Neonatal tetanus in southern Iran: predisposing and prognostic factors

The predisposing and prognostic factors for neonatal tetanus [NNT] have not been adequately studied in southern Iran. The present study was undertaken in Fars Province to further clarify the status of neonatal tetanus in this region. The mortality rate was correlated with demographic and clinical findings in 112 cases of neonatal tetanus. In addition, the height and weight of NNT patients were compared to those of 112 age- and sex-matched normal neonates. Patients were predominantly males [82%] with a male to female ratio of 4.8:1. Although the clinical presentation and outcome of male and female patients were very similar, both groups had a significantly [p<0.05] lower birth weight compared to their control counterparts. None of the mothers had been immunized against tetanus and 92% had delivered at home under unsterile conditions. The mortality rate was 44% and strongly related to the age of the patients on admission. Conclusions: Male sex, low birth weight, and a lack of immunization of mother, all predispose the newborn to tetanus. The mortality rate was inversely proportional to the age of the newborn

Early acute respiratory failure due to severe tetanus: evidence for intrapulmonary shunting of blood

Early acute respiratory failure is a common presenting manifestation of severe tetanus, yet the underlying mechanism is not well understood. Our purpose was to clarify the issue by testing the contribution of various cardiopulmonary factors in the genesis of respiratory failure. We performed cardiac catheterization and pulmonary angiogram on 14 consecutive cases of severe tetanus with acute respiratory failure, Shunt fraction and alveolar-arterial oxygen difference were calculated in all patients after being ventilated with 100% oxygen for over 20 minutes. All patients had severe hypoxemia and hypocapnia at the time of presentation while receiving nasal oxygen. Cardiac catheterization and oximetric studies revealed normal mean pulmonary capillary wedge and left ventricular end diastolic pressures with no evidence of intracardiac shunting of blood. Pulmonary angiograms showed no evidence of pulmonary emboli or arteriovenous communication. Ventilation with 100% oxygen failed to correct hypoxemia. Calculated shunt fraction ranged from 27.3 to 38.1%. The alveolar-arterial oxygen difference was more than 450 mm Hg in all of the cases. Our results indicate that intrapulmonary shunting of blood is the underlying mechanism for the early acute respiratory failure seen in these patients

Contributing factors to the development of early acute respiratory failure and predisposiong factors to mortality in patients with severe tetanus

In this prospective study we compared the clinical data of 70 consecutive patients with severe tetanus and acute respiratory failure to those of 32 milder cases without acute respiratory failure. Also we investigated the predisposing factors to mortality among the former group. Severe hypoxemia [PaO2 <50 mmHg] was the initial presenting manifestation in all patients with acute respiratory failure. Along with severe hypoxia, 68 cases [97%] had hypocapnia [PaCO2 <36 mmHg]. Hypoxemia was unresponsive to ventilation with 100% oxygen. Alveolar-arterial oxygen difference ranged from 400 to 580 mmHg [497.37 +/- 54.36 mmHg]. Shunt calculation showed right-to-left shunting of blood ranging from 22.16 to 30.25% [27.89 +/- 1.70]. Convulsion [p<0.005], opisthotonos [p=0.01] and laryngospasm [p<0.001] were the major contributing factors to the development of early acute respiratory failure in cases with severe tetanus. Shorter incubation periods [p<0.05], sympathetic over activity [p<0.005] and sepsis [p<0.001] were the major predisposing factors to mortality in patients with acute respiratory failure. In conclusion, the early acute respiratory failure of severe tetanus is almost always of hypoxic and hypocapnic type. It is in part due to the generalized muscle spasms. In addition, intrapulmonary shunting of blood seems to be a major contributory factor in its genesis. Acute respiratory failure due to tetanus is a lethal disease especially if associated with a short incubation period and complicated with sepsis and or sympathetic overactivity

Renal disease in typhoid fever: some immunological aspects

The occurrence of renal disease was correlated with immunological events in acute, recovery, and convalescent stages of typhoid fever in 24 consecutively treated patients. Transient abnormal urinalysis was quite common: 59% of the patients had 2+ or greater proteinuria, amounting to 1.0 gm/ 24 hours in half of this group Approximately one-third of the patients with typhoid fever had significant hematuria BUN was elevated in 20% of the patients; and two patients developed classical acute tubular necrosis. Serum complement levels [C3] were significantly reduced in patients with renal disease during the acute stage [P<0.01] and increased to normal levels in the recovery stage. All immunoglobulins were significantly elevated to above control levels in patients with and without renal disease in all three stages. The percentage of B cells was increased and T cells were reduced significantly in the acute stage [P<0.01] except in patients with renal disease. However, in this group the percentage of T cells was significantly increased in the first and the second stages of the illness [P<0.005]. In the acute stage, IgA levels were significantly reduced in patients with renal disease compared to patients without renal involvement [P<0.025]. Renal biopsies in six patients with clinical and laboratory evidence of renal disease showed minimal proliferative changes as well as mild diffuse deposits of IgG, C3 and C4. It appears that renal involvment in typhoid fever commonly occurs as a transient glomerular or tubular disease, the glomerular disease being mild and associated with a decrease in serum complement levels. The immunological events associated with endemic [1,2] as well as experimental [3] typhoid fever are well known. The occurrence of transient glomerular disease [4,5], and acute renal failure due to hemolysis in typhoid fever has been the subject of a few brief reports [6-9]. However, no systematic study of the immunological events in relation to the occurrence of renal disease has been carried out. In addition, serum complement levels [C3c] have been variously reported as being normal or raised in different groups of patients [1,3,5,8] Typhoid fever, a common disease in Iran, has not been intensively studied. In this prospective study we report on the immunological events in different stages of typhoid fever as well as the occurrence of renal disease, and the correlation between immunological events and the occurrence of renal disease