Case presentationCase presentationA 5 days old newborn presented to nurseryA 5 days old newborn presented to nurserywith complaints of:with complaints of:1.1. Generalized body stiffness.Generalized body stiffness.2.2. Unable to suck.Unable to suck.3.3. FeverFever
Case presentationCase presentation The baby was delivered through NVD inThe baby was delivered through NVD inhome by a dai ,and the umbilicus was cuthome by a dai ,and the umbilicus was cutby some instrument present in the home.by some instrument present in the home.Some medicine & ghee was applied to itSome medicine & ghee was applied to itafter cutting.after cutting. The mother was not vaccinated againstThe mother was not vaccinated againstany disease during pregnancy.any disease during pregnancy.
Case presentationCase presentation On Examination:On Examination:1.1. Generalized body spasms, precipitatedGeneralized body spasms, precipitatedby sound, touch, light & procedures suchby sound, touch, light & procedures suchas IV cannulation.as IV cannulation.2.2. Lock jaw.Lock jaw.3.3. Tense abdomenTense abdomen4.4. Umbilicus contaminated with soil & bloodUmbilicus contaminated with soil & blood
Case presentationCase presentation All the investigations are normalAll the investigations are normal
DefinitionDefinition Tetanus is acuteTetanus is acutespastic paralyticspastic paralyticillness historicallyillness historicallycalled LOCK JAWcalled LOCK JAWthat is caused by thethat is caused by theneurotoxin producedneurotoxin producedby Clostridium tetani.by Clostridium tetani.
Etiology of TetanusEtiology of Tetanus The primary cause ofThe primary cause ofNeonatal tetanus isNeonatal tetanus isthe result of:the result of:Infection with C-Infection with C-Tetani, a motile, gramTetani, a motile, grampositive, sporepositive, sporeforming obligateforming obligateanaerobe, present inanaerobe, present insoil, house dust andsoil, house dust andanimal feces.animal feces.
Etiology of TetanusEtiology of Tetanus Tetanus occurs after introduced sporesTetanus occurs after introduced sporesgerminate, multiply, and produce tetanusgerminate, multiply, and produce tetanustoxin at the infected injury site.toxin at the infected injury site. The incubation period is usually 2-14The incubation period is usually 2-14days.days. Tetanus toxin binds at the neuromuscularTetanus toxin binds at the neuromuscularjunction and enters the motor nerve byjunction and enters the motor nerve byendocytosis after which it undergoesendocytosis after which it undergoesretrograde axonal transport to theretrograde axonal transport to thecytoplasm of motoneurons.cytoplasm of motoneurons.
Etiology of TetanusEtiology of Tetanus The toxin exits the motoneurons in theThe toxin exits the motoneurons in thespinal cord and next enters adjacentspinal cord and next enters adjacentspinal inhibitory interneurons.spinal inhibitory interneurons. It prevents release of the inhibitoryIt prevents release of the inhibitoryneurotransmitters glycine and GABA.neurotransmitters glycine and GABA. The autonomic nervous system is alsoThe autonomic nervous system is alsorendered unstable in tetanus.rendered unstable in tetanus.
TypesTypes The disease can show 4 possible types:The disease can show 4 possible types:-Generalized tetanus can affect all skeletal muscles. It is-Generalized tetanus can affect all skeletal muscles. It isthe most common as well as the most severe form of thethe most common as well as the most severe form of thefour types.four types.- Local tetanus manifests with muscle spasms at or near- Local tetanus manifests with muscle spasms at or nearthe wound that has been infected with the bacteria.the wound that has been infected with the bacteria.-Cephalic tetanus primarily affects one or several-Cephalic tetanus primarily affects one or severalmuscles in the face rapidly (in one to two days) aftermuscles in the face rapidly (in one to two days) aftera head injury or ear infection. Trismus ("lockjaw") maya head injury or ear infection. Trismus ("lockjaw") mayoccur. The disease can easily progress to generalizedoccur. The disease can easily progress to generalizedtetanus.tetanus.-Neonatal tetanus is similar to generalized tetanus-Neonatal tetanus is similar to generalized tetanusexcept that it affects a baby that is less than 1 month oldexcept that it affects a baby that is less than 1 month old(called a neonate).(called a neonate).
1212Neonatal tetanusNeonatal tetanus is a form of generalized tetanus that occurs inis a form of generalized tetanus that occurs innewborn babies. Neonatal tetanus occurs innewborn babies. Neonatal tetanus occurs ininfants born without protective passive immunity,infants born without protective passive immunity,because the mother is not immune.because the mother is not immune. It usually occurs through infection of theIt usually occurs through infection of theunhealed umbilical stump, particularly when theunhealed umbilical stump, particularly when thestump is cut with an unsterile instrument.stump is cut with an unsterile instrument. Neonatal tetanus is common in some developingNeonatal tetanus is common in some developingcountries (estimated >270,000 deaths worldwidecountries (estimated >270,000 deaths worldwideper year)per year)
Neonatal tetanusNeonatal tetanus In 2012, in our department of Pediatrics,In 2012, in our department of Pediatrics,Total 38 neonates were admitted withTotal 38 neonates were admitted withtetanus neonatorum.tetanus neonatorum. Out of them, 24 died and 14 survived.Out of them, 24 died and 14 survived. Mortality rate was 63%.Mortality rate was 63%.
1414Neonatal tetanusNeonatal tetanus Neonatal tetanus presents most oftenNeonatal tetanus presents most oftenabout the seventh day of life with a shortabout the seventh day of life with a shorthistory of failure to feed. Spasms arehistory of failure to feed. Spasms aretypical but the diagnosis can be mistakentypical but the diagnosis can be mistakenfor meningitis or sepsis .for meningitis or sepsis .
Clinical feaClinical fea tures of neonataltures of neonataltetanustetanus Usually symptoms begins 3-10 days afterUsually symptoms begins 3-10 days afterbirth and pattern is generalized.birth and pattern is generalized. Initial symptom is failure to suck andInitial symptom is failure to suck andinability to open the mouth known asinability to open the mouth known astrismus or lockjaw.trismus or lockjaw. Spasm of the facial muscles immobilizesSpasm of the facial muscles immobilizesthe jaw and produces a fixed sardonic grinthe jaw and produces a fixed sardonic grincalled risus sardonicuscalled risus sardonicus
Clinical feaClinical fea tures of neonataltures of neonataltetanustetanus With in 12-24 hours after the 1With in 12-24 hours after the 1ststsymptom,symptom,generalized tonic muscular convulsionsgeneralized tonic muscular convulsionsoccur producing flexion & adduction of theoccur producing flexion & adduction of thearms, clenching of fists & extension of thearms, clenching of fists & extension of thelower extremities.lower extremities. Initially spasms are mild but later becomeInitially spasms are mild but later becomesevere with spasms of the glottis &severe with spasms of the glottis &respiratory muscles.respiratory muscles.
Clinical feaClinical fea tures of neonataltures of neonataltetanustetanus Abdominal muscles become rigid andAbdominal muscles become rigid andspasms of the muscles of the back mayspasms of the muscles of the back mayresult in opisthotonus.result in opisthotonus. Spasms may be precipitated by touch,Spasms may be precipitated by touch,noise or bright light.noise or bright light. Baby remains conscious and allert.Baby remains conscious and allert.
ManagementManagementThe aims of treatment are:The aims of treatment are: Remove the source of exotoxinRemove the source of exotoxin Neutralize the remaining circulating toxinsNeutralize the remaining circulating toxins Provide supportive care until toxin isProvide supportive care until toxin ismetabolized.metabolized.
ManagementManagementSpecific measures:Specific measures: Washing and debridment of the infectedWashing and debridment of the infectedsite, and administeration of antibioticssite, and administeration of antibioticssuch as Benzyl penicillin or Metronidazole.such as Benzyl penicillin or Metronidazole. Anti-toxinAnti-toxin1)Anti-tetanus serum -(50,000-100,000 U)1)Anti-tetanus serum -(50,000-100,000 U)2)Human tetanus immunoglobulin (3000-2)Human tetanus immunoglobulin (3000-6000 u)6000 u)
ManagementManagementFeeding by:Feeding by: NG tubeNG tube Daily milkDaily milkrequirement is 100-requirement is 100-120 ml/kg/day.120 ml/kg/day.
ManagementManagementNursing care:Nursing care: Clean the umbilicus/woundClean the umbilicus/wound Isolate the baby in dark silent roomIsolate the baby in dark silent room Change the postureChange the posture Cardiorespiratory monitoringCardiorespiratory monitoring
ComplicationsComplications Aspiration pneumoniaAspiration pneumonia Lacerations of mouth & tongueLacerations of mouth & tongue Intramuscular hematomas orIntramuscular hematomas orrhabdomyolysis leading to hemoglobinuriarhabdomyolysis leading to hemoglobinuria& renal failure.& renal failure. Vertebral fractures.Vertebral fractures. Decubitus ulcerations.Decubitus ulcerations. Autonomic disturbances.Autonomic disturbances.
PreventionPrevention Immunize the mother during pregnancyImmunize the mother during pregnancy Clean & safe deliveryClean & safe delivery Care of umbilical cordCare of umbilical cord Avoid early circumcission in male babies.Avoid early circumcission in male babies. Immunize the baby after disease.Immunize the baby after disease. Training of daisTraining of dais
PrognosisPrognosis Fatality rate mainly depends upon qualityFatality rate mainly depends upon qualityof supportive care.of supportive care. Main causes of death are respiratoryMain causes of death are respiratoryfailure and pneumonia.failure and pneumonia. MR is 60% or more for neonatal tetanus &MR is 60% or more for neonatal tetanus &20-50% in children.20-50% in children.
Good prognostic factorsGood prognostic factors Incubation period moreIncubation period morethan 8-10 days.than 8-10 days. Progression longer thanProgression longer than60 hrs.60 hrs. Absence of fever.Absence of fever. Local disease.Local disease. Survival for 10 days.Survival for 10 days.
Poor prognostic factorsPoor prognostic factors Duration betweenDuration betweeninjury and onset ofinjury and onset oftrismus less than 7trismus less than 7days.days. Duration betweenDuration betweentrismus and the onsettrismus and the onsetof generalized tetanicof generalized tetanicspasms less than 3spasms less than 3days.days.