CASE 4 “THE DISEASE

OF THE SEVENTH DAY”

“THE DISEASE OF THE SEVENTH DAY”

Baby J.D. is a 7-day old neonate born term in a faraway Bukidnon baragay reachable only by horseback and delivered by a traditional “hilot”. He was admitted because of poor sucking and inability to open the jaw. He was crying excessively and went into spasms when touched. A few hours later, he became highly febrile and his entire body became completely rigid

Questions to be answered1. What is the most likely diagnosis of this

patient?2. Explain the pathophysiology of Tetanus3. How is a diagnosis of Tetanus achieved?4. What are the differential diagnoses of

Tetanus?5. What are the goals of treatment of

Tetanus?6. What are the necessary Preventive

measures?

Q1:What is the most likely diagnosis of

this patient?

Answer: Neonatal Tetanus WHO estimates that >500,000 deaths

due to Tetanus neonatorum still occurs

Tetanus is an acute toxemic disease caused by Clostridium tetani , a spore forming gram (+) bacillus widely distributed in the soil, animal and human feces, house dust and even in contaminated street drugs.

Neonatal Tetanus Absence of immunity in the mother

and contamination of the umbilical cord account for the occurrence in regions where home delivery is conducted by untrained personnel with the cord cut by an unclean knife, scissors, bamboo etc. and the umbilical stump dressed with earth or animal dung

Neonatal Tetanus Inability to suck,

persistent crying, followed by fever and recurrent generalized spasms with deep cyanosis are the usual presenting symptoms

Risus sardonicus

Tetanus The most frequest

presenting symptom is painful trismus (lockjaw) due to spasm of the masseter muscles

When the jaw remains tightly clenched together with spasm of the facial muscles, the typical “risus sardonicus” expression results

Risus sardonicus

Tetanus Over the next 24-48

hrs., muscle rigidity spreads to involve the muscles of the neck,back, abdomen and limbs culminating in a very characteristic spasm.

The head is retracted, the spine arches backwards and the abdomen attains a board-like rigidity

•During these spasms, the child remains mentally alert but apprehensive•The spasms may be precipitated by a variety of stimuli as light or noise

Opisthotonus

Q2: Explain the

pathophysiology of Tetanus

PathophysiologyThe potent Tetanus neurotoxin (Tetanospasmin) is

synthesized intracellularly. After release it binds to motor end-plates in skeletal muscles. It acts by inhibiting acetylcholine release thereby impairing neuromuscular transmission

It reaches the CNS through the perineural spaces of nerve trunks of by hemotagenous dissemination

The toxin enters the neurones and becomes irreversibly fixed on to the gangliosides

Produces presynaptic inhibition resulting in unopposed muscle contraction and seizures

Q3:How is a diagnosis

of Tetanus achieved?

Diagnosis The diagnosis of tetanus is entirely

clinical It is often difficult to isolate the

bacilli from the wound + the presence of C. tetani does not mean the patient has tetanus (Paediatric Problems in Developing Countries, edited by Robinson M.J)

Q4:What are the differential

diagnoses of Tetanus?

Differential diagnosis of Tetanus Other convulsive

disorders posing a problem in diagnosis: meningitis, phenothiazine dystonia, strychnine poisoning, tetany

Trismus may be seen in rabies

Hydrophobia of Rabies

Differential diagnosis of Tetanus

Tetany with carpopedal spasm

Q5:What are the goals of treatment in the

management of Neonatal Tetanus

Treatment of Neonatal TetanusGoals of therapy:1. Neutralization of toxin still present in the blood

before it comes in contact with the CNSantitoxin (human tetanus immune globulin) or Equine antitoxin

Penicillin kills the vegetative forms2. Surgical removal of the site of entry of the organism3. General measures: mainly supportive

Constant and meticulous nursing care Control of seizures

4. Close monitoring of fluid, electrolyte and caloric balance

Treatment of Neonatal Tetanus

Incubator care External stimulation kept to a minimum but

suction of pharyngeal secretions must be done NGT feeding best avoided during the initial 2-3

days (aspiration precaution) IVF therapy Temporary nutritional support with dextrose,

amino acids and lipids before onset of gavage feedings

Periodic change of posture Catheterisation for distended bladder and

enemata for constipation

Q6:What are the

necessary Preventive measures?

Prevention of Neonatal Tetanus

By a combination of:1. Improving maternity care with

emphasis on increasing the immunization coverage of women of childbearing age esp. pregnant women with tetanus toxoid

2. Increasing the proportion of deliveries attended by trained attendants

Key Learning Points Tetanus is a totally preventable

disease. Its occurrence is a reflection of the failure of health delivery

Immunization of pregnant mothers at least 6 wks before delivery is the most efficient method of eliminating neonatal tetanus

CASE 4:“The Disease of the

Seventh Day”