AssessmentsClostridium tetani (Tetanus)
Clostridium tetani (Tetanus)
USMLE® Step 1 style questions USMLE
A 36-year-old woman is brought to the emergency department by a friend for evaluation of muscle pain. The patient is currently undomiciled and has limited access to medical care. A few days ago, the patient developed painful muscle spasms as well as difficulty opening her mouth. Temperature is 37.8 °C (100.0 °F), blood pressure is 127/68 mmHg, and pulse is 100/min. On physical examination, the patient is unable to open her jaw and facial expression appears fixed. There is also backward arching of the neck and head. Multiple deep puncture wounds and superficial lacerations are present on the bilateral feet. Which of the following proteins is targeted by the toxin responsible for this patient’s symptoms?
Clostridia, as a family, are obligate anaerobes, meaning that oxygen is toxic to them. In nature, they thrive in deep, compact soil, and when they feel the stress of fresh oxygenated air, they often produce spores, which are metabolically inert and extremely resilient to the environment.
Then, when environmental conditions improve, the spores are able to sprout into fully fledged Clostridia.
When doing a Gram stain, Clostridium tetani stains purple, or Gram positive, and it’s a bacillus, meaning that it looks like a big cylinder or rod under the microscope.
Tetanospasmin works by entering special inhibitory neurons called Renshaw cells.
Once they get inside, tetanospasmin cleaves SNARE proteins, which are proteins that pull vesicles that are loaded with neurotransmitters to the neuron membrane.
When the SNARE proteins are cleaved, it prevents the release of inhibitory neurotransmitters, like glycine and GABA.
You can think of SNARE proteins as the rails and the vesicles as trains that are loaded with neurotransmitters.
And tetanospasmin destroys the “rails”, so that the “trains” can’t move.
The role of Renshaw cells and inhibitory neurotransmitters is to fine tune the action of the alpha motor neuron, which is in charge of sending the actual signal for contraction to the muscle.
Spores of Clostridium tetani are most often introduced into the body through penetrating trauma, like a puncture wound. Puncture wounds are usually anaerobic and warm, and are therefore optimal for growth of Clostridium tetani.
In fact, any kind of puncture wound or cut brings along a risk of tetanus.
Tetanus usually starts with a delayed onset, about a week to a month after the initial injury.
The spasms are sudden, powerful, long lasting and very painful contractions of muscles.
These contractions are so powerful, that they can result in muscle tears or bone fractures.
The classical “tetanic triad” of symptoms involves trismus, or lockjaw, which are mild to severe spasms of the lower jaw, risus sardonicus, or “Sardinian grin”, which is an abnormal looking, sustained grin, caused by facial muscle spasm, and opisthotonos, which is a severe simultaneous spasm of all muscles in the body simultaneously, resulting in a high arched back and patient resting on his heels and the back of his head.