Tétanos generalizado: Una amenaza persistente, reporte de tres casos y revisión de la literatura / Generalized tetanus: A persistent threat, review of the literature and report of three cases

RESUMEN INTRODUCCIÓN: El tétanos es una enfermedad inmunoprevenible, ocasionada por la bacteria Clostridium tetani, desencadenando una enfermedad caracterizada por espasmos musculares, insuficiencia respiratoria y disautonomías, potencialmente mortal. MATERIALES Y MÉTODOS: Presentamos una serie de tres pacientes que consultaron al servicio de urgencias por presentar trismus, rigidez muscular generalizada y dificultad respiratoria, requiriendo manejo en la unidad de cuidados intensivos, con relajación muscular y administración intramuscular e intratecal de inmunoglobulina antitetánica, con evolución satisfactoria en todos los casos. DISCUSIÓN: Su tratamiento está divido en dos grandes secciones; la primera parte, el control de la infección y eliminación del agente causal, con lavado y desbridamiento de heridas, administración de antibióticos y neutralización de la neurotoxina. La segunda parte del tratamiento está en el soporte vital en la unidad de cuidados intensivos, con la administración de sedación, relajación muscular, control de disautonomías y manejo de complicaciones. CONCLUSIONES: El tétanos a pesar de los avances en vacunación aún es una enfermedad presente, cuyo diagnóstico y tratamiento rápido y adecuado, permite sobrevivir a los pacientes, como en los casos aquí reportados.

ABSTRACT INTRODUCTION: Tetanus is an immuno-preventable disease, produced by the bacterium Clostridium tetani, that causes a disease characterized by muscle spasms, respiratory insufficiency and life-threatening dysautonomia. MATERIALS AND METHODS: We present a series of three patients who consulted for trismus, muscle stiffness and respiratory failure, which required intensive care management, muscle relaxation, intramuscular and intrathecal administration of tetanus immu-noglobulin, with satisfactory outcomes in all the cases. DISCUSSION: Its treatment is divided into two main sections; the first part, the control of infection and elimination of the causative agent, with washing and debridement of wounds, administration of antibiotics and neutralization of the neurotoxin. The second part is life support in the intensive care unit, with the administration of sedation, muscular relaxation and control of dysautonomia and the management of complications. CONCLUSIONS: Despite the advances in vaccination, tetanus is still a present disease, whose diagnosis and rapid and adequate treatment allows patients to survive, as in the cases reported here.

Tétanos generalizado en adulto. Reporte de caso / Adult generalized tetanus. Case report

RESUMEN Fundamento: El tétanos es una enfermedad infecciosa causada por las esporas de la bacteria Clostridium tetani que afecta el sistema nervioso. La inmunización contra esta enfermedad ha permitido reducir la morbilidad y la mortalidad en Cuba por esa causa. Los pocos casos reportados son pacientes sin previa vacunación contra el tétanos, por lo que constituye de interés para la comunidad científica el reporte de aquellos que desarrollan esa enfermedad después de haber sido vacunados. Objetivo: Describir el caso de un paciente con diagnóstico de tétanos generalizado a pesar de que ya había sido vacunado contra esa enfermedad. Presentación del caso: Paciente de 33 años, con el antecedente de haber sido vacunado contra el tétanos, al cual le diagnosticaron tétanos generalizado, por lo se decidió su ingresó en la unidad de cuidados intensivos. Clínicamente se manifestó por contracciones musculares generalizadas y rigidez, los síntomas y signos neurológicos tuvieron una duración de 4 semanas. A pesar de las complicaciones el paciente egresó con adecuada calidad de vida. Conclusiones: La presentación de este caso busca concientizar en la comunidad científica la importancia de considerar el diagnóstico de tétanos en pacientes ya vacunados, lo cual es poco frecuente y obliga a actuar con prontitud.

ABSTRACT Background: Tetanus is an infectious disease caused by the bacterium Clostridium tetani spores which affects the nervous system. In Cuba, immunization against this disease has made it possible to reduce morbidity and mortality from this cause. The few cases reported are patients without prior vaccination against tetanus, so is the interest to the scientific community the reporting of those who develop this disease after having been vaccinated. Objective: To describe a patient´s case with a generalized tetanus diagnosis despite has already been vaccinated against this disease. Case report: A 33-year-old patient, with a history of has been vaccinated against tetanus, and diagnosed with generalized tetanus, so it was decided he to be admitted to the intensive care unit. Clinically manifested by generalized muscle contractions and stiffness, the neurological symptoms and signs lasted 4 weeks. Despite the complications, the patient discharged from hospital with an adequate life quality. Conclusions: This case presentation searches for raising awareness in the scientific community about the importance of considering the diagnosis of tetanus in previous vaccinated patients, which is rare and requires quickness of action.

Clinical profile and management of tetanus: A 5-year retrospective case series in a referral tertiary hospital in Metro Manila

OBJECTIVE@#To describe the profile, management, and outcome of adult patients admitted for tetanus. @*METHODOLOGY@#A search of the hospital and department database was conducted for patients with admitting or final diagnosis of tetanus. Patients below 19 years old, with alternative diagnosis, incomplete or unavailable records, transferred to another institution, and went home against medical advice were excluded. Data on patient demographics, source of infection, symptom severity, and management were obtained. Data was described using proportions and averages.@*RESULTS@#Thirty-two patients were included in the study. Twenty-seven were male with a mean age of 45.63 ± 13.39. All cases had no history of tetanus vaccination. The most common focus of infection was acute injuries. More than half of patients would be diagnosed within 72 hours of symptom onset. The most common symptoms on presentation were trismus, rigidity, dysphagia, and spasms. On admission, Cole severity for 11 (34.4%) cases was mild, 17 (53.1%) moderate, and 4 (12.5%) severe. Prophylactic tracheostomy was performed in 31 patients and 19 (59.4%) were placed on assisted ventilation. All cases were treated with metronidazole. A benzodiazepine was started in all cases for spasm control. Baclofen, magnesium sulfate, and antiepileptic drugs such as carbamazepine were also used. Twenty (62.5%) patients suffered from complications, the most common of which was nosocomial pneumonia, which resulted in longer ICU and hospital stays. Eleven patients exhibited progression in Cole severity: 8.6% at stage 1, 57.1% at stage 2, and 34.3% cases were at stage 3. Mortality rate was 19% with the proportion increasing with Cole severity. @*CONCLUSION@#We describe the presentation and course of patients admitted for tetanus in our institution. Most cases were males and all cases had no vaccination history. Trismus was the most common presenting symptom. Metronidazole was the antibiotic of choice and benzodiazepines were the mainstay for spasm control. Majority of cases were mild to moderate in severity on presentation. Advanced disease stages were associated with higher fatality rates. Complications were associated with longer ICU and hospital stay. These findings suggest that prevention of progression of disease severity and complications must be the focus of tetanus protocols to shorten hospital stay and decrease mortality rate. Promoting vaccination of at-risk adults is recommended to lower the incidence of tetanus.

Aspects épidémiologiques, cliniques et évolutifs du tétanos au CHR de Maradi au Niger

Introduction : Le tétanos est caractérisé par un tableau clinique fait des spasmes musculaires sévères faisant suite à des blessures. La bactérie en cause, Clostridium tétani, a été découverte en 1884 et mise en culture pour la première fois en 1889. C'est une maladie totalement évitable et d'ailleurs quasiment éliminée des pays développés grâce à la vaccination généralisée et à une rigoureuse prophylaxie post-exposition, toutes deux parfaitement codifiées. Objectif : Cette étude rétrospective avait pour but de décrire les aspects épidémiologiques, cliniques et évolutifs du tétanos au CHR de Maradi au Niger. Matériel et méthodes : Les dossiers de malades hospitalisés au service des maladies contagieuses du CHR de janvier 2011 à aout 2018 ont été évalués. Résultats : Nous avions colligé 49 cas de tétanos sur un total de 2930 malades hospitalisés dans le service soit un taux de prévalence de 1,67 %; 32,65 % des patients étaient âgés de 0 à 15 ans. La porte d'entrée tégumentaire a été la plus fréquemment retrouvée (vingt huit cas). D'autres portes d'entrée ont été notées : fracture ouverte (5 cas), injection intramusculaire (1 cas), ombilicale (2 cas), brulure corporelle (2cas). 57,14% des malades étaient au stade II de la classification de Mollaret. On a enregistré 19 décès sous traitement, soit un taux de létalité de 38,78 %. Le stade clinique des patients à l'admission a été associé au décès avec une P = 0,0030.Conclusion: La sensibilisation des populations, le renforcement du programme élargi de vaccination et l'amélioration de la prise en charge des malades devraient permettre de réduire encore davantage la mortalité liée au tétanos

Tetanus in horses: an overview of 70 cases / Tétano em equinos: um panorama de 70 casos

Tetanus is characterized by high case fatality rates in horses. Comprehensive case series studies involving equine tetanus from different geographic areas enable the evaluation of prognosis, efficacy of treatment, and control measures. We retrospectively investigated some selected epidemiological data (breed, age, gender, use of the horses, history of vaccination, seasonality, presence of wound/history of surgical procedures, clinical outcomes) and main clinical aspects (clinical signs, incubation period, length of hospitalization, and period between onset signs and hospitalization) in 70 cases of equine tetanus over 1990-2015, with emphasis in the association between these data and the clinical outcomes. High mortality rate (72.9%) was observed in this study. Forty (57.1%) horses presented history of wounds or surgical procedures related with tetanus, represented mainly by lesions in the hind limbs (42.5%), front limbs (15.0%), umbilical infections (7.1%), castration (4.3%), and face wounds (4.3%). Hyperesthesia, limb spasticity, cervical stiffness, tetanic spasms, and restriction of jaw movement were the main consistent clinical signs. Besides no statistical association, all the horses with umbilical infections, wounds in face, prolonged recumbency, sweating, dysphagia/aphagia died, and together with delay between onset of first clinical signs and prompt veterinary assistance (< 5 days) were considered indicative of poor prognosis; whereas there was a significant association (p=0.001) between survival and length of hospitalization > 7 days, seemed as an evidence of good prognosis. The high mortality rate of tetanus, even in horses under specific treatment, highlight the need for early diagnosis, prompt veterinary assistance, and establishment of prophylatic measures in equine farms.(AU)

Tétano é caracterizado por elevada mortalidade em equinos. Estudos envolvendo séries de casos da doença provenientes de diferentes áreas geográficas possibilitam avaliar o prognóstico, eficácia do tratamento e ações de controle. Foram avaliados, retrospectivamente, os principais achados epidemiológicos (raça, idade, sexo, uso dos equinos, história de vacinação, sazonalidade, presença de lesões/histórico de procedimentos cirúrgicos e evolução dos casos) e aspectos clínicos (sinais clínicos, período de incubação, tempo de hospitalização e período entre início dos sinais e hospitalização) em 70 casos de tétano em equinos atendidos entre 1990 e 2015, com ênfase na associação entre os dados clínico-epidemiológicos e a evolução dos casos (mortalidade). Foi observada alta mortalidade (72,9%) nos equinos. Do total de equinos, 57,1% apresentavam lesões ou histórico de procedimentos cirúrgicos relacionados com tétano, representados principalmente por lesões em membros posteriores (42,5%), membros anteriores (15,0%), infecções umbilicais (7,1%), castração (4,3%) e lesões de face (4,3%). Hiperestesia, espasticidade dos membros, rigidez de pescoço, espasmos tetânicos e restrição aos movimentos de mandíbula foram os principais sinais clínicos observados. Apesar da ausência de significância estatística, todos os animais com presença de infecções umbilicais, lesões na face, decúbito prolongado, sudorese e disfagia/afagia evoluíram para óbito e, associado ao início dos sinais clínicos e a demora no atendimento (< 5 dias), foram considerados indicativos de prognóstico reservado. Em contraste, foi observada associação significante (p=0,001) entre a sobrevivência dos animais e o tempo de hospitalização maior que 7 dias, considerado uma indicação de bom prognóstico. A elevada mortalidade do tétano, mesmo em equinos tratados, enfatiza a necessidade do diagnóstico precoce, do rápido atendimento veterinário e adoção de medidas profiláticas nos criatórios.(AU)

Tétanos generalizado: caso clínico y revisión del tema / Generalized tetanus: clinical case report and review of the literature

Tetanus is a severe and potentially mortal disease, which affects the Nervous System, caused by the bacteria Clostridium tetani. It's endemic in developing countries, presenting in Chile with a rate of 0,02 cases per 100.000 habitants, but the antitetanic vaccine has reduced its incidence in developed countries. We present here a case report of a patient with generalized tetanus from our hospital. The clinical presentation was characterized by generalized increased muscle tone and trismus, and the patient was hospitalized in the Intensive Care Unit. The neurologic manifestations were important for a period of 3 weeks, but then they started decreasing until the patient was discharged, without complications and being able to sit and walk with assistance. In relation to this case, we will review the actualizations in the subject of Tetanus. The recommended treatment includes support therapy, prevention of complications, antibiotics, muscle relaxants and anti-tetanospasmin immunoglobulin; all therapies that our patient received partially. The disease has a mortality that reaches the 50 percent in some series, but the ones who survive have a good prognosis and full recovery. This is why the presentation of this case is important, being an infrequent disease that must be diagnosed timely and be treated adequately.

Introducción: El tétanos es una enfermedad grave y potencialmente mortal, que afecta al sistema nervioso y causada por la bacteria Clostridium tetani. Es endémica en países en desarrollo, teniendo en Chile el año 2007 una tasa de 0,02 casos por cien mil habitantes. La vacuna con el toxoide antitetánico ha disminuido ostensiblemente su incidencia en países desarrollados. Caso clínico: Se presenta el caso clínico de un paciente de 18 años con tétanos generalizado ingresado a nuestro hospital. Clínicamente se manifestó con un aumento del tono muscular generalizado y trismo. Se hospitalizó en la Unidad de Cuidados Intensivos. Los síntomas y signos neurológicos tuvieron una máxima intensidad de aproximadamente cuatro semanas; posteriormente fueron disminuyendo sin presentar complicaciones severas. Al alta el enfermo lograba sentarse y caminar con ayuda. Discusión: A propósito de este caso se hace una revisión de la literatura y actualización de esta grave enfermedad. El tratamiento recomendado incluye terapia de soporte, prevención de complicaciones, antibioterapia, relajantes musculares e inmunoglobulina antitetánica; terapias que este paciente recibió. Si bien esta enfermedad tiene una letalidad promedio de un 50 por ciento, los pacientes que sobreviven tienen buen pronóstico y recuperación completa. Por ello, la presentación de este caso clínico es importante, sobre todo siendo una condición poco frecuente, que debe diagnosticarse con prontitud y, así, recibir el tratamiento adecuado.

Tetanus epidemiology in Santa Catarina, Brazil from 1998 to 2008 / Epidemiología del tétanos en Santa Catarina, Brasil, entre 1998 y 2008

Objetive: This work describes demographic and clinical characteristics of individuals with accidental tetanus in Santa Catarina, Brazil. Materials and Methods: 291 cases of accidental tetanus reported from 1998 to 2008 were analyzed retrospectively through a cross-sectional, descriptive andcorrelated study based on percentage and numeric frequency as well as on number and incidence rate (i.r.) found in compulsory notification forms. Results: Most cases (73,54%) occurred among men residing in Vale do Itajaí (30,24%). The age group with the highest incidence was within the 35 to 49 range(32,30%). Complete immunization history was reported in seven cases (2,40%), the perforating injury being the most observed and the lower limbs the most affected ones. Among the reported cases, 87,62% were confirmed; 114 (39,17%) patients died.Conclusions: Accidental tetanus in SantaCatarina affects the population in asignificant way despite the fact that it is an immune preventable disease. The authorities and administrators must plan strategies to address changes in public policies related to immunization coverage of the susceptible population, mainly adults. Above all, it is important to warn society that the success of immunization programs depends on theapplication of three doses at set intervals, application of booster doses and compliance with the vaccination schedule.

Objetivo: El presente trabajo describe las características demográficas y clínicas de los individuos con tétanos accidental en Santa Catarina, Brasil. Materiales y métodos: se analizaron 291 casos de tétanos accidental reportadosdesde el año 1998 hasta 2008, a través de un estudio descriptivo tipo corte transversal. Con base en el porcentajey frecuencia numérica, así como enla tasa de incidencia registrada según los formularios de notificación obligatoria. Resultados: La mayoría de los casos (73,54%) ocurrieron en los hombres que residen en Vale do Itajaí (30,24%). El grupo con mayor incidencia fue en el rango de edad de 35 a 49 años (32,30%). La historia completa de inmunización se informó ensiete casos (2,40%), la lesión erforantefue la más observada, las extremidadesinferiores fueron las más afectadas. Entre los casos reportados 87(62%) fueron confirmados; 114 (39,17%) pacientes murieron. Conclusiones: el tétanos accidental en Santa Catarina afecta a la población de manerasignificativa a pesar del hecho de que esuna enfermedad prevenible. Las autoridades y los administradores deben planear estrategias para generar cambios en las políticas públicas relacionadas con la cobertura deinmunización de la población susceptible, sobre todo los adultos. Es importante advertir a la sociedad que el éxito de los programas de inmunización depende de la aplicación de tres dosis a intervalos establecidos, la aplicación de las dosis de refuerzo y el cumplimiento del calendario de vacunación.

Tetanus Developed in Gangrenous Perforation of Small Bowel

Tetanus is a neurologic disorder caused by a tetanospasmin released from Clostridium tetani and usually occurs following a stab wound or dirty abrasion. Tetanus is uncommon in Korea due to the introduction of vaccination programs. Furthermore, tetanus associated with a gangrenous perforation of the small bowel is extremely rare. We report a case of tetanus developed in a patient who was diagnosed with a gangrenous perforation of the small bowel. This is the first reported case in Korea.

Tetanus in a Breast Cancer Patient with Adjuvant Chemotherapy

Tetanus is a neurologic disorder caused by a tetanoplasmin which is a neurotoxin elaborated by Clostridium tetani. It is characterized by increased muscle tone and spasm. Since a nationwide childhood vaccination program, tetanus has become a rare disease in Korea. Because many physicians have little experience, misdiagnosis or therapeutic delay may result in unexpected consequences. Although it has high mortality rate on attack, early detection, proper immunization and supportive care can increase survival rate. We report a case of tetanus due to puncture injury by splinter in a 69-year-old woman who has been treated with adjuvant chemotherapy of breast cancer. She was admitted to emergency room with difficulty of opening mouth for 3 days. After two days, we detected that the patient suddenly fell on her back with muscle spasm, so we diagnosed her with tetanus. She was given human tetanus immunoglobulin intramuscularly and supportive care. Forty days after admission, she was discharged without complications.

Tratamento cirúrgico da úlcera por pressão como complicação do tétano / Surgical treatment of pressure sore as tetanus complication

Introdução: O tétano é uma doença infecciosa, não contagiosa, causada pela ação doClostridium tetani. O tétano é caracterizado pela hipertonia dos músculos estriados,preferencialmente, os músculos masseteres, da parede anterior do abdome e dos membrosinferiores. Essa contratura pode se intensificar e causar espasmo generalizado, à medidaque o paciente é submetido a estímulos intrínsecos e extrínsecos de movimento, como tosseou deglutição e reposicionamento no leito, respectivamente. As principais complicaçõesdo tétano são atribuídas às exacerbações paroxísticas da hipertonia, que levam a asfixia eparada respiratória. São também registrados instabilidade hemodinâmica, distúrbios hidroeletrolíticose quadros infecciosos secundários. Não há na literatura relatos de úlceras porpressão como complicação relacionada à infecção por tétano. A úlcera por pressãoconstitui importante comorbidade, acometendo pacientes que necessitam de prolongadosperíodos de internação hospitalar, especialmente, nas unidades de terapia intensiva, comoos portadores de tétano. Método: O Grupo de Feridas Complexas da Divisão de CirurgiaPlástica do Hospital das Clínicas da Faculdade de Medicina da USP observou o desenvolvimentode 3 casos de úlceras por pressão, associadas ao tratamento clínico do tétano.Apresentamos e discutimos opções de tratamento cirúrgico para resolução de úlceras porpressão associadas ao tétano.

Introduction: Tetanus is an infectious disease caused by Clostridium tetani. Clinicalpresentation includes muscle hypertony, particularly of masseter muscle, of the anteriorabdominal wall and on lower extremity musculature. Contracture may be intense, causingspasms, mostly when the patient is submitted to intrinsic and extrinsic stimulus, like coughingbut specially when managed in the bed by the health personal. Complications related to tetanusare usually severe as asphyxia and respiratory failure. Hemodinamic instability and infectiveprocesses are also reported. We did not find report of the association of pressure sore withtetanus. Pressure ulcer is an important comorbidity in patients that need long period ofhospitalization and bed rest, specially if they are in intensive care units. Methods: The groupfor treatment of complex wounds of the Plastic Surgery Division in the Hospital das Clínicas,University of São Paulo treated three of those patients with pressure ulcer related with tetanusduring the last year. Description of the appropriate surgical treatment is presented.

Immunogenicity, reactogenicity and consistency of production of a Brazilian combined vaccine against diphtheria, tetanus, pertussis and Haemophilus influenzae type b

A randomized, double-blinded study evaluating the immunogenicity, safety and consistency of production of a combined diphtheria-tetanus-pertussis-Haemophilus influenzae type b vaccine entirely produced in Brazil by Bio-Manguinhos and Instituto Butantan (DTP/Hib-BM) was undertaken. The reference vaccine had the same DTP vaccine but the Hib component was produced using purified materials supplied by GlaxoSmithKline (DTP/Hib-GSK), which is registered and has supplied the Brazilian National Immunization Program for over more than five years. One thousand infants were recruited for the study and received vaccinations at two, four and six months of age. With respect to immunogenicity, the vaccination protocol was followed in 95.6 percent and 98.4 percent of infants in the DTP/Hib-BM and DTP/Hib-GSK groups, respectively. For the Hib component of the study, there was 100 percent seroprotection (>0.15 µg/mL) with all three lots of DTP/Hib-BM and DTP/Hib-GSK. The geometric mean titer (GMT) was 9.3 µg/mL, 10.3 µg/mL and 10.3 µg/mL for lots 1, 2 and 3 of DTP/Hib-BM, respectively, and the GMT was 11.3 g/mL for DTP/Hib-GSK. For diphtheria, tetanus and pertussis, seroprotection was 99.7 percent, 100 percent and 99.9 percent, respectively, for DTP/Hib-BM, three lots altogether and 99.2 percent, 100 percent and 100 percent for DTP/Hib-GSK. GMTs were similar across all lots and vaccines. Adverse events rates were comparable among the vaccine groups. The Brazilian DTP/Hib vaccine demonstrated an immunogenicity and reactogenicity profile similar to that of the reference vaccine.

Comparación cinética y bioquímica de tres cepas de clostridium tetani, para la producción de toxina tetánica / Kinetic and biochemical comparison between three strains of clostridium tetani for production of titanic toxin

En este estudio se comparó el comportamiento bioquímico y cinético de tres cepas de Clostridium tetani, Harvard (Ha), Massachusetts (Ms) y Caracas (Ca); cepas utilizadas comúnmente en la producción del toxoide tetánico. Se realizaron pruebas bioquímicas para la identificación de los microorganismos anaerobios y se desarrollaron cultivos en reactor de 5L, bajo las siguientes condiciones: Medio Latham Mueller "Con" y "Sin" glutamato de sodio; 1 por ciento (v/v) de inóculo, pH inicial, 7.1 ± 0.2 (variable), 35ðC y 100 r.p.m. Los resultados mostraron características bioquímicas similares entre las tres cepas y la cepa control ATCC 9441. El comportamiento cinético de las cepas Ms y Ha fue similar para todos los parámetros evaluados, obteniéndose mayor productividad en cultivos suplementados con 2.5g/L de glutamato de sodio (Ms: Sin: 625Lf/L.h y Con: 658Lf/L.h; Ha: Sin: 610Lf/L.h y Con: 658Lf/L.h). La cepa Ca, produjo mayor cantidad de biomasa (Ca: 0.5420g/L; Ms: 0.2721g/L y Ha: 0.2009g/L); sin embargo, la productividad de toxina fue menor (Sin: 174Lf/L.h y Con: 417Lf/L.h). Estos resultados descartan la utilización de la cepa Ca para la producción del toxoide, bajo las condiciones de fermentación ensayadas.

Tétanos: Todavía un problema de salud pública / Tetanus: still a public health problem

El tétanos es una enfermedad inmunoprevenible que todavía causa estragos en las naciones que no han logrado coberturas protectoras de vacunación. Su tasa de letalidad alcanza el 50 por ciento. Es necesario que nuestro personal de salud esté familiarizado con su prevención, diagnóstico, tratamiento y rehabilitación. Esta revisión tiene como objetivo presentar una actualización de conocimientos sobre esta importante enfermedad, haciendo énfasis en el diagnóstico y el tratamiento.El tétanos es una enfermedad aguda de distribución mundial y presentación esporádica, infrecuente en países industrializados. Por su elevada tasa de letalidad aún representa un problema de salud pública, en especial en regiones con programas preventivos deficientes.

Tetanus is an immune-preventable disease which still causes ravages in nations without protective vaccination coverage. Its lethality rate is almost 50%. It is necessary that healthpersonnel are familiarized with its prevention, diagnosis, treatment and rehabilitation. Tetanus is an acute illness of worldwide distribution, sporadic occurrence and low frequency inindustrialized countries. Due to its high lethality rate it still is a public health problem, especially in regions with deficient preventive programs. This review presents up to date knowledge on different aspects of this important disease, with emphasis on its diagnosis and treatment.

One Case of Tetanus after Taking Acupuncture

Tetanus is a neurologic disease which features the muscle spasm as the hallmark. It is an infectious disease with high mortality rate triggered by tetanospasmin produced by Clostridium tetani. This report concerns incidence of tetanus consequent to oriental medical care such as acupuncture and moxibustion. Although the tetanus occurrence has shown a remarkable decline since nationwide vaccinations in some of the developed countries, including Korea, it still remains to be an important issue, to be dealt within Korea, as the majority of the patients are old aged and Korean population is rapidly becoming an aging society. Furthermore, since more elders are coming to rely on Oriental medicine in Korea, the Korean elders are at a higher risk than elsewhere. The lack of medical experiences, including those in oriental medical field, has been hindering early diagnosis of Tetanus. This study aims to encourage rapid and accurate decisions in diagnosis and treatment through reviewing symptoms particularly specific to tetanus, and also to arouse attention to the riskiness of invasive procedures involving skin puncture.

Prevalence of diphtheria and tetanus antibodies and circulation of Corynebacterium diphtheriae in São Paulo, Brazil

The introduction of routine vaccination against tetanus and diphtheria in Brazil has decreased the incidence and changed the epidemiology of both diseases. We then investigated the prevalence of Corynebacterium diphtheriae carrier status and diphtheria and tetanus immunity in São Paulo, Brazil. From November 2001 to March 2003, 374 individuals were tested for the presence of C. diphtheriae in the naso-oropharynx and of serum diphtheria and tetanus antibodies. Participants were all healthy individuals without acute or chronic pathologies and they were stratified by age as follows: 0-12 months and 1-4, 5-9, 10-14, 15-24, 25-39, 40-59, and ³60 years. Antibodies were assessed using a double-antigen ELISA. C. diphtheriae species were identified by biochemical analysis and toxigenicity was assessed by the Elek test. For diphtheria, full protection (antibodies ³0.1 IU/mL) was present in 84 percent of the individuals, 15 percent had basic protection (antibodies ³0.01 and <0.1 IU/mL) and 1 percent were susceptible (antibodies <0.01 IU/mL). Full tetanus protection (antibodies ³0.1 IU/mL) was present in 79 percent of the participants, 18 percent had basic protection (antibodies ³0.01 and <0.1 IU/mL) and 3 percent were susceptible (antibodies <0.01 IU/mL). The geometric mean of diphtheria and tetanus antibodies reached the highest values at 5-9 years and decreased until the 40-59-year age range, increasing again in individuals over 60 years. Three participants (0.8 percent) were carriers of C. diphtheriae, all non-toxigenic strains. The present results demonstrate the clear need of periodic booster for tetanus and diphtheria vaccine in adolescents and adults after primary immunization in childhood.

O trismo como primeira manifestação do tétano / The trismus as tetanus's first manifestation

O tétano é uma doença infecciosa severa, não contagiosa, usualmente de início agudo, resultante da solução de continuidade da pele/mucosa e contaminação pelo bacilo Clostridium tetani.O diagnóstico do tétano é clínico e seu quadro inicia-se, na maior parte das vezes, por espasmos moderados dos músculos da boca, face e pescoço, seguido de aparecimento rápido de rigidez dorsal, toraco-abdominal e por vezes dos músculos da laringe com comprometimento da respiração. Não há exames laboratoriais que confirmem o diagnóstico e os exames bacteriológicos são negativos na maior parte dos casos. O fato de não ser encontrada a porta de entrada, o que acontece em 29% 2,3 das situações, não exclui o diagnóstico. O prognóstico está relacionado com a idade, estado de saúde prévio, estado de imunidade, local da infecção primária e período de incubação. O tétano deve ser suspeitado e tratado empiricamente em todo o paciente que apresenta sinais e sintomas, mesmo sem sinal ou lesão aparente...

Detección inmunoenzimática de la toxina de la bacteria Clostridium tetani: una alternativa a las pruebas biológicas con ratones / Immunoenzimatic detection of the Clostridium tetani bacterial toxin: an alternative to mice bioassays

Cell-free extracts from 20 strains of Clostridium tetani isolated from soil samples, were tested for tetanus toxin production using an enzyme immunoassay. All the extracts were classified as positive for the toxin presence, and eight of them showed absorbance values corresponding to tetanus toxin concentrations between 3.2 and 88 ng/ml; thus, they fell within the linear absorbance range (0.135-0.317). All dilutions of toxin used to obtain the calibration curve (0.0071 to 1.1 ng) were lethal for mice.

Clostridial toxins - potent poisons, potent medicines

Clostridium is an anaerobic bacterial genus. The clostridia produce more protein toxins than any other bacterial genus and are a rich reservoir of toxins for research and medicinal uses. Clostridia are widely spread in the environment: soil, dust and water, presenting more than 120 described species, although few can cause diseases. Diseases can grossly be divided into neurotropic disorders (nervous system is primarily affected), enterotoxemias (affecting intestinal tract and parenchymatous organs), and gas gangrene (myonecrosis with toxemia). Undoubtedly the most widely recognized infection due to anaerobes was clostridial myonecrosis, but recently interest has arisen for the role of clostridia in intestinal diseases. This report describes the most important species, the diseases caused by them, and their occurrence in Brazil, focusing on cattle raising

Methods of tetanus prevention in primary care clinic

Tetanus is a highly fatal disease principally affecting non-immunized or under immunized persons. Aggressive childhood vaccination with tetanus toxoid and widespread use of tetanus toxoid boosters combined with improved wound management have resulted in a decease in tetanus reported. The disease is largely preventable but not completely so. Experience worldwide affirms that the most cost effective pattern for preventing tetanus. In any community is primary health education with antenatal and infant immumization followed by booster doses given in childhood combined with improved wound management. Patients presenting for wound management should be questioned by health care providers concerning the date of their last tetanus containing vaccine or booster to avoid unnecessary repeat vaccination