Tétanos, una enfermedad que se creyó superada: revisión de caso / Tetanus, a disease that was believed to be overcomed: a case review

El tétanos generalizado es una enfermedad infecciosa altamente mortal sin intervenciones médicas y en nuestro tiempo, prevenible mediante inmunización activa. Se presenta el caso de un preescolar de 4 años quien sufre herida cortante en la palma de la mano izquierda y quien se presenta 4 días más tarde con datos clínicos de tétanos generalizado. Fue intubado y admitido a la terapia intensiva del Hospital del Niño Dr. José Renán Esquivel. Su hospitalización se vio caracterizada por neumonía nosocomial, una lesión anfractuosa lingual e inestabilidad autonómica. Además de la antibioticoterapia con metronidazol y la aplicación de inmunoglobulina antitetánica, precisó apoyo hemodinámico con dobutamina y norepinefrina. Para lograr un completo control de las crisis de hipertonía, se ofreció manejo con infusión de midazolam, levetiracetam, clobazam, baclofeno y toxina botulínica.

Generalized tetanus is a highly fatal infectious disease without medical interventions and in our time, preventable by active immunization. The case of a 4-year-old preschooler is presented who suffers a sharp wound in the palm of the left hand and who presents 4 days later with generalized tetanus. He was intubated and admitted to intensive care unit at Dr. José Renán Esquivel Children's Hospital. His hospitalization was characterized by nosocomial pneumonia, an anfractuous lingual lesion and autonomic instability. In addition to antibiotic therapy with metronidazole and the application of tetanus immunoglobulin, hemodynamic support with dobutamine and norepinephrine was required. To achieve complete control of hypertonic crisis, management with infusion of midazolam, levetiracetam, clobazam, baclofen and botulinum toxin was offered.

Kinesioterapia en varón con tétano generalizado / Kinesitherapy in men with generalized tetanus

Introducción: El Tétanos es una enfermedad causada por la bacteria Clostridium tetani, siendo el tétanos generalizado la forma más común de la infección, caracterizándose por espasmos generalizados de la musculatura, que involucra a los músculos del tronco más que a los de las extremidades y, manifiesta síntomas de hiperactividad autonómica. Descripción del caso: Se presenta el caso de un varón de 48 años internado en el Hospital de Clínicas, traqueostomizado, con diagnóstico de tétanos generalizado. En el día 30 de su enfermedad recibió kinesioterapia respiratoria y motora, con 15 sesiones realizadas. La kinesioterapia aplicada al paciente consistió en facilitar la eliminación de secreciones bronquiales, mejorar la expansión pulmonar, reeducar la deglución, mejorar la fuerza muscular y amplitud articular, inhibir la secuelas de la hipertonía muscular. Resultados: Se logró mejorar la mecánica respiratoria, el retiro de la cánula de traqueostomía y sonda nasogástrica, mejoró la fuerza muscular y amplitud articular, pudiendo el paciente realizar la sedestación sin apoyo y la bipedestación con asistencia. Discusión: Con el tratamiento relajante, traqueostomía y respiración asistida aparecen nuevos problemas, aspectos que fueron abordados kinésicamente en el presente caso clínico, observándose un menor tiempo de hospitalización y mayor independencia física en comparación con otros casos publicados. Conclusión: Para la aplicación de kinesioterapia en pacientes con tétanos generalizado, es necesario conocer la enfermedad, su evolución y manejo clínico. El trabajo interdisciplinario, es muy importante, específicamente en lo que respecta a la medicación y control del dolor, para que el avance de las técnicas kinésicas alcance su objetivo.

Introduction: Tetanus is a disease caused by the bacterium Clostridium tetani, with tetanus being the most common form of infection, characterized by generalized spasms of the musculature, which involves the muscles of the trunk rather than those of the limbs and, manifests symptoms of autonomic hyperactivity. Case description: The case of a 48-year-old male admitted to the Tracheostomized Clinic Hospital with a generalized tetanus diagnosis is presented. On the 30th day of his illness he received respiratory and motor kinesiotherapy, with 15 sessions performed. The kinesitherapy applied to the patient consisted of facilitating the elimination of bronchial secretions, improving lung expansion, re-educating swallowing, improving muscle strength and joint amplitude, inhibiting the sequelae of muscular hypertonia. Results: It was possible to improve the respiratory mechanics, the removal of the tracheostomy cannula and nasogastric tube, improved muscle strength and joint amplitude, being able to perform unsupported sitting and standing with assistance. Discussion: With the relaxing treatment, tracheostomy and assisted breathing, new problems appear, aspects that were addressed kinésicamente in the present clinical case, observing a shorter hospitalization time and greater physical independence compared to other published cases. Conclusion: For the application of kinesitherapy in patients with generalized tetanus, it is necessary to know the disease, its evolution and clinical management. Interdisciplinary work is very important, specifically with regard to medication and pain control, so that the advancement of kinesic techniques reaches its goal.

A Case of Tetanus Treated with Propofol and Shakuyakukanzoto / 日本東洋医学雑誌

Shakuyakukanzoto is effective for pain primarily related to muscle contractions and the powder works rapidly after oral intake. We successfully treated a patient who presented with spastic convulsions by using shakuyakukanzoto. A 32-year-old man had injury to his left hand from a dog bite, resulting in tetanus. Intravenous propofol was chosen as a sedative at first. On day1, shakuyakukanzoto was also administered to control his spastic convulsions. It was effective in reducing his propofol dose and improving various symptoms such as priapism, abdominal pain, tremor, and insomnia. The patient was discharged from our hospital on day 14. This is the first report we know of tetanus treated with shakuyakukanzoto. And we believe that shakuyakukanzoto may be useful for the control of muscle spasms and the management of dysautonomia caused by generalized tetanus.

The clinical course and outcome of generalized tetanus: A 5 - year - experience from the medical intensive care unit, Siriraj Hospital.

A retrospective analysis of patients with tetanus who were admitted to the Medical ICU during January 1995 - December 1999 is reported. The aims were to examine potentially different clinical course as well as outcome. Of 21 patients, 16 were male and 5 were female. The mean age was 44.3 +16 years. The site of infection was noted in 17 patients; and of these, 8 patients sought medical care where tetanus toxoid was given but not passive immunization. The mean incubation period was 6.1 + 8.7 days (range 4-30 days) while the mean period of onset was 3 + 2.7 days (range 1-13 days). Seven patients (33%) died. Six of them had pneumonia as a cause while the other one died from hyperkalemia. The cause of pneumonia in 5 patients was ventilator associated and the other had severe pneumonia following bronchopulmonary aspiration. Early cardiac arrest occurred in 3 patients, two resulted from bronchopulmonary aspiration and one from hyperkalemia. The mean ICU stay was 17 + 24.6 days and the mean duration of ventilation was 12.3 + 24.9 days. The mean cost of treatment was 112,207 + 100,194 baht (range 7,259 - 200,165 baht). In conclusion, tetanus can occur despite post-exposure medical care and the outcome as judged by mortality rates, ICU stays, complications and costs were not satisfactory. Proper post-exposure wound care and immunization needs to be emphasized. Strict adherence to management guidelines regarding the care of these patients and prevention of nosocomial infection are necessary. New treatment modalities which could shorten the disease course or reduce the need to paralyze and provide respiratory support would be useful in improving the patients' outcomes.