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

Brain damage after neonatal tetanus in a rural Kenyan hospital

OBJECTIVE

Neonatal tetanus (NNT) is an important cause of mortality in resource poor countries, particularly sub-Saharan Africa. There are no reports of the long-term outcome of children who survive NNT in African hospitals.

DESIGN

In a retrospective study of children discharged from Kilifi District Hospital (KDH), Kenya with NNT, each child was linked with a comparative child (CC) in the community matched for age, sex and locality.

PARTICIPANTS

A total of 123 patients were admitted with NNT between 1992 and 1996, of whom 68% died. Twenty-three (59%) of the 39 survivors were traced in the community, 10 had moved away, six had died.

OUTCOME MEASURES

NNT survivors underwent a neurological and developmental examination and a questionnaire was administered to the parents about the behaviour of the child. A verbal autopsy was used to determine the cause of death in children who had died after discharge.

RESULTS

The head circumference of NNT survivors was significantly smaller than that of CC (P=0.037); eight children had microcephaly compared with one CC (P=0.011). NNT survivors had more problems with hand-eye co-ordination tasks (P=0.035), a lower summated developmental score (P=0.023) and more mild neurological abnormalities (P=0.008) than CC. Parents of NNT survivors reported more behavioural problems (P=0.02) than parents of CC.

CONCLUSIONS

Children who survive NNT have evidence of brain damage that manifests as microcephaly, mild neurological abnormalities, developmental impairment - particularly fine motor difficulties - and behaviour problems.

Long-term prognosis after neonatal tetanus

Twenty-four Turkish children who had had neonatal tetanus were evaluated by means of physical and neurological examinations and psychometric tests at four to 15 years of age. Enuresis, mental retardation and growth retardation were frequent findings. The prevention of neonatal tetanus is important not only because of the high mortality rate but also because of its sequelae.

Cephalic tetanus studied with single fibre EMG

In a case of cephalic tetanus with left facial spasms and trismus, the repetitive stimulation of the left facial nerve at 3, 10 and 20 Hz showed no facilitation or decrement. The amplitudes of the blink reflex were 50% lower on the affected side. The silent period of the masseter muscles was shortened. Concentric needle examination of the masseters and left facial EMG of the left frontalis muscle showed increased jitter and blocking in a significant proportion of the recorded potentials. Both jitter and blocking improved on higher innervation rates. All electrophysiological findings were normal on the second examination when the patient was asymptomatic. The single fibre EMG findings point to a presynaptic defect in the neuromuscular transmission in human tetanus.