Tetanus Neonatorum
Tetanus neonatorum is a severe, high mortality disease caused by Clostridium tetani, an anaerobic species of bacteria. Children born to unimmunized mothers under unsanitary delivery conditions may be exposed to this pathogen. Early diagnosis and prompt therapy are potentially lifesaving, but prevention by population immunization is the optimal approach.
Presentation
In some regions of the world, tetanus neonatorum is known as "seventh day evil" [1], because this is when symptoms first set in. In underdeveloped countries, this is the cause of up to half of neonatal deaths, while infection of all types represents the reason for 15% of newborn deaths worldwide [2]. Newborns develop the generalized form of the disease because exposure is made via the umbilical stump, when asepsis is not achieved. Other infectious agents leading to sepsis can also be transmitted to the child in this manner [3]. In some areas, the umbilical stump is covered with dust or spider webs, that are thought to promote healing, but actually contain Clostridium tetani. Proper umbilical cord handling [4] and population vaccination may help reduce tetanus neonatorum .
The incubation period for tetanus neonatorum is 3 to 10 days, but most newborns develop it at the end of their first week of life, when they present with irritability, feeding difficulties due to trismus and an inability to swallow, excessive crying caused by hunger, rigidity and generalized muscle spasms induced by touch, including those of the face, and opisthotonus. Patients exhibit tachycardia and tachypnea, are febrile and may have convulsions. The sooner generalized spasms occur, the worse the prognosis, with mortality usually higher than 70% [5] [6] [7]. During spasms, the child may be cyanotic. Death is caused by hemodynamic instability as a consequence of dysautonomia or heart arrhythmias, hydro-electrolytic imbalance or asphyxia.
Entire Body System
Fever
- Short incubation period, short period of onset, low birth weight, presence of fever and tachycardia were associated with a poor prognosis. The cases were divided into 2 groups of 46 and 30. First group was given TIG while second group was given ATS.[ncbi.nlm.nih.gov]
- الصفحة 99 - An extremely infectious disease with a sudden onset, fever, malaise, headache, severe backache, prostration and occasionally abdominal pain.[books.google.com]
- Seite 99 - An extremely infectious disease with a sudden onset, fever, malaise, headache, severe backache, prostration and occasionally abdominal pain.[books.google.de]
- The four cases described by the latter author 4 are somewhat unusual in that each was accompanied with a fever of 103.6 F. to 107 F. and each showed an astonishingly rapid recovery.[jamanetwork.com]
- Descriptive Epidemiology 587 Mechanisms and Routes of Transmission 7 Pathogenesis and Immunity 590 Patterns of Host Response 591 Control and Prevention 592 References 593 Suggested Reading 595 Rocky Mountain Spotted Fever Theodore E Woodward and J Stephen[books.google.com]
Feeding Difficulties
- The incubation period for tetanus neonatorum is 3 to 10 days, but most newborns develop it at the end of their first week of life, when they present with irritability, feeding difficulties due to trismus and an inability to swallow, excessive crying caused[symptoma.com]
Gastrointestinal
Abdominal Pain
- الصفحة 99 - An extremely infectious disease with a sudden onset, fever, malaise, headache, severe backache, prostration and occasionally abdominal pain.[books.google.com]
- Seite 99 - An extremely infectious disease with a sudden onset, fever, malaise, headache, severe backache, prostration and occasionally abdominal pain.[books.google.de]
- Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
Abdominal Rigidity
- A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, although rigidity is sometimes confined to the region of injury. Generalized spasms occur, frequently induced by sensory stimuli.[cdc.gov]
Jaw & Teeth
Trismus
- The incubation period for tetanus neonatorum is 3 to 10 days, but most newborns develop it at the end of their first week of life, when they present with irritability, feeding difficulties due to trismus and an inability to swallow, excessive crying caused[symptoma.com]
- Tetanus Neonatorum or neonatal tetanus is also known in Western medicine by the terms trismus nascentium, 7-day sickness, 9-day fits and the lock-jaw of infants. In ancient Chinese medicine it was called infant cord body stiffness .[nature.com]
- Tetanus Neonatorum or neonatal tetanus is also known in Western medicine by the terms trismus nascentium, 7-day sickness, 9-day fits and the lock-jaw of infants. In ancient Chinese medicine it was called infant cord body stiffness.[nature.com]
- Omphalitis of newborn NOS tetanus A33 Tetanus, tetanic (cephalic) (convulsions) A35 ICD-10-CM Diagnosis Code A35 Other tetanus 2016 2017 2018 2019 Billable/Specific Code Type 1 Excludes obstetrical tetanus ( A34 ) tetanus neonatorum ( A33 ) neonatorum A33 Trismus[icd10data.com]
Cardiovascular
Tachycardia
- Short incubation period, short period of onset, low birth weight, presence of fever and tachycardia were associated with a poor prognosis. The cases were divided into 2 groups of 46 and 30. First group was given TIG while second group was given ATS.[ncbi.nlm.nih.gov]
- Patients exhibit tachycardia and tachypnea, are febrile and may have convulsions. The sooner generalized spasms occur, the worse the prognosis, with mortality usually higher than 70%. During spasms, the child may be cyanotic.[symptoma.com]
- Tachycardia. High frequency and greater severity and duration of muscular spasms especially of larynx. Frequent and prolong duration of apneic episodes.[jemds.com]
- Some of the side effects associated with dantrolene include: drowsiness dizziness headache tiredness confusion depression a skin rash loss of appetite diarrhoea breathing difficulties increased heartbeat (tachycardia) visual and speech disturbances If[hse.ie]
Musculoskeletal
Muscle Twitch
- twitches are fused and cannot be distinguished from one another, also called tonic spasm and tetany). tetanus 1.[wordinfo.info]
Muscle Spasticity
- Dantrolene Dantrolene is sometimes prescribed in cases of chronic (long-term) muscle spasticity (where your muscles are overly tight or rigid).[hse.ie]
Face, Head & Neck
Facial Spasm
- “Risussardonicus” or “rigid smile” is characteristic in the facial spasms caused by tetanus in which the eyebrows are raised and there is a fixed smile.[pchrd.dost.gov.ph]
Neurologic
Seizure
- Diagnosis had to be differentiated between MSUD and other metabolic disorders and neonatal infections (especially neonatal tetanus because of severe opisthotonos) and generalized seizures of the patient.[ncbi.nlm.nih.gov]
- Tetanus was frequently confused with neonatal seizures at time of presentation. All infants were delivered at home. Mean age of onset of symptoms of poor suck, hypertonicity, and generalized spasms was 5.4 days with hospital admission at 6.4 days.[ncbi.nlm.nih.gov]
- Poor hygiene and limited access to health services and vaccinations increase the risk of maternal tetanus, which, in extreme cases, can result in violent seizures, difficulty in breathing and death.[web.archive.org]
- However, sometimes, uncontrolled seizures may carry a greater risk of harming the baby. Therefore, seek advice from your GP if you are pregnant or if you decide to try for a baby. Do not breastfeed if you are taking phenobarbital.[hse.ie]
Opisthotonus
- […] their first week of life, when they present with irritability, feeding difficulties due to trismus and an inability to swallow, excessive crying caused by hunger, rigidity and generalized muscle spasms induced by touch, including those of the face, and opisthotonus[symptoma.com]
- Related Concepts SNOMET-CT Tetanus neonatorum (disorder) Tetanic opisthotonus (disorder) Age at onset of clinical finding (observable entity) 29.0 days ICD-10-CM Alphabetical Index References for 'A33 - Tetanus neonatorum' The ICD-10-CM Alphabetical Index[icd.codes]
- 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[slideshare.net]
- The usual flexed posture of the baby is replaced by generalized rigidity and opisthotonus in extension. The spasm of larynx and respiratory muscles is associated with apnea and cyanosis.[jemds.com]
Neonatal Seizures
- Tetanus was frequently confused with neonatal seizures at time of presentation. All infants were delivered at home. Mean age of onset of symptoms of poor suck, hypertonicity, and generalized spasms was 5.4 days with hospital admission at 6.4 days.[ncbi.nlm.nih.gov]
Neglect
- In a retrospective appraisal of treatment, it would seem that antitoxin serum has not been specific in the treatment of tetanus or in a decrease of the mortality rate; whereas heretofore, neglected supportive treatment was the primary factor contributing[pediatrics.aappublications.org]
- This is also an amazing opportunity to reach the poorest, most neglected mothers and babies with lifesaving health care.[sites.kiwanis.org]
Dysautonomia
- Death is caused by hemodynamic instability as a consequence of dysautonomia or heart arrhythmias, hydro-electrolytic imbalance or asphyxia. Tetanus neonatorum diagnosis is mainly clinical.[symptoma.com]
Workup
Tetanus neonatorum diagnosis is mainly clinical. Careful history inquiry should include metoclopramide administration. The clinician should search for meningeal signs [8] and labor related cerebral injury. Once the suspicion is raised, the physician is required to perform a spatula test. This consists of trying to elicit a gag reflex by touching the oropharynx with a spatula. In tetanus newborns, this reflex is replaced by masseter muscles spasm, leading them to byte the spatula. This maneuver is highly specific [9] and is sometimes involuntarily performed by mothers while attempting to feed the baby. The next step in the clinical evaluation is to assess the severity of the disease, based on the state of the limbs: flexed or extended and the presence of generalized rigidity.
Laboratory workup offers little information, because no specific diagnosis test is available. Serum muscle enzyme levels are increased due to the muscle spasms. The calcium blood level should be measured in order to exclude hypocalcemia, which is an important differential diagnosis. If an antitoxin level test is feasible, a titer of more than 0.01 IU/mL is considered to be protective. Umbilical stump secretion can be cultured and the bacteria may be found there, but this does not necessarily mean the patient has tetanus. On the other hand, in a patient with clear clinical signs of tetanus, the pathogen may be absent from the secretion. Blood cultures are not useful in this disease.
The electrocardiogram may show nonspecific changes or several types of arrhythmia, while the electromyogram describes continuous discharge of motor subunits, the substrate of spasms and rigidity.
Treatment
- In a retrospective appraisal of treatment, it would seem that antitoxin serum has not been specific in the treatment of tetanus or in a decrease of the mortality rate; whereas heretofore, neglected supportive treatment was the primary factor contributing[pediatrics.aappublications.org]
- It is concluded that intrathecal ATS is superior to intramuscular ATS in the treatment of neonatal tetanus.[ncbi.nlm.nih.gov]
- Abstract A prospective study has been conducted to assess the efficacy of oral pyridoxine in the treatment of neonatal tetanus. A little reduction in mortality was observed by adding pyridoxine to the conventional therapy.[ncbi.nlm.nih.gov]
- You need to get treatment in a hospital. A vaccine can prevent tetanus. It is given as a part of routine childhood immunization. Adults should get a tetanus shot, or booster, every 10 years.[icdlist.com]
- […] where the umbilical cord was not treated ( n 147) as compared to births with cord treatment ( n 69).[webmedcentral.com]
Prognosis
- Early diagnosis of the MSUD patient is very important for effective therapy and better long-term prognosis as well as genetic counselling and prenatal diagnosis for future pregnancies.[ncbi.nlm.nih.gov]
- Abstract Pyridoxine, a coenzyme in the production of gamma-amino-n-butyric acid, was added (100 mg per day) to conventional therapy for tetanus neonatorum in 20 infants who were graded according to prognosis and severity of spasms.[ncbi.nlm.nih.gov]
- Short incubation period, short period of onset, low birth weight, presence of fever and tachycardia were associated with a poor prognosis. The cases were divided into 2 groups of 46 and 30. First group was given TIG while second group was given ATS.[ncbi.nlm.nih.gov]
- The sooner generalized spasms occur, the worse the prognosis, with mortality usually higher than 70%. During spasms, the child may be cyanotic.[symptoma.com]
- Cole , The Prognosis of Tetanus , Lancet 1 , 164 (1940). CrossRef Google Scholar Copyright information Birkhäuser Verlag Basel 1975 Authors and Affiliations V. B. Athavale 1 P. N. Pai 1 A. Fernandez 1 P. N. Patnekar 1 V. S. Acharya 1 1.[link.springer.com]
Etiology
- The etiology and mechanism tetanus neonatorum was the subject of debate and uncertainty throughout more than 2,000 years of recorded Western medicine.[nature.com]
- 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[slideshare.net]
- ., Ziai, M. and Tahernia, C. (1970) Tetanus neonatorum in Iran; notes on etiology, manifestation and therapy, Clin. Paediatr., 9:609. 8. Pinheiro, D. (1964) Tetanus of the newborn infant.[jpma.org.pk]
Epidemiology
- Descriptive Epidemiology 587 Mechanisms and Routes of Transmission 7 Pathogenesis and Immunity 590 Patterns of Host Response 591 Control and Prevention 592 References 593 Suggested Reading 595 Rocky Mountain Spotted Fever Theodore E Woodward and J Stephen[books.google.com]
- Denchev , Epidemiological Peculiarities of Tetanus in Bulgaria, works of the Research Institute of Epidemiology and Microbiology 8 , 73–82 (1962). Google Scholar [20] K. W. Newell , Tetanus Neonatorum. Epidemiology and Prevention .[link.springer.com]
- ) Annadurai K...Mani G 2017 7 Eliminating maternal and neonatal tetanus and closing the immunity gap. ( 28402808 ) Burgess C...Johansen K 2017 8 Validation of maternal and neonatal tetanus elimination in Equatorial Guinea, 2016. ( 28622465 ) 2017 9 Epidemiological[malacards.org]
- International Journal of Epidemiology. 39 (Suppl 1): i102–9. doi:10.1093/ije/dyq027. PMC 2845866. PMID 20348112.[en.wikipedia.org]
- International Journal of Epidemiology . 39 (Suppl 1): i102–9. doi : 10.1093/ije/dyq027 . PMC 2845866 . PMID 20348112 . External links [ edit ] Wikimedia Commons has media related to Tetanus .[en.wikipedia.org]
Prevention
- Descriptive Epidemiology 587 Mechanisms and Routes of Transmission 7 Pathogenesis and Immunity 590 Patterns of Host Response 591 Control and Prevention 592 References 593 Suggested Reading 595 Rocky Mountain Spotted Fever Theodore E Woodward and J Stephen[books.google.com]
- Immediate and proper wound care can prevent tetanus infection.[icdlist.com]
- Although hospital management of tetanus neonatorum may be expected to have a satisfactory outcome, it represents a costly and complex approach to a preventable disease.[ncbi.nlm.nih.gov]
- Possible methods of prevention are discussed in the light of the findings.[ncbi.nlm.nih.gov]
- The concept of prevention of the disease by proper handling of the cord was not even suggested.[nature.com]
References
Article
- Murahovschi J. Tétano dos recém-nascidos: revisitado. Rev Paul Pediatr. 2008;26(4):312-4.
- Black RE. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730):1969–87.
- Ganatra HA, Stoll BJ, Zaidi AK. International perspective on early-onset neonatal sepsis. Clin Perinatol. 2010;37(2):501–23.
- Blencowe H et al. Tetanus toxoid immunization to reduce mortality from neonatal tetanus. Int J Epidemiol. 2010;39(1):i102–9.
- Glezen WP. Prevention of neonatal tetanus. Am J Public Health. 1998;88(6):871-2.
- Prevots DR. Neonatal tetanus. MMWR Morb Mortal Wkly Rep. 1999;(48):176-7.
- Darmstadt GL Population-based incidence and etiology of community-acquired neonatal bacteremia in Mirzapur, Bangladesh: an observational study. J Infect Dis. 2009;200(6):906–15.
- Nida H. Neonatal tetanus in Awassa: retrospective analysis of patients admitted over 5 years. Ethiop Med J. 2001;39(3):241-6.
- Apte NM, Karnad DR. Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg. 1995;53(4):386-7.