Neonatal tetanus

1. IDENTIFICATION- B.A
AGE-11Days
SEX-M
DATE OFADMISSION-22/11/00
DATE OF DISCHARGE- 26/12/00
ADRESS-A.A
CASE PRESENTATION

2. Hx & P/E
 C/C- Irritability /3 Days & failure to suck /1 day
 Patient is born from a 27yrs old para III Lady whose LMP was
on 28/2/00 making GA by date 40wks+3d.Mother had a
regularANC follow up, Blood group UK,VDRL-NR, &
claims to be non reactive for HIV.
 Labor started spontaneously & lasted for 5hrs; ROM was just
before delivery & the outcome was an alive male neonate who
cried immediately. Delivery was attended at home (mother
was alone) & neonate was left on the ground(soil) for
~30’before his umblicus is cut, which was done after boiling a
new lancet.

3. Hx cotd.
 Neonate was relatively healthy sucking well until 9 days of
age when he started to become irritable followed by
decreased sucking after a day.
 On the 3rd
day patient completely failed to open his mouth &
suck; he had also frequent twitching of the exterimities
 Despite the ANC ffup mother didn’t receive any vaccination
in the current or previous pregnancies despite medical
advice.
 Mother denied any application of herbal medication or butter
on the umblicus

4. Hx contd.
 There’s no maternal Hx of fever or foul smelling vaginal
discharge.
 No maternal Hx of HTN or DM.
 Mother is illiterate, Father learnt up to grade 8.
 Mother is a daily laborer & father is a weaver & earn ~800
birr/month.

5. P/E
 Wt-3000gms, Length-43cm, HC-35-5cm
 AHR-140’ , RR-78’ , Temp.-37 C
 HEENT- Pink conjuctiva ,NIS ;Locked jaw
 CHEST- has IC & SC retraction,clear
 CVS- S1 & S2 well heard ,no murmur or gallop
 ABD.- Rigid abdomen, difficult to palpate for organomegally
 GUS.- NMEG
 EXT – no edema
 CNS- Conscious; Moro- Incomplete, Grasp-strong ,Tone -
increased: Sucking – sustained but difficult to open the jaw

6. Hx & P/E Contd.
 Assessment –Term, LONS ?Meningitis , N.Tetanus
 Plan- CBC,LP,RBS
-Start Crystalline Penicillin(333,333IU/kg/d) &
Gentamycin (5mg/kg/d)
-Diazepam 1.5mg iv bid (1mg/kg/d) alternated with
-CPZ 1.5mg iv bid (1mg/kg/d)
-TAT 5000IU IV & IM 6000IU
-Intranasal Oxygen & kept NPO
-Put under a dark cabin

7. INVESTIGATIONS
•LP-done 3x
(traumatic),culture
& Gram stain –
negative
•VDRL(23/11/00)-
NR
•Cranial
U/S(9/12/00)-NL
•CXR(15/12/00)-
NR
•Blood
culture(14/12/00)-
Neg.
•LP(14/12/00)-non
revealing
DATE WBC PLT HCT NEUTROPH
IL(%)
LYMPHOCYT
E(%)
22/11/
00
1510
0
- 55 40 58
26/11/
00
8460 12400
0
52 36 51
14/12/
00
1060
0
31100
0
42 45 46

8. COURSE & MANAGEMENT
ON 23/11/00 Eth.C.
 P-NeonatalTetanus
LONS? Meningitis
-On iv Crystalline & Gentamycin
-On IV Diazepam & CPZ
O- PR-162’ RR-86’ Temp- 37.6c
HEENT- Pink conjuctiva, NIS: Edematous eyelids; mild trismus
CHEST- Flaring, IC/SC retractions;clear
CVS- no murmur or gallop
ABD. - mild rigidity
CNS - Irritable
ASS. - Fair
PLAN- Continue with the same management; observe for spasms.

9. Course contd
ON 24/11/00
 Diazepam was discontinued b/c of resp. embarassment & was
made to continue CPZ only; but mother couldn’t afford anything &
patient was on IV antibiotics only.
ON 28/11/00
 P- N.Tetanus
 On IV Antibiotics
 S- Frequent spasm, periorbital swelling, Sweating
 O-V/S- AHR-124’ RR-64’regular Temp—
 HEENT- Periorbital swelling with discharge
 CHEST- Clear

10. Course contd
 ABD.-Rigid abdomen
 EXT- increased tone
 CNS- Conscious, spasms witnessed
 ASS.- same, + ?sepsis with meningitis+ conjuctivitis
 PLAN- Resume CPZ & Diazepam; continue antibiotics ;TTC
eye ointement
Mother couldn’t get the CPZ & was put on Diazepam only

11. Course contd.
ON 2/12/00
 P-As above
 O-PR-120’ RR-72’ T-36.7C
 HEENT-Pink conjuctiva, NIS; mild trismus
 CHEST- clear
 CVS-NO murmur or gallop
 ABD-No organomegally, tense abdomen
 CNS-Conscious; intact reflexes
 Ass.- improving(spasm decreasing)

12. Course contd
ON 5/12/00
 P-As above
 S-No spasms, has sweating
 O-PR-110’ RR-58’ Afeb.
 HEENT- Pink conj,NIS; Opens mouth
 ABD- No spasm
 CNS-Intact reflexes
 Ass- improving(spasm & RR decreasing)
 Plan-Tapper diazepam

13. Course contd
ON 14/12/00
 P-ASAbove
 S-Fast breathing ,sweating
 O- AHR-144’ RR-98’ T-Afeb
 CHEST- Flaring, IC/SC retraction, clear
 ABD- Slight rigidity to touch
 CNS- conscious, intact reflexes
 ASS-? Hospital aquired sepsis
 PLAN- CBC,CXR,BLOOD & Urine culture
 -Start ceftriaxone & cloxacillin

14. Course contd
ON 26/12/00
 P-N.Tetanus, HAS
 On iv ceftriaxone & cloxacillin; iv diazepam
 S-No complaint except for sweating
 O-AHR-124’ RR-56’ Temp-afeb
 HEENT-Pink conj.NIS
 CHEST-Clear
 ABD-No organomegally, mildly tense
 CNS-Conscious & intact reflexes
 ASS- Improved
 PLAN- Discharge with advice on vaccination& po diazepam.

15. NEONATAL TETANUS
 Caused by a spore forming obligate, gram positive anaerobe
which is present in the soil, dust,& alimentary tracts of many
animals.
 In developing countries approximately 1,000,000 cases of
tetanus are estimated to occur worldwide each year
 Neonatal tetanus, which theWHO originally targeted for
elimination by 1995, accounted for 200,000 deaths in the year
2000 ( 200,000-500,000 deaths /year)
 In Ethiopia ,a community based study conducted in Southern
Ethiopia(1989) ,estimated MR of neonatal tetanus
6.7deaths /1000 live births ; or 40% of all neonatal deaths.

16. PATHOGENESIS
 In a newborn, the portal of entry of the bacilli is almost
always the site at which the umbilical cord is cut .
 After inoculation C. tetani can then transform into a
vegetative rod-shaped bacterium and produces toxins called
tetanospasmin & tetanolysin.
 Through retrograde axonal transport ,it reaches the SC &
brainstem where it binds tightly and irreversibly to receptors
(inhibitory interneurons) & thus blocks neurotransmission
by its cleaving action on membrane proteins involved in
neuroexocytosis (i.e. prevents release of GABA)

17. Pathogenesis contd.
 Lack of neural control of adrenal release of catecholamines
induced by tetanospasmin produces a hyper sympathetic state
that manifests as sweating, tachycardia and hypertension.
 Recovery requires the growth of new axonal nerve
terminals, thus the usual duration of clinical tetanus is four
to six weeks.
TRANSMISSION - occurs through infection during
unhygienic cutting of the umbilical cord or improper handling
of the cord stump;
It’s the only vaccine preventable Ds that’s not
communicable.

18. CLINICAL FEATURES
 Different types
 Generalized (the most common)
 Localized
 Cephalic in older children
Incubation Period - the time between the start of infection
and the occurrence of the first symptom, usually
trismus (lockjaw).
Ranges from 3-28 days; but usually lasts 2-14 days
Period of Onset - time from 1st
symptom to
occurrence of spasms; important for prognosis.

19. C/F CONTD.
 As a rule, neonatal tetanus follows a
descending pattern of nerve
involvement
 Failure to suckle is often the first sign of
infection , followed by difficulty swallowing,
stiffness in the neck, rigidity of abdominal
muscles, and a temperature rise of 2ºC –
4ºC above normal.

20. C/F CONTD.
• Trismus, dysphagia, rhisus
sardonicus
• Neck muscle spasm, laryngeal
spasm
HEENT
• Respiratory muscle spasm leading
to apnea, cyanosis
• Airway obstruction, pulmonary
embolism
CHEST
• Tachycardia,Arrhythmia, labile HTN
• Diaphoresis, cutaneous vasoconstriction
CVS

21. C/F CONTD.
•Rigidity
•+/- Infected stump
ABD
•Dysuria, urinary retention
•Forced defecation, myoglobinuria, sometimes
RF
GUS
•Opistotonus ,Fractures,
•Bleeding into muscle
MSS

22. C/F CONTD.
• Conscious & in extreme pain
• irritability, restlessness
CNS
•Fever, sweating
Others
•Spasms peak in the 1st
1wk after onset, stabilize
in the 2nd
wk & lessons in the following 1-
4wks.
Spasms

23. DIAGNOSIS
 Clinical
 Lab investigations –
• WBC- NL OR Increased if there is
superinfection
• -LP- Non revealing
• Gram stain- positive in only 1/3rd
of the cases
• EEG & Electromyogram - Normal

24. CASE DEFINITIONS
 Suspected Case
 Any infant with a history of tetanus-compatible illness during the first month of life
who fed and cried normally for the first 2 days of life;
 Any neonatal death in a child who could suck and cry normally during
the first 48 hours of life.
 Confirmed Case
 Normal feeding and crying during the first two days of life
plus
Onset of illness between age 3 and 28 days plus
 Inability to suckle (trismus), followed by stiffness (generalized
muscle rigidity) and/or convulsions (muscle spasms).

25. CASE DEFINITIONS CONTD.
 Discarded case
A discarded case is one which has been
investigated and does not satisfy the
clinical criteria for confirmation.

26. DDx
Neonatal meningitis
Hypocalcemia
Perinatal Asphyxia
Structural brain lesions

27. MANAGEMENT
The goals of treatment include:
 Halting the toxin production
 Neutralization of the unbound toxin
Control of muscle spasms
General supportive management
Prevention

28. Management contd.
A. Halting Toxin Production
Wound debridement - to eradicate spores and necrotic tissue
 Antimicrobial therapy -
 Penicillin G (100,000IU/kg/day) for 10-14 days
OR
 Metronidazole (30 mg/kg/day, given at six hour
intervals; maximum 4 g/day) ; currently more
recommended than the penicillins which have a
GABA antagonistic effect.

29. Management contd.
B. Neutralization of the unbound toxin
TIG- Doses as small as 500IU is sufficient to neutralize the
unbound toxin as soon as possible.
TAT- 10,000IU ,Given as ½ IM & ½ IV
C. Control of Muscle Spasms
o Admit to a quiet, darkened room where all possible auditory,
visual, tactile, or other stimuli are minimized
o Sedatives- Diazepam (0.1-0.2mg/kg upto 2-6wks); CPZ,
Dantrolene can be used;
o Neuromuscular Blocking Agents – Pancuronium( though it
exacerbates autonomic instability) ; Vecuronium- given as a
continious infusion can be used but with mechanical ventilation.

30. Management contd.
D . General supportive care
Use of High Calorie diet,TPN if possible or vigourous
support through NGT
Frequent change of position esp. after spasms have decreased
Preparation for possible tracheostomy
Frequent Cardio respiratory monitoring, continuous
suctioning
Use of antacids or H2 blockers to prevent GI hemorrhage
Nursing care to the mouth ,skin, bladder

31. COMPLICATIONS
 Aspiration pneumonia,
 Pneumothorax & pneumomediastinum if pt was
intubated;
 Cardiac arrythmias,Asystole
 Tongue bite, fractures, bleeding into muscles &
myoglobinuria leading to Renal failure
 Venous trombosis, pulmonary embolism, gastric
ulcer
 Paralytic Ileus & Decubitous ulcers

32. PREVENTION
 Infants born to immune mothers acquire temporary immunity for
about five month, if mother had completed before 2wks of
delivery.
Vaccintion of ALL women in child bearing age is recommended
Use of safe delivery practices
Female education
 Generally,TT vaccine given will produce protective antibodies
in 80-90% of the cases after the second dose,95-98% after the
3rd
dose
 Fourth & fifth doses given will give protection for 10 & 20yrs
respectively.

33. PROGNOSIS
 MR <10% with ICU Rx & > 75% without it
 Poor prognosis is associated with
 IP < 7 DAYS
 Period of onset < 3 days
 Presence of autonomic dysfunction
 Fever & frequent spasms
 Good Prognosis is associated with
 IP>7Days ,& period of onset >3days
 Localized form
 Occasional spasms, absence of fever

34. COMMENTS
 Mother didn’t receive any vaccination, home & risky delivery
 No adequate treatment given;TAT, Muscle relaxants
 Dose of Crystalline should have been 400,000IU/kg/d ; use
of Gentamycin good choice
 Follow up should have included use of charts withV/S sheet,
type of resp., frequency of contraction, urine output, if
possible BP monitoring help us to guide management
& peak complications early.
 Ideally management should be at NICU.
 Maternal education!!!