The management and prevention of tetanus

Annual two-dose tetanus toxoid vaccination induces protective humoral immunity to all age groups of rhesus macaques

A tetanus outbreak occurred during 2014-2015 in the rhesus macaques reared in an open enclosure in our facility. As the soil of the facility was suspected to be contaminated with Clostridium tetani spores, there was a risk of further tetanus occurring among the macaques. To protect them from tetanus, a tetanus toxoid vaccination was recommended; however, the vaccinated elderly animals might not be effectively protected due to insufficient humoral immune responses. Hence, we evaluated the dynamics of antibody responses among rhesus macaques of all age groups vaccinated with two-dose tetanus toxoid at a 1-year interval during a 3-year follow-up study. The vaccination developed anti-tetanus toxin-specific antibodies in animals of all age groups, the antibody levels peaked 1 year after the second vaccination, and the peak levels decreased with age. However, the levels among elderly individuals (aged ≥13 years) were still higher than the threshold level, which was supposed to protect them from tetanus development. Although the rhesus macaques in our facility had a risk of occasional exposure to the spores due to the outbreak, no incidence of tetanus has ever occurred to date. These results indicate that the vaccination protocol is effective in protecting not only younger but also older animals from tetanus.

The Role of Surgical Debridement in the Treatment of Systemic Tetanus: A Case Report

CASE

Tetanus is a potentially life-threatening infection of Clostridium tetani characterized by painful muscular spasms and hypertonia. Surgical debridement of infected tissue is intended to reduce the number of spores and limit the extent of the disease. We report a case of an unvaccinated 13-year-old adolescent boy who presented with systemic tetanus after stepping on a nail, and we describe the role that surgical debridement of infected tissue plays in optimizing outcomes.

CONCLUSION

Orthopaedic surgeons must remain aware of the role of surgical debridement of wounds potentially infected with C. tetani because it is an important component of proper management.

An L-2 burst fracture and cauda equina syndrome due to tetanus

Thoracic vertebral compression fractures are a known complication of generalized tetanus. The authors report the first known case of an L-2 burst fracture leading to cauda equina syndrome, as a result of generalized tetanus. This 51-year-old man had generalized tetanus with a constellation of symptoms including compartment syndrome requiring fasciotomies, severe axial spasms and spasms of the extremities, autonomic dysreflexia, hypercarbic respiratory failure, and rhabdomyolysis. During the course of his illness, areflexic paraparesis developed in his lower extremities. He was found to have an L-2 burst fracture with retropulsion of a bone fragment resulting in cauda equina syndrome. Operative intervention was undertaken to decompress the cauda equina and stabilize the spine. The natural progression of tetanus can be complex, with a mixed picture ranging from spasms plus increased tone and reflexes to reduced tone and reflexes as presynaptic nerve terminals become damaged. The authors suggest that all sudden changes in the neurological examination should prompt consideration of diagnostic imaging before attributing such changes to natural progression of the disease.

Ketamine in the management of generalised cephalic tetanus

BACKGROUND

Tetanus is a fatal infection caused by the neurotoxin tetanospasmin released by the vegetative spores of Clostridium tetani. The high mortality rate is related to frequent tetanic fits with laryngeal spasm and airway obstruction. Numerous anticonvulsants are in use, with varying efficacy in controlling fits. This case report highlights the use of ketamine as adjunctive therapy in the management of tetanus.

CASE REPORT

A 20-year-old woman was admitted with a history of recurrent left ear pain, with bloody, purulent discharge, following a self-inflicted injury. She developed tetanic spasms 24 hours after admission. She had received no immunisations. A tracheostomy was established to relieve airway obstruction, and ketamine was added to the medication when breakthrough seizures were refractory to diazepam.

CONCLUSION

Ketamine is of proven safety as an anaesthetic agent, especially in cases in which an anaesthetist is not readily available. Its effectiveness in this case, in combination with diazepam, warrants further evaluation.

An audit of the tetanus immunisation status of plastic surgery trauma and burns patients

This study audits the tetanus immunisation management of plastic surgery trauma patients by their referring Accident and Emergency departments, and compares this to nationally published guidelines. We assessed 269 burns and trauma patients, referred from across South Wales, using a questionnaire together with their Accident and Emergency notes or letter. The precise question(s) that had been asked regarding the tetanus immunisation status of the patient, and the immunisation management based on the results of those questions, were recorded. The accurate tetanus immunisation status of the patient was established, the wound was assessed and further management was given as indicated. Only 16 patients had been asked whether they had received a course of tetanus, and 41 patients were not questioned about their tetanus immunisation status by the referring Accident and Emergency department. As a consequence of more accurate questioning, 73 patients (27%) required further action after their arrival in the Plastic Surgery unit. This audit has demonstrated that the management of tetanus immunoprophylaxis in plastic surgery trauma patients cannot be confidently left to the referring Accident and Emergency department but should form an integral part of the treatment at the admitting unit.

Tetanus after a resection for a gangrenous perforated small intestine: report of a case

We report herein the case of a 75-year-old man who developed severe tetanus 24 h after the resection of a gangrenous perforated small intestine. It seemed that the tetanus was caused by a spillage of the intestinal contents harboring Clostridium tetani; however, this was not identified by a culture. The diagnosis of tetanus was made only when opisthotonus in this patient became evident and normal tetanus treatment proved to be successful.

Generalized tetanus in a patient with a diabetic foot infection

Tetanus is a preventable disease that continues to affect people in the United States due to poor immunization practices in our health care system. A 57-year-old man with type 2 diabetes mellitus, hypertension, and end-stage renal disease with many hospital admissions came to the hospital emergency department because of a blackened great toe. He denied pain in the toe or knowledge of foot injury. The patient also complained of temporomandibular tenderness accompanied by inability to open his mouth completely. The man's problems progressed to generalized tetanus and required a long hospitalization. Clostridium tetani can flourish in the anaerobic environment of a diabetic foot infection. Practitioners should be aware of tetanus as a rare but potentially serious complication of diabetic foot infections.

The presentation of tetanus in an emergency department

Traditionally, the literature has described a certain population as at risk for tetanus infection. We reviewed the demographics, clinical presentation, laboratory findings, management, and outcome of all patients who presented to our emergency department (ED) with tetanus in the last 10 years and compared our experience with this classic literature. We performed a retrospective case series review at a large, inner-city medical center; 11 cases of tetanus were identified from 1986 to 1997. Nine male and two female patients were identified with an average age of 45 years. All had an acute injury to the skin, and most (82%) reported having no history of recent immunization. The most common recorded symptoms were trismus and rigidity in the abdomen, neck, back, or extremities. There was only one misdiagnosis in the ED. Three patients died in the hospital, while the other eight were discharged either home or to a rehabilitation facility. In contrast to the classic literature, we found that tetanus in our inner city ED presented in recent immigrants, particularly younger men, over half of whom had received no childhood immunization. Laboratory results and cultures are of little diagnostic value, so timely recognition of the clinical presentation is important.

Tetanus--the silent killer: how safe are you?

Despite the fact that tetanus is entirely preventable, mortality and morbidity as a result of this disease remain significant. The tetanus toxoid is one of the most potent poisons known. While immunisation programs focus on children, the elderly remain at risk of contracting immunisable diseases. Tetanus often leads to prolonged hospital stays and requires emergency and intensive care intervention and management. This case study illustrates a number of important points concerning the recognition, treatment, management and prevention of tetanus poisoning, and highlights the importance of considering the immunisation status of our elderly patients.

Immunologic response to tetanus toxoid in the elderly: one-year follow-up

STUDY OBJECTIVE

To determine whether elderly patients documented to have nonprotective titers of anti-tetanus antibodies (ATA) are able to achieve and maintain protective ATA titers for at least 1 year after tetanus immunization.

METHODS

Thirty-five outpatients aged 65 or older with documented inadequate ATA titers were given 1 tetanus immunization. Repeat titers were obtained 2 months and 12 months after immunization. Titers were measured with an enzyme-linked immunoassay kit (Bindazyme kit). ATA titers in excess of .17 IU were considered protective. The study was conducted at a large urban geriatric center.

RESULTS

The mean age of participants was 78.7 years; 86% (24/28) were women. Repeat ATA titers were obtained an average of 122 days and 493 days after immunization. The mean preimmunization ATA titer was .1 IU, (range .04 to .16 IU). After immunization, the 2-month ATA titer rose a mean of .61 (95% confidence interval [CI] .35 to .87) IU, with 86% (30/35) achieving protective titers. After 1 year only 28 of 35 patients were available for follow-up. Protective titers had been present in all 7 patients lost to follow-up. After 1 year, 82% (23/28) patients had protective titers. The mean ATA titer for the 28 patients was .54 (95% CI -.78 to 1.86) IU, a significant increase from preimmunization levels (P=.002). However, ATA titers changed -.18 (95% CI -.98 to .62) IU between 2 months and 1 year (P=.02). There was no correlation between gender, country of birth, and medical history with development or maintenance of protective titers.

CONCLUSION

Administration of 1 tetanus toxoid affords protective immunization to a large portion of the elderly population after 1 year.

DHEAS as an effective vaccine adjuvant in elderly humans. Proof-of-principle studies

We have demonstrated that in aged mice, the titer of serum antibody induced against tetanus toxoid correlates with resistance to local paralysis caused by injection of tetanus toxin. Only mice immunized shortly after oral dosing with DHEAS demonstrated high serum antibody titers and complete protection from paralysis. These results became the basis for initiating proof-of-principle studies in human volunteers above age 65 using a licensed influenza vaccine and tetanus toxoid in two independent studies. The use of an oral delivery form of DHEAS before influenza vaccination was associated with a demonstrable increase in the number of individuals with a fourfold increase in HAI titers following vaccination. The overall mean increase in HAI titers was highest in the DHEAS-treated group. The use of DHEAS in the immunization of elderly subjects against tetanus toxoid, while unable to enhance the responses, was not a detriment to antibody response. We conclude that further studies will justify the use of DHEAS as an adjuvant for antigens that represent primary responses in the elderly.