Cannot Miss Diagnosis No.8
- Section Editor: Prof. T.K. Partha Sarathy
A 45 year old construction site unskilled worker came to see a family practitioner with a history of headache, feverishness and not feeling well for the last two days. There was no history of similar episodes in the past and there was no history of any cough, urinary symptoms etc. A cursory physical examination revealed that the cardio respiratory status was normal. Examination of the abdomen revealed varying degrees of guarding in some areas. The patient appeared tired and was trying to rest. Her husband indicated that she became so tired that she could not move out of the bed in the last 2 days and was not taking any food. Her complete blood count and urine analysis done immediately were within normal. The family practitioner felt that there was some thing more than what surfaced in that patient and so he carefully started to examine her again. At this point he was convinced that the patient had a stiff jaw and was not able to open her mouth even to drink water. The presence of trismus warranted examination of the oropharynx and with some difficulty he was able to find out that there were no other abnormalities.
With this finding the family practitioner definitely came to a conclusion and made additional enquiries regarding any injury in the recent past. On careful examination of the feet he found out that there was a punctured wound in her left foot with some redness and tenderness in the area. When enquired about it the patient and her husband said that about 8 days before, while at work she had stepped on a nail which had to be pulled out following which she continued to work and almost forgot about it. With this history and presenting symptoms the family practitioner readily recognized the possibility of Tetanus as the most likely diagnosis. The Practitioner was reminded of another patient he had an year ago. This was a new born 3 day old baby brought to his office with a history that the child absolutely could not accept feeds either by nursing or by utilizing droppers and since the morning of the arrival to the clinic was becoming rigid all over the body with clenched fists. The baby was delivered in a hut by the grand mother and apparently the mother was recovering fairly well after the delivery. The family practitioner then had requested a paediatrician also to see the patient and made the diagnosis of Tetanus Neonatorum.
As any one can readily appreciate the diagnosis of tetanus is essentially a clinical one. Unless the family practitioner is aware of this condition it is possible to miss when the symptoms are less pronounced thereby loosing very valuable time in the management of the disease. The mortality of tetanus is an excess of 40% and particularly in the neonatal period it is close to 80%. The prognosis is considerably better if one is able to make the diagnosis early at the onset of the disease and appropriate treatment is started immediately. If not properly treated the disease will progress rapidly and patient dies of exhaustion and respiratory arrest.
Tetanus is caused by anaerobic spore bearing organism called Clostridium Tetani and the dormant spores are present in the animal feces and also mixed in dirt and debri. The organism enters into the human body through an injured site. The injuries can be single, multiple, superficial, deep or penetrating. Tetanus can also infect human and animal bite sites as well as needle and nail puncture wounds. Those wounds which are not immediately attended to are the ones worst affected. Once the organism makes entry into the human tissue it releases powerful exotoxins which gets bound to peripheral motor neuron terminal from where it is transported to the nerve cell body in the brain stem and the spinal cord. No major changes take place in the wound itself due to this infection.
Tetanus manifests in two forms, most of which is a generalized tetanus and rarely a local form of tetanus around the injured site can also occur. One of the earliest symptoms that is readily recognized during the first contact of the patient is the presence of rigidity of the muscles of masseter leading to trismus or lockjaw. The rigidity of the face muscle can lead to a grimace which is referred to as Risus Sardonicus. The muscle rigidity spreads to other parts of the body often showing a rigid abdomen and rigid spine (ophisthotonus) and will also involve muscles that help breathing. Patients can develop cyanosis, ventilaroty failure, laryngospasms and apnea. Other symptoms at times seen are hypertension, tachycardia, arrythmia, hyper pyrexia, profuse sweating, bradycardia, thrombophlebitis etc.
In the neonatal tetanus, it is usually a generalized type and is caused because of the poor care of the umbilical cord at the time of delivery. Inability to feed , rigidity of muscles and spasm are classical features of this form of tetanus. As stated earlier the diagnosis is essentially clinical and should not wait for any laboratory confirmation. Most laboratory tests may still be normal. Other diseases that may be considered as a differential diagnosis will be strichnine-poisoning, meningitis, encephalitis, rabies etc. It is not difficult to make positive diagnosis of tetanus if one can elicit a history and findings of
a. inadequate or improper immunization against tetanus
b. a recognized or unrecognized injury in the recent post
c. presence of trismus
d. absence of significant findings of sepsis as one would expect in any other infection.
Treatment of tetanus is fairly a well laid out approach. Principles are
a. To provide human immune globulin (TIG) in a dose of 3000 to 6000 units intramuscularly.
b. Debridement of the wound and appropriate care of the wound
c. Antibiotic therapy particularly massive doses of aqueous crystalline penicillin (10 to 12 million units I.V.) for 10 days with addition of Metronidazole coverage.
d. Avoid unnecessary stimulation by treating the patient in a calm quiet atmosphere protected from noise, lighting and other stimulations.
e. Control of muscle spasm with diazepam or lorazepam
f. Intubation and total respiratory assistance when spasms persist
g. Provide adequate respiratory care in terms of handling secretions and ventilation
h. Endotracheal intubation and tracheostomy when needed
i. A total nutritional and critical care.
All these care could be provided in a good moderately equipped hospital with facilities for critical care. The outcome largely depends upon the severity of the case at the time the diagnosis is established and the appropriateness and the intensity of the treatment given. It has to be said in conclusion that tetanus is better prevented than treated and in many advanced countries tetanus is already a disease of the past. In India, inspite of the rapid immunization programme tetanus is still a frequently seen problem and the prophylactic management should revolve around the following: 1. Every child born in the country should receive the 3 dose of appropriate initial immunization with DTP and polio
2. Subsequent to this the children should be provided at the age of 10 and 20 with booster doses, unless they get injured and depending on the type of injury they may require booster doses of tetanus earlier.
3. The schedule of immunization required for children and adult are given in our previous lessons. Please refer Page Nos.DFH/Ped/5 and DFH/IM/10 to 13.
It has to be noted that the use of anti-tetanus serum prepared from the equine source is less favoured in the management of tetanus because of the serious allergic reactions that one may encounter. It is now preferred to use the human tetanus immune globulin (TIG) in the treatment of tetanus. TIG could also be used in a dosage of 250 to 500 units in dealing with injuries where patients are vulnerable to tetanus (no previous immunization, delayed care, multiple injuries, gross contamination etc).
Most family practitioners would encounter cases of Tetanus in the adult or neonate and it is vital for the practitioner to be able to make a quick diagnosis and admit the patient for appropriate care in a suitable facility. Family Practitioners should also pay special attention to the management of wounds. Use of antibiotics as well as active and passive tetanus immunization are hall makers of good prophylaxis.
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