Case Presentation

Tetanus
Ella de Vries

Identification
Name: Cinta Age: 23 months Gender: female

History
Chief complaint: Inability to open mouth History of present illness: 5 days before arrival in the hospital, patient started having difficulty opening mouth, difficulty walking, eating. History of past illness: none Pregnancy and delivery: normal Development: normal Immunization: complete History of family illness: none

Physical examination on admission

General Full consciousness, responding Temp: 36.7 C pulse 120 bpm Resp. rate: 28/min 82 cm, 10 kg
BW/age: 0--1 Length/age: 0--1 BW/length: 0--1

Physical Examination on Admission

Specific Head: nasal flare -, anemia -, ict. , trismus + Thorax: symmetric, retraction Pulm: vesicular, wheezing -, rhonchi + Cor: normal S1S2, murmur -, gallop Abdomen: flat, no visible masses, bowel sounds heard, variable tympanic, soft, no liver/spleen palpable Extremity: warm, crt < 2 sec

Neurological examination
Right arm Movements Strength Tonus Klonus Fysiological reflexes Good 5/5 Eutonic + Normal Left arm Good 5/5 Eutonic + Normal Right leg Good 5/5 Eutonic + Normal Left leg Good 5/5 Eutonic + Normal

Differential Diagnosis
Tetanus (generalized) Mandible dislocation Peritonsillar abces Meningitis Encephalitis

Management
CBC 20.000 IU anti tetanus serum Diazepam Penicillin procain Good prognosis

Tetanus
C. tetani (anaerobic, gram-positive) Spore survive heat, dessication, disenfectants Anearobic spores germinate tetanolysin + tetanospasmin enters motorneuron travels to spinal cord enters central inhibitory neurons cleaves synaptobrevin that binds neurotransmittervesicles to cell membrane GABA and glycine vesicles are not releases loss of inhibitory function

Etiology
Wound (65%) Skin ulcer (5%) No obvious source Complication of abcess, burns, frostbite, otitis media, surgery, abortion, childbirth, IV or subcutaneous drug use, foreign bodies, corneal abrasions

Signs and symptoms

Trismus (75%), risus sardonic Dysphagia Stiffness Neck rigidity Head ache Restlessness Reflex spasms (noise, light, touch) Elevated temperature (no fever) Sweating Elevated blood pressure Rapid heart rate Severe: opisthotonus, flexion arms, extension legs Autonomic dysfunction Seizures with consciousness

Spatula test
Stimulate posterior pharyngeal wall with spatula Normal: gag reflex, try to expell spatula Pathological for tetanus: bite down on spatula Sensitivity 94% Specificity 100%

Treatment
Neutralization unbound toxin
Tetanus immune globulin 3000-6000 units Anti tetanus serum

Wound debrided Antibiotics

Penicillin, antagonist of GABA Metronidazole 0,5 mg 4dd clindamycine, erythromycin, tetracycline, vancomycin

Tetanus toxoid-containing vaccin Benzodiazepine for symptoms

Diazepam 10-40 mg 1-8 hrly: reduces anxiety, sedates, relaxes muscles, prevents spasms

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Prognosis
Incubation period < 7 days Onset <48 hours Acquired from burns, surgical wounds, compound fractures, septic abortion, umbilical stump, IM injection Narcotic addiction Generalized tetanus Temperature > 40 C Tachycardia > 120 bpm

0-1 = mild tetanus mortality <10% 2-3 = moderate tetanus mortality 10-20% 4 = severe tetanus mortality 20-40% 5 -6 = severe tetanus mortality >50%

Prevention
Vaccination (DTP)
3x infancy

TT booster
4-7 years 12-15 years 20-23 years