Intrathecal tetanus immunoglobulins in the management of tetanus

Tetanus- a case report highlighting the challenges in diagnosis and treatment

Tetanus has become an increasingly rare infectious disease due to the development of successful vaccination programs in the mid-20th century. In resource-rich countries, mainly unvaccinated or partly vaccinated risk groups are affected, whereas tetanus still remains prevalent in resource-limited countries. The decreasing incidence in developed countries has hindered clinical trials evaluating the best treatment modalities for tetanus infections. Current guidelines are based on a small number of studies and case reports. So far, these studies have shown potential benefits of treating tetanus infections with benzodiazepines, magnesium sulfate and baclofen. Additionally, several treatments have been shown to be useful in stabilizing and supporting patients with tetanus. However, each treatment modality has limitations, from negative side effects to logistical challenges, especially in developing countries. Therefore, further knowledge is required to evaluate the best use of each treatment and to further optimize patient care. This knowledge can contribute to the reduction of the burden of disease in countries where tetanus remains prevalent and where resources are limited, though vaccination is the most effective method to achieve this. This case report describes the treatment of a Dutch patient with tetanus infection and illustrates the role of benzodiazepines as well as other key aspects of treating patients with tetanus.

Intrathecal Immunoglobulin for treatment of adult patients with tetanus: A randomized controlled 2x2 factorial trial

Despite long-standing availability of an effective vaccine, tetanus remains a significant problem in many countries. Outcome depends on access to mechanical ventilation and intensive care facilities and in settings where these are limited, mortality remains high. Administration of tetanus antitoxin by the intramuscular route is recommended treatment for tetanus, but as the tetanus toxin acts within the central nervous system, it has been suggested that intrathecal administration of antitoxin may be beneficial. Previous studies have indicated benefit, but with the exception of one small trial no blinded studies have been performed. The objective of this study is to establish whether the addition of intrathecal tetanus antitoxin reduces the need for mechanical ventilation in patients with tetanus. Secondary objectives: to determine whether the addition of intrathecal tetanus antitoxin reduces autonomic nervous system dysfunction and length of hospital/ intensive care unit stay; whether the addition of intrathecal tetanus antitoxin in the treatment of tetanus is safe and cost-effective; to provide data to inform recommendation of human rather than equine antitoxin. This study will enroll adult patients (≥16 years old) with tetanus admitted to the Hospital for Tropical Diseases, Ho Chi Minh City. The study is a 2x2 factorial blinded randomized controlled trial. Eligible patients will be randomized in a 1:1:1:1 manner to the four treatment arms (intrathecal treatment and human intramuscular treatment, intrathecal treatment and equine intramuscular treatment, sham procedure and human intramuscular treatment, sham procedure and equine intramuscular treatment). Primary outcome measure will be requirement for mechanical ventilation. Secondary outcome measures: duration of hospital/ intensive care unit stay, duration of mechanical ventilation, in-hospital and 240-day mortality and disability, new antibiotic prescription, incidence of ventilator associated pneumonia and autonomic nervous system dysfunction, total dose of benzodiazepines and pipecuronium, and incidence of adverse events. Trial registration: ClinicalTrials.gov NCT02999815 Registration date: 21 December 2016.

Intrathecal Immunoglobulin for treatment of adult patients with tetanus: A randomized controlled 2x2 factorial trial

Despite long-standing availability of an effective vaccine, tetanus remains a significant problem in many countries. Outcome depends on access to mechanical ventilation and intensive care facilities and in settings where these are limited, mortality remains high. Administration of tetanus antitoxin by the intramuscular route is recommended treatment for tetanus, but as the tetanus toxin acts within the central nervous system, it has been suggested that intrathecal administration of antitoxin may be beneficial. Previous studies have indicated benefit, but with the exception of one small trial no blinded studies have been performed. The objective of this study is to establish whether the addition of intrathecal tetanus antitoxin reduces the need for mechanical ventilation in patients with tetanus. Secondary objectives: to determine whether the addition of intrathecal tetanus antitoxin reduces autonomic nervous system dysfunction and length of hospital/ intensive care unit stay; whether the addition of intrathecal tetanus antitoxin in the treatment of tetanus is safe and cost-effective; to provide data to inform recommendation of human rather than equine antitoxin. This study will enroll adult patients (≥16 years old) with tetanus admitted to the Hospital for Tropical Diseases, Ho Chi Minh City. The study is a 2x2 factorial blinded randomized controlled trial. Eligible patients will be randomized in a 1:1:1:1 manner to the four treatment arms (intrathecal treatment and human intramuscular treatment, intrathecal treatment and equine intramuscular treatment, sham procedure and human intramuscular treatment, sham procedure and equine intramuscular treatment). Primary outcome measure will be requirement for mechanical ventilation. Secondary outcome measures: duration of hospital/ intensive care unit stay, duration of mechanical ventilation, in-hospital and 240-day mortality and disability, new antibiotic prescription, incidence of ventilator associated pneumonia and autonomic nervous system dysfunction, total dose of benzodiazepines and pipecuronium, and incidence of adverse events. Trial registration: ClinicalTrials.gov NCT02999815 Registration date: 21 December 2016.

Post-neonatal Tetanus in a PICU of a Developing Economy: Intensive Care Needs, Outcome and Predictors of Mortality

OBJECTIVES

To evaluate pediatric intensive care unit (PICU) needs, outcome and predictors of mortality in post-neonatal tetanus.

MATERIALS AND METHODS

Review of 30 consecutive post-neonatal tetanus cases aged 1 months to 12 years admitted to a PICU in north India over a period of 10 years (January 2006 to December 2015).

RESULTS

Chronic suppurative otitis media was the commonest portal of entry. All received tetanus toxoid, human tetanus immunoglobulin (HTIG) and appropriate antibiotics; 7 (23.3%) received intrathecal HTIG. Common complications were respiratory failure, rhabdomyolysis, autonomic dysfunction, acute kidney injury and healthcare-associated infections. PICU needs were as follows: ventilation; benzodiazepine, morphine and magnesium sulfate infusion; neuromuscular blockers, inotropes, tracheostomy and renal replacement therapy. Mortality rate was 40%; severity Grade IIIb, autonomic dysfunction, use of vasoactive drugs and those who did not receive intrathecal HTIG were significantly associated with mortality.

CONCLUSION

Post-neonatal tetanus is associated with high mortality, and PICU needs include management of spasms, autonomic dysfunction and complications and cardiorespiratory support.

A systematic review of tetanus in individuals with previous tetanus toxoid immunization

Objectives

To assess the characteristics of tetanus in previously immunized individuals.

Methods

A systematic literature search was undertaken using Ovid MEDLINE(R) and EMBASE databases for articles published between 1946 and September 3, 2013. The search strategy was developed using MESH terms for "tetanus", "immunization" and "vaccination". Inclusion criteria were articles in English or French that described at least one case of tetanus, immunization history and/or the results of anti-tetanus antibodies. Articles were reviewed for relevant references.

Results

51 unique articles published from1946-2013 were included in the review. The articles described 359 cases of clinical tetanus in individuals with prior receipt of one or more doses of tetanus toxoid vaccine and/or levels of tetanus antibody titres generally considered protective. Of the 210 cases that reported patient status at discharge, 180 (85.7%) survived with only three cases reporting residual deficits.

Conclusion

Tetanus spores are ubiquitous and this report clearly documents that tetanus cases can occur in individuals previously immunized with tetanus toxoid vaccine. Clinicians should not rule out tetanus when clinical symptoms suggest it, regardless of the vaccination history. When treated, the prognosis for tetanus is good. Further research is needed to assess the incidence of tetanus in partially- and fully-immunized populations and determine whether this is due to waning immunity of vaccine failure.

Current practice in the management of tetanus

Tetanus is still a scourge among the under-privileged populations of the world, and unfortunately remains an important cause of death although a cheap, safe and highly efficacious vaccine is available. The rarity of the disease in some parts of the world results in newly trained physicians being unable to make a clinical diagnosis, and hampers the conduct of adequately powered randomized controlled trials. Several new and experimental pharmacological agents are being used to control the spasms in tetanus, and to combat the autonomic instability that occurs in the disease. New evidence is emerging regarding the use of antibiotics and intrathecal immunoglobulin in tetanus. It is imperative, therefore, that all physicians working in critical care should be aware of the current advances and evidence-based guidelines for management of tetanus in order to achieve the best outcomes, which Rodrigo and colleagues have reviewed in a recent issue of Critical Care.

Pharmacological management of tetanus: an evidence-based review

Tetanus is becoming rarer in both industrialized and developing nations due to an effective vaccination program. In 2010, the World Health Organization estimated there was a 93% reduction in newborns dying from tetanus worldwide, compared to the situation in the late 1980s. Due to its rarity, many diagnostic delays occur as physicians may not consider the diagnosis until the manifestations become overt. Without timely diagnosis and proper treatment, severe tetanus is fatal (mortality is also influenced by the comorbidities of the patient). The principles of treating tetanus are: reducing muscle spasms, rigidity and autonomic instability (with ventilatory support when necessary); neutralization of tetanus toxin with human antitetanus immunoglobulin or equine antitetanus sera; wound debridement; and administration of antibiotics to eradicate locally proliferating bacteria at the wound site. It is difficult to conduct trials on different treatment modalities in tetanus due to both logistical and ethical reasons. However, it is imperative that physicians are aware of the best evidence-based treatment strategies currently available to improve the outcome of patients. This review concentrates on analyzing the current evidence on the pharmacological management of tetanus.

Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms

Tetanus toxin, the product of Clostridium tetani, is the cause of tetanus symptoms. Tetanus toxin is taken up into terminals of lower motor neurons and transported axonally to the spinal cord and/or brainstem. Here the toxin moves trans-synaptically into inhibitory nerve terminals, where vesicular release of inhibitory neurotransmitters becomes blocked, leading to disinhibition of lower motor neurons. Muscle rigidity and spasms ensue, often manifesting as trismus/lockjaw, dysphagia, opistotonus, or rigidity and spasms of respiratory, laryngeal, and abdominal muscles, which may cause respiratory failure. Botulinum toxin, in contrast, largely remains in lower motor neuron terminals, inhibiting acetylcholine release and muscle activity. Therefore, botulinum toxin may reduce tetanus symptoms. Trismus may be treated with botulinum toxin injections into the masseter and temporalis muscles. This should probably be done early in the course of tetanus to reduce the risk of pulmonary aspiration, involuntary tongue biting, anorexia and dental caries. Other muscle groups are also amenable to botulinum toxin treatment. Six tetanus patients have been successfully treated with botulinum toxin A. This review discusses the use of botulinum toxin for tetanus in the context of the pathophysiology, symptomatology, and medical treatment of Clostridium tetani infection.

Fundal changes in children receiving Vigabatrin

Visual field defects and other abnormalities are reported in patients receiving the newer antiepileptic Vigabatrin (VGB). Field testing in children younger than 6 years and those with mental retardation is difficult. The authors, therefore, studied ophthalmoscopic abnormalities in seven pediatric patients receiving VGB for median duration of 9 month (range, 3-32 months). Abnormal findings were seen in two (33.3%) in the form of surface wrinkling retinopathy and abnormal macular reflexes. The proportion of abnormal findings was in agreement with previous reports. Thus it is concluded that simple ophthalmoscopy by an ophthalmologist picks up the abnormalities due to ocular toxicity of VGB, and helps in rationalizing further AED therapy in the clinic.

Successful treatment with intravenous immunoglobulin of acute flaccid paralysis caused by west nile virus

West Nile virus (WNV) is one of the leading causes of insect-borne encephalitis and acute flaccid paralysis in the US. Acute flaccid paralysis is a potentially serious illness, which manifests itself as a Guillain-Barré-like syndrome with generalized weakness and shortness of breath. We report a case involving a patient who presented with acute flaccid paralysis due to WNV infection and was successfully treated with intravenous immunoglobulin from Israeli donors.