Tetanus presenting primarily as periocular discomfort in a patient who underwent surgery for sleep apnea: A case report and brief literature review

RATIONALE

Tetanus is caused by a neurotoxin (tetanospasmin) secreted by a spore forming gram-positive, anaerobic rod-shaped motile bacillus, Clostridium tetani. The most common symptoms of tetanus are trismus (100%), dysphagia (70.5%), dysarthria (35.2%), and neck stiffness (29.4%). Respiratory failure, laryngeal spasm, seizure, chest pain, nausea/vomiting, opisthotonus, back pain, and rigid abdominal wall can also be observed during progression of the disease. However, there has been no report of periocular discomfort as an initial manifestation after endoscopic sleep surgery in a patient with tetanus. Here, we report a patient who underwent endoscopic sleep surgery with a concurrent diagnosis of tetanus infection presenting with atypical periocular discomfort as the initial symptom.

PATIENT CONCERNS

A 63-year-old man complaining of sleep apnea, snoring, and daytime sleepiness visited our department. He subsequently underwent sleep surgery (anterior pharyngoplasty with tonsillectomy, septoplasty, microdebrider-assisted inferior turbinoplasty, and an endoscopic sinus surgery) for the treatment of his newly diagnosed obstructive sleep apnea. After 3 weeks of surgery, he visited the outpatient clinic of our department with right side periocular discomfort.

DIAGNOSES

Four days after presenting with periocular discomfort, he was diagnosed with tetanus by presenting trismus, jaw pain, dysphagia, and ptosis at an emergency department of a different hospital.

INTERVENTIONS

Tetanus immunoglobulin and antibiotics were administered.

OUTCOMES

His symptoms then resolved after a month without sequelae.

LESSONS

Although periocular discomfort is atypical and is not uncommon after nasal and oral surgeries, care should be taken when patients present with periocular pain because it could be a rare initial symptom of tetanus.

[PROPERTIES OF INDIVIDUAL CONTRACTILE RESPONSES WITHIN TETANUS OF RAT SLOW MUSCLE UNDER CONDITIONS OF MODULATION OF SARCOPLASMIC RETICULUM Ca²⁺ RELEASE]

During direct stimulation of m. Soleus by trains of 5, 10 and 50 stimuli with a frequency of 20 Hz in control experiments (n = 16) a biphasic change was observed in the amplitude of the last contractile responses (LCRN) depending on N, where N is the number of individual contractile responses within the te- tanus. Thus, an initial decrease of LCRN amplitude (up to 54 ± 8 % for LCR₅) was replaced by their subsequent growth (up 218 ± 14 % for LCR5o) associated with a significant shortening of their half-relaxation time relative to the initial response (to 44 ± 8 % for LCR₅₀). Caffeine at concentrations of 5 mM (n = 6) and 10 mM (n = 4), at the background of developing characteristic stationary contracture respon- ses, increased LCR5 depression during the initial inhibitory phase (31 ± 8 % and 15 ± 4 %, respectively). The subsequent growth of LCRN amplitude was significantly lower than in the control (114 ± 18 % and 46 ± 9 % for LCR₅₀ at 5 and 10 mM caffeine, respectively). LCR₅₀ half-relaxation time during the action of both caffeine concentrations remained still considerably shorter than the individual responses recorded both in the presence of caffeine and in control. In contrast to the control and caffeine effects, LCR5 and ₁₀ (to 143 ± 14 %) than was observed in the control muscle. Additionally, dantrolene enhanced muscle relaxation at rest. Caffeine (10 mM), at the background of dantrolene, restored the dynamics of changes of amplitude time characteristics of the last contractile responses to values close to the control. The time-amplitude characteristics of the extracellular AP recorded in individual muscle fibers in m. Soleus did not change significantly during tetanic stimulation under protocol similar to that used for mechanografical experiments. These data can be interpreted to support the previously suggested theory about the participation of <<Ca²⁺-dependent Ca²⁺ release>> as an additional mechanism of excitation-contraction coupling in skeletal muscle under conditions of tetanic stimulation [1, 2].

Retrospective analysis of wound characteristics and tetanus development in captive macaques

Traumatic wounds and access to outdoor enclosures containing soil contribute to development of tetanus in nonhuman primates. A retrospective, matched case-control study was conducted at a primate center to evaluate these factors by analysis of medical records of animals sustaining traumatic injuries during a 3-yr study period. Thirty-one macaques with traumatic injuries and a clinical diagnosis of tetanus were selected as cases, and 62 macaques with traumatic injuries and no diagnosis of tetanus were selected as controls. For an animal with injuries to the digits, the odds of developing tetanus were 9.6 times those of a similar animal without injuries to the digits (Odds Ratio [OR] = 9.55, 95% CI = 1.56-58.59); with injuries to the tail, the odds of developing tetanus were 8.0 times those of a similar animal without injuries to the tail (OR = 7.95, 95% CI = 0.82-77.04); and with injuries in more than one location, the odds of developing tetanus were 8.5 times those for a similar animal with injuries in just one location (OR = 8.45, 95% CI = 1.01-70.46). A nonhuman primate with injuries to the leg was less likely to develop tetanus than a similar nonhuman primate without injuries to the leg (OR = 0.19, 95% CI = 0.03-1.2). Results indicated that wound location is associated with development of tetanus infection in rhesus macaques. Identification of high-risk trauma cases will allow better allocation of wound management and tetanus prophylaxis in institutions, especially in those housing nonhuman primates outdoors.

Tetanus in the equine species: a retrospective study of 31 cases

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.

Thirteen cases of tetanus in dogs

The records of 13 dogs with tetanus were reviewed, 12 of the dogs survived and were discharged, but the other died as a result of the acute onset of hyperthermia. Long-term follow up was available for 10 of the survivors of which nine were reported to be normal. One case was euthanased after a cervical spine fracture four months after it was discharged. Complications encountered during management included aspiration pneumonia in three cases, urinary tract infection in two cases, and upper respiratory tract obstruction, hiatal hernia, coxofemoral luxation, seizures and respiratory arrest in one case each. None of the dogs required ventilatory support, and the complications were managed successfully. The dogs were nursed intensively and monitored carefully.

Risk factors associated with outcome in dogs with tetanus: 38 cases (1987–2005)

OBJECTIVE

To assess the clinical course of disease and risk factors associated with outcome in dogs with tetanus.

DESIGN

Retrospective case series.

ANIMALS

38 dogs with tetanus.

PROCEDURES

Data were collected from medical records of dogs with tetanus, including signalment; wound characteristics; initial clinical signs; severity of worst clinical signs; time to wound management, antimicrobial treatment, and antitoxin administration; and 28-day survival rate. Statistical analyses were performed to evaluate relationships between the potentially predictive variables and disease progression and outcome.

RESULTS

The 28-day survival rate was 77% (among 35 uncensored dogs). The most common initial clinical signs in affected dogs were ocular (n = 18) and facial (11) abnormalities. Nineteen dogs progressed to recumbency with severe muscle spasms, and 14 dogs had high or low heart rate or blood pressure values. Eight dogs died or were euthanized because of complications of tetanus. There was a significant association between younger age and development of more severe clinical signs. Furthermore, a significant inverse relationship between development of severe clinical signs and survival was identified. There was no association between earlier initiation of wound management, antimicrobial administration, or antitoxin administration and either progression of signs or 28-day survival rate. Wound type was not associated with 28-day survival rate.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that younger dogs with tetanus may be more likely to develop severe clinical signs. The prognosis for survival in dogs with tetanus is good if abnormalities in heart rate or blood pressure values do not develop.

Neurohumoral, immunoinflammatory and cardiovascular profile of patients with severe tetanus: a prospective study

INTRODUCTION

Autonomic disturbances in tetanus are traditionally associated with adrenergic variations and/or cardiac dysfunction, based on case report data. The objective of this study was to measure catecholamines, (TNF)-alpha and troponin T relative to and left ventricular ejection fraction (LVEF) in patients with severe tetanus.

METHODS

This prospective study was carried out at two general Intensive Care Units and included 21 patients consecutively admitted with severe tetanus. Catecholamines (dopamine, norepinephrine, epinephrine and total catecholamines), tumor necrosis factor (TNF)-alpha and LVEF were assessed during the first week of autonomic instability and following tetanus recovery. Troponin T was measured during autonomic instability only.

RESULTS

Mean age of patients was 46 +/- 17 years, median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 8 (range 1-23). All patients had both blood pressure and heart rate instability. Two patients were recuperated from cardiac arrest. Intensive Care Unit mortality was 14% (3 cases). No increase in total catecholamines or in TNF-alpha levels was observed during autonomic instability or in the recovery period. Six patients had troponin T > 0.01 ng/ml and six had > 0.1 ng/ml. Mean LVEF was similar during autonomic instability and after tetanus recovery, 67 +/- 7% and 65 +/- 7%, respectively. Troponin T levels correlated with pressoric instability during autonomic instability.

CONCLUSION

Our study demonstrated that in patients with severe tetanus no significant increased levels of catecholamines or TNF-alpha or evidence of cardiac systolic dysfunction was observed either during autonomic instability or in the recovery period. Elevated values of troponin T detected during autonomic instability were not associated with left ventricular dysfunction. Our data do not support the hypothesis that autonomic disturbances in tetanus are associated with adrenergic variations or cardiac dysfunction.

Tetanus in England and Wales, 1984-2000

A review of national tetanus surveillance in England and Wales during 1984-2000 was undertaken to evaluate the surveillance system and national vaccination policy. Hospital Episode Statistics for tetanus in England for fiscal years 1989/90-1995/6 were also examined to estimate under-reporting. A total of 175 cases of tetanus were reported, giving an annual incidence of 0.20 per million, the lowest levels ever recorded. The highest incidence was in those aged over 64 years (0.66 per million) with no significant sex difference. Twenty (11%) cases were reported in people who were eligible for routine childhood vaccination. Outdoor injuries were the commonest reported exposure risk. Tetanus case under-reporting was estimated as 54-64%. We conclude that GPs should ensure that all their patients are fully vaccinated, targeting those born before 1961. High childhood tetanus vaccination coverage remains a priority. As the disease becomes rarer, enhanced tetanus case surveillance is essential for tetanus immunization policy evaluation.

Tetanus

Tetanus is a potentially life threatening disease affecting nearly 50,000 to 1 million people world wide every year. Four major clinical forms of tetanus are described i.e. generalized, cephalic, localized and neonatal. Neonatal tetanus is particularly common in developing countries, due to unhygienic child birth practices, social taboos and improper immunization of pregnant mothers. Management of this disorder involves a team approach and aims at eradicating focus of infection, neutralizing the toxin, controlling spasms and dysautonomia and providing adequate ventilatory and supportive care. Metronidazole may be the preferred antibiotic although penicillin is still used frequently. Adequate wound debridement is necessary to prevent spore germination. Spasms are usually managed by sedatives like diazepam and neuromuscular blocking agents. Magnesium sulphate is an attractive substitute and may be tried if ventilatory facilities are unavailable. Use of baclofen is potentially advantageous but cannot be routinely prescribed. Dysautonomia is difficult to manage and requires therapy with benzodiazepines, morphine, magnesium sulphate, adrenergic blockers and recently tried baclofen therapy. Supportive care including ventilatory assistance are highly essential for successful outcome of the patients. It is imperative that complications are diagnosed early and managed appropriately. Immunization is extremely effective and is the key to prevention. Adequate steps and measures should be taken to increase awareness of this potentially preventable disease.

Pharmacotherapy of tetanus--a review

With adequate immunization, tetanus caused by the gram-positive anaerobic cocci, clostridium tetani, is a preventable disease. In treating C. tetani infection, Metronidazole as an antibiotic is more effective than Penicillin G since it is a GABA antagonist. Agents used to control spasm and rigidity should have little effect on the level of consciousness, respiration and blood pressure. The drug of choice for treating spasm and rigidity is benzodiazepine, a GABA agonists. Large doses of benzodiazepines may be required to overcome the spasm and are safe. Baclofen is another GABA agonist, which has been tried as an alternative to benzodiazepine with moderate success. Clinical experience with dantrolene sodium is limited. Magnesium with its unique properties on the neuromuscular junction and sympathetic system has been used to treat both spasms and autonomic dysfunction with limited success. Neuromuscular blocking drugs are indicated depending on the severity of spasms. Neuromuscular blocking drugs with steroid molecule should be avoided in view of prolonged weakness. No drug has consistently proven to be effective in the treatment of autonomic dysfunction. Beta-blockers, variation of and beta blockers, opioids, clonidine, magnesium, spinal and epidural anaesthesia have been tried with varying success. Beta-blockers should be used with caution as they have been implicated in the deaths of some patients with autonomic dysfunction.

A ten-year retrospective study of tetanus at a general hospital in Malaysia

AIMS

To study the demographic and clinical features as well as outcomes of tetanus patients at the Sarawak General Hospital, Kuching from 1990 to 1999.

METHODS

All cases of tetanus from January 1990 to September 1999 were identified from the computer record at the hospital and these were then restrospectively reviewed.

RESULTS

A total of 22 cases of tetanus was seen at the Sarawak General Hospital in the ten-year period with a mean of 2.2 cases per year. There were 15 male (68.2%) and 7 female (31.8%) patients. Most cases occurred in the age group 60-69. Eighteen patients (81.8%) had a reasonably identifiable injury prior to the onset; all had their wounds debrided. Body stiffness, trismus and dysphagia were the three commonest presenting complaints. Twenty-one patients (95.5%) were admitted to the intensive care unit (ICU), with an average length of ICU stay of 21.4 days. Nineteen patients (86.4%) required mechanical ventilation for a varying period of time in the ICU. All patients (100%) had tracheostomy performed and intravenous diazepam infusion as part of their management. Twenty patients (90.9%) received intravenous crystalline penicillin as the treatment antibiotics. Twenty-one patients (95.5%) received intramuscular human antitetanus immunoglobulin. There were four deaths, accounting for a mortality of 18.2%.

CONCLUSION

In general, tetanus remains in Sarawak an important disease with substantial mortality and morbidity that primarily affects unvaccinated or inadequately vaccinated individuals. It is, however, highly preventable through both routine vaccination and appropriate wound management. Our case series show comparable pattern and outcome with other case series reported in the literatures.

Tetanus in the horse: a review of 20 cases (1970 to 1990)

The case records of 20 horses with tetanus referred to the Ontario Veterinary College-Veterinary Teaching Hospital between 1970 and 1990 were reviewed. The fatality rate was 75%. There was a strong association with previous vaccination and survival (P = .03). Most of the animals had been injured an average of 9 days (range 2 to 21 days) prior to development of clinical signs. Hyperesthesia and prolapse of the third eyelid were the most common clinical signs. Treatment regimens varied during hospitalization; however, all horses received parenteral penicillin, tranquilizers, tetanus toxoid, and antitoxin. Five of the nonsurviving animals were given intrathecal tetanus antitoxin. One animal had seizures as a complication of intrathecal treatment. The prognosis was best for horses that (1) had been vaccinated prior to the injury, (2) responded to the phenothiazine tranquilizers, and (3) did not rapidly (over 24 to 48 hours) become recumbent. Considering the species susceptibility, potential for contaminated wounds, and the increased survival of vaccinated horses, yearly revaccination is recommended.

Tetanus prophylaxis following ocular injuries

The administration of prophylaxis against tetanus following a corneal abrasion is routinely performed in many acute care facilities, despite a lack of support in the literature for its necessity. The risk of developing clinical tetanus from three different types of injuries to the eye was evaluated in an animal model. Clinical tetanus was induced in unimmunized mice by injecting Clostridium tetani organisms or toxin into the anterior chamber. Immunized mice injected intracamerally did not develop signs of tetanus. Tetanus was not induced by topical inoculation of either live organisms or toxin following corneal epithelial debridement or stromal scarification of unimmunized and immunized mice. The results of this study support the administration of prophylaxis against tetanus following perforating ocular injuries. However, our results do not support its routine use following uncomplicated corneal abrasions or other types of nonperforating ocular injuries.

Morphological correlates of protein kinase C induced potentiation in the chick brain slice

Continuous perfusion of a chick brain slice with 10 microM 4 beta phorbol 12,13 diacetate (PDAc) produces a significant increase in the amplitude of the response to electrical stimulation at 0.1 Hz recorded within the intermediate and medial part of the hyperstriatum ventrale (IMHV). This PDAc-induced potentiation and that induced by tetanising stimulation appear to share similar mechanisms. Quantitative electron microscopy of synapses within the IMHV from slices in which a PDAc induced potentiation had been produced 30 minutes earlier showed that compared with control slices there was a significant increase in the size of the postsynaptic density of spine synapses. The change was greater in magnitude than that observed in spine synapses following tetanically induced potentiation. No other synaptic parameters were affected.

Glucose tolerance during experimental tetanus toxicity in rabbits

Tetanus was induced in rabbits by injection of high doses of purified tetanus toxin. After the induction of tetanus, the fasting blood glucose level was significantly elevated in the rabbits with tetanus--blood glucose level being 137.5 mg% compared with 114.8 mg% in controls. The Glucose tolerance showed the expected curve in control rabbits while in the rabbits with tetanus, there was a continuous rise in blood glucose levels even after 3 hours. Histological studies show degranulation of the beta cells of the pancreas in the tetanus rabbits. Thus, the high fasting blood sugar level and the diabetic pattern of Glucose tolerance observed in the tetanus animals are suggestive of reduced insulin production during tetanus, as part of the mechanism involved.

Soleus-specific myopathy induced by passive stretching under local tetanus

Twenty-four adult albino rats were injected with tetanus toxin into the right gastrocnemius muscle and then subjected to sustained dorsiflexion of the right ankle joint for 2 to 14 days. Histologic examinations of the soleus after this procedure showed myopathic changes, characterized by variations in fiber diameters, myonecrosis with opaque fibers, interstitial fibrosis, and small groups of regenerated fibers. Electron microscopy revealed derangement of T-tubules immediately adjacent to the sarcolemma in the early degenerative stage. The size and wet weight of soleus increased compared to that of the control side between 2 and 5 days post-tetanus. Serum GOT, LDH, and creatine kinase (CK) levels were elevated especially in the early degenerative stages. Peri- and endomysial fibrosis developed gradually from about 3 days post-tetanus. Pathomechanisms inducing these changes were discussed.

[Immunomorphologic aspects of local (wound) revaccination with tetanus anatoxin]

The immunomorphological reaction of regional lymphoid organs, the pathomorphology of wound tissues, humoral antitoxic response and a protective effect after local (wound) booster immunization with tetanus toxoid have been studied in observations on 100 guinea pigs with experimental wound infection. The study has shown that the local application of tetanus toxoid, besides stimulating humoral response, induces a more rapid effect aimed at the primary elements of the infectious process (the germination of spores, the adhesion, colonization and toxin formation of the causative agent), thus facilitating the localization of the focus of infection, the development of reparative processes in the wound and the arresting of the infection.

The role of cell population kinetics in the efficacy of penicillin--an experimental analysis and stochastic modeling of the tumour tetanus and wound tetanus of the mouse

When investigating tetanus lethality summation curves of mice under comparable quantitative conditions following a temporarily limited administration of penicillin, the curves obtained can be calculated by the kinetics of tumour cells or wound fibroblasts. In particular, it has been shown that the optimal efficacy of penicillin, after short-time usage as compared with a long-time administration schedule, is determined by the generation time of the tetanus rods as a function of the mitotic cycle of the "pace-making" tumour cells or wound fibroblasts. Further variables of the mathematical model imply the pharmacokinetics of penicillin and the recovery process of the "hit" tetanus rods. From these results some basic experimental and clinical tetanus issues can be elucidated; thus, the mitosis theory of tetanus is being verified for the stage of incubation and of clinical manifestation, while the classical necrosis theory of the pathogenesis of tetanus infection should be valid only for the final stage.

Minor trauma, disastrous results

An 81-year-old-woman developed a right facial palsy and orbital cellulitis following an apparently innocuous puncture injury of the right lower eyelid. Generalized tetanus ensued which proved fatal despite aggressive treatment including use of tetanus immune globulin, wound debridement, and neuromuscular blockade with ventilatory assistance. Tetanus immunization status should be ascertained in all patients with potentially contaminated wounds in and around the eye. Cephalic tetanus, may be misleading initially because of the presence of cranial nerve palsies and the absence of classic signs such as trismus and risus sardonicus.

Induction of spheroid cytoplasmic bodies in a rat muscle by local tetanus

The term "cytoplasmic body" or "spheroid body" myopathy refers to a heterogeneous group of familial or sporadic diseases characterized primarily by the presence of abundant spheroid or cytoplasmic bodies in the muscles. The morphogenesis of these inclusions remains unclear. This article describes the induction and evolution of spheroid cytoplasmic bodies (SCBs) in the rat plantaris muscle (PL) with local tetanus, which was induced in rats by the injection of a minute amount of tetanus toxin. In contrast to the tetanized soleus muscle (SOL), which developed core fibers (central cores, minicore, target fiber, targetoid fiber, and rods), the tetanized PL produced numerous SCBs with a predictable time course. They were induced in both type 1 and 2 fibers of PL, which is composed predominantly (95%) of type 2 fibers, in contrast to SOL (85% type 1 fibers). Factors inducing SCBs may include immobilization, shortening, intact innervation, and disuse atrophy.

[Changes in lipid metabolism, oxygen balance and muscle ultrastructure in tetanus in an experiment]

Dogs and white rats with experimental tetanus were examined for blood plasma lipids and red cells, their acid resistance, oxygen balance, cytochrome oxidase and aspartate transaminase activity and muscle ultrastructure. The amount of blood plasma lipids was found to be increased, the lipid content in red cells was lowered because of phospholipid washing out. The red cell resistance was lowered, their sedimentation rate was accelerated. Oxygen metabolism in muscles was first enhanced to form excess lipid peroxides, disturbing the integrity of cell membranes and myocyte ultrastructure, and then it was suppressed because of depletion of the compensatory mechanisms and eventuated in the destruction of part of cells and later on in the death of animals.

Changes in blood chemistry and liver histopathology of rabbits during experimental tetanus toxicity

Changes in blood chemistry, especially blood glucose, were studied in rabbits developing tetanus after injection of tetanus toxin. Blood glucose levels increased significantly above control values after the animals developed tetanus. The increase in glucose level paralleled the depletion of liver glycogen, detected by means of PAS staining. The observed changes were not affected by adrenergic receptor block or catecholamine depletion by reserpine, suggesting non-mediation of the sympathetic nervous system in the response. A direct action of the toxin on the liver, initiating glycogen depletion, is being postulated.

The metabolic response and problems with nutritional support in acute tetanus

Thirteen patients with severe tetanus were studied in the first and second week of illness in order to assess metabolic changes and nutritional requirements. Nine required muscular paralysis and subsequent assisted ventilation in order to control spasms. Symptoms and signs of sympathetic overactivity were especially common in the latter groups with a fourfold increase in urinary adrenaline and noradrenaline excretion. Other hormonal and metabolic abnormalities included hyperglycemia, mildly elevated insulin concentrations with no significant rise in cortisol, and glucagon. Evidence of excessive protein catabolism was obtained particularly during the second week of illness, mean urinary nitrogen excretion being 20.5 +/- 13.8 g/d. Maintenance of nutrient homeostasis proved impossible with conventional enteral-feeding techniques: high-density feeds exacerbated hyperglycemia and diarrhea; low-density feeds were unable to maintain nitrogen balance (-12.34 g/d in ventilated patients, second week). The results indicate that loss of lean body mass is inevitable in such patients unless the metabolic response can be suppressed or more aggressive forms of nutritional support (eg, total parenteral nutrition including sufficient insulin to maintain normoglycemia) are employed.

[Tetanus. Apropos a case]

The authors report a case of tetanus in a 19 months infant who has only received BCG. After a four days period during which two laryngeal spasms occurred, the infant presents a generalized tetanus. The outcome was favorable with specific serotherapy myorelaxants and assisted ventilation of four weeks duration.

Chronic tetanus: clinical report and histochemistry of muscle

A patient who was partially immune to tetanus developed nonfulminant tetanus after a minor injury. Manifestations of the disease persisted for over 17 months. Electrophysiologic studies revealed an absent silent period in the masseter muscle, large-amplitude F-responses, and denervation. A muscle biopsy showed neurogenic atrophy with reinnervation. This observation supports the existence of chronic tetanus and provides morphologic evidence for a peripheral action of tetanus toxin in humans.

Permanent tetraplegia as a consequence of tetanus neonatorum. Evidence for widespread lower motor neuron damage

It is generally believed that no permanent neurological damage is found among survivors of tetanus neonatorum. Newborns dying shortly after the onset of tetanus also lack significant neurological abnormalities. In adults a variety of neuromuscular lesions have been reported; however, a uniform pathological picture is absent. We report a case of a newborn with severe tetanus in whom striking evidence of anterior horn neuronal damage was documented, causing permanent nonprogressive tetraplegia. We suggest that the mechanism responsible for this lesion involves the retrograde axoplasmic flow of tetanus toxin reaching the spinal cord via nerve endings in the infected umbilical cord stump.

The action of tetanus toxin: a case report

A case of neonatal tetanus in an infant with myelomeningocele is described, and the possible action of tetanus toxin is discussed.

Toxin-neutralizing effect of antibody against subtilisin-digested tetanus toxin

A form of systemic tetanus with atypical symptoms was observed in mice injected in the left thigh with a mixture of tetanus toxin and antibody produced in guinea pigs against a fragment of toxin obtained from a subtilisin digest of the crystallized toxin. The mice did not show typical symptoms of the local tetanus such as convulsions or spastic paralysis of the injected limb.

Decrease of muscle extensibility and reduction of sarcomere number in soleus muscle following a local injection of tetanus toxin

Slow soleus muscle in guinea pig developed within 4--6 days after local injection of a sublethal dose of tetanus toxin and 2--4 days after the first signs of local tetanus, a myostatic contracture characterized by a change in the passive tension--lengthening curve associated with a considerable decrease of the sarcomere number. It was demonstrated by clinical and EMG investigations that the soleus did have a tetanic spasm at least within the 2--4 day period of observation. When local tetanus was confined to slow soleus by functional suppression of rapid gastrocnemius and ankle flexor muscles, the decrease of the sarcomere number still persisted. This decrease failed to occur after section of the nerve supplying the soleus when associated with an injection of the tetanus toxin, and was much greater than when the soleus was passively shortened for the same period of time by plaster cast.

Histoautoradiography of central nervous system in rats with generalized tetanus due to 125I-toxin

Rats were injected i.v. with 125I-tetanus toxin. In autoradiographs of the spinal cord radioactivity was found over the pericarya and in the surroundings of the motoneurones whereas grain density was less over their nuclear region. In addition, pericarya in the lateral horn of the thoracic region and also the bipolar cells of the spinal ganglia contained radioactivity. The central part and the dorsal horns of spinal cord, and the white substance did not show any appreciable radioactivity. Within the medulla oblongata, clusters of large cells representing motor nuclei, as well as some fibre tracts close to them, contained 125I. Forebrain and cerebellum remained free. According to its histoautoradiographic appearance, generalized tetanus can be described best as a combination of multiple local tetani.

Tetanus antibody production in serum and cerebrospinal fluid in the rabbit and correlated histopathological features of the central nervous system

The histopathological features in the central nervous system (CNS) developing during the active phase of tetanus antibody formation in the cerebrospinal fluid (CSF) as induced in 15 rabbits were studied. The measurement of antibody titres in serum and CSF by electroimmunodiffusion and histological examination were done sequentially at the 1st, 3rd, 5th, 7th and 9th days after cisternal secondary inoculation with fluid tetanus toxoid. Tetanus antibodies appeared in serum after the 1st and in CSF after the 5th day. Decreasing values of CSF total protein were found. The meaning of an elevated Q ratio as observed in this situation of strong antibody formation in the CSF was enhanced. The histopathological features in the central nervous system consisted of perivascular inflammatory infiltration, at first polymorphic and then composed almost exclusively of mononuclear cells with a predominantly leptomeningeal and subpial localization, which might represent the origin of CSF tetanus antibodies. The localization was related to the contact zone between the antigen- and antibody-containing compartments, respectively the subarachnoid space and vascularized structures of the brain and spinal cord. Four control rabbits presented neither tetanus antibodies in the CSF nor perivascular inflammatory infiltration in the CNS. Similarity between the present experimental results and the immunopathological features of the primary demyelinating diseases provides some useful information about the immunological inflammatory events in these diseases.