Case presentation

CASE PRESENTATION BY; DR BALWANT LAL PGR M.D (INTERNAL MEDICINE) WEST MEDICAL WARD MAYO HOSPITAL LAHORE.

BIO DATA

RAFIQUE S/O AMMIR BAKSH

45 YEARS OLD /MALE

MARRIED

SHOPKEEPER BY PROFESSION

FROM SHERA KOT

DOA 23.5.2014

Presenting complaints

PRESENTED IN EMERGENCY WITH HISTORY OF

ROAD TRAFFIC ACCIDENT 3 DAYS

ASOC 2 DAYS

FEVER 1 DAY

LOCK JAW 1 DAY

HISTORY OF PRESENT ILLNESS

• ACCORDING TO THE PATIENT ATTENDENT , PATIENT GOT

SUFFERED FROM RTA 3 DAYS AGO ON MOTORBIKE,

BROUGHT TO JINNAH HOSPITAL EMERGENCY WHERE TT

INJECTED , BACKSLAB APPLIED FOR LEFT SIDED TIBIA

AND FIBULA FRACTURE AND DISCHARGED ON

ANALGESIC AND ANTIBIOTICS .

CONT…….

DURING HIS STAY AT HOME HE DEVELOPED ASOC

GRADUAL ONSET & PROGRESSIVE

NO HX OF HEADACHE, FITS,

WEAKNESS OF ANY PART OF THE BODY

NO HX OF NECK STIFFNESS

NO HX OF BLEED FROM EAR NOSE AND THROAT

VOMITING 2 EPISODE

CONT…….

Fever

SUDDEN ONSET

CONTINUOUS

HIGH GRADE

ASSOCIATED WITH CHILLS

Lock Jaw

SUDDEN ONSET,

HISTORY OF TRAUMA,

NO HISTORY OF DENTAL /URT INFECTION

• PAST HISTORY

• NOT SIGNIFICANT

• FAMILY HISTORY

• NOT SIGNIFICANT

• PERSONAL HISTORY

• MARRIED HAVING FOUR CHILDREN

• SMOKER

• SHOPKEEPER

• APPETITE AND BOWL HABBIT NORMAL

SOCIOECONOMIC HISTORY

• SATISFACTORY

On Examination

GENERAL PHYSICAL EXAMINATION

YOUNG MAN LYING ON BED UNCONSCIOUS WITH NORMAL

BUILT AND HEIGHT HAVING FOLLOWING VITALS

PULSE 90/MIN

BP 120/70

TEMP 100

RESP; RATE 20/MIN

BACK SLAB ON LEFT LEG

CNSGCS E2 V1 M3 06/15

CRANIAL NERVES NO OBVIOUS CRANIAL NERVE PALSY

MOTOR

APPEARANCE NORMAL

TONE NORMAL

POWER

RIGHT LEFT

UPPER LIMB 1/5 UPPER LIMB 3/5

LOWER LIMB 0/5 FRACTURED

REFLEXES

PLANTERS RT; SIDE UPGOING LEFT NOT ASSESSED

SENSATIONS NOT ASSESSABLE

SOMI -VE

Musculoskeletal

• AT PRESENTATION

LOCK JAW

NECK RIGIDITY ABSENT

OPISTHOTONUS ABSENT

RISUS SARDONICUS ABSENT

MUSCLE SPASM ABSENT

• DURING HIS STAY IN WARD PATIENT DEVELOPED ALL OF THE ABOVE

FEATURES

RESPIRATORY SYSTEM BILATERAL COARSE CREPTITATION THROUGHOUT THE CHEST

OTHER SYSTEMIC EXAMINATION UNREMARKABLE

CONT…….

SUMMARY• HISTORY OF RTA• ASOC• VOMITING• HEMIPARESIS / HEMIPLEGIA SUBDURAL HAEMATOMA• PLANTER UPGOING• SOMI -VE

• FEVER• TACHYOPNEA ASPIRATION PNEUMONIA• BILATERAL COARSE CREPITATIONS

• LOCK JAW TETANUS MANDIBLE FRACTURE

Diagnosis

HEAD INJURY ( SUB DURAL HEMATOMA)

TETANUS

ASPIRATION PNEUMONIA

SEPTICEMIA

Investigation Date 23/5/14 29/5/14 04/6/14 14/6/14

CBCHB 12.6 10.6 9.1 9.7

MCH 28.3 26.2 27.3 26.9

MCV 86.5 88.1 88.3 89.7PLT 223 228 294 210TLC 14.8 11.2 5 5.7

NEUTRO 78.6 70 69 65

ABG,S

SHOWS RESPIRATORY ALKALOSIS

LFTS & RFTS & S/E

NORMAL

PRESENTATION BSL

32 mg

BLOOD CULTURE (28/05/14)

NO GROWTH FOUND

URINE CULTURE (12/6/14)

E COLI GROWTH SENSITIVE TO TAZOCIN

PT & APPT

> 1 MIN

SPUTUM C& S

PSEUDOMONAS GROWTH SENSITIVE TO TAZOCIN

ECG NORMAL

VIRAL MARKERS

NEGATIVE

DEFENITIVE DIAGNOSIS

TETANUS SEPTICEMIA D/T CHEST INFECTION (ASPIRATION PNEUMONIA)

Treatment Given in wardINJ TAZOCIN

INJ BENZYL PENICILLINE

INJ FLAGYL

TETANUM BURNA

INJ MERONUM

INJ SULZONE

Treatment Given in wardIV FLUIDS

DIAZEPAM

PHENOBARBITONE

TINAZIDINE

INJ CLEXANE

INJ RISEK

TETANUS INFECTIOUS DISEASE CHARACTERISED BY ;

ACUTE ONSET OF HYPERTONIA

PAINFUL MUSCLE CONTRACTIONS

GENERALIZED MUSCLE SPASMS

WITHOUT OTHER APPARENT MEDICAL CAUSES.

PATHOPHYSIOLOGYCLOSTRIDIUM TETANI (gram +ve, motile, anaerobe, obligate rod)-

SPORES (resistant to heat, desiccation and disinfectant)

WOUND ( dead tissue low oxidation/reduction potential)

TOXIN (upon germination, spore produce tetanospasmin, most toxic substance with lethal dose 2.5 ng /kg body wt.)

PATHOPHYSIOLOGYMOTOR NEURON ( central inhibitory neuron, tetanospasmin enters in retrograde

fashion from wound to motor neuron in spinal cord where it cleaves

synaptobrevin that results in inhibition of release of GABA and

GLYCINE resulting in autonomic hyperactivity and uncontrolled muscle

contraction in response to normal stimuli).

Toxins fixed to neurons can not be neutralized with antitoxins.

ETIOLOGYCAUSATIVE AGENT;

• CLOSTRIDIUM TETNAI

SOURCE OF INFECTION;

• WOUND (65%) BY WOOD, THORN, METAL SPLINTERS

• CHRONIC SKIN ULCERS (5%)

• ABSCESS / GANGRENE

ETIOLOGY• FROST BITE / BURNS

• MIDDLE EAR INFECTION

• DENTAL / SURGICAL PROCEDURES

• ABORTION / CHILD BIRTH

• I/V DRUG ABUSERS

•UNDER IMMUNIZATION. 12 to 14 % tetanus affected patients are properly immunized.

EPIDEMIOLOGY• AFFECTS;

ALL AGES / BOTH GENDERS

MORE PREVALENT IN NEWBORNS AND YOUNGS

• ANNUAL INCIDENCE;

0.5 TO 1 MILLION / YEAR (WHO)

PRESENTATION• INCUBATION PERIOD 4 TO 14 DAYS

• SORE THROAT WITH DYSPHAGIA IS EARLY SIGN

• BASED ON CLINICAL PRESENTATION TETANUS IS DIVIDED INTO 4

TYPES

• GENERALIZED TETANUS• LOCALIZED TETANUS• CEPHALIC TETANUS• NEONETAL TETANUS

PRESENTATION GENERALIZED TETANUS;

1. MOST COMMON FORM OF TETANUS (85 TO 90 %)

2. LOCK JAW (trismus, muscle of mastication, 75%)

3. NECK RIGIDITY (neck muscles involvement)

4. FASCIAL MUSCLES CAUSE RISUS SORDONICUS

5. ABDOMINAL TENDERNESS AND GAURDING

MIMICKING ACUTE ABDOMEN

PRESENTATION 6. STIFFNESS AND REFLEX SPASMS

Triggered by minimal external stimuli ,

lasts seconds to minutes , more intense

and frequent with disease progression

can cause apnea , fractures , and

rhabdomyolysis. Laryngeal spasm can

occur at any time and cause asphyxia.

PRESENTATION

7. RESTLESSNESS

8. MUSCLE RIGIDITY (descending pattern)

9. INCREASED TEMPERATURE

10. HIGH BLOOD PRESSURE

11. SWEATING

12. EPISODIC RAPID HEART RATE

13. IRRITABILITY

14. HYDROPHOBIA

15. DROOLING

PRESENTATION• LOCALIZED TETANUS;

INVOLVES EXTREMITY WITH INFECTED WOUND

UNUSUAL FORM , LESS SEVERE

• CEPHALIC TETANUS;

FOLLOW HEAD INJURY / EAR INFECTION

POOR OUTCOME

ISOLATED OR COMBINED INVOLVEMENT OF

CRANIAL NERVES i.e. 7TH NERVE

INCUBATION PERIOD 1 TO 2 DAYS

PRESENTATION• NEONATEL TETANUS;

FORM OF GENERALIZED TETANUS IN NEONATES

IRRITABILITY , POOR FEEDING , SPASMS AND

FASCIAL

GRIMASING

DIFFERENTIALS• STRYCHNINE POISONING

• DENTAL INFECTIONS

• HYSTERIA

• MALIGNENT HYPERTHERMIA

• HEPATIC ENCEPHALOPATHY

• SEIZURES

• ACUTE ABDOMEN

DIFFERENTIALS• ENCEPHALITIS

• CONVERSION DISORDER

• MENINGITIS

• NEUROLEPTIC MALIGNENT SYNDROME

• PERITONSILLER ABSCESS

• STROKE

• INTRACRANIAL HAEMORRHAGE / SAH

WORK UP• CLINICAL DIAGNOSIS

• LABS HELP TO EXCLUDE DIFFERENTIALS

• CBC ; PERIPHERAL LEUCOCYTOSIS

• RAISED MUSCLE ENZYME LEVEL (CPK , ALDOLASE)

• CSF ; RAISED OPENING PRESSURE

• WOUND C/S

WORK UP• SPATULA TEST ;

1. TOUCHING POSTERIOR PHARYNGEAL WALL CAUSES GAUGE

REFLEX IN NORMAL PERSONS WHILE TETANUS PATIENT

CLENCH THEIR MOUTH DUE TO REFLEX CONTRACTION OF

MASTICATION MUSCLES .

2. NO ADVERSE SEQUELE

3. 94 % SENSITIVE AND 100 % SPECIFIC

EMG ;

CONTINEOUS MOTOR UNIT DISCHARGES / ABSENT SILENT INTERVAL

MANAGEMENT • MAIN GOALS OF TREATMENT ARE

1. SUPPORTIVE THERAPY

2. STOPPING PRODUCTION OF TOXIN

3. NEUTRALIZING UNBOUND TOXIN

4. CONTROLLING DISEASE MANIFESTATION

5. MANAGING COPMLICATIONS

6. DIET AND NUTRITION

MANAGEMENT SUPPORTIVE THERAPY INCLUDE

ADMISSION IN ICU

DARK AND QUITE ENVIRONMENT

AIRWAY MAINTINANCE

PROPHYLACTIC INTUBATION ( 67%)

SUCCINYLCHOLINE TO AVOID REFLEX

LARYNGEOSPASM

TRACHEOSTOMY

INTUBATION > 10 DAYS

FIRST SIEZURE

MANAGEMENT STOPPING PRODUCTION OF TOXIN AT WOUND SITE

BY WOUND DEBRIDEMENT

DONE WHEN PATIENT IS STABLE

TO EXCISE 2 CM OF NORMAL VIABLE TISSUE

AFTER ADMINISTERATION OF ANTITOXIN

BY ANTIBIOTICS

METRONIDAZOLE ( 0.5 GM 6 HOURLY )

OTHERS INCLUDE CLINDAMICIN , VANCOMYSIN

PENICILLIN G NO MORE RECOMMENDED AS IT IS ANTAGONIST OF GABA

MANAGEMENT NEUTRALIZATION OF UNBOUND TOXIN

TETANUS IMMUNOGLOBULIN I/M

( 3000-5000 IU SINGLE DOSE , PART AROUNDWOUND)

TETANUS TOXOID

( 0.5 ML I/M , 2nd +3rd doses in non-immunized )

CONTROL OF DISEASE MANIFESTATION

BENZODIAZEPINES

DIAZEPAM , LORAZEPAM , MIDAZOLAM

DOSE 10-40 mg /1-8 hrs. MAX; 600 mg / day

MANAGEMENT PHENOBARBITAL

NEUROMUSCULAR BLOCKING AGENTS

VECURONIUM

PENCURONIUM

DANTROLIN

BACLOFIN ( INTRATHECAL /ORAL)

CHLORPROMAZINE

PROPOFOL

MANAGEMENT MANAGING COMPLICATION

MgSO4 ( LOADING DOSE 5 gm. , 2- 3 gm. / hr.)

MORPHINE

B- BLOCKERS (ESMOLOL)

HYPOTENSION ( FLUIDS , DOPA + NORPINE)

BRADYCARDIA ( PACEMAKER )

DIET AND NUTRITION

NASODUEDENAL TUBE

GASTROSTOMY TUBE

PARENTRAL

DAKAR SCORING SYSTEM

Prognostic Factor

Score 1 Score 0

Incubation period < 7 days ≥ 7 days or unknown

Period of onset < 2 days ≥ 2 days

Entry site Umbilicus, burn, uterine,open fracture, surgicalwound, IM injection

All others plus unknown

Spasms Present Absent

Fever > 38.4oC < 38.4oC

Tachycardia Adult > 120 beats/minNeonate > 150 beats/min

Adult < 120 beats/minNeonate < 150 beats/min

Total Score

PHILLIP SCORING SYSTEMFactor Score

INCUBATION TIME < 48 hours 52-5 days 45-10 days 310-14 days 2> 14 days 1

SITE OF INFECTION Internal and umbilical 5Head, neck, and body wall 4Peripheral proximal 3Peripheral distal 2Unknown 1

STATE OF PROTECTION None 10Possibly some or maternal immunisation in neonatal patients 8Protected > 10 years ago 4Protected < 10 years ago 2Complete protection 0

COMPLICATING FACTORS Injury or life threatening illness 10Severe injury or illness not immediately life threatening 8Injury or non life threatening illness 4Minor injury or illness 2

TOTAL SCORE

CLINICAL ASSESSMENT OF SEVERITY

Grade 1 (Mild): Mild to moderate trismus, general increased tone, no respiratory distress, no spasms, and no dysphagia

Grade 2 (Moderate): Moderate trismus, marked rigidity, short lasting spasms, tachypnoea ≥ 35minute-

1, mild dysphagia.

Grade Three (Severe):

Severe trismus, generalised increased tone, reflex spontaneous or prolonged spasms, respiratory distress with tachypnoea ≥ 40minute-1, apnoeic spells, severe dysphagia, tachycardia ≥120 minute-1, moderate increase in autonomic nervous system dysfunction.

Grade Four (Very Severe): Features of Grade III, plus severe autonomic dysfunction, persistent labile blood pressure and pulse rate.

VACCINATION Vaccine Children under 7 years

1-DPT 6-8 weeks

2-DPT 4-8 weeks after previous dose

3-DPT 4-8 weeks after previous dose

4-DPT 1 year after previous dose

Booster-DPT 4-6 years of age

Adults and children not previously vaccinated

1-Td At presentation

2-Td 4-8 weeks after previous dose

3-Td 6 months - 1 year after previous dose

Booster- Td Every 10 years after previous dose

Pregnant women previously vaccinated

Booster- TT During first six months of pregnancy

Pregnant women not previously vaccinated

1-TT First encounter during pregnancy

2-TT 4 weeks after previous dose

PROPHYLAXIS ( WOUND)• Tetanus• Prophylaxis: 250 Units IM (single dose)• Active tetanus: 3000-6000 Units• Clean minor wound• # doses unknown or 0-2 doses; toxoid only• >3 doses; toxoid if >10 years ago• All other wounds• # doses unknown or 0-1 doses; toxoid plus IG• 2 doses; toxoid, but no IG if wound <24 hours old• >3 doses; toxoid if >5 years ago, and no IG

THANK YOU