Tétanos generalizado en un adolescente / Spread tetanus in an adolescent

Se presenta el caso clínico de un adolescente de 13 años de edad, con antecedentes de buena salud, quien solo recibió inmunización durante la etapa neonatal, el cual sufrió una herida causada por un clavo enmohecido en el dorso del pie derecho y acudió al Hospital Wete de Zanzíbar, Tanzania, por presentar dolores musculares, espasmos generalizados, risa sardónica y trismo, por lo cual se le diagnosticó tétanos generalizado. Se prescribió tratamiento médico con hidratación parenteral, toxina antitetánica, toxoide tetánico, antibióticos, sedantes y curación local de dicha herida. Luego de 2 meses de hospitalización el paciente tuvo una evolución satisfactoria.

The case report of a 13 years adolescent, with history of good health who just received immunization during the neonatal period is presented. He suffered from a wound caused by a rusty nail in the back of the right foot and he went to the Wete Hospital in Zanzibar, Tanzania, presenting muscular pains, spread spasms, sardonic laugh and trismus, reason why he was diagnosed spread tetanus. Treatment was prescribed with parenteral hydration, anti-tetanus toxin, anti-tetanus toxoide, antibiotics, sedative and total cure of this wound. After 2 months of hospitalization the patient had a favorable clinical course.

La morbimortalité du tétanos à l'hôpital Sominé Dolo de Mopti

Introduction. Le tétanos est un problème de santé publique. La létalité qui lui est associée est très élevée. L'objectif de ce travail était de décrire les aspects cliniques, thérapeutiques et évolutifs du tétanos chez l'adulte. Méthodes. Il s'agissait d'une étude rétrospective des cas de tétanos à l'hôpital Sominé Dolo de Mopti. Les données ont été collectées à partir des dossiers des malades et portaient sur le nom, le sexe, l'âge, la profession, la provenance, le statut vaccinal, la porte d'entrée. Le score de Dakar a été utilisé pour évaluer le pronostic des patients. Résultats. Nous avons colligé 11 cas dont un tétanos obstétrical. La prévalence hospitalière était de 1,03% ; l'âge moyen de 41ans avec des extrêmes de 21 et 70 ans. La tranche d'âge de 20 - 30 ans était la plus affectée avec 36,36%. Aucun des patients n'avait été antérieurement vacciné contre le tétanos. La durée moyenne d'hospitalisation a été de 11,36 jours. Tous les patients ont présenté le trismus, dans plus de 50% des cas, la fièvre était associée aux paroxysmes. Nous rapportons un taux de létalité de 54,54% dont 83,33% sont survenus dans les quatre jours qui ont suivi l'hospitalisation. Le délai moyen de survenu du décès était de 4 jours. Conclusion. Le tétanos continue d'être une menace à l'atteinte de l'objectif de la couverture sanitaire universelle. Des efforts de sensibilisation et des programmes de vaccination plus inclusifs devraient permettre d'en réduire la morbimortalité

Tétanos generalizado como complicación de fractura cerrada de tibia y peroné / Generalized tetanus as a complication of closed fracture of the tibia and the fibula

Introducción: El tétanos es una enfermedad infecciosa prevenible que puede causar la muerte. Las manifestaciones clínicas son debidas a una potente toxina secretada por el Clostridiumtetani, un bacilo Gram positivo que penetra a través de pérdidas de continuidad de la piel, independientemente del tamaño de la herida. Objetivo: Presentar la evolución clínica de una paciente residente en una zona rural en Latacunga, Cotopaxi, Ecuador. Desarrollo: Paciente sin antecedentes de inmunización previa que acudió a sala de emergencias por fractura cerrada de tibia y peroné en miembro inferior izquierdo como secuela de un accidente de tránsito. El diagnóstico clínico de tétanos generalizado se basó en la aparición al noveno día del trauma de disfagia, trismus, rigidez nucal y posteriormente contracturas generalizadas con opistóstono, parada cardiorrespiratoria y disfunción autonómica. Con una prolongada estadía hospitalaria de 82 días, recibió anestesia en críticas condiciones durante 15 ocasiones, sufrió complicaciones graves y amenazantes para la vida que requirió la permanencia durante 46 días en sala de cuidados intensivos. Conclusiones: Este caso enfatiza la amenaza permanente del tétanos en este entorno, así como la necesidad de implementar esquemas de inmunización de una forma más abarcadora y constante(AU)

Introduction: Tetanus is a preventable infectious disease that can cause death. The clinical manifestations are due to a powerful toxin secreted by Clostridiumtetani, a Gram-positive bacillus that penetrates through losses of skin continuity, regardless of the wound's size. Objective: To present the clinical evolution of a female patient living in a rural area in Latacunga, Cotopaxi, Ecuador. Development: Patient with no history of previous immunization who went to the emergency room due to a closed fracture of the tibia and the fibula in the left lower limb as a result of a traffic accident. The clinical diagnosis of generalized tetanus was based on the appearance on the ninth day of dysphagia´s trauma, trismus, nuchal rigidity, and later on: generalized contractures with opistho-tonus, cardiorespiratory arrest, and autonomic dysfunction. With a prolonged hospital stay of 82 days, she received anesthesia under critical conditions in 15 occasions, and suffered serious complications. She remained for 46 days in the intensive care unit. Conclusions: This case emphasizes the permanent threat of tetanus in this environment, as well as the need to implement immunization schemes in a more comprehensive and constant manner(AU)

Informe especial: Tétanos otras edades (No neonatal) / Special report: Tetanus other ages (Nonneonatal)

Entre las Semanas Epidemiológicas (SE) 51 del año 2016 y 5 del 2017 (período comprendido entre el 18/12/2016 y el 04/02/2017), la Gerencia Operativa de Epidemiología recibió la notificación de 3 casos de tétanos otras edades a través de alertas del módulo C2 del Sistema Nacional de Vigilancia de la Salud (SNVS). Se trató de 3 pacientes asistidos en el Departamento de Atención Intensiva del Paciente Infeccioso Crítico (D.A.I.P.I.C.), del Hospital de Infecciosas Francisco Muñiz, de la Ciudad de Buenos Aires. Dos casos correspondieron a residentes de Provincia de Buenos Aires y el restante a un residente de la Ciudad. Este informe resume estos tres casos, los cuales destacan la necesidad que los médicos y quienes están encargados de los cuidados de salud, constaten en oportunidad de toda consulta, la cobertura de vacunación antitetánica e indiquen la vacuna a pacientes no vacunados, incompletamente vacunados o con vacunación desconocida.(AU)

Tétanos, una enfermedad vigente en población pediátrica: Reporte de un caso / Tetanus, a current disease in pediatric population: Case report

Introducción: El tétanos es una enfermedad aguda causada por una toxina producida por Clostridium tetanii. La enfermedad puede afectar a personas de cualquier edad, y la tasa de letalidad es alta. Gracias a la inmunización se ha logrado reducir el número de casos de la enfermedad, aunque se siguen presentando casos sobre todo en países con rezago social y económico. Objetivo: Describir caso clínico de un paciente pediátrico con tétanos generalizado, para reforzar la importancia de la profilaxis y diagnóstico precoz. Caso clínico: Escolar femenina de 6 años de edad con antecedente de esquema de inmunizaciones incompleto (una dosis de pentavalente), quien 10 días después de hacerse una herida cortopunzante por astilla de madera en brazo derecho, evolucionó con fiebre, dolor muscular y contracciones generalizadas, diagnosticándose tétanos generalizado en base a los antecedentes y el cuadro clínico. El tratamiento se estableció en base a las últimas recomendaciones de la Organización Mundial de la salud (OMS): esquema antibiótico Penicilina-Metronidazol, toxoide tetánico y gammaglobulina antitetánica a dosis altas. Se da de alta con secuelas motoras leves, las que se remitieron luego de 2 años de seguimiento y terapia de rehabilitación. Conclusión: El tétanos se sigue presentando en la población pediátrica principalmente asociado a falta de vacunación, es necesario conocer la enfermedad para hacer diagnóstico temprano y ofrecer manejo acorde a recomendaciones internacionales.

Introduction: Tetanus is an acute disease caused by a toxin produced by Clostridium tetanii. The disease can affect people of any age, and the fatality rate is high. Thanks to immunization the number of cases of the disease has decreased, although they are still present in isolation in countries with social and economic backwardness. Objective: To describe a case of a pediatric patient with generalized tetanus to reinforce the relevance of prophylaxis and early detection. Case Report: 6 years old female patient, with only one dose of pentavalent vaccine, 10 days after sharps injury by wood chips, starts with fever, muscle pain and generalized contractions, Tetanus was diagnosed by clinical symptoms and history. The management was based on the latest recommendations of the World Health Organization (WHO): Penicillin-Metronidazole antibiotic regimen, tetanus toxoid and tetanus high-dose gammaglobulin. After 2 years of follow-up under physiotherapy support, slight motor sequelae were observed. Conclusion: Tetanus is still presented in the pediatric population, associated with lack of vaccination. It is necessary to know the disease to provide proper diagnosis and management according to international lineaments.

Tétano grave associado a choque séptico em uma paciente idosa internada em unidade de terapia intensiva / Tétanos grave asociado con choque séptico en una paciente anciana ingresada en la unidad de cuidados intensivos / Severe tetanus associated with septic shock in an elderly patient admitted to the intensive care unit

Nós relatamos um caso de tétano grave associado a choque séptico em uma paciente de 61 anos admitida na Unidade de Terapia Intensiva (UTI) após perfurar o pé direito. A paciente apresentou perda de força muscular, paresia em membro inferior direito e disfagia. A paciente evoluiu com espasmos musculares generalizados, dispnéia e insuficiência respiratória. O espasmo intenso levou ao uso prolongado de ventilação mecânica invasiva, sedação e bloqueador neuromuscular. A evolução favorável deste caso está provavelmente relacionada aos avanços na gestão de UTI e uma equipe médica e de enfermagem bem treinadas.

Se presenta un caso de tétanos relacionado con choque séptico grave en una paciente de 61 años ingresada en la Unidad de Cuidados Intensivos (UCI) después de perforar el pie derecho. El paciente tenía pérdida de fuerza muscular, parálisis de la pierna derecha y disfagia. El paciente desarrolló espasmos musculares generalizados, disnea e insuficiencia respiratoria. El espasmo intenso llevó al uso prolongado de ventilación mecánica, sedación y bloqueo neuromuscular. La evolución favorable de este caso está probablemente relacionada con los avances en la gestión de cuidados intensivos y un personal médico y de enfermería bien capacitado.

We report a case of severe tetanus associated with septic shock in a 61-year-old female admitted to the Intensive Care Unit (ICU) after perforating injury in the right foot. The patient presented with loss of muscle strength, paresis in the right lower limb and dysphagia. The patient’s conditions worsened, progressing to generalized muscle spasms, dyspnea, and respiratory failure. Intense spasm made the prolonged use of invasive mechanical ventilation, sedation, and neuromuscular blockers necessary. The favorable outcome in the present case is probably related to advances in ICU management and well-trained medical and nursing staff.

Tendência temporal do tétano acidental no período de 1981 a 2004 em Pernambuco com avaliação do impacto da assistência em unidade de terapia intensiva sobre a letalidade / Mortality trend due to accidental tetanus from 1981 to 2004 in Pernambuco and analysis of the impact on intensive care unit attendance

Apesar da redução na incidência de tétano acidental no Brasil, não houve queda significativa na letalidade. Nesta série de casos, comparamos a letalidade antes e após o estabelecimento padrão de manejo em unidade de terapia intensiva do paciente com tétano no Hospital Universitário Oswaldo Cruz, no período de 1981 a 2004. Em 24 anos, foram internados 1.971 pacientes e antes do manejo em Unidade de terapia intensiva a letalidade era de 35 por cento. Durante 1997 foi instituída a unidade de terapia intensiva para assistência dos pacientes com tétano, e de 1998 a 2004, a letalidade caiu para 12,6 por cento, OR= 0,27 (IC95 por cento= 0,18- 0,39); p<0,001. Esta tendência foi evidenciada em todas as faixas etárias e em ambos os sexos. A centralização da assistência a esses pacientes em um único serviço especializado com Unidade de terapia intensiva de forma precoce, portanto, tem sido decisiva na redução da letalidade, por contar com a vasta experiência da equipe de saúde no manejo do tétano e melhor tratamento sintomático, antecipando as graves complicações da doença.

Despite reductions in the incidence of accidental tetanus cases in Brazil, there has not been any significant decrease in its mortality. In this case series, the mortality rates before and after establishing standard management practices for tetanus patients in the intensive care unit at the Oswaldo Cruz University Hospital are compared over the period from 1981 to 2004. Over these 24 years, 1.971 patients were admitted. Before establishing the intensive care unit management, the mortality rate was 35 percent. The Intensive care unit for attending to tetanus patients was established in 1997. From 1998 to 2004, the mortality rate fell to 12.6 percent: OR = 0.27 (95 percent CI = 0.18-0.39); p < 0.001. This trend was seen in all age groups and both sexes. The centralization of attendance for these patients into a single specialized service with early treatment in an intensive care unit has therefore been decisive in reducing the mortality rate. This service can count on the medical team's vast experience of tetanus management, with better treatment of symptoms that forestalls the serious complications from this disease.

Tetanus: presentation and outcome in adults

Tetanus is still a common clinical entity, especially in developing countries. The purpose of this study was to evaluate the presenting features as well as the outcome of tetanus in adult patients admitted to the hospital. This was a hospital based descriptive study conducted at the Infectious Diseases Unit, Rashid Hospital Dubai, United Arab Emirates from Jan. 2003 to Dec. 2008. The study was designed to include demographics, clinical information and outcome observed in the patients admitted with clinical diagnosis of tetanus. Patients with malignancy, immunosuppression [AIDS/Drugs], significant cardiac dysfunction and renal impairment were excluded. The patients were treated as per the standard protocol for the management of tetanus. A total of 44 patients were enrolled into the study. The mean age+SD of the patients were 26.3+5.8 years and all of the study patients were males. Thirty six [81.81%] patients gave the history of injury prior to onset of the symptoms, whereas eight [18.18%] patients were unable to recall any history of injury. All the study patients were laborers working in construction companies except for four who were gardeners. Body stiffness/spasm, difficulty in opening the mouth, difficulty in swallowing, body pain, neck pain and backache were the main presenting complaints. The patients with upper limb injuries had shorter incubation period and more severe disease with high frequency of autonomous nervous system insufficiency. Overall, hospital stay was 46.6+11.4 days. Forty [90.9%] patients required mechanical ventilation. The mean+SD ICU stay was 26.4+5.8 days and on weaning all the ventilated patients required tracheostomy. Eight [18.18%] patients died as a result of ventilator associated complications [Pneumonia] and autonomic nervous system dysfunction. Tetanus still carries high morbidity and mortality rate despite the available advanced management facilities including ICU care. The incidence of tetanus can be reduced significantly by an effective immunization program and proper wound management of the patients

Tetano: relaçao de dois casos internados no Hospital Regional de Araranguá em santa Catarina e abordagem fisioterapeutica / Tetanus: Relationship between two cases hospitalised at the Regional Hospital of Araranguá in Santa Catarina and physical therapy approach

Este artigo compara dois pacientes do sexo masculino, classificados com tetano acidental grave entre os meses de julho de 2002 a julho de 2003, internados na Unidade de Tarapia Intensiva-UTI do Hospital Regional de Araranguá-HRA em Santa Catarina. Os pacientes entraram em contato com o bacilo Clostridium tetani que é causador do tétano de forma acidental. Foram analisadas a evoluçao clinica dos pacientes e a influencia da intervençao da fisioterapia nos aspectos motores, demonstrando suas alteraçoes, complicaçoes e limitaçoes no atendimento.

Tétanos en consulta de urgencia: ¿mito o realidad? / Tetanus in urgency services: myth or reality?

El tétanos, patología infecciosa causada por el bacilo Clostridum tetani, constituye actualmente en Chile una patología infrecuente gracias al programa nacional de vacunación en heridas de riesgo. Es por ello que su presentación en servicios de urgencia es raro. Por lo cual se consideró muy útil recordar la plena vigencia de esta antigua patología, así como sus severas consecuencias a través del análisis de dos casos clínicos en nuestro Hospital.

Recently Occurring Adult Tetanus in Korea: Emphasis on Immunization and Awareness of Tetanus

Since a nationwide childhood vaccination with tetanus toxoid, tetanus has become a rare disease in Korea. However, we recently experienced 17 cases of adult tetanus in a university hospital during a 21-month period. Seventy percent of the patients were female, and the mean age was 63 yr (range, 29-87). The majority (88.2%) of the patients did not get primary vaccinations for tetanus and decennial tetanus-diph-theria toxoid booster. Most patients (88.2%), who sustained acute injury, did not seek medical care for their wounds or did not receive the prophylaxis for tetanus. Tetanus was found most frequently among farmers. Tetanus was diagnosed initially only in 53% of patients. The case-fatality ratio was 23.5%. These cases show that recently occurring tetanus in Korea is a disease, affecting the elderly and the female who may have a lower immunity against tetanus, and the farmers who are likely to be exposed to Clostridium tetani. In addition, diagnosis of tetanus is often delayed in area where cases are seen infrequently. Therefore, improved education among patients and physicians, emphasis of anti-tetanus immunization and awareness of tetanus respectively, may be essential for the prevention of disease and the reduction of its mortality.

Horse hair and tetanus. A case study

A case of tetanus is reported. The disease was contracted from a horse hair used by a quack to excise a mole. The causative organism, Clostridium tetani, resides in horse hair and excreta. Unhealthy practices still prevalent in rural areas of Pakistan which can lead to this fatal disease

Un caso de tétanos infantil posiblemente asociado a una aguja contaminanda / Infantile case of tetanus possibly associated to contaminated needle

Clostridium tetani es el agente etiológico del tétanos. Esta bacteria es un bacilo esporulado anaerobio, habitante normal del suelo. Antes de 1970 se presentaban de 300 a 200 muertes anuales por esta causa. Luego fue prácticamente controlada y actualmente se presentan menos de 3 casos anuales y no hay tétanos neonatorum. El último caso de tétanos infantil presentado en Costa Rica, ocurrió en 1989, y debido las características relevantes que rodearon la historia de ese caso, cuyo desenlace fue fatal es que lo informamos, como un ejemplo de hechos que no debieron ocurrir. Se trató de un niño de 50 días de edad, hospitalizado por una diarrea con vómitos y manifestaciones espasmóticas, que murió 24 horas más tarde con el diagnóstico de tétanos. Su historia clínica reveló que cuando se inició la diarrea un médico particular le recetó antibióticos intramusculares. Los antibióticos fueron inyectados en su casa por el abuelo del niño. Presuminos que la puerta de entrada para las esporas de C. tetani fue la lesión de la aguja intramuscular. Este caso representa una lección sobre el manejo de agujas. También, es necesario que siempre pensemos en tétanos porque su agente etiológico es un habitante normal de nuestros suelos y la vacunación no elimina de nuestro ambiente.

Clostridium tetani is the etiological agent of tetanus. This bacterium is a spore forming anaerobic rod, that inhabit the soil. Before 1970 it causes 200 to 300 deaths per year in Costa Rica. Afterwards the disease was practically controlled and nowadays there are less than 3 cases by year and no cases in infants were observed. The last case in an infant tetanus that occurred in Costa Rica was in 1989; some relevance characteristics of its clinical story, which end was fatal, aimed this report, this is an example of facts that never would occur. He was a 50 day old child that had diarrhea and vomiting 3 days before admission, his grandfather gave him antibiotic injection at home. The child was admitted to hospital with muscular spasms and dead 24 hours later. We presume an infected needle was the entrance door for the Clostridium tetani spores. This case represents a lesson for the antiseptic management of needles. We should always keep tetanus in mind because its agent is a normal inhabitant in our soils and vaccination does not eliminate it from the environment.

Post-neonatal tetanus: issues in intensive care management.

Tetanus is an acute neurological disease characterized by muscle rigidity and spasms, autonomic dysfunction and in severe forms requires respiratory and hemodynamic support. Though it is entirely preventable by immunization, it still occurs in developing countries causing significant morbidity and mortality. Intensive care management of tetanus is fraught with problems of ventilator-associated pneumonia, nosocomial sepsis and a variety of other complications. Various treatment protocols have been tried in managing diverse manifestations of severe tetanus but the consensus is yet to emerge. In this review we have discussed the pathophysiology, clinical features and management controversies and suggest on basis of our experience use of high dose diazepam (20-120 mg/kg/day) and vecuronium with mechanical ventilation if required for control of spasms, and early detection of autonomic dysfunction and use of propranolol, in our circumstances.