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“THE DISEASE
OF THE
SEVENTH DAY”
“THE DISEASE OF THE
SEVENTH DAY”
Baby J.D. is a 7-day old neonate born
term in a faraway Bukidnon baragay
reachable only by horseback and
delivered by a traditional “hilot”. He
was admitted because of poor sucking
and inability to open the jaw. He
was crying excessively and went into
spasms when touched. A few hours
later, he became highly febrile and his
entire body became completely rigid
Questions to be answered
1. What is the most likely diagnosis of
this patient?
2. Explain the pathophysiology of
Tetanus
3. How is a diagnosis of Tetanus
achieved?
4. What are the differential diagnoses of
Tetanus?
5. What are the goals of treatment of
Tetanus?
6. What are the necessary Preventive
Q1:
What is the most
likely diagnosis of
this patient?
Answer: Neonatal Tetanus
WHO estimates that >500,000
deaths due to Tetanus neonatorum
still occurs
Tetanus is an acute toxemic
disease caused by Clostridium
tetani , a spore forming gram (+)
bacillus widely distributed in the
soil, animal and human feces,
house dust and even in
Neonatal Tetanus
Absence of immunity in the mother
and contamination of the umbilical
cord account for the occurrence in
regions where home delivery is
conducted by untrained personnel
with the cord cut by an unclean
knife, scissors, bamboo etc. and
the umbilical stump dressed with
earth or animal dung
Neonatal Tetanus
Inability to suck,
persistent crying,
followed by fever
and recurrent
generalized
Risus sardonicus
spasms with deep
cyanosis are the
usual presenting
symptoms
Tetanus
The most frequest
presenting symptom
is painful trismus
(lockjaw) due to
spasm of the
masseter muscles
When the jaw
remains tightly
clenched together
with spasm of the
facial muscles, the
typical “risus
sardonicus”
Risus sardonicus
expression results
Tetanus
Over the next 24-48
hrs., muscle rigidity
spreads to involve
the muscles of the
neck,back, abdomen
and limbs
culminating in a very Opisthotonus
characteristic spasm.•During these spasms, the
The head is child remains mentally alert
retracted, the spine but apprehensive
arches backwards •
The spasms may be
and the abdomen
attains a board-like precipitated by a variety
rigidity of stimuli as light or noise
Q2:
Explain the
pathophysiology of
Tetanus
Pathophysiology
The potent Tetanus neurotoxin (Tetanospasmin) is
synthesized intracellularly. After release it binds to
motor end-plates in skeletal muscles. It acts by
inhibiting acetylcholine release thereby impairing
neuromuscular transmission
It reaches the CNS through the perineural spaces of
nerve trunks of by hemotagenous dissemination
The toxin enters the neurones and becomes
irreversibly fixed on to the gangliosides
Produces presynaptic inhibition resulting in
unopposed muscle contraction and seizures
Q3:
How is a diagnosis
of Tetanus
achieved?
Diagnosis
The diagnosis of tetanus is entirely
clinical
It is often difficult to isolate the
bacilli from the wound + the
presence of C. tetani does not
mean the patient has tetanus
(Paediatric Problems in Developing Countries, edited by
Robinson M.J)
Q4:
What are the
differential
diagnoses of
Tetanus?
Differential diagnosis of
Tetanus
Other convulsive
disorders posing a
problem in
diagnosis:
meningitis,
phenothiazine
dystonia,
strychnine
poisoning, tetany
Trismus may be
seen in rabies
Hydrophobia of Rabies
Differential diagnosis of
Tetanus