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Phuenpathom W, Wongwan P, Bhidayasiri R, Sringean J. The Myriad Presentations of Tetanus: Where Do You Look for Clinical Clues in an Intubated Highly Sedated Patient? Mov Disord Clin Pract 2024; 11:175-178. [PMID: 38386487 PMCID: PMC10883398 DOI: 10.1002/mdc3.13935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 02/24/2024] Open
Affiliation(s)
- Warongporn Phuenpathom
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross SocietyBangkokThailand
| | - Piyanat Wongwan
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross SocietyBangkokThailand
| | - Roongroj Bhidayasiri
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross SocietyBangkokThailand
- The Academy of Science, The Royal Society of ThailandBangkokThailand
| | - Jirada Sringean
- Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross SocietyBangkokThailand
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Pham OKN, Tran BN, Duong MC, Do TCN, Pham TL, Lam MY, Thwaites L, Nguyen VH. Magnitude, Patterns, and Associated Predictors of Cardiovascular Events in Tetanus: A 2-Year, Single-Center, Ambidirectional Cohort Study Involving 572 Patients. Open Forum Infect Dis 2023; 10:ofad473. [PMID: 37795506 PMCID: PMC10546955 DOI: 10.1093/ofid/ofad473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023] Open
Abstract
Background Cardiovascular events (CEs) remain the leading cause of death in patients with tetanus. We examined the incidence, patterns, and associated predictors of CEs among patients with tetanus in Vietnam. Methods An ambidirectional cohort study was conducted on hospitalized adult patients with tetanus at the Hospital for Tropical Diseases between 2019 and 2020. Information on demographics, tetanus disease, CEs and outcomes were collected. Results Among all 572 included patients, CEs accounted for 10.8% (95%CI 8.6-13.7%) and included Takotsubo cardiomyopathy (40.3%, 95%CI 29.0-52.8%), arrhythmia (19.4%, 95%CI 11.4-30.9%), sudden cardiac arrest (16.1%, 95%CI 9.0-27.2%), myocardial infarction (11.3%, 95%CI 5.6-21.5%), heart failure (6.5%, 95%CI 2.5-15.4%) and pulmonary embolism (6.5%, 95%CI 2.5-15.4%). CEs occurred from day 5 to 20 of illness. Among 62 CE patients, 21% (95%CI 12.7-32.6%) died and 61.3% (95%CI 48.9-72.4%) developed autonomic nervous system dysfunction (ANSD). Three-fourths (24/32) of patients with Takotsubo cardiomyopathy or myocardial infarction had ANSD. CEs were significantly associated with modified Ablett scores (AOR = 2.42, 95%CI 1.1-5.6, P = .04), underlying diseases (AOR = 2.7, 95%CI 1.1-6.8, P = .04) and overweight (AOR = 0.18, 95%CI .04-.8, P = .02). Conclusions CEs are not rare and associated with high mortality. The most common CE is Takotsubo cardiomyopathy. CEs can occur at any stage of illness, with or without ANSD. To prevent mortality, it is pivotal to screen CEs in patients with tetanus, especially those with underlying diseases, high modified Ablett scores, and a normal or low BMI. More studies are needed to fully elucidate the impact of ANSD on the cardiovascular function and the CE associated mortality in tetanus.
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Affiliation(s)
- Oanh Kieu Nguyet Pham
- Faculty of Infectious Diseases, School of Medicine, Vietnam National University, Ho Chi Minh City, Vietnam
- Viet Anh Department, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Bao Nhu Tran
- Faculty of Infectious Diseases, School of Medicine, Vietnam National University, Ho Chi Minh City, Vietnam
| | - Minh Cuong Duong
- School of Population Health, University of New South Wales, Kensington, New South Wales, Australia
| | - Thi Cam Nhung Do
- Viet Anh Department, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Thi Lieu Pham
- Emerging Infection Group, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Minh Yen Lam
- Emerging Infection Group, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Louise Thwaites
- Emerging Infection Group, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Van Hao Nguyen
- Department of Infectious Diseases, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam
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Sangwe Clovis N, Palle JN, Linwa EMM, Ndung Ako F, Tabe Benem-Orock V, Chichom Mefire A. Factors associated with mortality in patients with tetanus in Cameroon. Sci Prog 2023; 106:368504221148933. [PMID: 36617884 PMCID: PMC10370253 DOI: 10.1177/00368504221148933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tetanus constitutes a significant cause of death in sub-Saharan Africa, with case fatality rates as high as 64%, 47%, and 43.1% reported in Nigeria, Uganda, and Tanzania, respectively. However, the knowledge gap on factors that influence tetanus mortality still exists in Cameroon. OBJECTIVE To identify the factors that influence the mortality of tetanus patients in three regional hospitals in the North West and South West Regions of Cameroon. METHODOLOGY This was a 7-year retrospective case-series study. Socio-demographic and clinical data of tetanus cases admitted in Bamenda, Buea, and Limbe Regional Hospitals from January 2010 to March 2017 were collected and analysed. RESULTS This study recorded 38 cases, but excluded five due to missing inpatient files. Of the 33 cases considered in this study, 27 (81.8%) were males. The mean age of the patients was 32 years. A tetanus mortality rate of 48.5% was recorded - thus, 16 tetanus-related deaths. Mortality was higher amongst patients with incubation periods less than 7 days; the onset of trismus and generalized spasms less than 8 days after exposure; the presence of autonomic dysfunction; the presence of respiratory dysfunction; application or introduction of local regimens, soil or animal waste at the portal of entry; delayed debridement greater than 2 days after onset of tetanus; and a severe clinical disease state. CONCLUSION This study, therefore, highlights the need to ensure universal vaccination coverage for high-risk populations; males, active population (20-40 years), and farmers. More still, this study emphasizes the need to improve access and utilisation of mechanical ventilation in severe tetanus cases.
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Zitzl J, Dyckers J, Güssow A, Lehmann H, Hazuchova K. Survival in canine tetanus - retrospective analysis of 42 cases (2006-2020). Front Vet Sci 2022; 9:1015569. [PMID: 36590798 PMCID: PMC9797805 DOI: 10.3389/fvets.2022.1015569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/29/2022] [Indexed: 12/16/2022] Open
Abstract
Objective To define factors associated with survival in dogs with tetanus and to evaluate the prognostic significance of an established severity classification scheme. Methods Medical records of dogs with the clinical diagnosis of tetanus were retrospectively reviewed with regard to signalment, clinical signs, clinicopathological findings on admission, wound characteristics, complications, therapeutic measures, and survival to discharge. Based on the extracted data, dogs were graded according to a previously published 4-class severity scheme. Non-parametric tests were applied for comparisons between survival categories. Results Forty-two dogs fulfilled inclusion criteria, of which 32 survived. Of 10 non-survivors, 4 died and 6 were euthanised. Non-survivors were more often younger than 2 years of age (6/10 vs. 7/32 dogs, p = 0.023), had shorter duration of specific signs of tetanus (time from onset of typical signs to presentation) (2 vs. 4 days, p = 0.016), were prescribed less often antibiotics prior to presentation (p = 0.006), had higher tetanus severity grade (10/12 dogs in Class III or IV died, p < 0.001), more often received acepromazine (p = 0.009) and atropine (p = 0.012), and more often had hyperthermia (p = 0.005) and respiratory complications (pneumonia, laryngeal spasm; p = 0.008). Wound characteristics, the use of tube feeding, metronidazole, methocarbamol, magnesium and antitoxin were not significantly different between non-survivors and survivors. Clinical significance and conclusion Young dogs with a rapid course of severe generalized tetanus have a guarded prognosis. The previously described severity classification scheme proved valuable in predicting survival. Prospective multi-center studies are needed to clarify the prognostic significance of age, sedative usage and modified versions of an established classification scheme, including the presence of respiratory complications.
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Khan MAS, Hasan MJ, Rashid MU, Kha Sagar S, Khan S, Zaman S, Sumon SM, Basher A, Hawlader MDH, Nabi MH, Kakoly NS. Factors associated with in-hospital mortality of adult tetanus patients–a multicenter study from Bangladesh. PLoS Negl Trop Dis 2022; 16:e0010235. [PMID: 35231035 PMCID: PMC8887756 DOI: 10.1371/journal.pntd.0010235] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/05/2022] [Indexed: 01/22/2023] Open
Abstract
Background
Tetanus, a vaccine-preventable disease, is still occurring in the elderly population of low- and middle-income countries with a high case-fatality rate. The objective of the study was to elucidate the factors associated with in-hospital mortality of tetanus in Bangladesh.
Methods
This prospective observational study, conducted in two specialized infectious disease hospitals, conveniently selected adult tetanus patients (≥18 years) for inclusion. Data were collected through a preformed structured questionnaire. Kaplan Meier survival analysis and univariate and multivariable Cox regression analysis were carried out to assess factors associated with in-hospital mortality among patients. All analysis was done using Stata (version 16) and SPSS (version 26).
Results
A total of 61 tetanus cases were included, and the overall in-hospital mortality rate was 34.4% (n = 21). Patients had an average age of 46.49 ±15.65 years (SD), and the majority were male (96.7%), farmers (57.4%), and came from rural areas (93.4%). Survival analysis revealed that the probability of death was significantly higher among patients having an age of ≥ 40 years, incubation time of ≤12 days, onset time of ≤ 4 days, and having complication(s). However, on multivariable Cox regression analysis, age (adjusted hazard ratio [aHR] 4.03, 95% Confidence Interval [CI] 1.07–15.17, p = 0.039) and onset time (≤4 days) (aHR 3.33; 95% CI 1.05–10.57, p = 0.041) came as significant predictors of in-hospital mortality after adjusting for incubation period and complications.
Conclusion
Older age and short onset time are the two most important determinants of in-hospital mortality of tetanus patients. Hence, these patients require enhanced emphasis and care.
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Affiliation(s)
- Md. Abdullah Saeed Khan
- Infectious Disease Hospital, Dhaka, Bangladesh
- Pi Research Consultancy Center, Dhaka, Bangladesh
- * E-mail:
| | | | - Md. Utba Rashid
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Soumik Kha Sagar
- Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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BEYDİLLİ İ, YILMAZ F, DUYAN M. Tetanozun Önlenmesinde Sağlık Çalışanlarının Uygulama ve Bilgi Düzeyleri Üzerine Bir Araştırma. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2020. [DOI: 10.30934/kusbed.668222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Vicente-Alcalde N, Martín-Casquero T, Ruescas-Escolano E, Tuells J. The Survivor: A Clinical Case of Tetanus in a Non-Immunized, Parenteral Drug User, Former Female Convict with HIV and HCV. Vaccines (Basel) 2020; 8:vaccines8020308. [PMID: 32560315 PMCID: PMC7350239 DOI: 10.3390/vaccines8020308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022] Open
Abstract
Tetanus is a serious and potentially fatal systemic disease, caused by the bacterium Clostridium tetani. It is estimated that 1 million cases occur worldwide annually. Immunization programs have drastically decreased tetanus in developed countries, and the sporadic cases have been linked to injecting drug users (IDUs), immunosuppressed individuals, or those older than 65 without complete vaccination. Regrettably, it is still endemic in under-developed countries. In Spain, an average of 10 cases are notified each year, especially affecting those older than 65. The present article describes a case of a 48-year-old Spanish woman, an ex-convict and IDU with infection antecedents of Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV), who was admitted to the Emergency Department of a University Hospital with cervical rigidity and trismus. In a few hours, a neurological and respiratory deterioration was observed, resulting in admittance to the intensive care unit under the suspicion of a generalized tetanus infection. The treatment included hemodynamic support and respiratory therapy, antibiotics, muscle relaxants, sedatives, and tetanus immunoglobulin. Her stay in the ICU lasted 47 days. The clinical suspicion, the antecedents of risk, and the verification of the vaccination records should provide early guidance for diagnostics and the establishment of a treatment in these cases.
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Affiliation(s)
- Nancy Vicente-Alcalde
- Penitentiary Center Alicante II, Villena, Alicante, Carretera N-330, Km. 66, 03400 Villena, Spain;
| | - Tamara Martín-Casquero
- Servicio de Urgencias, Hospital Universitario del Vinalopó-Elche, Calle Tonico Sansano Mora, 03293 Elche, Spain; (T.M.-C.); (E.R.-E.)
| | - Esther Ruescas-Escolano
- Servicio de Urgencias, Hospital Universitario del Vinalopó-Elche, Calle Tonico Sansano Mora, 03293 Elche, Spain; (T.M.-C.); (E.R.-E.)
| | - José Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain
- Correspondence:
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Zaragoza NE, Orellana CA, Moonen GA, Moutafis G, Marcellin E. Vaccine Production to Protect Animals Against Pathogenic Clostridia. Toxins (Basel) 2019; 11:E525. [PMID: 31514424 PMCID: PMC6783934 DOI: 10.3390/toxins11090525] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 12/19/2022] Open
Abstract
Clostridium is a broad genus of anaerobic, spore-forming, rod-shaped, Gram-positive bacteria that can be found in different environments all around the world. The genus includes human and animal pathogens that produce potent exotoxins that cause rapid and potentially fatal diseases responsible for countless human casualties and billion-dollar annual loss to the agricultural sector. Diseases include botulism, tetanus, enterotoxemia, gas gangrene, necrotic enteritis, pseudomembranous colitis, blackleg, and black disease, which are caused by pathogenic Clostridium. Due to their ability to sporulate, they cannot be eradicated from the environment. As such, immunization with toxoid or bacterin-toxoid vaccines is the only protective method against infection. Toxins recovered from Clostridium cultures are inactivated to form toxoids, which are then formulated into multivalent vaccines. This review discusses the toxins, diseases, and toxoid production processes of the most common pathogenic Clostridium species, including Clostridiumbotulinum, Clostridiumtetani, Clostridiumperfringens, Clostridiumchauvoei, Clostridiumsepticum, Clostridiumnovyi and Clostridiumhemolyticum.
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Affiliation(s)
- Nicolas E. Zaragoza
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane, QLD 4072, Australia; (N.E.Z.); (C.A.O.)
| | - Camila A. Orellana
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane, QLD 4072, Australia; (N.E.Z.); (C.A.O.)
| | - Glenn A. Moonen
- Zoetis, 45 Poplar Road, Parkville VIC 3052, Australia; (G.A.M.); (G.M.)
| | - George Moutafis
- Zoetis, 45 Poplar Road, Parkville VIC 3052, Australia; (G.A.M.); (G.M.)
| | - Esteban Marcellin
- Australian Institute for Bioengineering and Nanotechnology (AIBN), The University of Queensland, Brisbane, QLD 4072, Australia; (N.E.Z.); (C.A.O.)
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Naseem F, Hussain A, Arif F. Frequency of Acute Kidney Injury in tetanus patients of Paedriatic Intensive Care Unit: A Public Hospital Experience. Pak J Med Sci 2018; 34:363-367. [PMID: 29805409 PMCID: PMC5954380 DOI: 10.12669/pjms.342.14254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and Objective: Tetanus is a potentially fatal but preventable disease. Mortality is related to severity of the disease, cardiovascular, pulmonary and renal complications. Acute kidney injury (AKI) is a frequent and lethal complication of tetanus. The objective was to determine the frequency of AKI in tetanus patients managed in a public hospital. Methods: Children aged 1-12 years admitted in Paediatric Intensive Care Unit (PICU) with the clinical diagnosis of tetanus over three and half years were recruited for the retrospective study. pRIFLE (Pediatric Risk, Injury, Failure, Loss, End) criteria was applied to all cases of tetanus to categorize them as having AKI or not, on the basis of estimated creatinine clearance (ECCL). Comparison was done between AKI and non-AKI cases, as well as between AKI survivors and AKI non-survivors. The study was conducted at PICU of Dr. Ruth K.M. PFau Civil Hospital Karachi for tetanus cases admitted during July 2013 to December 2016 Results: During the study period, 44 patients of tetanus were enrolled. Nearly 32 % of tetanus patients developed acute renal dysfunction according to PRIFLE criteria. There were overall 15 (34.09%) expiries among tetanus patients among which nine (60%) had AKI. Oliguria was observed in five (35.71%) cases. All the AKI non-survivors had ECCL below 50% and all had autonomic instability. AKI developed towards the end of first week in three cases, mid of second week in four cases and third week in seven cases. Renal replacement therapy (RRT) i.e. peritoneal dialysis (PD) was done in four AKI cases but it did not improve the outcome. CRP was more than 50 in 24 (54.54%) cases. Ventilatory support was given to 85.71% with AKI as compared to 66.66% of non AKI patients. Conclusion: Development of AKI in tetanus is multifactorial. Major contributors are severity of the tetanus itself, presence of autonomic instability, ventilator dependency, and sepsis. Presence of AKI worsens the outcome of tetanus in terms of survival, length of stay, hospital cost and ventilator days.
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Affiliation(s)
- Faizia Naseem
- Faizia Naseem, MBBS, DCH, MCPS, FCPS. Assistant Professor Department of Paediatrics, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Abid Hussain
- Abid Hussain, MBBS, DCH, FCPS. Assistant Professor Department of Paediatrics, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Fehmina Arif
- Fehmina Arif, MBBS, DCH, FCPS. Professor, Department of Paediatrics, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Sugiura T, Yamamoto K, Sato M, Kirita T. Tetanus: A Report of Two Cases and Review of Literature - A Continuing Threat to the Elderly in Japan. Contemp Clin Dent 2018; 8:642-644. [PMID: 29326519 PMCID: PMC5754989 DOI: 10.4103/ccd.ccd_259_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Tetanus has become rare in industrialized countries, largely due to the effectiveness of immunization. However, the elderly are susceptible to tetanus because many have not received primary immunization; the incidence of tetanus in Japan is still 120 cases/year. The initial symptoms of tetanus, such as trismus and dysphagia, are observed in the orofacial region. However, because of the disease's rarity, the clinician may be unfamiliar with the clinical presentation and may not suspect tetanus. We report two cases of elderly patients with generalized tetanus. Both patients presented trismus and/or dysphagia and consulted three different departments before the diagnosis of tetanus. Japanese clinicians will encounter tetanus more frequently than practitioners in other countries. Dental surgeons should be familiar with the clinical appearance of tetanus and should consider this disease in a nonimmunized patient presenting as an atypical case of trismus and dysphagia.
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Affiliation(s)
- Tsutomu Sugiura
- Department of Oral and Maxillofacial Surgery, Nara Kasuga Hospital, Nara, Japan.,Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan
| | - Kazuhiko Yamamoto
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan
| | - Masatoshi Sato
- Department of Infectious Diseases, Nara City Hospital, Nara, Japan
| | - Tadaaki Kirita
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Nara, Japan
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Abstract
We describe a patient presenting with altered mental state, generalised stiffening of the body and limbs as a result of acute generalised tetanus. Discussion of the clinical manifestations, diagnosis, initial management in the emergency department and complications is put forth.
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Admission of tetanus patients to the ICU: a retrospective multicentre study. Ann Intensive Care 2017; 7:112. [PMID: 29116572 PMCID: PMC5676569 DOI: 10.1186/s13613-017-0333-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/25/2017] [Indexed: 01/18/2023] Open
Abstract
Background
An extended course of tetanus (up to 6 weeks) requiring ICU admission and protracted mechanical ventilation (MV) may have a significant impact on short- and long-term survival. The subject is noteworthy and deserves to be discussed. Methods Twenty-two ICUs in France performed tetanus screenings on patients admitted between January 2000 and December 2014. Retrospective data were collected from hospital databases and through the registers of the town hall of the patients. Results Seventy patients were included in 15 different ICUs. Sixty-three patients suffered from severe or very severe tetanus according to the Ablett classification. The median age was 80 years [interquartile range 73–84], and 86% of patients were women. Ninety per cent of patients (n = 63) required MV for a median of 36 days [26–46], and 66% required administration of a neuromuscular-blocking agent for 23 days [14–29]. A nosocomial infection occurred in 43 patients (61%). ICU and 1-year mortality rates were 14% (n = 10) and 16% (n = 11), respectively. Forty-five per cent of deaths occurred during the first week. Advanced age, a higher SAPS II, any infection, and the use of vasopressors were significantly associated with a lower number of days alive without ventilator support by day 90. Age was the only factor that significantly differed between deceased and survivors at 1 year (83 [81–85] vs. 79 [73–84] years, respectively; p = 0.03). Sixty-one per cent of survivors suffered no impairment to their functional status. Conclusion In a high-income country, tetanus mainly occurs in healthy elderly women. Despite prolonged MV and extended ICU length of stay, we observed a low 1-year mortality rate and good long-term functional status.
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van Galen G, Rijckaert J, Mair T, Amory H, Armengou L, Bezdekova B, Durie I, Findshøj Delany R, Fouché N, Haley L, Hewetson M, van den Hoven R, Kendall A, Malalana F, Muller Cavalleri J, Picavet T, Roscher K, Verwilghen D, Westermann C, Saegerman C. Retrospective evaluation of 155 adult equids and 21 foals with tetanus from Western, Northern, and Central Europe (2000-2014). Part 2: Prognostic assessment. J Vet Emerg Crit Care (San Antonio) 2017; 27:697-706. [PMID: 28960891 DOI: 10.1111/vec.12669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 03/07/2016] [Accepted: 04/07/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify prognostic variables for adult equids and foals with tetanus. DESIGN Multicenter retrospective study (2000-2014). SETTING Twenty Western, Northern, and Central European university teaching hospitals and private referral centers. ANIMALS One hundred fifty-five adult equids and 21 foals with tetanus. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Variables from history and clinical examination were statistically compared between survivors and nonsurvivors (adults: 49 survivors, 85 nonsurvivors; foals: 7 survivors, 10 nonsurvivors). Cases euthanized for financial reasons were excluded. Mortality rates in adults and foals were 68.4% and 66.7%, respectively. Variables associated with survival in adults included: standing, normal intestinal sounds and defecation, voluntarily drinking, eating soft or normal food, lower heart and respiratory rates, high base excess on admission, longer diagnosis time, treatment and hospitalization delay, and mild severity grade. Variables associated with death included: anorexia, dysphagia, dyspnea, low blood potassium concentration on admission, moderate and severe disease grading, development of dysphagia, dyspnea, recumbency and seizures during hospitalization, treatment with glycerol guaiacolate, intravenous fluids, and intravenous glucose solutions. Variables associated with survival in foals included standing on admission, voluntarily eating soft food and drinking, older age, and longer hospitalization delay. Outcome was not different between different tetanus antitoxin (TAT) dosages, although there was a trend of increasing survival rate with increasing TAT dosages. Cases with appropriate vaccination prior to development of tetanus were rare, but had improved outcome and shorter hospitalization. CONCLUSIONS Prognosis for equine tetanus is poor with similar outcome and prognostic factors in foals and adults. The prognostic assessment of cases with tetanus provides clinicians with new evidence-based information related to patient management. Several prognostic indicators relate to the ability to eat or drink, and more severe clinical signs relate to poor outcome. Increasing intravenous dosages of TAT has no significant effect on outcome, but the positive trend identified may support a recommendation for high intravenous TAT dosages. Further evaluation is warranted.
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Affiliation(s)
- Gaby van Galen
- Department of Veterinary Clinical Sciences, University Copenhagen, University of Copenhagen, Denmark
| | - Joke Rijckaert
- the Equine Hospital, Faculty of Veterinary Medicine, University of Ghent, Belgium
| | - Tim Mair
- Bell Equine Veterinary Clinic, Maidstone, United Kingdom
| | - Helene Amory
- The Equine Hospital, Center for Fundamental and Applied Research for Animal and Health (FARAH), Faculty of Veterinary Medicine, University of Liege, Belgium
| | - Lara Armengou
- The Unitat Equina, Fundació Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Spain
| | - Barbora Bezdekova
- The Equine Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Czech Republic
| | - Inge Durie
- Evidensia Strömsholm Equine Hospital, Strömsholm, Sweden
| | - Rikke Findshøj Delany
- Department of Veterinary Clinical Sciences, University Copenhagen, University of Copenhagen, Denmark
| | - Nathalie Fouché
- the Swiss Institute of Equine Medicine (ISME), Vetsuisse Faculty, University of Bern, Switzerland
| | - Laura Haley
- the University Veterinary Teaching Hospital, School of Veterinary Medicine, University College Dublin, Ireland
| | - Michael Hewetson
- the Faculty of Veterinary Medicine, University of Helsinki, Finland
| | | | - Anna Kendall
- the Equine Hospital, Faculty of Veterinary Medicine, University of Uppsala SLU, Sweden
| | - Fernando Malalana
- the Philip Leverhulme Equine Hospital, University of Liverpool, United Kingdom
| | - Jessika Muller Cavalleri
- the Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Germany, De Bosdreef, Moerbeke-Waas, Belgium
| | - Tresemiek Picavet
- the Clinic for Horses, University of Veterinary Medicine Hannover, Foundation, Germany, De Bosdreef, Moerbeke-Waas, Belgium
| | - Katja Roscher
- the Equine Clinic, Faculty of Veterinary Medicine, University of Giessen, Germany
| | - Denis Verwilghen
- Department of Veterinary Clinical Sciences, University Copenhagen, University of Copenhagen, Denmark
| | - Cornélie Westermann
- the Equine Hospital, Faculty of Veterinary Medicine, University of Utrecht, The Netherlands
| | - Claude Saegerman
- The Equine Hospital, Center for Fundamental and Applied Research for Animal and Health (FARAH), Faculty of Veterinary Medicine, University of Liege, Belgium
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An unexpected tetanus case. THE LANCET. INFECTIOUS DISEASES 2017; 16:746-752. [PMID: 27301930 DOI: 10.1016/s1473-3099(16)00075-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 12/29/2015] [Accepted: 02/01/2016] [Indexed: 10/21/2022]
Abstract
1 million cases of tetanus are estimated to occur worldwide each year, with more than 200 000 deaths. Tetanus is a life-threatening but preventable disease caused by a toxin produced by Clostridium tetani-a Gram-positive bacillus found in high concentrations in soil and animal excrement. Tetanus is almost completely preventable by active immunisation, but very rarely unexpected cases can occur in individuals who have been previously vaccinated. We report a case of generalised tetanus in a 22-year-old woman that arose despite the protective antitoxin antibody in her serum. The patient received all her vaccinations in the USA; her last vaccination was 6 years ago. The case was unusual because the patient had received all standard vaccinations, had no defined port of entry at disease onset, and had symptoms lasting for 6 months. Tetanus can present with unusual clinical forms; therefore, the diagnosis and management of this rare but difficult disease should be updated. In this Grand Round, we review the clinical features, epidemiology, treatment, and prognosis of C tetani infections.
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15
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Spontaneous Nosocomial Pseudomonas aeruginosa Meningitis Presenting as Trismus. Case Rep Infect Dis 2017; 2017:8705860. [PMID: 28567316 PMCID: PMC5439181 DOI: 10.1155/2017/8705860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/28/2017] [Accepted: 04/19/2017] [Indexed: 11/17/2022] Open
Abstract
We describe the case of a 78-year-old female receiving adjuvant postsurgical chemotherapy for colon adenocarcinoma who spontaneously developed nosocomial Pseudomonas meningitis causing severe trismus. The patient was initially admitted for ileus, developing neck stiffness and trismus on the thirteenth day of admission. Cerebrospinal fluid grew pansensitive Pseudomonas aeruginosa. Magnetic resonance imaging of the brain was consistent with bilateral subacute infarcts secondary to meningitis. The patient responded well to 21 days of broad spectrum antimicrobial therapy modified to ceftazidime alone following speciation and sensitivity. Outpatient follow-up at 46 days revealed normal maximal mouth opening with the ability to chew and tolerate a full diet. Trismus is a motor disturbance of the trigeminal nerve with difficulty in opening the mouth. Infectious etiologies commonly described include tetanus, odontogenic infections, or deep neck space infections. This is the first reported case of simultaneous nosocomial Pseudomonas meningitis and trismus in a patient with no history of neurosurgery or lumbar spinal manipulation.
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Jeremijenko A, Mclaws ML, Kosasih H. A Tsunami Related Tetanus Epidemic in Aceh, Indonesia. Asia Pac J Public Health 2016; 19 Spec No:40-4. [DOI: 10.1177/101053950701901s07] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A Jeremijenko
- Woodside Energy Ltd, Perth, Western Australia, Australia
| | - ML Mclaws
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - H Kosasih
- Viral Diseases Program, Naval Medical Research Unit No. 2, Jakarta, Indonesia
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17
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Brandsæter B, Aaberge IS, Dunlop O. Tetanus after a minor injury leading to death in a previously non-immunized, elderly, Norwegian woman. IDCases 2015; 2:53-5. [PMID: 26793455 PMCID: PMC4672617 DOI: 10.1016/j.idcr.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 10/31/2022] Open
Abstract
Tetanus vaccination is part of the Norwegian childhood vaccination program. An elderly woman injured her arm and leg after a minor fall on her outdoor stairs. Two weeks later she presented with trismus. This developed into tetanic spasms, obstructed airways and the need for a tracheostomy. She died 14 days later due to pneumonia and multi-organ failure. ELISA for tetanus toxoid IgG was negative, probably because the patient was born before the introduction of tetanus vaccination in the Norwegian childhood vaccination program. Lack of adherence to the vaccination programs should be considered in patients presenting with symptoms resembling diseases they normally would be protected from. Although the patient presented with typical symptoms the diagnosis was not suspected initially, probably due to the rareness of this disease in Norway.
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Affiliation(s)
- Bjørn Brandsæter
- Department of Infectious Diseases, Oslo University Hospital Ullevaal, Norway
| | - Ingeborg S Aaberge
- Norwegian Institute of Public Health, Division of Infectious Disease Control, Oslo, Norway
| | - Oona Dunlop
- Department of Acute Medicine, Oslo University Hospital Ullevaal, Norway
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18
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Aksoy M, Celık EC, Ahıskalıoglu A, Karakaya MA. Tetanus is still a deadly disease: a report of six tetanus cases and reminder of our knowledge. Trop Doct 2013; 44:38-42. [DOI: 10.1177/0049475513515213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We analysed the data in the medical records of six patients admitted for tetanus in the intensive care unit (ICU) of the anaesthesia department in the Medical Faculty of Ataturk University from 1 January 2010 to 31 December 2012. All patients received the generalized form of treatment for tetanus in the ICU. The average age of the patients was 65.33 ± 13.45 years. Treatment modalities were administered to the patients in accordance with the literature. Four patients died despite all therapeutic interventions and two patients were discharged uneventfully. All those who died had chronic disease and infected wounds on their head, but only one patient had an infected wound on his leg. The surviving patients had no chronic illnesses but did have injuries on their legs. The presence of chronic disease increases tetanus-related mortality. More information about the disease must be made available in order to make it preventable with regular vaccinations.
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Affiliation(s)
- Mehmet Aksoy
- Assistant Professor and Medical Doctor, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Erkan Cem Celık
- Research Assistant and Medical Doctor, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Alı Ahıskalıoglu
- Anesthetist and Medical Doctor, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Muhammet Ahmet Karakaya
- Research Assistant and Medical Doctor, Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
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19
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Laverse E, Dhamija K, Meyers M, Grant K. Pre-emptive treatment for Clostridium tetani: importance of early recognition and treatment in the community. BMJ Case Rep 2009; 2009:bcr03.2009.1649. [PMID: 21686979 DOI: 10.1136/bcr.03.2009.1649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The case of a 79-year-old woman with neurotoxin producing Clostridium tetani identified in a lower limb laceration that was promptly treated is presented; the patient developed no symptoms of tetanus. Her antibody levels were measured as 0.01 U/ml (protective levels >0.01 U/ml) and were therefore not protective. The isolate of C tetani was identified by 16S sequencing. The potential to produce tetanus toxin was determined by detection of a fragment of the C tetani neurotoxin gene. She was given a week long course of oral flucloxacillin, 500 mg four times a day and metronidazole, 400 mg three times a day, for 5 days. The patient was subsequently given prophylactic immunoglobulin (500 IU) as per guidelines. The fact that the patient did not manifest any symptoms of localised or generalised tetanus could be attributed to prompt management when she presented to her primary care site.
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Gouveia PADC, Silva CEF, Miranda Filho DDB, Bernardino SN, Escarião AG, Ximenes RADA. Tendência temporal do tétano acidental no período de 1981 a 2004 em Pernambuco com avaliação do impacto da assistência em unidade de terapia intensiva sobre a letalidade. Rev Soc Bras Med Trop 2009; 42:54-7. [DOI: 10.1590/s0037-86822009000100011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 01/19/2009] [Indexed: 11/22/2022] Open
Abstract
Apesar da redução na incidência de tétano acidental no Brasil, não houve queda significativa na letalidade. Nesta série de casos, comparamos a letalidade antes e após o estabelecimento padrão de manejo em unidade de terapia intensiva do paciente com tétano no Hospital Universitário Oswaldo Cruz, no período de 1981 a 2004. Em 24 anos, foram internados 1.971 pacientes e antes do manejo em Unidade de terapia intensiva a letalidade era de 35%. Durante 1997 foi instituída a unidade de terapia intensiva para assistência dos pacientes com tétano, e de 1998 a 2004, a letalidade caiu para 12,6%, OR= 0,27 (IC95%= 0,18- 0,39); p<0,001. Esta tendência foi evidenciada em todas as faixas etárias e em ambos os sexos. A centralização da assistência a esses pacientes em um único serviço especializado com Unidade de terapia intensiva de forma precoce, portanto, tem sido decisiva na redução da letalidade, por contar com a vasta experiência da equipe de saúde no manejo do tétano e melhor tratamento sintomático, antecipando as graves complicações da doença.
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Abstract
Maternal and neonatal tetanus are important causes of maternal and neonatal mortality, claiming about 180 000 lives worldwide every year, almost exclusively in developing countries. Although easily prevented by maternal immunisation with tetanus toxoid vaccine, and aseptic obstetric and postnatal umbilical-cord care practices, maternal and neonatal tetanus persist as public-health problems in 48 countries, mainly in Asia and Africa. Survival of tetanus patients has improved substantially for those treated in hospitals with modern intensive-care facilities; however, such facilities are often unavailable where the tetanus burden is highest. The Maternal and Neonatal Tetanus Elimination Initiative assists countries in which maternal and neonatal tetanus has not been eliminated to provide immunisation with tetanus toxoid to women of childbearing age. The ultimate goal of this initiative is the worldwide elimination of maternal and neonatal tetanus. Since tetanus spores cannot be removed from the environment, sustaining elimination will require improvements to presently inadequate immunisation and health-service infrastructures, and universal access to those services. The renewed worldwide commitment to the reduction of maternal and child mortality, if translated into effective action, could help to provide the systemic changes needed for long-term elimination of maternal and neonatal tetanus.
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Simpson J, Inglis A, Gordon MWG. Back pain as the presenting symptom of generalised tetanus. Emerg Med J 2007; 24:e5. [PMID: 17183029 PMCID: PMC2658177 DOI: 10.1136/emj.2006.041269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Back pain is a common presenting symptom in emergency departments and primary care across the UK. The extensive differential diagnosis includes mechanical, infective, thoracic, abdominal and vascular causes. This case report describes a patient who presented with lower back pain with a rare diagnosis, which is becoming more common in certain population groups, and emphasises the importance of clinical skills and insuring adequate tetanus prophylaxis.
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Affiliation(s)
- J Simpson
- Royal Alexandra Hospital, Paisley, UK.
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23
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Linnenbrink T, McMichael M. Tetanus: pathophysiology, clinical signs, diagnosis, and update on new treatment modalities. J Vet Emerg Crit Care (San Antonio) 2006. [DOI: 10.1111/j.1476-4431.2006.00192.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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Thwaites CL, Yen LM, Glover C, Tuan PQ, Nga NTN, Parry J, Loan HT, Bethell D, Day NPJ, White NJ, Soni N, Farrar JJ. Predicting the clinical outcome of tetanus: the tetanus severity score. Trop Med Int Health 2006; 11:279-87. [PMID: 16553907 DOI: 10.1111/j.1365-3156.2006.01562.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To create a new tetanus score and compare it with the Phillips and Dakar scores. METHODS We used prospectively acquired data from consecutive patients admitted to the Hospital for Tropical Diseases, Ho Chi Minh City, to create the Tetanus Severity Score (TSS) with multivariate logistic regression. We compared the new score with Phillips and Dakar scores by means of resubstituted and prospective data, assessing performance in terms of sensitivity, specificity and area under receiver operator characteristic curves. RESULTS Resubstitution testing yielded a sensitivity of 77% (298/385) and a specificity of 82% (1,183/1,437) for the TSS; 89% (342/385) and 20% (281/1,437) for the Phillips score; and 13% (49/385) and 98% (1,415/1,437) for the Dakar score. The TSS showed greatest discrimination with 0.89 area under the receiver operator characteristic curve (95% CI 0.88-0.90); this was 0.74 for the Dakar score and (95% CI 0.71-0.77) and 0.66 for the Phillips score (95% CI 0.63-0.70; P values <0.001). Prospective testing showed 65% (13/20) sensitivity and 91% (210/230) specificity for the TSS; 80% (16/20) and 51% (118/230) for the Phillips score; and 25% (5/20) and 96% (221/230) for the Dakar score. The TSS achieved the greatest area under TSS of 0.89 (95% CI 0.82-0.96), significantly greater than the Phillips score [0.74 (0.6-0.88), P = 0.049] but not the Dakar score [0.80, (0.71-0.90), P = 0.090]. CONCLUSIONS The TSS is the first prospectively developed classification scheme for tetanus and should be adopted to aid clinical triage and management and as a basis for clinical research.
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Affiliation(s)
- C L Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
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