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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.


Neonatal tetanus 6374
Neonatal tetanus 6374
Neonatal tetanus 6374, Public Domain

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.

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]
  • 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]
Abdominal Rigidity
  • He developed tetanic generalized spasms with opisthotonos, risus sardonicus and abdominal rigidity. The patient was transferred to the PICU where he was placed on a continuous infusion of midazolam at 0.1 mg/kg/hr.[pedsccm.org]
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]
  • Trismus pada neonati tidak sejelas pada anak, karena kekakuan pada leher lebih kuat dan akan menarik mulut kebawah, sehingga mulut agak menganga.[kampusdokter.blogspot.com]
  • Penyakit ini biasanya terjadi mendadak dengan ketegangan otot yang makin bertambah terutama pada rahang dan leher,dalam 24 jam penyakit menjadi nyata dengan adanya trismus.[sumbarsehat.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]
  • Penyakit tetanus neonatorum ini biasanya terjadi secara mendadak dengan ketegangan pada otot yang semakin bertambah terutama di bagian rahang dan juga leher, dan dalam waktu 24 jam maka penyakit kan menjadi nyata yaitu dengan adanya trismus.[pusatmedik.org]
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]
  • Pengaruh toksin pada saraf otonom akan menyebabkan gangguan sirkulasi (akibat gangguan irama jantung misalnya block, bradycardi, tachycardia, atau kelainan pembuluh darah/hipertensi), dapat pula menyebabkan suhu badan yang tinggi (hiperpireksia) atau[kampusdokter.blogspot.com]
  • Tachycardia. High frequency and greater severity and duration of muscular spasms especially of larynx. Frequent and prolong duration of apneic episodes.[jemds.com]
  • During the second day after intubation, the spasms were controlled but cardiovascular instability continued with sinus tachycardia of 150 beats per minute and intermittent systolic hypertension up to 160 mm Hg.[pedsccm.org]
Muscle Twitch
  • twitches are fused and cannot be distinguished from one another; called also tetanic or tonic contraction and tetanic or tonic spasm . tet·a·nus ne·o·na·to·rum tetanus occurring in newborn infants, usually due to infection of umbilical area with Clostridium[medical-dictionary.thefreedictionary.com]
  • twitches are fused and cannot be distinguished from one another, also called tonic spasm and tetany). tetanus 1.[wordinfo.info]
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]
Suggestibility
  • 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]
  • We suggest that the mechanism responsible for this lesion involves the retrograde axoplasmic flow of tetanus toxin reaching the spinal cord via nerve endings in the infected umbilical cord stump.[ncbi.nlm.nih.gov]
  • The concept of prevention of the disease by proper handling of the cord was not even suggested.[nature.com]
  • Existing evidence suggests home delivery to be a significant risk factor (Pinheiro, 1964). Our study confirms this fact as all cases were home delivered.[jpma.org.pk]
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]
  • As long as the patient is acutely ill and likely to suffer from convulsive seizures, someone should be in constant attendance.[medical-dictionary.thefreedictionary.com]
  • Jaw cramping Sudden, involuntary muscle tightening (muscle spasms) — often in the stomach Painful muscle stiffness all over the body Trouble swallowing Jerking or staring (seizures) Headache Fever and sweating Changes in blood pressure and a fast heart[cdc.gov]
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]
  • Opisthotonus Kekakuan otot-otot yang menunjang tubuh : otot punggung, otot leher, trunk muscle dan sebagainya. Kekakuan yang sangat berat menyebabkan tubuh melengkung seperti busur, bertumpu pada tumit dan belakang kepala.[kampusdokter.blogspot.com]
  • 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]
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]
Confusion
  • 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]
Generalized 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]

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.

Staphylococcus Aureus
  • Pilih antibiotika yang efektif terhadap Staphylococcus aureus dan Escherichia coli.[jurnalpediatri.com]

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]
  • […] of tetanus neonatorum. ( 2488239 ) Caglar M.K. 1989 16 Double-blind trial of intramuscular and intramuscular plus intrathecal human tetanus immunoglobulin and intramuscular equine tetanus antitoxin in the treatment of tetanus neonatorum. ( 3232228 )[malacards.org]
  • 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]
  • As the disease is self limiting the main aim of treatment should be to prevent its many complications.[jpma.org.pk]

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]
  • 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]
  • ETIOLOGI Penyakit ini disebabkan oleh bakteri clostradium tetani yang merupakan bakteri gram-positif berbentuk batang dengan spora pada sisi ajungnya sehingga mirip pemukul genderang ( drumstick). bakteri tetanus bersifat obligat anaerob, yaitu berbentuk[radardokter.blogspot.com]
  • METODE PENELITIAN 2.3 Kerangka Teori 2.1 Tetanus Neonatorum 2.1.1 Definisi Tetanus Neonatorum 2.1.2 Etiologi Tetanus Neonatotum 2.1.3 Epidemiologi Tetanus Neonatotum 2.1.4 Penularan Tetanus Neonatorum 2.1.5 Masa Inkubasi Tetanus Neonatorum 2.1.6 Gejala[prezi.com]
  • ETIOLOGI Penyebab penyakit ini adalah clostridium tetani yang hidup anaerob. Kuman ini mudah dikenal karena pembentukan spora dan karena bentuk yang khas, tersebar luas di tanah dan mengeluarkan toksin bila dalam kondisi baik.[kadaverboy.wordpress.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]

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]
  • Manfaat Teoritis Menambah khasanah ilmu dalam bidang epidemiologi deskriptif Menambah referensi mengenai tren penyakit pada bagian Epidemiologi dan Biostatistika-Kependudukan Menjadi landasan penliti mengenai gambaran pengetahuan dukun mengenai Tetanus[prezi.com]
  • Children's Hospital, New Delhi in the year 1965 and a decade later. ( 7461816 ) Sehgal H....Sidhu K.K. 1980 41 Intrathecal anti-tetanus serum in management of tetanus neonatorum. ( 6894134 ) Bhandari B....Jagetiya P.R. 1980 42 Tetanus neonatorum--its epidemiology[malacards.org]
  • Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C, Child Health Epidemiology Reference Group of WHO and, UNICEF (Jun 5, 2010).[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology
  • Pathophysiology Clostridium tetani is an obligate, anaerobic, motile, gram-positive bacillus. It is nonencapsulated and forms spores that are resistant to heat, desiccation, and disinfectants.[emedicine.medscape.com]
  • Tetanus: pathophysiology, management and prophylaxis. Disease-a-Month 1991;37:549-602. 2. Centers for Disease Control Tetanus - United States, 1987 and 1988. JAMA 1990;263:1192. 3. Prevots R, Sutter RW, Strebel PM, et al.[pedsccm.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]
  • The incidence of neonatal tetanus in Turkey is on the decline, but a fraction of the population, the so-called urban poor, is still at high risk for preventable diseases.[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

  1. Murahovschi J. Tétano dos recém-nascidos: revisitado. Rev Paul Pediatr. 2008;26(4):312-4.
  2. Black RE. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730):1969–87.
  3. Ganatra HA, Stoll BJ, Zaidi AK. International perspective on early-onset neonatal sepsis. Clin Perinatol. 2010;37(2):501–23.
  4. Blencowe H et al. Tetanus toxoid immunization to reduce mortality from neonatal tetanus. Int J Epidemiol. 2010;39(1):i102–9.
  5. Glezen WP. Prevention of neonatal tetanus. Am J Public Health. 1998;88(6):871-2.
  6. Prevots DR. Neonatal tetanus. MMWR Morb Mortal Wkly Rep. 1999;(48):176-7.
  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.
  8. Nida H. Neonatal tetanus in Awassa: retrospective analysis of patients admitted over 5 years. Ethiop Med J. 2001;39(3):241-6.
  9. 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.

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Last updated: 2018-06-22 06:03