the organisms in a nonantigenic medium. Serological studies demonstrated the occurrence of considerable strain variation within each species. Interactions among the nine species, as well as with the previously characterized Clostridium perfringens, were also investigated. Extreme heterogeneity was observed among the species studied, with many cross-reactions due to common antigens, although species-specific antigens were also found in some cases. Occasional weak reactions were also demonstrated between certain clostridial antisera and the soluble antigens of three of the four species of Bacillus studied.

ISOLATION OF CLOSTRIDIUM TETANI FROM SOIL

Sanada, Ichiro (Kanazawa University, Kanazawa, Japan), and Shoki Nishida. Isolation of Clostridium tetani from soil. J. Bacteriol. 89:626-629. 1965.-The higher the temperatures applied to soil specimens, the weaker the toxigenicity of Clostridium tetani strains isolated from them. The glucose- and maltose-fermenting ability of these isolates was inversely proportional to their toxigenicity. The biological properties of atoxic strains were indistinguishable from those of C. tetanomorphum. Since a considerable number of toxic strains fermented glucose and maltose, these criteria are of doubtful value for differentiating C. tetani from C. tetanomorphum.

IN VITRO AND IN VIVO LABORATORY EVALUATION OF CEPHALOGLYCIN AND CEPHALORIDINE

Two new antibiotics, structurally related to cephalothin, have been given the generic names cephaloglycin and cephaloridine. Cephaloglycin is the dipolar ion of 7-(d-alpha-aminophenylacetamido)-cephalosporanic acid. Cephaloridine is 7-[alpha-(2-thiophene)acetamido]-3-(1-pyridylmethyl)-3-cephem-4-carboxylic acid betaine. These new compounds were evaluated simultaneously. The broad spectrum of activity observed in vitro and in vivo with both antibiotics, the good oral absorption obtained with cephaloglycin, and the stability of cephaloridine are emphasized. The data suggest that both antibiotics merit clinical trial in humans.

A cellular pertussis vaccine (Infanrix-DTPa; SB-3). A review of its immunogenicity, protective efficacy and tolerability in the prevention of Bordetella pertussis infection

SB-3 (Infanrix-DTPa) is one of a new generation of vaccines for immunisation against pertussis (whooping cough), diphtheria and tetanus. It is a 3-component (pertussis toxin, filamentous haemagglutinin and pertactin) chemically inactivated acellular pertussis pertussis-diphtheria-tetanus toxoid (DTaP) vaccine, and it differs from conventional whole-cell pertussis-diphtheria-tetanus toxoid (DTwP) vaccines in that it comprises inactivated purified Bordetella pertussis antigens rather than whole cells of the bacillus. SB-3, like a number of other DTaP vaccines, elicits a similar or more often, a significantly greater immune response than various DTwP vaccines in healthy infants and young children. initial data from comparative studies indicate that SB-3 also remains immunogenic when given in combination with hepatitis B vaccine or concurrently administered with Haemophilus influenzae type b (HbOC) conjugate vaccine. A combination of SB-3 and H. influenzae type b tetanus (PRP-T) conjugate vaccine results in lower anti-PRP antibody response than when both vaccines are administered concurrently. Data from two large, multicentre, German and Italian studies in infants indicate that the protective efficacy of SB-3 against pertussis was significantly better than one DTwP (DTwP-CON) but similar to another one (DTwP-BW) under investigation. Compared with another DTaP vaccine (BIO-3), SB-3 was just as protective. Overall, the data from these 2 studies indicate that primary vaccination with SB-3 provides effective protection against pertussis, even under the stringent conditions of a household contact with typical pertussis. As the other DTaP vaccines, SB-3 is better tolerated than DTwP vaccines, with a significantly lower incidence of common adverse events such as local reactions (swelling, pain and a erythema), irritability, fever, persistent crying and local tenderness. Clinical experience with SB-3 thus far indicates that, like other DTaP vaccines, it is associated with significantly fewer common (non-serious) adverse events than DTwP vaccines. Less clear is whether it has any advantage over DTwP vaccines with respect to protective efficacy or over other DTaP vaccines with respect to tolerability and protective efficacy. Nevertheless, the available data support the use of SB-3 for infant immunisation, as well as providing a suitable basis for the development of new combination vaccines.

Delineation and comparison of ganglioside-binding epitopes for the toxins of Vibrio cholerae, Escherichia coli, and Clostridium tetani: evidence for overlapping epitopes

Binding studies of various glycolipids, mainly belonging to the ganglio series, to the toxins isolated from Vibrio cholerae, Escherichia coli, and Clostridium tetani have been performed, using the microtiter well assay. By using the found binding preferences in conjunction with minimum-energy conformations obtained from molecular modeling of the various ligands, binding epitopes on the natural receptor glycolipids for the toxins have been defined. The binding preferences for the cholera toxin and the heat-labile E. coli toxin are very similar, with the ganglioside GM1 being the most efficient ligand. The tetanus toxin binds strongly to gangliosides of the G1b series, with GT1b as the most efficient ligand. It is found that the binding epitope on GM1 for the cholera and heat-labile toxins to a large extent overlaps with the epitope on GQ1b for the tetanus toxin.

A simplified method for the preparation of tetanus toxin binding fragment for neurobiology

The non-toxic binding fragment of tetanus toxin (fragment C) binds avidly to neural tissue and has a growing number of neurobiological uses. Its current utility is limited by both its high commercial cost and the complex procedure for its preparation requiring highly purified tetanus toxin. We have developed a short procedure which prepares fragments of tetanus toxin from crude C. tetani extracts. The resultant proteins are atoxic with molecular sizes and immunological properties closely resembling fragment C. These proteins undergo retrograde axonal and apparent transneuronal transport in a fashion similar to fragment C.

Tetanus

Tetanus is produced by the action of the potent neurotoxin, tetanospasmin, which is elaborated during the growth of Clostridium tetani. The objectives of management of tetanus are to provide supportive care until the tetanospasmin that is fixed in tissue has been metabolized, to neutralize circulating toxin, and to remove the source of tetanospasmin. This disease, which is frequently fatal, is prevented by immunization.

Mechanism of tetanolysin-induced membrane damage: studies with black lipid membranes

Tetanolysin produced similar rates of leakage of K+ and hemoglobin from erythrocytes. When studied by using cholesterol-containing black lipid membranes, this hemolysin induced conductance steps with a broad frequency distribution. These findings are inconsistent with the formation of structural channels and suggest that tetanolysin acts by causing lipid perturbations.

Interaction between tetanolysin and Mycoplasma cell membrane

1. A partially purified tetanolysin preparation lysed the sterol-requiring Mycoplasma capricolum cells but had no effect on M. capricolum cells adapted to grow with no or very little cholesterol. The sterol-non-requiring Acholeplasma laidlawii cells grown either in a cholesterol-rich or a cholesterol-poor medium were unaffected by the tetanolysin preparation. 2. The lysis of M. capricolum cells by the tetanolysin preparation was temperature dependent, inhibited by cholesterol, sublytic concentrations of lucensomycin, and Mg2+. The sensitivity to lysis was greatly affected by the age of the culture, being highest in cells from the early logarithmic phase of growth and declining sharply thereafter. 3. Isolated M. capricolum membranes were capable of binding large amounts of the tetanolysin activity (up to 30 hemolytic units per mug membrane protein), 20 times as much as membranes of the adapted strain. The binding of tetanolysin activity to membranes was almost the same at 4,22, or 37 degrees C, and was very little affected by the age of the culture. The binding capacity of the membranes was not affected by the removal of 60-70% of membrane proteins by pronase digestion but markedly decreased with the removal of membrane lipids. 4. Of the five polypeptide bands detected in electrophorograms of the partially purified tetanolysin preparation, two bands (mol. wt. 44 000 and 42 000) were found to bind to the cholesterol-containing mycoplasma membrane preparation. EPR spectrometry revealed that the freedom of motion of fatty acid spin labels in the tetanolysin-treated membranes was markedly higher than that in untreated membranes. 5. The concept that tetanolysin interacts specifically with membrane cholesterol resulting in the shielding of cholesterol from its interaction with membrane phospholipids is discussed.

Effect of Clostridium toxoids, especially of Clostridium perfringens toxoid, on mouse transplanted tumors

The antitumor activities of toxoids of Clostridium perfringens, C. nouyi, C. septicum, and C. tetani were tested against sarcoma-180 and Ehrlich carcinoma. Among them, C. perfringens toxoid showed a high antitumor activity against the growth of the implanted sarcoma-180 ascites form. The results of the inhibiting effect of C. perfringens toxoid on Nakahara-Tokuzen-Fukuoka (NTF) reticulum cell sarcoma and methylcholanthrene-induced fibrosarcoma were also described.

Tetanus: review of the literature and report of a case

The clinical features, active and passive immunization schedules, and an approach to management of established tetanus are reviewed and discussed. A case of localized tetanus is presented in which the patient's initial complaint was inability to open the mouth. Prompt diagnosis and treatment contributed to a large extent to the patient's successful recovery.