Tetano: sintomi, incubazione e trattamento
Table of Contents
Descrizione
Iltetanoè una grave malattia del sistema nervoso centrale caratterizzata principalmente da spasmi muscolari e gravata da una notevole mortalità, causata dalla neurotossina prodotta da un bacillo Gram+aerobico, sporigeno, denominato Clostridium tetani.
Laneurotossina viene prodotta in condizioni di anaerobiosi dalle forme vegetative del bacillo, quando queste si localizzano in corrispondenza di ferite non deterse, normalmente profonde e anfrattuose, o in sede di infezioni croniche necrotizzanti (ascessi, otiti croniche), ancora in corrispondenza di manovre chirurgiche non sterili (tetano chirurgico, tetano neonatale).Iltetanoneonatale è praticamente scomparso grazie alle copertura del vaccino infantile (intorno al 95%).
Epidemiologia
L’incidenza del tetano nei paesi del mondo occidentale è ormai estremamente ridotta, in seguito alle campagne divaccinazioni di massa, ed è compresa dello 0,1 è da 0,2/ casi/ milione/anno. La maggior parte dei casisi verifica tra persone oltre 60 anni, mai vaccinati,anche se vi sono recenti segnalazioni di un aumento di casi nella popolazione 25-60 anni e di alcuni casi di tossicodipendenti per via endovenosa.
Patogenesi
Le spore diClostridium tetanivengono eliminate daglierbivori con le feci e possono resistere nel terreno per molto tempo, resistenti ad agenti chimici e fisici, esse vengono distrutte solo dal glutaraldeide, ossido di etilene o calore umido a 150° per un’ora. Il contagio avviene tramiteferite dovute a oggetti metallici, schegge di legno, spine, normalmente piuttosto lacere e profonde, e contaminate da terriccio o polvere.
Il rischio maggiore si verifica in prati, campi coltivati e zone boschive. Altre possibilità sono legate all’uso di siringhe contaminate, particolarmente da parte di tossicodipendenti o alla contaminazione di ferite chirurgiche, suture, piaghe, moncone del cordone ombelicale o prepuzio dopo circoncisione.
A contatto con il tessuto umano danneggiato le spore germinano, trasformandosi in un bacillo in grado di produrre la metalloproteasi tetanospasmina o tossina tetanica. La tossina segue gli assoni delle cellule nervose periferiche e va localizzarsi al livello del sistema nervoso centrale (sia encefalo sia midollo spinale). Ne consegue un aumento del tono muscolare, spasmi dolorosi e instabilità del sistema autonomo.
Aspetti clinici
L’incubazione del tetanopuòdurare da un giorno a diversi mesi con una mediana di 7-8 giorni, essendo correlate in modo diretto, la distanza fra la ferita e il sistema nervoso centrale: la velocità di spostamento della tossina lungo l’assone è calcolata in circa 250 mm al giorno. Le principali forme cliniche del tetano sono:
- tetano generalizzato
- tetano locale
- tetano cefalico
- tetano neonatale
La gravità della malattia è variabile e dipende dalla quantità di tossina prodotta. E’ clinicamente correlabile in modo inverso al periodo di incubazione, l’intervallo tra la comparsa dei sintomi e la comparsa degli spasmi.
Sintomi
I segni clinici caratteristici deltetanosono:
- rigidità del collo
- opistotono(stato di rigidità spastica che porta il soggetto ad assumere un’innaturale posizione inarcata)
- riso sardonico
- rigidità dei muscoli addominali
- apnea periodica da contrazioni dei muscoli respiratori o faringe
- disfagia.
La temperatura corporea è elevata, in seguita all’iperattività muscolare. Durante gli spasmitetanici il paziente caratteristicamente stringe i pugni, arcua il dorso, adduce e flette le braccia, stende le gambe e va in apnea.
Trattamento
Il trattamento deltetanorichiede un ambiente rianimatorio, sia per il trattamento dell’ ipertono muscolare, sia per il supporto alla respirazione. I cardini della cura sono:
- l’interruzione della produzione di tossina
- la neutralizzazione della tossina libera
- il controllo degli spasmi muscolari
- il controllo delle disfunzioni autonomiche
- il trattamento di supporto.
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( dott.Giancarlo Agnelli e dott.ssa Chiara Busti- Medicina d’Urgenza-Edizioni Medico Scientifiche s.r.l.)
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