A 6-year review of post-neonatal tetanus at Usmanu Danfodiyo University Teaching Hospital, Sokoto

Background: Tetanus is a vaccine-preventable disease but its incidence has remained unacceptably high in developing countries. Objective: To determine the prevalence, risk factors and outcome of post-neonatal tetanus at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. Methods: A retrospective descriptive study from 1st January 2010 to 31st December 2015. Children aged 1 month to 15 years diagnosed with post-neonatal tetanus were studied. Information from the admission files was extracted. Data was analysed using SPSS version 20. Results: Total admissions during the study period were 14,458; 61 had post-neonatal tetanus, giving a prevalence of 0.4%. The M: F ratio was 1.5:1. The mean age was 7.4±3.2 years. Fifty-nine (96.7%) were not immunised against tetanus. Portal of entry for the organism was trauma injuries to the foot in 33(54.1%). Thirty-one (50.8%) were discharged, 5(8.2%) DAMA, while 25(41.0%) died, and case fatality was 41.0%. Conclusion: Post-neonatal tetanus is a major cause of morbidity and mortality in Sokoto. There is need for improved health education, sustainability of immunisation programmes and coverage to eradicate this scourge

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)

Alternative approach to autonomic instability of very severe tetanus: stellate ganglion block / Abordagem alternativa para instabilidade autonômica no tétano muito grave: bloqueio do gânglio estrelado

Abstract Tetanus is an acute and deadly disease caused by Clostridium tetani. A 60-year-old male came to hospital after he injured his thumb with a knife. Ten days later, he returned to hospital with abdominal spasms. He was vaccinated against tetanus and referred to intensive care unit. As he had sudden difficulty in respiration, he was entubated. Midazolam, magnesium and esmolol infusion were started. Next day, muscle spasms progressed all over his body. Midazolam infusion was replaced with propofol and vecuronium. At the third day, morphine infusion was added. At the 16th day, dexmedetomidine infusion was started. At the 20th day, ultrasound guided stellate ganglion block was performed to denervate sympathetic activity. The block was performed three times in a 10 days period. At the 30th, the patient recovered from very severe tetanus. The mainstay of tetanus treatment is adequate sedation. Neuroaxial blocks were proved to be effective for the control of sympathetic overactivity in recent years. Circulatory collapse remains to be the major cause of death. The mechanism is unclear but altered myocardial function is thought to be related to changeable catecholamine levels. The effect of stellate ganglion block on sympathetic and parasympathetic control of heart has been studied since the beginning of 1980s. Recently Scanlon et al. reported they treated a patient with medically refractory ventricular arrhythmias by ultrasound guided bilateral stellate ganglion block. In conclusion, stellate ganglion block can be an alternative method when the autonomic storm cannot be controlled with medical agents.

Resumo O tétano é uma doença aguda e fatal causada por Clostridium tetani. Um homem de 60 anos deu entrada em nosso hospital depois de ferir o polegar com uma faca. Após dez dias, deu entrada no hospital com espasmos abdominais; foi vacinado contra tétano e enviado para a unidade de terapia intensiva. Como apresentava dificuldade súbita na respiração, foi intubado. Foi iniciada uma infusão de midazolam, magnésio e esmolol. No dia seguinte, os espasmos musculares progrediram para o corpo todo. A infusão de midazolam foi substituída por propofol e vecurônio. No terceiro dia, foi adicionada morfina à infusão. No 16º dia, foi iniciada uma infusão de dexmedetomidina. No 20º dia, o bloqueio do gânglio estrelado guiado por ultrassom foi realizado para dessensibilizar a atividade simpática. O bloqueio foi feito três vezes em dez dias. No 30º dia, o paciente recuperou-se de um tétano muito grave. A base do tratamento de tétano é a sedação adequada. Nos últimos anos, os bloqueios neuraxiais provaram ser eficazes para o controle da hiperatividade simpática. O colapso circulatório continua a ser a principal causa de morte. O mecanismo não está claro, mas se acredita que a função alterada do miocárdio esteja relacionada com os níveis de catecolaminas mutáveis. O efeito do bloqueio do gânglio estrelado sobre o controle simpático e parassimpático do coração tem sido estudado desde o início da década de 1980. Recentemente, Scanlon et al. relataram o tratamento de um paciente com arritmia ventricular refratária a medicamentos com bloqueio bilateral do gânglio estrelado guiado por ultrassom. Em conclusão, o bloqueio do gânglio estrelado pode ser um método opcional quando a tempestade autonômica não pode ser controlada com agentes medicamentosos.

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.

A 10-year review of outcome of management of tetanus in adults at a Nigerian Tertiary Hospital

Background : Tetanus remains one of the major public health hazards of the developing world. Previous studies in Nigeria indicate that mortality ranged from 26to 60. Mortality is much lower in the developed world because of the availability of facilities for intensive care of cases; unlike in most developing countries. Aim : To report our experience with the management of adult tetanus at the University of Port Harcourt Teaching Hospital over the past 10 years (1996-2005). Methods : Data of all patients aged 16 years and above managed for tetanus in the medical wards between January 1996 and December 2005 were retrieved from their case records and analyzed. Results : Eighty-six patients were managed for tetanus (50 males and 36 females); constituting about 1of all medical admissions over the 10-year period. Students; civil servants and commercial motorcyclists formed the major groups at risk. The commonest portal of entry was lower limb injuries (54). Case fatality rate (CFR) was 42.9; with a statistically significant higher CFR found among patients above 40 years of age (P= .000); patients with incubation period shorter than 7 days (P= .04); those with a shorter duration of hospitalization (P= .000) and those administered higher average daily diazepam doses (P= .044). Complications such as aspiration pneumonitis; laryngospasm and respiratory failure were major causes of mortality. Conclusion : Case fatality rate of tetanus has remained consistently high at our center. Factors that were significantly associated with high mortality included older age; age above 40 years ; incubation period of less than 7 days and higher degree of sedation with diazepam. It is recommended that preventive immunization against tetanus be given to all Nigerians with secondary vaccination at adulthood

Pediatric and neonatal tetanus: a hospital based study at eastern Nepal.

A prospective hospital based study of childhood (<15 yrs) and neonatal tetanus cases from July 2004 - May 2006 was done to study the demography, clinical features and outcome of pediatric and neonatal tetanus cases at BPKIHS. During the study, 24 cases of tetanus were admitted from 9 districts including 5 neonatal tetanus. Among children with tetanus, 31.5% received 3 doses of DPT and 10.5% received TT vaccine as tetanus prophylaxis. In 16.0% children there was no recognizable injury preceding the disease. Otitis media preceded tetanus in 16.0%. All neonatal tetanus cases occurred following umbilical sepsis. Despite their mothers receiving 2 doses of TT during pregnancy, 2 neonates developed tetanus. A neonate delivered in hospital also developed neonatal tetanus. Average incubation period was 7.7 days and average onset time was 16.9 hours. Short onset time predicted the favorable outcome (p=0.005). Generalized tetanus cases were 75.0%, neonatal tetanus 21.0% and cephalic tetanus 4.0%. Generalized spasm was present in all cases. Common autonomic dysfunctions were fever, tachycardia and hypotension. Respiratory failure, aspiration pneumonia, rhabdomyolysis and seizure were common complications. Only one case received Intensive Care Unit (ICU) care. Survival rate was 21.1% for childhood tetanus and 40.0% for neonatal tetanus. Respiratory failure was the cause of death in majority. Study finds tetanus as an important disease in eastern Nepal, with substantial morbidity and mortality, primarily affecting the unvaccinated and inadequately vaccinated individuals. Despite lack of adequate resources, we can still manage tetanus cases with comparable outcome to other case series reported in the literatures.

Sympathetic overactivity and arrhythmias in tetanus: electrocardiographic analysis

As a result of the advances in the control of pulmonary insufficiency in tetanus, the cardiovascular system has increasingly been shown to be a determining factor in morbidity and mortality but detailed knowledge of the cardiovascular complications in tetanus is scanty. The 24h-Holter was carried out in order to detect arrhythmias and sympathetic overactivity in 38 tetanus patients admitted to an ICU. The SDNN Index (standard deviation from the normal R-to-R intervals), was useful in detecting adrenergic tonus, and ranged from 64.1 ± 27 in the more severe forms of tetanus to 125 ± 69 in the milder ones. Sympathetic overactivity occurred in 86.2 percent of the more severe forms of the disease, but was also detected in 33 percent of the milder forms. Half the patients had their sympathetic overactivity detected only by the Holter. The most frequent arrhythmias were isolated supraventricular (55.2 percent) and ventricular (39.4 percent) extrasystoles. There was no association of the arrhythmias with the clinical form of tetanus or with the presence of sympathetic overactivity. The present study demonstrated that major cardiovascular dysfunction, particularly sympathetic overactivity, occurs in all forms of tetanus, even in the milder ones. This has not been effectively detected with traditional monitoring in ICU and may not be properly treated.

Com os avanços no controle da insuficiência respiratória no tétano, o sistema cardiovascular tem participado de forma crescente na morbidade e mortalidade da doença, mas o conhecimento dessas complicações é escasso. No intuito de detectar arritmias e hiperatividade simpática, o holter de 24 h foi utilizado em 38 pacientes com tétano admitidos numa UTI de doenças infecciosas. O índice SDNN (desvio standard dos intervalos normais R-a-R), foi útil na detecção do tônus adrenérgico, e variou de 64,1 ± 27 nas formas mais severas de tétano a 125 ± 69 nas formas mais leves. Hiperatividade simpática ocorreu em 86,2 por cento das formas mais severas da doença, mas também foi identificada em 33 por cento das formas leves. Cerca da metade dos pacientes tiveram sua hiperatividade simpática detectada apenas pelo Holter. As arritmias mais freqüentes foram extrassístoles isoladas, do tipo supraventriculares (55,2 por cento) ou ventriculares (39,4 por cento). Não houve associação das arritmias com a forma clínica do tétano ou com a presença de hiperatividade simpática. O presente estudo demonstrou que importantes alterações cardiovasculares, particularmente a hiperatividade simpática, ocorrem em todas as formas de tétano, mesmo as mais leves. Estas alterações não estão sendo detectadas pelos métodos tradicionais de monitorização em UTI, podendo resultar em falhas na abordagem terapêutica.

Neuroparalysis and ventilatory support in severe tetanus.

In severe form of tetanus, even with maximum dose of muscle relaxants, spasms and apnoeic spells may persist and that may be life-threatening. The aim of this study was to assess the effect of neuroparalysing the patients and then providing ventilatory support in bringing about their recovery. Forty-nine adult patients of severe tetanus (Ablett's grade IIIA--6 patients and Ablett's grade IIIB--43 patients) were studied during the period from April, 1993 to February, 1996. Mean period of onset ie, period from trismus to first spasm, in these patients was 24 hours. Patients were neuroparalysed with a bolus dose of 2-4 mg of pancuronium followed by a continuous infusion of 1-2 mg/hour and simultaneously supported with mechanical ventilation until spasms subsided. Fourteen patients (28.6%) survived and rest died. Mean duration of ventilatory support on survived patients was 14.4 days. The commonest complication encountered during ventilatory support was respiratory tract infection observed in 36 patients (73.5%). Commonest cause of death was autonomic imbalance encountered in 15 patients (30.6%). Treatment of choice in severe tetanus should be neuroparalytic ventilatory support. With use of new generation ventilators and better intensive care facility, death in severe tetanus is likely to be very less.

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.

Case report: Diazepam in severe tetanus treatment.

The causes of death in tetanus are muscle spasms and spasm of the larynx, which are caused by blocking the release of inhibitory neurotransmitters in the spinal synapses, causing the uncontrolled spread of impulses. Diazepam controls the spasms by blocking the polysynaptic reflexes, working peripherally, without depressing the cortical center and has no cardiovascular or endocrine effects. High dose diazepam had been used and proved to be a good muscle relaxant. Diazepam seems to work better with tetanus than pancuronium bromide, but both drugs need mechanical ventilation. In cases where the dose exceeds 240 mg per day in a child, a ventilator should be on hand, and if the dose required is more than 480 mg per day, other drugs should be considered. In three cases of severe tetanus presented here, the first two were managed by diazepam and pancuronium bromide and the last case by high dose diazepam only. In the first case, the dose of diazepam was up to 480 mg/day. By using high dose diazepam in severe tetanus, management of the clinical manifestations of autonomic nerve involvement and the weaning process become easier. Most complications of severe tetanus became more manageable.

Tétanos asociados a acupuntura: a propósito de un caso / Tetanus associated with acupucture: a purpose of a case

Se describe el caso de un paciente femenino de 32 años de edad, con antecedente de inserción de guías de acupuntura en región pre-auricular quien ingresó al departamento de Medicina Interna Hospital Central de la F.A. Dr. Carlos Arvelo" con dolor y contractura muscular generalizada. Se apreciaron lesiones micronodulares en pie y aumento del tono muscular en cuello, maseteros, abdomen, región dorso lumbar, cuadriceps, así como opistótonos a la estimulación del raquis. Se planteó el diagnóstico de tétanos. Se realiza una discusión clínica del caso

A potenciação pós-tetânica e a transmissão neuromuscular / Post-tetanic potenciation and neuromuscular transmission

Potenciação pós-tetânica (PPT) é o nome dado ao aumento transitório da amplitude das contrações musculares após estimulação indireta com alta frequência aplicada ao nervo motor. É um fenômeno característico, mas não exclusivo da junção neuromuscular, podendo também ocorrer em transmissões do sistema nervoso central. Apesar de várias teorias propostas, o mecanismo da origem da PPT não foi, pelo menos até o momento, totalmente esclarecido. Por outro lado, sabe-se que fármacos podem modificar o perfil da PPT levando a comprometimentos na eficiência das transmissões neuronais. O presente trabalho descreve os possíveis mecanismos que determinam a PPT e mostra como diferentes agentes podem modificá-la.

Tétanos complicado con hipercalcemia: reporte de un caso / Tetanus complicated with hypercalcemia: a case report

Antecedentes: el tétanos es una enfermedad cada vez menos frecuente y con mejor pronóstico. Sin embargo, la supervivencia de estos pacientes nos enfrenta a nuevas complicaciones. Objetivo: reporta un caso de tétanos que, además de las complicaciones pulmonares esperadas, desarrolló hipercalcemia relacionada con la inmovilización prolongada. Material y métodos: ingresó un paciente con herida punzocortante en el antebrazo; se manejó con sedación, relajación muscular, antibióticos, apoyo ventilatorio mecánico, insulina y nutrición parenteral. Resultados: egresó a los 128 días de hospitalización y permaneció en programa de diálisis peritoneal continua ambulatoria (DPCA) y rehabilitación física. Conclusiones: en la actualidad, los pacientes con diagnóstico de tétanos severo pueden recibir apoyo multisistémico, por lo cual las complicaciones relacionadas tienen una mejor evolución y disminuye la mortalidad. Ahora se deben enfrentar otras complicaciones que repercuten en el pronóstico de estos pacientes