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situations in the US where ppl still get tetanus
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progenitor tetanus neurotoxin
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tetanus & botulism

lecture 13 gregg

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situations in the US where ppl still get tetanus 70% following injury, elderly women with waning immunity or inadequate adult immunizations, "skin-popping" black tar heroin users, body piercings
progenitor tetanus neurotoxin light chain - toxic moiety (strongly homologous with botulinum toxin) binds peripheral nerves and travels retrograde to GABA and glycinergic interneuron terminals // heavy chain is cleaved from light chain - cell receptor specificity @ neuron target
tetanus neurotoxin Zn-dependent endopeptidase cleaves synaptobrevin to prevent NT release by descending inhibitory neurons = continuous contraction of antagonist muscles = muscular rigidity and hypersympathetic state
signs and sx of generalized tetanus aka spastic paralysis afebrile, trismus, risus sardonicus, abd rigidity, opisthotonus, resp compromise, severe pain all while being completely mentally alert
cephalic tetanus from head or neck wound, involves the CN musculature predominantly. facial paralysis can lead to generalized tetanus
accidental umbilical stump inoculation leads to: generalized tetanus in neonates, esp. whose mother's weren't adequately immunized. high mortality rate from sepsis
DDx for trismus or tetanus-like rigidity electromyography and spatula test to confirm true tetanus. o/w: metoclopramide or phenothiazine-induced dystonia or dental abscess
tx for tetanus maintain airway & feeding tube for hypernutrition, keep room quiet and dark, benzodiazepines IV or intrathecal baclofen, NMJ blockers, passive and active immunization to tetanus, metronidazole and wound debridement, labetalol IV or morphine & heparin
populations that require Tdap booster preg women, those in close contact with neonates and infants, adults > 65 y/o
cases in which one receives human tetanus Ig via IM route and tetanus toxoid booster via another IM site if fresh contaminated wound in pt with inadequate immunization hx OR pts who clinically have tetanus
unique feature about C. botulinum in cx grows on egg yolk agar and is lipase (+) so it leaves a clear halo around the colonies
primary mechanism for botulism in US ingestion of spores in home-canned foods or fruits or fish products with pH > 4.6 or eating meat/blubber in Alaska
specific cases where wound botulism risk goes way up "skin popping" black tar heroin use, intranasal cocaine use, dental abscesses, major traumas
botulinum toxin resembles tetanospasmin, is the single most poisonous substance known on earth. forms A, B, E & F are most often seen in foods and cause human infections.
subtypes of botulinum toxin seen in drug users A and B - they will only have wound botulism and no GI sx
infant botulism the most frequently encountered form in the US. due to colonization of the gut by the clostridia and then production of the toxin in vivo.
pathogenesis of botulinum toxin attaches to cholinergic ganglionic and parasympathetic synapses and NMJs via the heavy chain // light chain separates and is a Zn-containing enzyme that, depending on serotoxiciity cleaves 1 of 3 enzymes
3 enzymes affected by botulinum toxin SNAP-25, syntaxin or VAMP/synaptobrevin - causes irreversible release of ACh from NMJ, which results in flaccid paralysis
clinical manifestations of botulism 4-36 hrs after exposure - n/d, dry mouth, slurred speech, blurred vision, difficulty chewing and swallowing, ophthalmoplegia then descending symmetrical weakness of CNs, BUE, trunk and BLE. autonomic dysfunction
unique feature of botulism seen only in infants constipation instead of diarrhea (other nl signs/sx: weak cry, lethargy, poor feeding, hypotonia, drooling and resp failure)
DDx for botulism MG, Guillain-Barre syndrome, Eaton-Lambert syndrome, acute intermittent porphyria, tick paralysis, paralytic shellfish poisoning, puffer fish ingestion, organophosphates, nerve gas or atropine poisoining
dx of botulism may send off a toxin assay to CDC or do cx, but you need to take charge as soon as its suspected b/c of the corresponding clinical picture
tx of botulism botulinum antitoxin neutralizes circulating toxin that hasn't bound to neurons yet (not for infants). ONLY works to prevent further paralysis. // supportive tx and purgatives to expel any remaining food in stomach
tx of botulism for infants baby BIG IV (botulism immune globulin)
abx of choice to treat wound botulism debride and give PCN or metronidazole. DON'T GIVE clindamycin or aminoglycosides - may make things worse
Created by: sirprakes
 

 



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