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Kataria V, Agha T, Ryman K, Iyer N. Strategic Utilization of Dantrolene in a Case of Severe Acute Generalized Tetanus. J Pharm Pract 2024; 37:766-769. [PMID: 37226965 DOI: 10.1177/08971900231178429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Tetanus is a life-threatening, vaccine-preventable disease caused by an endotoxin produced by Clostridium tetani. We report a case of severe tetanus in an adult male with a history of intravenous drug use. The patient presented with a 1-day history of inability to open his jaw and a right lower extremity necrotic wound. Initial management consisted of tetanus toxoid, human tetanus immunoglobulin, antimicrobials and intermittent lorazepam. Due to progressive symptoms, wound debridement and placement of an advanced airway in the operating room ensued. Episodes of tetany were associated with fever, autonomic instability, acute desaturations and preemptive ventilator triggering despite maximum doses of continuous propofol and midazolam. Neuromuscular blockade with cisatracurium was added, resulting in control of tetany. Despite initial control, NMB could not be weaned due to recurrent spasms. Intravenous dantrolene was therefore sought as an alternative antispasmodic. Following an initial load, patient was successfully liberated from cisatracurium. Dantrolene was therefore converted to enteral to facilitate gradual down-titration of intravenous sedatives with subsequent conversion to oral benzodiazepines. After a prolonged hospital course, the patient was able to be discharged home. Dantrolene was thus effectively utilized as an adjunctive antispasmodic agent to facilitate liberation from cisatracurium and continuous sedation.
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Affiliation(s)
- Vivek Kataria
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Terra Agha
- Baylor Scott and White Pulmonary and Critical Care Specialists, Dallas, TX, USA
| | - Klayton Ryman
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX, USA
| | - Nithya Iyer
- Baylor Scott and White Pulmonary and Critical Care Specialists, Dallas, TX, USA
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Fatly ZA, Betjes MGH, Dik WA, Fouchier RAM, Reinders MEJ, de Weerd AE. Mycophenolate mofetil hampers antibody responses to a broad range of vaccinations in kidney transplant recipients: Results from a randomized controlled study. J Infect 2024; 88:106133. [PMID: 38432583 DOI: 10.1016/j.jinf.2024.106133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/10/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES To study the effect of mycophenolate mofetil (MMF) on various vaccination responses in kidney transplant recipients. METHODS In a randomized controlled trial (EudraCT nr.: 2014-001372-66), low immunologically risk kidney transplant recipients were randomized to TAC/MMF or TAC-monotherapy (TACmono), six months post-transplantation. One year after transplantation, in a pre-specified sub-study, recipients were vaccinated against pneumococcus, tetanus and influenza. Blood was sampled before and 21 days after vaccination. Adequate vaccination responses were defined by international criteria. A post-hoc analysis was conducted on SARS-CoV-2 vaccination responses within the same cohort. RESULTS Seventy-one recipients received pneumococcal and tetanus vaccines (TAC/MMF: n = 37, TACmono: n = 34), with 29 also vaccinated against influenza. When vaccinated, recipients were 60 (54-66) years old, with median eGFR of 54 (44-67) ml/min, tacrolimus trough levels 6.1 (5.4-7.0) ug/L in both groups and TAC/MMF daily MMF dose of 1000 (500-2000) mg. Adequate vaccination responses were: pneumococcal (TAC/MMF 43%, TACmono 74%, p = 0.016), tetanus (TAC/MMF 35%, TACmono 82%, p < 0.0001) and influenza (TAC/MMF 20%, TACmono 71%, p = 0.0092). Only 7% of TAC/MMF responded adequately to all three compared to 36% of TACmono (p = 0.080). Additionally, 40% of TAC/MMF responded inadequately to all three, whereas all TACmono patients responded adequately to at least one vaccination (p = 0.041). Lower SARS-CoV-2 vaccination antibody responses correlated with lower pneumococcal antibody vaccination responses (correlation coefficient: 0.41, p = 0.040). CONCLUSIONS MMF on top of tacrolimus severely hampers antibody responses to a broad range of vaccinations.
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Affiliation(s)
- Z Al Fatly
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - M G H Betjes
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - W A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - R A M Fouchier
- Department of Viroscience, Erasmus Medical Center, Rotterdam, the Netherlands
| | - M E J Reinders
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A E de Weerd
- Erasmus MC Transplant Institute, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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Rahim AIA, Azlan EAM, Rahman MR, Pathi NM, Ismail M, Sulaiman WAW. Case Report: A Challenging Case of Tetanus Presenting with Headache. Am J Trop Med Hyg 2023; 109:1242-1244. [PMID: 37955309 DOI: 10.4269/ajtmh.23-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/18/2023] [Indexed: 11/14/2023] Open
Abstract
Tetanus is a life-threatening infectious neurological condition that has become uncommon due to large-scale immunization campaigns. We describe a rare instance of generalized tetanus presenting with a headache on a tropical island in Malaysia. A 43-year-old woman presenting with headaches and generalized body weakness, which progressed into trismus and neck stiffness. Her medical history indicated a wound on the sole of her foot caused by shattered glass in an unhygienic area, but no tetanus prophylaxis had been administered. The patient was subsequently given immunoglobulin, tetanus toxoid, metronidazole, and sedatives in the recommended dosages. Her neurological condition improved remarkably, but she suffered blood pressure fluctuations due to dysautonomia. She was successfully discharged with complete recovery after 6 months of follow-up. The case demonstrates the significance of appropriate identification and care of tetanus, as well as the lethal effects of untreated wounds in vulnerable patients.
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Affiliation(s)
- Afiq Izzudin A Rahim
- Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia Health Campus, Kubang Kerian, Kelantan, Malaysia
- Langkawi Health District Office, Kompleks LADA, Kuah, Langkawi, Kedah, Malaysia
| | - Emir Afif Mohammad Azlan
- Communicable Disease Unit, Kedah Health State Department, Simpang Kuala, Jalan Kuala Kedah, Alor Setar, Kedah, Malaysia
| | | | | | - Mansor Ismail
- Langkawi Health District Office, Kompleks LADA, Kuah, Langkawi, Kedah, Malaysia
| | - Wan Aliaa Wan Sulaiman
- Neurology Department, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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Nunes MC, Tamblyn A, Jose L, Ntsimane M, Lerotholi N, Machimana C, Taylor A, Laher F, Madhi SA. Immunogenicity of tetanus, diphtheria and acellular pertussis vaccination among pregnant women living with and without HIV. AIDS 2023; 37:2305-2310. [PMID: 37773052 PMCID: PMC10653295 DOI: 10.1097/qad.0000000000003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE Vaccination during pregnancy with tetanus-diphtheria-acellular pertussis (Tdap) vaccine is recommended to protect the young infants against pertussis. There is a paucity of data on immune responses to Tdap in pregnant women with HIV (PWWH), and its impact on the protection of their infants has not been described. METHODS In an open label phase IV clinical trial in South Africa, we evaluated the immunogenicity and safety of Tdap in PWWH compared with HIV-uninfected women. Antigen-specific immunoglobulin G (IgG) to pertussis toxoid, filamentous haemagglutinin, pertactin, fimbriae, diphtheria and tetanus were measured by electrochemiluminescence-based multiplex assay. RESULTS Overall, 91 PWWH and 136 HIV-uninfected pregnant women were enrolled. All PWWH were on antiretroviral treatment and 94.5% had HIV viral loads <40 copies per millilitre. Antibody levels prevaccination were lower among PWWH compared with HIV-uninfected women for all antigens. At 1 month postvaccination PWWH compared with HIV-uninfected women had lower fold-increase and antibody concentrations for all epitopes. Also, a lower proportion of PWWH achieved ≥4-fold increase from pre to postvaccination for pertussis toxoid and pertactin, or diphtheria IgG levels ≥0.1 IU/ml and ≥1 IU/ml postvaccination. Adverse events postvaccination were similar in PWWH and HIV-uninfected. CONCLUSION Tdap vaccination was safe and immunogenic. PWHW had, however, attenuated humoral immune responses, which could affect the effectiveness of protecting their infants against pertussis compared with those born to women without HIV.ClinicalTrials.gov identifier: NCT05264662.
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Affiliation(s)
- Marta C. Nunes
- Center of Excellence in Respiratory Pathogens (CERP), Hospices Civils de Lyon and Centre International de Recherche en Infectiologie (CIRI), Équipe Santé publique, épidémiologie et écologie évolutive des maladies infectieuses (PHE3ID), Inserm U1111, CNRS UMR5308, ENS de Lyon, Université Claude Bernard Lyon 1, Lyon, France
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Amy Tamblyn
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Lisa Jose
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Mathapelo Ntsimane
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Ntoetse Lerotholi
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Charmaine Machimana
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Ashleigh Taylor
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Farzanah Laher
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
| | - Shabir A. Madhi
- South African Medical Research Council, Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences
- Wits Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Van Hao N, Loan HT, Yen LM, Kestelyn E, Hong DD, Thuy DB, Nguyen NT, Duong HTH, Thuy TTD, Nhat PTH, Khanh PNQ, Dung NTP, Phu NH, Phong NT, Lieu PT, Tuyen PT, Hanh BTB, Nghia HDT, Oanh PKN, Tho PV, Tan Thanh T, Turner HC, van Doorn HR, Van Tan L, Wyncoll D, Day NP, Geskus RB, Thwaites GE, Van Vinh Chau N, Thwaites CL. Human versus equine intramuscular antitoxin, with or without human intrathecal antitoxin, for the treatment of adults with tetanus: a 2 × 2 factorial randomised controlled trial. The Lancet Global Health 2022; 10:e862-e872. [PMID: 35561721 PMCID: PMC9115864 DOI: 10.1016/s2214-109x(22)00117-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/11/2022] [Accepted: 03/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background Intramuscular antitoxin is recommended in tetanus treatment, but there are few data comparing human and equine preparations. Tetanus toxin acts within the CNS, where there is limited penetration of peripherally administered antitoxin; thus, intrathecal antitoxin administration might improve clinical outcomes compared with intramuscular injection. Methods In a 2 × 2 factorial trial, all patients aged 16 years or older with a clinical diagnosis of generalised tetanus admitted to the intensive care unit of the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam, were eligible for study entry. Participants were randomly assigned first to 3000 IU human or 21 000 U equine intramuscular antitoxin, then to either 500 IU intrathecal human antitoxin or sham procedure. Interventions were delivered by independent clinicians, with attending clinicians and study staff masked to treatment allocations. The primary outcome was requirement for mechanical ventilation. The analysis was done in the intention-to-treat population. The study is registered at ClinicalTrials.gov, NCT02999815; recruitment is completed. Findings 272 adults were randomly assigned to interventions between Jan 8, 2017, and Sept 29, 2019, and followed up until May, 2020. In the intrathecal allocation, 136 individuals were randomly assigned to sham procedure and 136 to antitoxin; in the intramuscular allocation, 109 individuals were randomly assigned to equine antitoxin and 109 to human antitoxin. 54 patients received antitoxin at a previous hospital, excluding them from the intramuscular antitoxin groups. Mechanical ventilation was given to 56 (43%) of 130 patients allocated to intrathecal antitoxin and 65 (50%) of 131 allocated to sham procedure (relative risk [RR] 0·87, 95% CI 0·66–1·13; p=0·29). For the intramuscular allocation, 48 (45%) of 107 patients allocated to human antitoxin received mechanical ventilation compared with 48 (44%) of 108 patients allocated to equine antitoxin (RR 1·01, 95% CI 0·75–1·36, p=0·95). No clinically relevant difference in adverse events was reported. 22 (16%) of 136 individuals allocated to the intrathecal group and 22 (11%) of 136 allocated to the sham procedure experienced adverse events related or possibly related to the intervention. 16 (15%) of 108 individuals allocated to equine intramuscular antitoxin and 17 (16%) of 109 allocated to human antitoxin experienced adverse events related or possibly related to the intervention. There were no intervention-related deaths. Interpretation We found no advantage of intramuscular human antitoxin over intramuscular equine antitoxin in tetanus treatment. Intrathecal antitoxin administration was safe, but did not provide overall benefit in addition to intramuscular antitoxin administration. Funding The Wellcome Trust.
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Affiliation(s)
- Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Duc Du Hong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | | | | | | | - Phung Tran Huy Nhat
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Phan Nguyen Quoc Khanh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Phuong Dung
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Pham Thi Lieu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Thi Tuyen
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Bui Thi Bich Hanh
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | | | - Phan Vinh Tho
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Tan Thanh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Hugo C Turner
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK
| | - Le Van Tan
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nicholas Pj Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK
| | | | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK.
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Röttgering JG, Herderscheê D, Lionarons DA, de Vries PJ. [An unvaccinated man with a painful arm and jaw]. Ned Tijdschr Geneeskd 2020; 164:D3932. [PMID: 32186824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Clostridium tetani is a gram-positive spore-forming bacterium that produces toxins and grows under anaerobic conditions. Infections with this bacterium can lead to local or generalised forms of tetanus. CASE DESCRIPTION An 83-year-old man presented to the acute cardiac care unit with a painful left arm and jaw. Because the patient had a hypertonic left arm and was unable to open his mouth fully, the neurologist was consulted. The patient had been to the emergency department 9 days earlier for an infected wound after falling in the garden. He had not been actively or passively immunised against tetanus at that time. On inquiry, it appeared that the patient had also not been vaccinated as a child. We made a clinical diagnosis of tetanus. The patient was admitted and treated with tetanus immunoglobulin, metronidazole, diazepam and painkillers. He was also administered tetanus toxoid and the wound was cleaned. After 1 month and 7 months, the patient was again administered tetanus toxoid. CONCLUSION Patients with a wound that may have come into contact with road grime, dirt or manure, should always be asked for their vaccination status, especially people from high-risk groups, such as the elderly.
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Affiliation(s)
- J G Röttgering
- Tergooi, afd. Neurologie, Blaricum
- Contact: J.G. Röttgering
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Ulfa M, Husna NA. A case report of generalized tetanus in a 42-year-old man with dental infection. J Basic Clin Physiol Pharmacol 2019; 30:/j/jbcpp.ahead-of-print/jbcpp-2019-0243/jbcpp-2019-0243.xml. [PMID: 31811803 DOI: 10.1515/jbcpp-2019-0243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/27/2019] [Indexed: 06/10/2023]
Abstract
Background In the post-vaccination era, as it is today, generalized tetanus is a rare diagnosis, although mortality and morbidity continue to increase significantly throughout the world. Infection occurs when the Clostridium tetani spores are introduced into wounds, skin lesions and infections. The symptoms often begin with stiffness or spasms in the jaw muscles; they are called trismus or "lockjaw" and/or then spread to the neck and abdominal muscles. Case presentation This is a report of a 42-year-old man who was referred to the hospital with dysphagia, rigidity and trismus. He was diagnosed with generalized tetanus with a Philips score of 15. The patient was admitted to the isolation unit, received treatment that included procaine penicillin, metronidazole, diazepam, human tetanus immunoglobulin (TIG) and anti-tetanus serum (ATS). Treatment was considered according to the guidelines of the World Health Organization, and also, the drug dose has no adverse event reaction during the treatment. Conclusion The therapeutic response is related to the identification and appropriate treatment, especially in hospitalized patients with inadequate immunization so that patients recover soon.
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Affiliation(s)
- Maria Ulfa
- Magister of Clinical Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Kampus C Unair, Jl. Mulyorejo, Surabaya50115,Indonesia
| | - Nuril Auliya Husna
- General Hospital RSUD Dr. Soetomo, Department of Pharmacy, Surabaya East Java, Indonesia
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Abstract
A 70-year-old woman was admitted to our hospital due to difficulty in moving her limbs. She had trismus and a necrotic and contaminated wound in her left lower leg. A diagnosis of tetanus was confirmed and intensive care was started. On the second day, her blood pressure fell and a ST segment elevation on electrocardiography (ECG) was detected. She was diagnosed with takotsubo cardiomyopathy by echocardiogram and improved undergoing conservative therapy.
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Affiliation(s)
- Taisuke Araki
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Japan
| | - Naoya Iwanami
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Japan
| | - Yoshitaka Yamazaki
- Center of Infectious Diseases, Nagano Prefectural Shinshu Medical Center, Japan
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10
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Abstract
Tetanus is a vaccine-preventable disease that still commonly occurs in many low-income and middle-income countries, although it is rare in high-income countries. The disease is caused by the toxin of the bacterium Clostridium tetani and is characterised by muscle spasms and autonomic nervous system dysfunction. Global vaccination initiatives have had considerable success but they continue to face many challenges. Treatment for tetanus aims to control spasms and reduce cardiovascular instability, and consists of wound debridement, antitoxin, antibiotics, and supportive care. Recent research has focused on intravenous magnesium sulphate and intrathecal antitoxin administration as methods of spasm control that can avoid the need for ventilatory support. Nevertheless, without access to mechanical ventilation, mortality from tetanus remains high. Even with such care, patients require several weeks of hospitalisation and are vulnerable to secondary problems, such as hospital-acquired infections.
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Affiliation(s)
- Lam Minh Yen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
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Duss FR, Voide C. [Toxin-infections and toxin-related diseases due to Clostridia other than Clostridium difficile]. Rev Med Suisse 2018; 14:1795-1798. [PMID: 30307139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Clostridia cause severe diseases. Tetanus is rare in Switzerland because of vaccine coverage and the application of guidelines for the management of contaminated wounds. Tetanus requires wound debridement and the administration of antibiotics and anti-tetanus immune. Besides gastroenteritis, infections due to C. perfringens most often require surgery, in addition to antibiotic treatment with penicillin and clindamycin. Botulism is a rare disease caused by a toxin produced by C. botulinum that causes flaccid paralysis. The clinical syndrome must be recognized early in order to administer the antitoxin and improve the prognosis. The other, rarer species of Clostridia require surgical and antibiotic management, but their prognosis remains poor.
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Affiliation(s)
- François-Régis Duss
- Service des maladies infectieuses, Institut Central des Hôpitaux, Hôpital du Valais, Avenue du Grand-Champsec 86, 1950 Sion
| | - Cathy Voide
- Service des maladies infectieuses, Institut Central des Hôpitaux, Hôpital du Valais, Avenue du Grand-Champsec 86, 1950 Sion
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Affiliation(s)
| | - Ymkje Stienstra
- *Address correspondence to Ymkje Stienstra, Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands. E-mail:
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13
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Holzgraefe B, Koria A, Sem V, Johansson J. [Tetanus, an almost forgotten but serious disease]. Lakartidningen 2017; 114:EITX. [PMID: 28535026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Tetanus, an almost forgotten but serious disease Tetanus is the systemic consequence of a local infection with Clostridium tetani, that produces toxin which spreads in the systemic circulation. In developed countries, it is extremely rare. Women born before 1950 are a group at risk due to lower prevalence of immunisation. This report describes a case of tetanus. The patient is a previously healthy 82-year-old woman. She presented to primary care with a complaint of stiffness in the neck and jaw. A physical exam and basic laboratory tests were normal apart from a slightly increased blood pressure. Later the same day she was admitted to the intensive care unit for suspected tetanus. During the night she deteriorated with marked stiffness in her thorax and, as a result of this, severe respiratory distress. After induction of anesthesia she was ventilated and intubated without problem. The treatment for tetanus, an antibody, was given 5 hours later after urgent delivery from the national supply. The patient was successfully weaned from the ventilator after 37 days. During intensive care she had fluctuating stiffness and autonomic instability, both commonly described in patients with tetanus.
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Affiliation(s)
- Bernhard Holzgraefe
- AnOpIVA klinken, Sjukhuset i Arvika, Landstinget i Värmland - Arvika, Sweden AnOpIVA klinken, Sjukhuset i Arvika, Landstinget i Värmland - Arvika, Sweden
| | - Akad Koria
- Kirurg kliniken, Arvika Sjukhus, Landstinget i Värmland - Arvika, Sweden Kirurg kliniken, Arvika Sjukhus, Landstinget i Värmland - Arvika, Sweden
| | - Victoria Sem
- AnOpIVA kliniken, Centralsjukhuset i Karlstad, Landstinget i Värmland - Karlstad, Sweden AnOpIVA kliniken, Centralsjukhuset i Karlstad, Landstinget i Värmland - Karlstad, Sweden
| | - Joak Johansson
- Forsknings och Utvecklingsenheten, Region Jämtland Härjedalen - Östersund, Sweden Forsknings och Utvecklingsenheten, Region Jämtland Härjedalen - Östersund, Sweden
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Abstract
In the early literature, vitamin C deficiency was associated with pneumonia. After its identification, a number of studies investigated the effects of vitamin C on diverse infections. A total of 148 animal studies indicated that vitamin C may alleviate or prevent infections caused by bacteria, viruses, and protozoa. The most extensively studied human infection is the common cold. Vitamin C administration does not decrease the average incidence of colds in the general population, yet it halved the number of colds in physically active people. Regularly administered vitamin C has shortened the duration of colds, indicating a biological effect. However, the role of vitamin C in common cold treatment is unclear. Two controlled trials found a statistically significant dose-response, for the duration of common cold symptoms, with up to 6-8 g/day of vitamin C. Thus, the negative findings of some therapeutic common cold studies might be explained by the low doses of 3-4 g/day of vitamin C. Three controlled trials found that vitamin C prevented pneumonia. Two controlled trials found a treatment benefit of vitamin C for pneumonia patients. One controlled trial reported treatment benefits for tetanus patients. The effects of vitamin C against infections should be investigated further.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki FI-00014, Finland.
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Ogunrin OA, Unuigbe EI. Tetanus: An Analysis of the Prognosticating Factors of Cases Seen in a Tertiary Hospital in a Developing African Country between 1990 and 2000. Trop Doct 2016; 34:240-1. [PMID: 15510958 DOI: 10.1177/004947550403400422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This is an analysis of the effects of prognosticating factors on the outcome of a case series of 66 patients with tetanus, presenting between 1990 and 2000. The mortality rate was 26.2% with a fatality rate of 16.2% for those under 40 years of age. This increased to 75% for those patients above 70 years of age. The socio-economic status, immunization status, the incubation period, and age of the patient together with the severity of the spasms, duration of hospital stay, type of treatment received and time of onset were found to affect the outcome of the patients.
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Affiliation(s)
- Olubunmi A Ogunrin
- University of BeninTeaching Hospital, Benin City and Department of Medicine, University of Benin, Benin, Nigeria.
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Hanif H, Anjum A, Ali N, Jamal A, Imran M, Ahmad B, Ali MI. Isolation and Antibiogram of Clostridium tetani from Clinically Diagnosed Tetanus Patients. Am J Trop Med Hyg 2015; 93:752-6. [PMID: 26175031 PMCID: PMC4596594 DOI: 10.4269/ajtmh.15-0040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 06/16/2015] [Indexed: 11/07/2022] Open
Abstract
Clostridium tetani, the etiologic agent of tetanus, produces a toxin that causes spastic paralysis in humans and other vertebrates. This study was aimed for isolation, identification, and determination of antimicrobial susceptibility of C. tetani from clinically diagnosed tetanus patients. Isolation was done from deep-punctured tissues of the foot and arm injuries of 80 clinically diagnosed tetanus patients from the Pakistan Institute of Medical Sciences hospital. We successfully screened out five C. tetani isolates out of 80 samples based on the strain-specific characteristics confirmed through biochemical testing and toxin production. A disc diffusion method was used for antimicrobial susceptibilities and C. tetani isolates showed susceptibility to cefoperazone, chloramphenicol, metronidazole, penicillin G, and tetracycline, but were found to be resistant to erythromycin and ofloxacin. During animal testing, all the infected mice developed symptoms of tetanus. The results showed that identification of C. tetani is possible using biochemical and molecular tools and that the strains of C. tetani isolated had not developed resistance against the antibiotics most often used for the treatment of tetanus.
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Affiliation(s)
- Hajra Hanif
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
| | - Awais Anjum
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
| | - Naeem Ali
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
| | - Asif Jamal
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
| | - Muhammad Imran
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
| | - Bashir Ahmad
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
| | - Muhammad Ishtiaq Ali
- Department of Microbiology, Quaid-i-Azam University, Islamabad; Department of Food Sciences, University of Nottingham, Nottingham, United Kingdom; Departmnet of Bioinformatics and Biotechnology, International Islamic University, Islamabad
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Okada T, Yabe H, Ando R, Iwaki H, Nishikawa N, Nagai M, Sei H, Nishida N, Nomoto M. [Case Report; A case of tetanus with dysphagia as an initial symptom]. Nihon Naika Gakkai Zasshi 2015; 104:1464-1468. [PMID: 26513966 DOI: 10.2169/naika.104.1464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
Animal and human bites are common in the United States. Although evidence-based practice guidelines have not been developed, bite wounds warrant an organized, standardized approach to care to help prevent complications. Such an approach involves first eliciting a history of the circumstances surrounding the bite and the patient's medical history. Next, basic bite wound care should be performed, including cleansing and irrigation of the wound. A good understanding of bite wound bacteriology and the situations in which antibiotics may be indicated is important. Finally, rabies and tetanus prophylaxis should be considered and appropriate follow-up care ensured.
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Affiliation(s)
- Randy A Taplitz
- Division of Infectious Diseases, Oregon Health & Science University School of Medicine, Portland 97239, USA.
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20
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Hertz MA, Sørensen SM. [Tetanus can still be found in Denmark]. Ugeskr Laeger 2014; 176:V06140334. [PMID: 25534221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Tetanus (lockjaw) is caused by toxins produced by Clostridium tetani, usually transmitted through contaminated wounds. We describe a case of tetanus in an unvaccinated, previously healthy 78-year-old woman. Twelve days after minor trauma to the right palm, initially treated with tetanus vaccination without immunoglobulins, she developed hoarseness, dyspnoea and difficulties swallowing and opening her mouth. She got severe, painful muscle cramps of especially the truncal muscles requiring large doses of sedatives and complicating respiratory insufficiency. She was treated in intensive care for 33 days, but recovered completely.
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Pokharel K, Tripathi M, Bhattarai B, Subedi A, Sah BP. Large versus Small Dose Magnesium Sulfate Infusion in Tetanus. JNMA J Nepal Med Assoc 2014; 52:796-801. [PMID: 26905707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms. METHODS Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h(-1)) than group 2 (n=5) (1.5 to 2 g.h(-1)). RESULTS The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d(-1)) than group 2 (n=3) (106±9 mg.d(-1)) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO(4) for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d(-1)) of infusion in group 2 (n=4) but not in group 1 patients (n=4). CONCLUSIONS The larger dose of MgSO(4) infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.
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Affiliation(s)
- K Pokharel
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Science, Dharan, Nepal
| | - M Tripathi
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Science, Dharan, Nepal, Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, UK, India
| | - B Bhattarai
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Science, Dharan, Nepal
| | - A Subedi
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Science, Dharan, Nepal
| | - B P Sah
- Department of Anaesthesiology and Critical Care, B. P. Koirala Institute of Health Science, Dharan, Nepal
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Abstract
BACKGROUND Tetanus is a severe disease that can be prevented by vaccination. In developing countries vaccination coverage is not always high. Cases still occur also in developed countries, particularly in elderly people owing to their reduced immuno protection. There are about 1 million tetanus cases per year globally. In animal studies, vitamin C has protected against various infections and bacterial toxins. In a study with rats, vitamin C protected against the purified tetanus toxin. OBJECTIVES To assess the prophylactic and therapeutic effect of vitamin C on tetanus. SEARCH METHODS In May 2013 we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations ); and Ovid EMBASE for this third update. SELECTION CRITERIA Controlled trials of vitamin C as a prevention or treatment for tetanus, whether or not these were placebo controlled, in any language, published or unpublished. Two review authors independently made inclusion decisions. DATA COLLECTION AND ANALYSIS Both review authors independently extracted data from trial reports and assessed methodological quality. Since one of the cells in a 2 × 2 table had no events, we calculated the odds ratio (OR) and its 95% confidence interval (CI) for case fatality rate by using the Peto-method. Another of the 2 × 2 tables had no empty cells and the inverse-variance method was used to calculate its risk ratio (RR) estimate and 95% CI. We also used the Fisher's exact test to calculate the exact 95% CI for the OR of the 2 × 2 table with the empty cell. MAIN RESULTS One single trial was eligible for inclusion. This non-randomised, unblinded, controlled trial undertaken in Bangladesh involved 117 tetanus patients. Vitamin C at a dosage of 1 g/day was administered intravenously alongside conventional treatment. At recruitment, the participants were stratified into two age groups and the results were reported by age. There was a significant difference in the vitamin C effect between the two age groups (P = 0.01). In the tetanus patients aged 1 to 12 years (n = 62), vitamin C treatment was associated with a 100% reduction in case fatality rate (95% CI from -100% to -94%). In patients aged 13 to 30 years (n = 55), vitamin C treatment was associated with a 45% reduction in case fatality rate (95% CI from -69% to -5%). AUTHORS' CONCLUSIONS A single, non-randomised, poorly reported trial of vitamin C as a treatment for tetanus suggests a considerable reduction in mortality. However, concerns about trial quality mean that this result must be interpreted with caution and vitamin C cannot be recommended as a treatment for tetanus on the basis of this evidence. New trials should be carried out to examine the effect of vitamin C on tetanus treatment.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, POB 41, University of Helsinki, Mannerheimintie 172, Helsinki, Finland, FIN-00014
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Legrand D, Delcour A, Lancellotti P. [Clinical case of the month. Tetanus still exists!]. Rev Med Liege 2013; 68:157-159. [PMID: 23755703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
We report the dramatic story of a 81 year old patient admitted to the intensive care unit following the development of tetanus. This man, perfectly autonomous, used to workin his garden without anti-tetanus immunization coverage. In this article, we report the therapeutic management of tetanus. We emphasize the importance of vaccination which permits to avoid the disease, the mortality and morbidity of which remain high.
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Affiliation(s)
- D Legrand
- Service de Cardiologie, CHU de Liège, Université de Liège, Belgique
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Smietańska K, Rokosz-Chudziak N, Rastawicki W. [Characteristics of Clostridium tetani and laboratory diagnosis of tetanus]. Med Dosw Mikrobiol 2013; 65:285-295. [PMID: 24730217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The causative agent of tetanus is the obligate anaerobic bacterium--Clostridium tetani. These bacteria form endospores that are able to survive long periods of exposure to air and other adverse environmental conditions. Infection generally occurs through wound contamination. We can distinguish several forms of tetanus: generalized, local and neonatal. Diagnosis of tetanus is based primarily on the patient's clinical symptoms (muscle cramps, painful back muscle spasms, generalized contractions of the arcuate curvature of the body) as well as on microbiological diagnosis. This article is a brief review of C. tetani and diagnosis of infections caused by these organisms in humans.
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Affiliation(s)
- Jae-Cheol Kwon
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea.
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26
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Affiliation(s)
- Mikael Alves
- Medical Intensive Care Unit, Hospital Saint-Antoine, Paris, France.
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27
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Aggarwal M, Sood V, Aggarwal KC. Tetanus in pediatric patients--predictors affecting mortality and role of immunoglobulin. Indian Pediatr 2011; 48:987-988. [PMID: 22253164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Analysis of pediatric tetanus cases was carried out to study the predictors of mortality and role of tetanus immunoglobulin (TIG). Shorter incubation period, onset time and autonomic dysfunction were significantly associated with mortality and may be used to stratify patients requiring intensive care. TIG may not have independent role in decreasing mortality in sick patients.
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Japanese Society of Chemotherapy Committee on guidelines for treatment of anaerobic infections., Japanese Association for Anaerobic Infection Research. Chapter 2-12-4. Anaerobic infections (individual fields): tetanus. J Infect Chemother 2011; 17 Suppl 1:125-32. [PMID: 21728110 DOI: 10.1007/s10156-010-0157-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Stucchi R, Fumagalli R. Treatment of Tetani infection using sevoflurane and AnaConDa: cases of transient renal impairment. Minerva Anestesiol 2011; 77:759-760. [PMID: 21709666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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30
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Aydin-Teke T, Bayhan GI, Afşarlar CE, Oz FN, Akansel AR, Tanir G. A report of two pediatric tetanus cases. Turk J Pediatr 2011; 53:437-440. [PMID: 21980847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Tetanus is still a difficult-to-treat disease with high morbidity and mortality. Although it most commonly occurs in non-immunized children, it can also be seen in partially immunized or immunized children. We report herein two pediatric cases of generalized tetanus. Case 1 presented with signs of acute abdomen, while Case 2 presented with the typical clinical findings of tetanus. In this report, we highlight the importance of obtaining a history of the vaccination status of pediatric patients as an essential part of the evaluation. Furthermore, the differential diagnosis of non-immunized children with abdominal rigidity should include generalized tetanus.
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Affiliation(s)
- Türkan Aydin-Teke
- Division of Pediatric Infectious Diseases, Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey
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31
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32
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Affiliation(s)
- E S Wijewickrama
- Professorial Medical Unit, Teaching Hospital, Colombo South, Sri Lanka.
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33
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Huang QM, You AP, Li YH. [Vecuronium as an adjunct treatment for neonatal tetanus: case report of 2 cases]. Zhongguo Dang Dai Er Ke Za Zhi 2010; 12:236-237. [PMID: 20350442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Qiu-Mei Huang
- Department of Pediatrics, the Nanping First Hospital, Fujian Medical University, Fujian 353000, China
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Cabrerizo García JL, Zalba Etayo B, Homs Gimeno CA. [Treatment of tetanus with intrathecal baclofen]. Neurologia 2009; 24:430-431. [PMID: 20050112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
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Sikendar RI, us Samad B, Ali S, Memon MI. Post traumatic tetanus and role of magnesium sulphate. J Ayub Med Coll Abbottabad 2009; 21:132-135. [PMID: 20524490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Tetanus is a life threatening disease. Reported mortality for tetanus is 15-39%. Conventional treatment includes heavy sedation and artificial ventilation. Complications resulting from long term heavy sedation and artificial ventilation contribute to 60% of the total mortality caused by tetanus. In this study magnesium sulphate was used to reduce the need for sedation and artificial ventilation. Objectives of this prospective study were to determine the role of magnesium sulphate in post traumatic tetanus. METHODS The study was carried out in surgical Intensive Care at Pakistan Institute of Medical Sciences (PIMS), Islamabad from Jan 2004 to Dec 2007. Forty-four patients presented during this period and 33 patients were included in the study. All patients had tracheostomy done within 48 hours. Every patient was started Magnesium Sulphate therapy for control of spasms after sending baseline investigations. Patients were given ventilatory support when needed. All data was entered in well structured proforma. SPSS-10 was used to analyse data. RESULTS Thirty-three patients were included in the study and all patients were given magnesium sulphate. Out of these, 45.5% cases were grade 4 tetanus, 73.6% and 63.3% cases did not require artificial ventilation and additional sedation respectively, 51.1% patients remained free of complications of tetanus. Overall mortality was 30.3%. CONCLUSIONS Use of Magnesium Sulphate is safe and reduces the need for sedation and artificial ventilation in high grade tetanus thus contributing to survival benefit in adult post-traumatic tetanus cases.
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Affiliation(s)
- Rana Imran Sikendar
- Department of Anaesthesia and Intensive Care Unit, Pakistan Institute of Medical Sciences, Islamabad, Pakistan.
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Lum SH, Chew MF. Neonatal tetanus: a study of five cases in Sandakan, Sabah. Med J Malaysia 2009; 64:80-82. [PMID: 19852330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This study aims to study the demographics, clinical presentation, treatment and outcome of neonatal tetanus patients managed at Hospital Duchess of Kent from January 1st 2006 to December 31st 2006. Five neonates were studied. All presented with fever, poor sucking and limb stiffness, with a history of unsterile delivery and uncertain maternal tetanus immunity status. All were nursed in a minimal-stimuli environment and were given IV penicillin G, IM tetanus immunoglobulin and sedatives to control spasms. Nutrition and chest physiotherapy were rendered. Three patients required artificial ventilation. Duration of treatment ranged from 25 to 44 days. All survived. Inadequate maternal immunization, unsterile delivery and inappropriate umbilical cord care are major contributing factors of neonatal tetanus in our study. Supportive measures are the mainstay of treatment in our setting with very limited resources.
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Affiliation(s)
- S H Lum
- Department of Paediatrics, Hospital Duchess of Kent, Sandakan, Sabah, Malaysia.
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Wakasaya Y, Watanabe M, Tomiyama M, Suzuki C, Jackson M, Fujimuro M, Kimura T, Seino Y, Kawarabayashi T, Yamamoto-Watanabe Y, Matsubara E, Shirahama I, Takamura A, Nakahata N, Shoji M. An unusual case of chronic relapsing tetanus associated with mandibular osteomyelitis. Intern Med 2009; 48:1311-3. [PMID: 19652437 DOI: 10.2169/internalmedicine.48.2136] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 55-year-old man underwent radiation therapy due to malignant lymphoma of the neck. Eight years after the therapy he developed tetanus. It appears that the radiation therapy resulted in mandibular necrosis, and that this lesion may have been the infectious focus of tetanus. Treatment with penicillin G was very effective in the acute stage, and chronic administration of metronidazole prevented relapse of the disease. However in spite of injections of tetanus toxoid, symptoms of tetanus returned when the administration of metronidazole was discontinued because the infectious focus could not be completely removed. This is the first report of chronic relapsing tetanus associated with radiation-induced mandibular osteomyelitis, and demonstrates that tetanus can occur due to mandibular focus but the chronic administration of metronidazole can prevent relapse.
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Affiliation(s)
- Yasuhito Wakasaya
- Department of Neurology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Hirosaki
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Sprott KR. Generalized tetanus in a Labrador retriever. Can Vet J 2008; 49:1221-1223. [PMID: 19252716 PMCID: PMC2583421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A 10-week-old, intact female, Labrador retriever was presented for progressive extensor rigidity, facial swelling, and difficulty in walking. Generalized tetanus was diagnosed and treated successfully.
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Affiliation(s)
- Kerri-Rae Sprott
- Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan
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Seid M, Abebe S, Feleke Y, Seboxa T. A case report of chronic tetanus. Ethiop Med J 2008; 46:407-410. [PMID: 19271407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Here, we report a case of tetanus who presented with five months of symptoms and signs suggesting the presence of unusual presentation of tetanus so called chronic tetanus. The available literature on this a typical presentation and difficulty in the diagnosis is briefly discussed.
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Affiliation(s)
- Million Seid
- Department of Internal Medicine, Faculty of Medicine, Addis Ababa University
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van Galen G, Delguste C, Sandersen C, Verwilghen D, Grulke S, Amory H. Tetanus in the equine species: a retrospective study of 31 cases. Tijdschr Diergeneeskd 2008; 133:512-517. [PMID: 18615902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Few studies exist about factors affecting the outcome of horses with tetanus. ANIMALS 31 equids (30 horses and 1 donkey) with a clinical diagnosis of tetanus admitted to the Equine Clinic of the University of Liege between 1991 and 2006. The cases were divided into two groups according to the outcome (survivors and non-survivors). METHODS The clinical data of survivors and non-survivors were compared using an ANOVA (continuous data) or a Fisher's test (discrete data). RESULTS The survival rate was 32%. Most animals were 5 years or younger, and none had been appropriately vaccinated. The non-survivors were significantly younger than the survivors. The development of dyspnoea, recumbency, and the combination of dysphagia, dyspnoea, and recumbency was observed significantly more in the non-survivors than in the survivors. The timing of tetanus antitoxin administration (either immediately after the onset of suggestive signs or after a delay) was not different between the two groups. The time between the occurrence of a wound and the first signs ranged from 2 days to 2 months and was not significantly different between groups. All non-survivors died within 8 days of the first signs. CONCLUSIONS & CLINICAL IMPORTANCE This study suggests that young animals are affected more often and more severely by tetanus than older animals. Dyspnoea, recumbency, and the combination of dysphagia, dyspnoea, and recumbency can be considered as indicators of a poor prognosis in equids suffering from tetanus.
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Affiliation(s)
- G van Galen
- Equine clinic, Faculty of Veterinary Medicine, University of Liege, Belgium.
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41
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Abstract
BACKGROUND Tetanus is a severe infection that can be prevented by vaccination. In developing countries vaccination coverage is not always high and in developed countries cases may still occur, particularly in elderly people owing to their reduced immunoprotection. It has been estimated that there are about one million cases of tetanus per year globally. In animal studies, vitamin C protected against various infections. In a study with rats, vitamin C protected against tetanus toxin. OBJECTIVES To assess the prophylactic and therapeutic effect of vitamin C in tetanus. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, issue 4), MEDLINE (1950 to January 2008), EMBASE (1980 to 2008 Week 03), the Cochrane Wounds Group Specialised Register (January 2008), the Cochrane Infectious Diseases Group Specialised Register (June 2007), and the reference lists of relevant reviews and monographs. SELECTION CRITERIA We included controlled trials of vitamin C as a prevention or treatment for tetanus, whether or not placebo controlled, in any language, published or unpublished. Two authors independently made inclusion decisions. DATA COLLECTION AND ANALYSIS Both review authors independently extracted data from trial reports. MAIN RESULTS One single trial was eligible for inclusion. This non randomised, controlled, unblinded treatment trial involved 117 tetanus patients and was undertaken in Bangladesh. Vitamin C at a dosage of 1 g/day was administered intravenously alongside conventional treatment. At recruitment, the participants were stratified into two age groups and the results were reported by age. In the children aged 1 to 12 years (n = 62), vitamin C treatment was associated with a 100% reduction in tetanus mortality (95% confidence interval from -100% to -94%). In people aged 13 to 30 years (n = 55), vitamin C treatment was associated with a 45% reduction in tetanus mortality (95% confidence interval from -69% to -5%). AUTHORS' CONCLUSIONS A single, non randomised, poorly reported trial of vitamin C as a treatment for tetanus suggests a considerable reduction in mortality. However, concerns about trial quality mean that this result must be interpreted with caution and vitamin C cannot be recommended as a treatment for tetanus on the basis of this evidence. New trials should be carried out to examine the effect of vitamin C on tetanus treatment.
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Affiliation(s)
- H Hemilä
- University of Helsinki, Department of Public Health, POB 41, Mannerheimintie 172, Helsinki, Finland, FIN-00014.
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Komolafe MA, Komolafe EO, Ogundare AO. Pattern and outcome of adult tetanus in Ile-Ife, Nigeria. Niger J Clin Pract 2007; 10:300-303. [PMID: 18293639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE This is a retrospective study of all adult patients with tetanus managed at the Obafemi Awolowo University Teaching Hospitals Complex from 1995-2004. The aim was to study the pattern of adult tetanus in Ile-Ife, Nigeria, and see what improvements could be made in the future in particular with regard to decreasing the prevalence in our environment. METHOD Data was obtained from the hospital records of all the patients, the admission and discharge registers of the medical wards of the hospital. RESULT 79 adult patients with tetanus were managed during the study period and they accounted for 44% of neurological admissions. There were 56 males and 23 females giving a M:F ratio of 2.4 to 1. 45 (57%) of the patients were under 30 yrs of age and two-thirds (67%) had puncture wounds in the lower limbs. 20 patients (25%) had mild tetanus, 16 (20%) had moderate disease and 43 (55%) had severe tetanus. The patients were treated with tetanus antitoxin, antibiotics and sedatives. The mortality rate was 45% and laryngeal spasm was the most common cause of death. None of the patients was managed in the intensive care unit (ICU). CONCLUSION Tetanus remains a major public health problem in Nigeria. It is commonly associated with high mortality due to late presentation. Health education should be promoted to reduce the unacceptable prevalence in our practice setting.
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Affiliation(s)
- M A Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State. Nigeria.
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Girgin NK, Iscimen R, Gurbet A, Kahveci F, Kutlay O. Dexmedetomidine sedation for the treatment of tetanus in the intensive care unit. Br J Anaesth 2007; 99:599-600. [PMID: 17827192 DOI: 10.1093/bja/aem251] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
After making a bibliographic search in our country and demonstrating the lack of original articles or communications on treatment with intrathecal baclofen for the generalized forms of tetanus, our objective is to present this treatment based on the successful experience of one clinical case. In relationship to the case, we review baclofen pharmacokinetic and pharmacodynamic effects and its possible utility in the treatment of tetanus.
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Affiliation(s)
- M Solsona
- Servicio de Medicina Intensiva, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Barcelona, España.
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Freshwater-Turner D, Udy A, Lipman J, Deans R, Stuart J, Boots R, Hegde R, McWhinney BC. Autonomic dysfunction in tetanus - what lessons can be learnt with specific reference to alpha-2 agonists? Anaesthesia 2007; 62:1066-70. [PMID: 17845661 DOI: 10.1111/j.1365-2044.2007.05217.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severe tetanus is seen infrequently in the developed world, but often requires intensive care support. Mechanical ventilation with neuromuscular blockade and heavy sedation, good wound care and prompt administration of antitoxin are important. The management of autonomic dysfunction remains challenging. We measured serum catecholamine levels in a patient with severe tetanus in whom autonomic crises were a major and persistent feature, and investigated the impact of sedatives plus alpha(2)-agonists on these levels. Serum adrenaline levels were elevated up to 100-fold with clinically observed crises, although noradrenaline levels were much more difficult to interpret. There was no appreciable difference in catecholamine levels following administration of alpha(2)-agonists in the doses we used, although clonidine did allow easier control of crises with other agents. This case highlights some important lessons in the management of severe tetanus.
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Affiliation(s)
- D Freshwater-Turner
- Department of Anaesthesiology and Critical Care, University of Queensland, Level 3 Ned Hanlon Building, RBWH, Butterfield Street, Herston, Qld 4029, Australia
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Sharma VK, Dubey TN, Nayak R, Agarwal A. Cephalic tetanus with left infranuclear facial palsy. J Assoc Physicians India 2007; 55:735-736. [PMID: 18173031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We report a case of 11 years old male who developed trismus associated with left infranuclear facial palsy following injury over forehead. Cephalic tetanus was diagnosed. Rarity of the case as well as mild course it ran, though the incubation period was less than seven days, is the reason for this case report.
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Affiliation(s)
- V K Sharma
- Department of Medicine, Gandhi Medical College and Hamidia Hospital, Bhopal (M.P.)
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Abstract
This manuscript reviews evidence indicating that intestinal bacteria, specifically clostridia, may play a role in certain cases of autism and hypothesizes that the clostridial spores (which are notably resistant to antimicrobial agents and commonly used germicides) are involved in: (1) relapse in the autistic subject after a response to an agent such as oral vancomycin, after the drug is discontinued, (2) the unexplained increased incidence of autism in recent years, and (3) the unexplained increase in numbers of multiple cases in the same family. Hypothesis (1), if established as valid, would spur research to find well-tolerated and safe agents that could be given together with vancomycin (or other appropriate antimicrobial agent) to eliminate spores; this would revolutionize the therapeutic approach. Hypotheses (2) and (3) relate to widespread use of antimicrobial agents, poor hygiene in young autistic children, and difficulty in removing spores from the home environment. These latter two hypotheses have major implications with regard to the epidemiology of this important and distressing disease and would encourage research into methods to eliminate clostridial spores from the home and other environments.
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Affiliation(s)
- Sydney M Finegold
- Infectious Diseases Section 111 F, VA Medical Center West Los Angeles, Los Angeles, CA 90073, United States.
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Abstract
We describe a case of tetanus in a previously healthy 34-month old child living in Piedmont Region, in north-west Italy. His parents refused to continue immunisation after the first dose of vaccine: their decision was influenced by misconceptions about the risks and benefits of immunisation.
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Affiliation(s)
- F Giovanetti
- Local Health Unit of Alba Bra, Department of Prevention, Alba, Italy.
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von Conrady D. Tetanus: a case report. Ir Med J 2007; 100:510. [PMID: 17668689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Abstract
The case records of 20 dogs that were treated for tetanus between 1988 and 2004 were reviewed. Young, large-breed dogs were most commonly affected. Twelve dogs had a likely source of infection identified. All dogs were treated with intravenous antibiotics and supportive care, such as muscle relaxants and sedation for muscle tremors and rigidity. Sixteen dogs received tetanus antitoxin. The mortality rate was 50%. Complete recovery in survivors required approximately 1 month.
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Affiliation(s)
- Carsten Bandt
- Department of Nephrology/Hemodialysis Service of the Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California-Davis, Davis, California 95616, USA
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