Cerebrospinal fluid (CSF) changes in tetanus

Cerebrospinal fluid changes in tetanus: raised proteins and immunoglobulins in patients with severe disease

34 patients with tetanus were studied; all had normal serum proteins and albumin. Only 3 samples of cerebrospinal fluid (CSF) contained cells (a few polymorphonuclear leucocytes). Protein levels in the CSF were elevated in 26 patients (76.5%); 11 cases with clinically mild tetanus had a mean CSF protein of 400 +/- 250 mg/litre (normal 100-400 mg/litre), while the CSF protein levels of 10 patients who died (mean 1596 +/- 985 mg/litre; P less than 0.005) and those of 4 others with severe disease who absconded were much higher (mean 1220 +/- 562 mg/litre; P less than 0.005). As a group, 19 patients with severe disease including the 10 fatal cases also had significantly higher mean CSF protein values (1582 +/- 938 mg/litre; P less than 0.005) than did the mild cases. Immunochemical analysis of the proteins using a radial immunodiffusion assay showed that these proteins were immunoglobulin G (IgG). Polyacrylamide gel electrophoresis demonstrated an oligoclonal gammaglobulin pattern, suggesting intrathecal IgG synthesis in these patients. These studies suggest that measurement of CSF proteins may supplement clinical evaluation in tetanus and that there may be a local immune stimulus (perhaps a tetanus antigen or to some other mitogen) in the central nervous system.

Tetanus in Finland: diagnostic problems and complications

In a 16-year nationwide study in Finland 106 patients were diagnosed as having tetanus. Tetanus was diagnosed on the first visit to a doctor in half the patients, it was suspected in 28% but not considered in 22%. Diagnosis of tetanus may be delayed if a patient is elderly or has no known primary lesion. Abnormal EEGs and CSF findings with increased protein level were unexpectedly common (76% and 24% respectively). The most significant complications were cardiac arrhythmias (34%), blood pressure lability (32%), an increased haemorrhagic tendency (28%), an increase in thrombosis (8%) and/or of anoxic periods (16%) and death (11%). Intensive care has markedly improved the prognosis of tetanus; the main problems at present are difficulty of early diagnosis and treatment of complications of the most serious cases.