Tetanus is still present in the 21st century: case report and review of literature.

Tetanus is a very serious disease that can be fatal. Its incidence in the developed world has diminished considerably since the introduction of tetanus toxoid. More importantly, tetanus is one of the few infectious diseases that can be prevented. The recommendations for immunization are clear and readily available. In spite of the progress, we still see cases of tetanus in which the prognosis is poor. We present the case of a 67 year-old man that was admitted to our hospital with one of the most common manifestations of tetanus: trismus. Even though his treatment was established immediately, the hospital stay was long and made him susceptible to various medical complications and nosocomial infections. The incidence of tetanus in Puerto Rico is low but the mortality rate continues to be elevated in the high-risk group: patients older than 60 years of age. This is the reason for which we present this case. Our goal is to provide information with regards to epidemiology, pathogenesis, clinical manifestations, diagnosis and management of tetanus. In addition, it is equally essential to remind our colleagues the significance of adequate prevention of this potentially mortal and disabling disease.

[Tetanus and HIV: a fortuitous association?]. / Tétanos et VIH : une association fortuite ?

OBJECTIVES: To describe the relation between HIV infection and tetanus. METHODS: This prospective study includes all patients admitted to our infectious diseases department with tetanus between July 15 and December 31, 2007, who underwent screening for HIV-1 and 2. RESULTS: The study included 21 patients (sex-ratio = 9.5). Their mean age was 37 years (SD: 5.3) were included. Nine patients (42%) had been immunized, but never received a booster dose. The portal of entry was found in 16 patients (76%) - all but one a skin injury. Tetanus was generalized in all patients (Mollaret classification: 76% Stage II, 24% stage III). Twelve (57%) patients were infected with HIV. Their mean CD4 cell count was 157/mm3 (SD: 75/mm3, range: 74-232/mm3). The overall mortality rate was 53%. It was 100% when no portal of entry was found. It was significantly higher among HIV-positive than HIV-negative patients (82 versus 18%). It did not, however, differ significantly between HIV-positive subjects with a CD4 count < 200/mm3 and those with a CD4 count > or = 200 (58 versus 42%). CONCLUSION: HIV and the absence of portal of entry are poor prognostic factors in tetanus. Therefore, a revision of the Dakar International Classification on tetanus should be revised, to score as 1 those patients with HIV infection and no portal of entry.

Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial.

BACKGROUND: The most common cause of death in individuals with severe tetanus in the absence of mechanical ventilation is spasm-related respiratory failure, whereas in ventilated patients it is tetanus-associated autonomic dysfunction. Our aim was to determine whether continuous magnesium sulphate infusion reduces the need for mechanical ventilation and improves control of muscle spasms and autonomic instability. METHODS: We did a randomised, double blind, placebo controlled trial in 256 Vietnamese patients over age 15 years with severe tetanus admitted to the Hospital for Tropical Medicine, Ho Chi Minh City, Vietnam. Participants were randomly assigned magnesium sulphate (n=97) or placebo solution (n=98) intravenously for 7 days. The primary outcomes were requirement of assisted ventilation and of drugs to control muscle spasms and cardiovascular instability within the 7-day study period. Analyses were done by intention to treat. This trial is registered as an International Standard Randomised Clinical Trial, number ISRCTN74651862. FINDINGS: No patients were lost to follow-up. There was no difference in requirement for mechanical ventilation between individuals treated with magnesium and those receiving placebo (odds ratio 0.71, 95% CI 0.36-1.40; p=0.324); survival was also much the same in the two groups. However, compared with the placebo group, patients receiving magnesium required significantly less midazolam (7.1 mg/kg per day [0.1-47.9] vs 1.4 mg/kg per day [0.0-17.3]; p=0.026) and pipecuronium (2.3 mg/kg per day [0.0-33.0] vs 0.0 mg/kg per day [0.0-14.8]; p=0.005) to control muscle spasms and associated tachycardia. Individuals receiving magnesium were 4.7 (1.4-15.9) times less likely to require verapamil to treat cardiovascular instability than those in the placebo group. The incidence of adverse events was not different between the groups. INTERPRETATION: Magnesium infusion does not reduce the need for mechanical ventilation in adults with severe tetanus but does reduce the requirement for other drugs to control muscle spasms and cardiovascular instability.

Clinical classification of tetanus patients.

The authors propose a clinical classification to monitor the evolution of tetanus patients, ranging from grade I to IV according to severity. It was applied on admission and repeated on alternate days up to the 10th day to patients aged > or = 12 years admitted to the State University Hospital, Recife, Brazil. Patients were also classified upon admission according to three prognostic indicators to determine if the proposed classification is in agreement with the traditionally used indicators. Upon admission, the distribution of the 64 patients among the different levels of the proposed classification was similar for the groups of better and worse prognosis according to the three indicators (P > 0.05), most of the patients belonging to grades I and II of the proposed classification. In the later reclassifications, severe forms of tetanus (grades III and IV) were more frequent in the categories of worse prognosis and these differences were statistically significant. There was a reduction in the proportion of mild forms (grades I and II) of tetanus with time for the categories of worse prognostic indicators (chi-square for trend: P = 0.00006, 0.03, and 0.00000) whereas no such trend was observed for the categories of better prognosis (grades I and II). This serially used classification reflected the prognosis of the traditional indicators and permitted the comparison of the dynamics of the disease in different groups. Thus, it becomes a useful tool for monitoring patients by determining clinical category changes with time, and for assessing responses to different therapeutic measures.

Autonomic nervous system dysfunction predicts poor prognosis in patients with mild to moderate tetanus.

BACKGROUND: Autonomic nervous system (ANS) dysfunction is present in up to one third of patients with tetanus. The prognostic value of ANS dysfunction is known in severe tetanus but its value is not well established in mild to moderate tetanus. METHODS: Medical records of all patients admitted with tetanus at two academic tertiary care centers in Karachi, Pakistan were reviewed. The demographic, clinical and laboratory data was recorded and analyzed. ANS dysfunction was defined as presence of labile or persistent hypertension or hypotension and sinus tachycardia, tachyarrythmia or bradycardia on EKG. Patients were divided into two groups based on presence of ANS dysfunction (ANS group and non ANS group). Tetanus severity was classified on the basis of Ablett criteria. RESULTS: Ninety six (64 males; 32 females) patients were admitted with the diagnosis over a period of 10 years. ANS group had 31 (32%) patients while non ANS group comprised of 65 (68%) patients. Both groups matched for age, gender, symptom severity, use of tetanus immunoglobulin and antibiotics. Twelve patients in ANS group had mild to moderate tetanus (Ablett I and II) and 19 patients had severe/very severe tetanus (Ablett III and IV). Fifteen (50%) patients in ANS group required ventilation as compared to 28 (45%) in non-ANS group (p = 0.09). Fourteen (47%) patients died in ANS group as compared to 10 (15%) in non ANS group (p= 0.002). Out of those 14 patients died in ANS group, six patients had mild to moderate tetanus and eight patients had severe/very severe tetanus. Major cause of death was cardiac arrhythmias (13/14; 93%) in ANS group and respiratory arrest (7/10; 70%) in non ANS group. Ten (33%) patients had complete recovery in ANS group while in non ANS group 35(48%) patients had complete recovery (p= 0.05). CONCLUSIONS: ANS dysfunction was present in one third of our tetanus population. 40% patients with ANS dysfunction had only mild to moderate tetanus. ANS dysfunction, irrespective of the need of mechanical ventilation or severity of tetanus, predicted poor outcome.

A new prognostic scoring system in neonatal tetanus.

A prospective study of 75 cases of neonatal tetanus was carried out with a view to developing a prognostic scoring system which can be used to assess the severity of the disease and to serve as a basis for comparing results of different therapeutic interventions from various centres. The case fatality rate was 77.3%. A table was designed containing 6 parameters and a rating of 1 to 4 was given to each parameter in decreasing order of severity. The minimum total score attainable was 6 and the maximum 24 (the severity of the disease was inversely proportional to the score). The differences between the means of each of the parameters among patients who died and the survivors were significant (P < 0.005). Regression analysis showed that each of the parameters independently had a significant effect on the total score (P < 0.005). Using the percentage mortality at each score, a pattern emerged such that total scores of 6-11 indicated severe tetanus (mortality rate 100%); 12-17, moderate disease (mortality rate 68%), and total scores of > 17 indicated mild neonatal tetanus (mortality rate 18%). Associated poor prognostic factors identified included pneumonia, recurrent apnoea, cyanosis, and opisthotonus.

[Attempt to improve the pronostic score of tetanus (author's transl)]. / Essai d'amélioration du score pronostic du tétanos.

A prognostic score based on 6 criteria has been proposed at the 4th International Conference on Tetanus (Dakar, April 1975). A computer study of 598 cases indicates that this score may be further improved by taking into account with more accuracy the frequency of peaks of paroxism and the special severity of the intra-gluteal infection.

[Tetanus osteoarticular complications in Dakar]. / Les complications ostéo-articulaires du tétanos à Dakar.

To assess the epidemiological and clinical features of osteoarticular symptoms during tetanus infection, we carried out a retrospective study in infectious Diseases Ward of the University Teaching Hospital in Dakar (Senegal). Over a period of 7 years (1990-1996), 1, 199 cases of tetanus of more than 1 month of age were diagnosed. Among those who survived (n = 948), 18 cases of osteo-articular manifestations were observed (1.8%): 15 presented with vertebral fracture located within the thoracical part T4-T8 (83.3%) while 3 patients had para-articular osteoma in the elbows (16.7%). These complications occurred on stage II (89%) and stage III (11%) of Mollaret's classification of tetanus infection. Males were more represented than females (sex-ratio = 5) and the median age was 13 years (range = 6-45 years). The mean hospitalisation duration was significantly higher for patients with para-articular osteoma (6 weeks) than for those with vertebral fracture (3 weeks). No major functional impairment was noticed during hospitalisation and patients required only physiotherapy and clinical and radiological surveillance. Although not frequent and of some little functional consequence, osteoarticular complications of tetanus, should invite to improve the antitetanic immunization strategies in developing countries.

Tétano canino ­ Relato de caso / Tetanus in dogs ­ Case report / Tétano canino ­ Relato de caso

O tétano refere-se a uma condição infecciosa ocasionada por toxinas do Clostridium tetani, bacilo Gram positivo e anaeróbico, o qual ao sofrer lise e morte nos tecidos do hospedeiro libera toxinas capazes de bloquear a liberação do neurotransmissor inibidor de glicina e a liberação do ácido gama-amino butírico, levando a um quadro de tetania. Os sinais clínicos da enfermidade são o trismo e opistótono, entre outros. O diagnóstico se dá por meio de histórico e sinais clínicos e o tratamento é sintomático. O presente artigo tem o objetivo de relatar um caso clínico de tétano em um macho canino da raça Pitbull, de um ano de idade. O cão foi, atendido no Hospital Veterinário da Universidade Paranaense, Umuarama, PR, com sinais clínicos neurológicos como rigidez muscular e opistótono, iniciados após ferimento no coxim plantar. Pelo histórico e sinais clínicos firmou-se o diagnóstico de tétano. Foi instituído tratamento, mas o animal teve óbito, sendo que a doença tem alta mortalidade na espécie.(AU)

Tetanus is an infectious condition caused by Clostridium tetani toxins, a Gram-positive, anaerobic bacillus, which, when undergoing lysis and death in the host tissues, releases toxins capable of blocking the release of the glycine inhibitory neurotransmitter and the release of gamma-amino butyric acid, leading to a tetanic state. The clinical signs of the disease are trismus and opisthotonus, among others. The diagnosis is made by means of history and clinical signs, with symptomatic treatment. This article aims to report a clinical case of tetanus in a one-year-old Pitbull male canine. The dog was attended at the Veterinary Hospital at Universidade Paranaense, in the city of Umuarama, Paraná, presenting neurological clinical signs such as muscular and opisthotonous rigidity, initiated after injury to the plantar cushion. The diagnosis of tetanus was confirmed by the history and clinical signs. Treatment was instituted but the animal died, since the disease present a high mortality rate in the species.(AU)

El tétano se refiere a una condición infecciosa ocasionada por toxinas de Clostridium tetani, bacilo Gram positivo y anaeróbico, el cual al sufrir lise y muerte en los tejidos del hospedero suelta toxinas capaces de bloquear la liberación del neurotransmisor inhibidor de glicina, y la liberación del ácido gama amino butírico, llevando a un cuadro de tetania. Los signos clínicos de la enfermedad son el trismo y opistódomo, entre otros. El diagnóstico se da por medio de histórico y signos clínicos y el tratamiento es sintomático. El presente artículo tiene el objetivo de relatar un caso clínico de tétano en un canino macho de la raza Pitbull, de un año de edad. El perro ha sido atendido en el Hospital Veterinario de la Universidad Paranaense, Umuarama PR, con señales clínicos neurológicos como rigidez muscular y opistódomo, iniciados tras herimiento en el coxin plantar. Por el histórico y señales clínicos se ha llegado al diagnóstico de tétano. Se empezó el tratamiento, pero el animal vino a óbito, siendo que la enfermedad tiene alta mortalidad en la especie.(AU)

[Clinical features of tetanus: a review with case reports].

Tetanus is a CNS disorder characterized by muscle spasms that is caused by the exotoxin of an anaerobic bacterium, Clostridium tetani. This disease is killing tens of thousands of neonates in developing countries. Although the incidence and mortality of tetanus has dramatically dropped in developed countries due to effective vaccination, appropriate wound management, and recent advances in intensive care, treatments remain difficult. From among developed countries, Japan has had a relatively high incidence of tetanus, and prevention is the problem especially in the elderly. We analyzed the data from 12 patients admitted to our hospital during 1997-2010. Their age ranged from 50-82 years; median 72 years with male to female ratio 5: 7, and all patients lacked a reliable history of toxoid immunization. Five patients out of 12 had history of cancer and one each had diabetes mellitus, pulmonary emphysema and Sjogren syndrome. In some cases, the patients had been initially misdiagnosed with ENT disorders, dental problems, or psychosis. Therefore to date, observation of clinical symptoms such as difficulty in mouth opening is considered the most crucial for diagnosis. The shorter was a period from onset to generalized convulsion (onset time), the longer was a duration of hospital stay. A notable complication was intramuscular hemorrhage in the lumbar muscles, which occurred in 2 patients. No patients died due to ICU managements, in which the most useful were propofol for spasm control and sedation, and magnesium sulfate for autonomic overactivity. Retrospectively, the Tetanus Severity Score (TSS) for mortality proposed by Thwaites et al (2006) is considered a useful tool also for predicting the clinical outcome at discharge. Although tetanus has been traditionally classified into the generalized, local, and cephalic types, a simpler severity-based classification into "severe", "moderate", and "mild" types may be more practical with regard to disease management.

Case-fatality of adult tetanus at Jimma University Teaching Hospital, Southwest Ethiopia.

BACKGROUND: Tetanus remains a major health problem in Ethiopia like in most other developing countries. OBJECTIVES: To assess the clinical presentation, complications and outcome of tetanus patients. METHODS: In this retrospective study, patients (age > 13 years) who were admitted to Jimma University Teaching Hospital from 1996 to 2009 were included. RESULTS: Data from 171 patients were analyzed (129 males, 42 females, mean age 33 years). The mean hospital stay for patients discharged cured and deceased was 21.5 ± 12 and 6.5 ± 6.7 days, respectively. None of our patients was immunized for tetanus. Tracheostomy and mechanical ventilation (MV) was done in 10.5% and 11 %, respectively. The case-fatality was 38%. The mean annual admission and case-fatality increased over the study period from 9 to 20.5 and from 21 % to 51%, respectively. Establishment of intensive care unit (ICU) did not improve mortality due to infrequent tracheostomy and MV. CONCLUSIONS: The case-fatality was high like in most other studies and the majority of patients died in the first few days indicating that adequate respiratory support was not given. Establishment of ICU did not improve mortality. Tetanus can be prevented by vaccination and if it occurs it needs well equipped ICU.

Tetanus.

Tetanus is a preventable disease with proper immunization. The marked decline in the incidence over the past several decades has resulted from widespread use of tetanus prophylaxis and improved wound management in the emergency department. Emergency physicians are among the most frequent providers of tetanus vaccination. We can stress the importance of proper immunization and encourage patients to keep accurate immunization records. This can maximize protection of patients from tetanus, and minimize adverse reactions from excessive administration of booster. Tetanus can be fatal even with proper treatment. Vital treatment measures can easily be completed in the emergency department.

Prognosis in tetanus: Use of data from therapeutic trials.

There is a need in clinical tetanus for a simple prognostic classification for all patients at time of admission to the hospital. Data from three randomized clinical trials performed in India in the 1960s, which contained information on several prognostic variables for 1,385 patients, have been used to study different methods of prognosis. A logistic regression performed on the combined data from the trials suggested that the probability of death is related separately to the period of onset (the time from the first symptom to generalized reflex spasms), to the time from first symptom to admission to the hospital, and to the clinical assessment of severity of tetanus on admission; the effects of these variables have been studied by tabulation. A new system is proposed for assigning patients to three prognostic groups, defined by time from first symptom to admission and whether or not reflex spasms were present on admission to the hospital. The range of fatality rates is 10%--63%. Neonates are assigned to a separate group with a fatality rate of 72%. Other prognostic groupings are also explored in case it is felt that the above method relies too heavily on local arrangements for medical care.

Tetanus--review of the literature and report of case.

This case presents many of the difficulties of management that are inherent in a severe case of tetanus. Also it shows a seldom-considered therapeutic modality, that of dental extraction, gingival debridement, and gingivectomy with a confirmed case of tetanus without an established portal of entry. It is well known that periodontal and periapical locations can easily give rise to an anaerobic focus. In this case, anaerobic culture of C tetani was unsuccessful, possibly because of the inherent difficulty of anaerobic transfer from an oral locus and the extreme fastidiousness of the organism. As a rule, all patients who recover from tetanus do so completely, without any residual deficit. This was true in the case discussed here. Conclusions that can be drawn from this case are the following: a diagnosis of tetanus should be considered in any case of unexplained trismus; aggressive treatment of the immunologic deficit by antitoxin should be instituted along with a course of active immunization; and aggressive symptomatic treatment should be started. The bases of the treatment of this case were management of airways, sedation, treatment of autonomic crisis, and eradication of the causative agent. The result was that a severely ill patient reponded to treatment and completely recovered from a devastating disease.

Clinical classification of tetanus patients

The authors propose a clinical classification to monitor the evolution of tetanus patients, ranging from grade I to IV according to severity. It was applied on admission and repeated on alternate days up to the 10th day to patients aged > or = 12 years admitted to the State University Hospital, Recife, Brazil. Patients were also classified upon admission according to three prognostic indicators to determine if the proposed classification is in agreement with the traditionally used indicators. Upon admission, the distribution of the 64 patients among the different levels of the proposed classification was similar for the groups of better and worse prognosis according to the three indicators (P > 0.05), most of the patients belonging to grades I and II of the proposed classification. In the later reclassifications, severe forms of tetanus (grades III and IV) were more frequent in the categories of worse prognosis and these differences were statistically significant. There was a reduction in the proportion of mild forms (grades I and II) of tetanus with time for the categories of worse prognostic indicators (chi-square for trend: P = 0.00006, 0.03, and 0.00000) whereas no such trend was observed for the categories of better prognosis (grades I and II). This serially used classification reflected the prognosis of the traditional indicators and permitted the comparison of the dynamics of the disease in different groups. Thus, it becomes a useful tool for monitoring patients by determining clinical category changes with time, and for assessing responses to different therapeutic measures.