Transcript CASE 4 “THE DISEASE OF THE SEVENTH DAY”

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 answered
1.
2.
3.
4.
5.
6.
What is the most likely diagnosis of this
patient?
Explain the pathophysiology of Tetanus
How is a diagnosis of Tetanus achieved?
What are the differential diagnoses of
Tetanus?
What are the goals of treatment of Tetanus?
What are the necessary Preventive
measures?
Q1:
What is the most
likely diagnosis of this
patient?
Answer: Neonatal Tetanus
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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
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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
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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
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Over the next 24-48
hrs., muscle rigidity
spreads to involve the
muscles of the
neck,back, abdomen
and limbs culminating in
Opisthotonus
a very characteristic
spasm.
•During these spasms, the
The head is retracted, child remains mentally alert
the spine arches
but apprehensive
backwards and the
•The spasms may be
abdomen attains a
precipitated by a variety
board-like rigidity
of stimuli as light or noise
Q2:
Explain the
pathophysiology of
Tetanus
Pathophysiology
 The 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
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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
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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 Tetanus
Goals of therapy:
1.
2.
3.
Neutralization of toxin still present in the blood
before it comes in contact with the CNSantitoxin
(human tetanus immune globulin) or Equine
antitoxin
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Penicillin kills the vegetative forms
Surgical removal of the site of entry of the
organism
General measures: mainly supportive
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4.
Constant and meticulous nursing care
Control of seizures
Close monitoring of fluid, electrolyte and caloric
balance
Treatment of Neonatal
Tetanus
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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
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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”