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UDC:616.98:579.86
Melenko Svitlana Romanivna
PhD, Associate Professor of the Department of Infectious Diseases and Epidemiology
Bukovinian State Medical University Oleksandra Kotenko student
Bukovinian State Medical University
Maria Basenko
student
Bukovinian State Medical University DOI: 10.24412/2520-6990-2023-9168-58-60 DESCRIPTION OF CASES OF GENERALIZED TETANUS AND THE ROLE OF PREVENTION OF
THIS DISEASE: A REVIEW.
Introduction:
Tetanus is a rare disease caused by anaerobic bacteria, Clostridium tetani causing painful muscle spasms and respiratory failure. This bacterium can enter the human body via a deep wound, burn injury or medical procedure. However, in addition to this, the following were described tetanus also originate from odontogenic infection.
Tetanus is an illness that mainly affects the central and peripheral nervous systems. The clinical features of tetanus and its relationship to wounds and injuries are well known, dating back to ancient times. Clostridium tetani is an obligate anaerobe that produces a toxin found in soil and mammalian intestines. C. tetani transforms into a vegetative bacterium which then travels to the spinal cord and brainstem via the motor neurons. It then produces neurotoxin tetanospasmin, which interferes with the nervous system inhibitory neurotransmit-ters. C. tetani also produce tetanolysin, which has he-molytic properties and causes membrane damage. It's role is currently unknown.
Tetanus is now rare in developed nations due to effective immunization programs, but it remains a threat to all unvaccinated people, especially in undevel-
oped nations. Most reported cases are attributed to un-vaccinated individuals and improper identification and treatment of wounds and traumatic injuries.
Tetanus has high morbidity and mortality worldwide before the development of tetanus toxoid. The first vaccine was not very effective and had significant adverse effects, but one of the next and safer options was used during World War II for soldiers, which led to a 95% reduction in tetanus rates. Nowadays, tetanus toxoid is considered the safest and most effective medicine in the world.
Tetanus prophylaxis includes understanding and knowing the current tetanus immunization guidelines, recommendations, and indications for prophylaxis.
The key to the prevention of tetanus is immunization, identification of those at risk, and proper identification and treatment of wounds and traumatic injuries.
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Tetanus has four manifestations, including localized, generalized, cephalic, and neonatal:
• Localized tetanus often have localized muscle rigidity.
• Generalized tetanus often presents with trismus, dysphagia, and nuchal rigidity associated with systemic rigidity and tonic contractions.
• Cephalic tetanus may present with cranial nerve paralysis.
• Neonatal tetanus presents with an irritable infant and develops severe rigidity.
How the pathogen works: C. tetani enter the body through a break in the skin or mucous membranes. Once within the body and in anaerobic conditions, the bacteria travel to the spinal cord and brainstem within the motor neuron. It then produces highly potent neu-rotoxin tetanospasmin. The toxin enters inhibitory in-terneurons and blocks neurotransmission at the synapses. There is then inactivation of inhibitory neurotransmission that normally modulates anterior horn cells and muscle contraction. Loss of inhibition of anterior horn cells will cause increased muscle tone and painful spasms. Loss of inhibition of autonomic neurons will cause widespread autonomic instability, mainly manifests as sweating, tachycardia, and hypertension. These effects are long-lasting, and recovery requires the growth of a new nerve terminal.
The incubation period for tetanus ranges from three days to 21 days but usually starts about 8 days. Predisposing factors must be present with the absence of inadequate vaccination plus the following: penetrating or devitalizing type injuries, polymicrobial infections, missed foreign body in wounds or injuries, and any blood flow compromise. Approximately 25% with tetanus has no identifiable causes. Important! Tetanus rarely occurs in patients who are timely and properly receive immunizations.
How the vaccine works: Tetanus vaccine is a type of artificial active immunity. This type of immunity produces antibodies when a dead or weakened version of C. tetani is inoculated. Thereby, when there is actual exposure, the immune system will recognize the antigen and will rapidly produce antibodies. Antibodies wane over time, so periodic vaccines will be needed to boost the production of antibodies.
The first case: A 44-year-old man went to the hospital because he could not open his mouth. Initially, he felt well, but a week before his hospitalization he felt stiffness in his neck and jaw. He also complained of pain in the same area. These symptoms worsened over several days and he had difficulty swallowing. The patient denied fever, ear infection, neck pain, neck trauma, or external perforation wound. He was not taking any medications. He also denied a history of seizures. The doctors found that the patient often pokes his gums with a toothpick. He has not been vaccinated against tetanus and does not remember being vaccinated as a child.
General examination showed that the patient's vital signs were normal. He had neck stiffness and tris-mus. A routine blood test showed an increased activity of the liver enzyme aspartate aminotransferase (AST) up to 107 U/l. The patient was consulted in the Department of Oral and Maxillofacial Surgery, and an intraoral examination revealed poor oral hygiene and the presence of dental caries. In the right upper quadrant of
the oral cavity (teeth № 11, 12, 15 and 16), caries and chronic gingivitis were detected. There was no visible swelling in the neck and submandibular space.
The patient was diagnosed with tetanus, and based on the Ablett classification, he suffered from moderate severity of the disease. The patient was administered a single intramuscular dose of 3000 IU of human tetanus immunoglobulin (HTIG), two grams of ceftriaxone intravenously twice daily, 500 mg of metronidazole intravenously three times daily, five mg of midazo-lam/hour and 1 g of paracetamol three times daily. A nasogastric tube was placed to ensure fluid intake/feeding and prevent aspiration. Dental treatment was postponed until the trismus disappeared.
While in the hospital, the patient felt stiffness and rigidity in his abdomen, and on the third day of hospi-talization he had one episode of generalized muscle spasm. His blood pressure also fluctuated between 140/90 and 110/70 mm Hg, and his heart rate was 70 and 90. Over the next six days, the trismus gradually weakened. The patient was able to open his mouth to eat a week after the start of treatment. After two weeks of hospitalization, the patient was discharged.
The patient's written informed consent was obtained for the publication of this report.
The second case: A 76-year-old married farmer from a rural area came to our ambulance with a seven day non-healing wound on the back of his left thigh that he had received after falling from a tree. The patient had no history of medical or surgical interventions. He also denied having any allergies. The patient did not smoke, but regularly drank alcohol.
On examination, a 3*2 cm purulent ulcer was found on the back of the left thigh. The emergency physician on duty examined the wound, treated it for suspected foreign body and bandaged it, and injected tetanus toxoid. If an infected wound was suspected, a wound swab was sent for culture and sensitivity. The patient was discharged taking oral Fluloxacillin, Met-ronidazole and analgesics and was advised to follow up in the outpatient department.
After being wounded, he sought treatment at a local medical center, where the wound was thoroughly cleaned and painkillers were given. There was a temporary relief of the pain, but it returned and gradually increased along with swelling and purulent discharge, which brought him to this center.
The next day, the patient went to the emergency department because his pain was not relieved by analgesics. The emergency room examination showed an increase in the number of white blood cells and the presence of purulent cells in the urine. He was discharged home, and was taking Ofloxacin in addition to the antibiotics he had been taking previously.
The patient was admitted to the emergency department again the same day with slurred speech and disorientation. On examination, he had plank-like abdominal rigidity, muscle spasms, and sardonic rhizosis. These symptoms were easily triggered by minor stimuli such as noise, light. During the neurological examination, bilateral plantar reflexes were decreased, but the jaw reflex was increased. With a serious suspicion of tetanus, the patient was hospitalized in the intensive care unit and started intravenous immunoglobulin (IVIG). The antibiotics were changed to Tazobactam-Piperacillin, Vancomycin, and Metronidazole.
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A lumbar puncture was impossible due to a stiff back, and a CT scan of the head without contrast was normal. The patient was routinely intubated in anticipation of airway obstruction due to laryngeal and pharyngeal spasms. To relieve the pain and spasms, the patient was administered the sedatives Fentanyl and Midazo-lam. However, sedation alone was not enough to control the spasms, so he began taking the neuromuscular blocker Vecuronium via an infusion pump. A blood culture sent on admission came back with Clostridium tetani growth.
Over the next few days, the patient's kidney function deteriorated, and he underwent 4 sessions of hemodialysis. His hemoglobin also dropped to 3, and he received five units of packed red blood cells. The patient's family was counseled about the course of the disease and the required cost of treatment. Due to financial difficulties, the patient left the intensive care unit against the doctor's advice on the eighth day after hospitaliza-tion and died of the disease one day after discharge.
Discussion: Due to universal vaccination with tetanus toxoid, the incidence of tetanus has declined dramatically in resource-rich countries. In contrast to resource-rich countries, tetanus remains endemic in resource-poor countries. The true incidence is unknown, as in many countries the disease is not reported.
The World Health Organization's Maternal and Newborn Prevention Initiative has shown the elimination of neonatal tetanus in 45 countries. In addition, cases of generalized tetanus in adults are very rare, even in developing countries.
Tetanus is caused by the spore-forming bacterium C. tetani, which is found in soil contaminated with animal and human excrement under anaerobic conditions. C. tetani releases two toxins: tetanospasmin and teta-nolysin. Tetanolysin can locally damage viable tissue surrounding the infection and optimize conditions for bacterial growth. Tetanospasmin is a powerful neuro-toxin that causes skeletal muscle contraction or autonomic dysfunction. It is well known that trismus is the main characteristic and initial sign of tetanus before progressing to generalized spasm. In addition to trismus or closed jaw, a common early sign of tetanus is abdominal rigidity and generalized spasms, which are often triggered by sensory stimuli.
In these reports, the diagnosis of tetanus was made using clinical findings along with standard case definitions available on the official World Health Organization (WHO) website. The survival rate of tetanus patients is increased if they are treated in intensive care units in large institutions (the first case). The patient was treated with the best available resources, but financial constraints sometimes made it difficult to follow the latest treatment methods (the second case).
In a similar report (the second case), a 78-year-old man diagnosed with generalized tetanus recovered after twenty-two days in the MICU. Another case in Saudi Arabia survived after more than forty days in the intensive care unit after being diagnosed with tetanus.
Tetanus of odontogenic origin (the first case) is rare, but has been reported in several previous studies. To the best of our knowledge, only six cases of tetanus
associated with odontogenic infection have been reported in the last decade. The suspicion of tetanus was reinforced by the patient's history, according to which the patient frequently used a toothpick to poke his interdental gum, which may have predisposed him to an oral wound.
There are certain principles of treatment for tetanus, including wound care at the site of penetration, antimicrobial therapy of C. tetani, neutralization of unbound toxin, and symptomatic treatment aimed at muscle spasm and autonomic dysfunction. For an external wound, care should be taken to clean the wound to ensure an aerobic condition; however, for an odontogenic infection, treatment of a dental infection can be difficult due to trismus.
Tetanus is a vaccine-preventable disease. The focus should be on regular revaccinations for the general population to prevent tetanus. Although tetanus infections from intraoral sources are rare, practitioners should be aware of the possibility of tetanus infections, as the disease is potentially dangerous and associated with a high mortality rate. It is recommended to identify high-risk patients, recognize the clinical manifestations of tetanus, and refer cases immediately to the appropriate department to ensure a better prognosis.
Inference: Although tetanus is rare nowadays, cases of the disease still occur. Tetanus continues to cause significant mortality in developing countries. Approximately two out of every ten people in such countries will not survive. Tetanus does not confer any immunity; those who do survive must be actively immunized.
Complications are rare in developed countries, they occur due to non-vaccination, missed booster shots, and improper treatment of wounds and traumatic injuries. When tetanus is diagnosed, it is only supportive care and often too late with high morbidity and mortality.
Educating people is key to reducing vaccine-preventable diseases. Awareness of vaccination is low, and people depend on their healthcare providers to educate them on their recommendations.
Prevention of tetanus infection through tetanus prophylaxis depends on the intervention of specialists. Information can be collected by a dedicated team that includes emergency physicians, nurse practitioners, physician assistants, surgeons, nurses, and pharmacists about the patient's history and reasons for presenting to the clinic, office, or emergency department. This ensures that a patient who has risk factors for tetanus is prophylactically treated in a timely manner, thus preventing the disease.
References:
1. M. Akbar, M. Ruslin, A.S.H. Yusuf, P. Boffano, K. Tomihara, T. Forouzanfare "Unusual generalized tetanus evolving from odontogenic infection: A case report and review of recent literature" 2022 Sep 28.
2. C. Callison, H. Nguyen "Tetanus Prophylaxis" 2022 June 5.
3. S. P. Sah, S. Khanal, S. Dahal, A. Shrestha, B. "Pradhana Generalized tetanus in an elderly patient: A case report" 2022 Aug 18 .
