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Kıratlı K, Hirsi IM, Çelik B, Aysin M, Ali AM, Turfan S, Zeybek H. Tetanus Cases in Mogadishu-Somalia: A Tragic Disease Despite the Existence of a Century-Old Safe and Efficient Tetanus Vaccine. Int J Gen Med 2024; 17:3825-3836. [PMID: 39246806 PMCID: PMC11380492 DOI: 10.2147/ijgm.s471130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 08/25/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction Despite the efforts and support of the World Health Organization and other international organizations to reduce the incidence of the disease, tetanus is still an acute condition with serious consequences, including death. The purpose of this study was to assess the tetanus patients we have been monitoring over the past two years in Somalia, a country with a protracted civil conflict, extreme poverty, and restricted access to hospital, social security, and public health facilities. Methods This study includes tetanus patients who were admitted to the Recep Tayyip Erdoğan Training and Research Hospital in Mogadishu, Somalia, Turkey between January 1, 2022, and November 1, 2023. Hospitalization, diagnosis, treatment, complications, death, and test results were all looked at in addition to the patients' sociodemographic details. Results The average age of the 196 patients was 10 years, with males making up 67.9% of the total (min-max: 7 days-71 years). Acute injury was the cause of 53.1% of tetanus cases, with the legs being the most frequently injured body area (28.8%). A mean duration of stay of 11 days was observed for 82.1% of the patients who were monitored in the hospital (min-max: 1-38 days). The total fatality rate was 14.3%, and 85.7% of patients had never had a tetanus vaccination. The group with severe tetanus had higher rates of intensive care admission (p<0.001), generalized/neonatal tetanus (p<0.001), high non-vaccination rate (p:0.011), antibiotic usage (p<0.001), and a positive blood culture (p<0.001). Almost all of the complications (p<0.001) and all of the deaths (p<0.001) were in the severe group. Conclusion In sub-Saharan Africa, immunization rates are regrettably still insufficient despite the tetanus vaccine's low cost and great effectiveness. Public education and encouragement on anti-vaccination must continue alongside the enhancement of vaccination programs. Otherwise, low- and middle-income countries will still be plagued by this illness, which has been overlooked in high-income nations.
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Affiliation(s)
- Kazım Kıratlı
- Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Mogadishu, Somalia
| | - Ibrahim Mohamed Hirsi
- Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Department of Pediatrics, Mogadishu, Somalia
| | - Burak Çelik
- Health Sciences University, Fatih Sultan Mehmet Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Murat Aysin
- Balikesir University Faculty of Medicine, Department of Public Health, Balikesir, Turkey
| | - Ahmed Mohamed Ali
- Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Mogadishu, Somalia
| | - Selim Turfan
- Giresun Training and Research Hospital, Department of Emergency Medicine, Giresun, Turkey
| | - Hakan Zeybek
- Mogadishu Somalia Turkey Recep Tayyip Erdoğan Training and Research Hospital, Department of Orthopedics and Traumatology, Mogadishu, Somalia
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2
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Wakatsuki M, Yamamoto K, Kawashima A, Sakurai A, Kurokawa M, Mizushima R, Okumura N, Yamada G, Nomoto H, Ohmagari N. Autopsy of tetanus with foot gangrene as portal of entry. J Infect Chemother 2024; 30:450-453. [PMID: 37944699 DOI: 10.1016/j.jiac.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/26/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023]
Abstract
Non-traumatic chronic skin lesions are the second most common cause of tetanus. Herein, we describe an 85-year-old woman who presented with a chronically infected skin lesion. She developed tetanus while in hospital and died of respiratory failure, after refusing mechanical ventilation. Routine immunization against tetanus began in Japan during 1968; hence many people born before 1968 are unvaccinated. Mortality due to tetanus is high and the proportion with protective antibodies is low in older adults. Therefore, we recommend tetanus vaccination for older persons in Japan who have chronic skin lesions and have never been vaccinated.
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Affiliation(s)
- Miyu Wakatsuki
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kei Yamamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Akira Kawashima
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Ayana Sakurai
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Masami Kurokawa
- Clinical Laboratory, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Ryo Mizushima
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Nobumasa Okumura
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Gen Yamada
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Hidetoshi Nomoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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3
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Dutta M, Panja T, Dutta I. Craniocervical Tetanus: A Practical Consideration During Work-up of Acute-Onset Trismus. EAR, NOSE & THROAT JOURNAL 2024:1455613231223895. [PMID: 38366878 DOI: 10.1177/01455613231223895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
This clinical record revisits the classical and pathognomonic features of craniocervical tetanus in a 65-year-old farmer who presented with acute-onset trismus, multiple cranial nerve pareses (III, IX, and X), risus sardonicus, and spasm of the head-neck musculature. This paper explores the relevant literature and presents a brief pictorial analysis of the global epidemiologic data. With most countries successfully adopting the maternal and neonatal tetanus elimination (MNTE) program, the incidence and mortality of tetanus across age groups have sharply reduced in high-income and most middle-income nations. In adults, tetanus is now encountered in specialized situations like waning immunity and incomplete vaccination, in the resource-poor and low-income nations, in countries achieving MNTE recently, and as cluster cases in the aftermath of natural disasters involving human settlements. Therefore, present-day practicing otolaryngologists and residents who have limited exposure to the tell-tale clinical features of craniocervical tetanus should consider it during work-up of acute-onset trismus in adults in susceptible situations and with a conducive background. The clinical spectrum of craniocervical tetanus as depicted in this report, including the demonstration of the pathognomonic positive spatula test, provides valuable learning points for otolaryngologists in this regard.
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Affiliation(s)
- Mainak Dutta
- Department of Otorhinolaryngology and Head-Neck Surgery, Medical College and Hospital, Kolkata, WB, India
| | - Tanaya Panja
- Department of Otorhinolaryngology and Head-Neck Surgery, Medical College and Hospital, Kolkata, WB, India
| | - Indranil Dutta
- Department of Neuromedicine, Medical College and Hospital, Kolkata, WB, India
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4
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An Y, Guo Y, Li L, Li Z, Fan M, Peng Y, Yi X, Lv H. Management and outcome of adult generalized tetanus in a Chinese tertiary hospital. Front Public Health 2024; 12:1301724. [PMID: 38425467 PMCID: PMC10902116 DOI: 10.3389/fpubh.2024.1301724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
Background Tetanus is a rare surgical infectious disease with a high reported relevant mortality. It still remains a serious problem in public health, particularly in low-income and middle-income countries. The purpose of this study was to investigate the management and prognosis of adult generalized tetanus in our hospital. Methods A total of 20 adult generalized tetanus patients were recruited in this retrospective observational study. Patients were retrieved from the hospital data base via discharge diagnosis. Patients were divided into two groups (Severe or Non-severe tetanus group) based on the severity of tetanus by using the Ablett classification. The differences between the two groups were compared. Results The study included 11 males (55%) and 9 females (45%). All tetanus patients recovered. The median age was 53.5 years [IQR: 19-78]. There were 1 mild (Grade 1) case (5%),5 moderate (Grade 2) cases (25%), 2 severe (Grade 3) cases (10%), and 12 very severe (Grade 4) cases (60%). Nineteen patients (95%) did not have tetanus immunization before. The majority of patients were farmers (60%), and came from rural areas (60%). Thirteen (65%) patients had a history of puncture injury. The rate of wound debridement after admission was 60% overall. Thirteen (65%) patients required mechanical ventilation for a median of 21 [IQR:12-41] days. Autonomic instability occurred in 13 (65%) patients. Pulmonary infections occurred in 12 (60%) patients. Median duration of hospital stay was 29.5 [IQR:12-68] days. More patients in the Severe group needed ICU admission, wound debridement, mechanical ventilation and heavy sedation combined with muscle relaxants (p < 0.05). The hospital stay was significantly longer in patients in the Severe group (p < 0.05). Conclusion After effective treatment, all adult patients with generalized tetanus in this study were cured and discharged. Severe tetanus requires early ICU treatment, wound debridement and effective treatment of autonomic instability.
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Affiliation(s)
- Yuling An
- Department of Surgical Intensive Care Unit, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yi Guo
- Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Lijuan Li
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ziyu Li
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mingming Fan
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - You Peng
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaomeng Yi
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Haijin Lv
- Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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5
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Söğüt Ö, Ergenc H, Yigit Y. Untangling Tetanus: A Comprehensive Case Report Describing Its Diagnosis and Treatment. Cureus 2023; 15:e44702. [PMID: 37809177 PMCID: PMC10552333 DOI: 10.7759/cureus.44702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Tetanus, caused by a grave and potentially lethal bacteria, is a medical condition that severely affects the central nervous system and demands vigilant attention and comprehensive preventive measures to safeguard public health. The onset of this condition is sudden and characterized by the emergence of intense tonic muscle spasms, underscoring its critical nature. In Türkiye, around 50 cases are officially reported each year; however, it is widely suspected that numerous cases remain unreported, contributing to an even more significant impact. This report aims to shed light on a remarkable case involving a 24-year-old male patient. Despite having a complete vaccination history, this individual contracted tetanus and required intensive care and mechanical ventilation due to the severity of his tetanus infection. This case serves as a poignant reminder of the importance of booster administration, highlighting the significance of continued and timely reinforcement of vaccinations.
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Affiliation(s)
- Özgür Söğüt
- Emergency Medicine, Department of Emergency Medicine, University of Health Sciences, Haseki Training and Research Hospital, Istanbul, TUR
| | - Hüseyin Ergenc
- Emergency Medicine, Department of Emergency Medicine, University of Health Sciences, Haseki Training and Research Hospital, Istanbul, TUR
| | - Yavuz Yigit
- Emergency Medicine, Department of Emergency Medicine, Hamad Medical Corporation, Doha, QAT
- Blizard Institute, Queen Mary University, London, GBR
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6
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Pati I, Cruciani M, Candura F, Massari MS, Piccinini V, Masiello F, Profili S, De Fulvio L, Pupella S, De Angelis V. Hyperimmune Globulins for the Management of Infectious Diseases. Viruses 2023; 15:1543. [PMID: 37515229 PMCID: PMC10385259 DOI: 10.3390/v15071543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
This review is focused on the use of hyperimmune globulin therapy to treat some infectious diseases of viral or bacterial origin. Despite the introduction of antibiotics and vaccines, plasma immunoglobulin therapy from whole blood donation can still play a key role. These treatments provide passive transfer of high-titer antibodies that either reduces the risk or the severity of the infection and offer immediate but short-term protection against specific diseases. Antibody preparations derived from immunized human donors are commonly used for the prophylaxis and treatment of rabies, hepatitis A and B viruses, varicella-zoster virus, and pneumonia caused by respiratory syncytial virus, Clostridium tetani, Clostridium botulinum. The use of hyperimmune globulin therapy is a promising challenge, especially for the treatment of emerging viral infections for which there are no specific therapies or licensed vaccines.
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Affiliation(s)
- Ilaria Pati
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Mario Cruciani
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Fabio Candura
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | | | - Vanessa Piccinini
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Francesca Masiello
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Samantha Profili
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Lucia De Fulvio
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Simonetta Pupella
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
| | - Vincenzo De Angelis
- National Blood Centre, Italian National Institute of Health, 00161 Rome, Italy
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7
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Deniz M, Erat T. Generalized tetanus: a pediatric case report and literature review. Rev Inst Med Trop Sao Paulo 2023; 65:e40. [PMID: 37377323 PMCID: PMC10313328 DOI: 10.1590/s1678-9946202365040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/03/2023] [Indexed: 06/29/2023] Open
Abstract
Pediatric tetanus is a rare and forgotten disease in countries with high childhood tetanus toxoid vaccination rates. Therefore, the clinical manifestations, treatment and management of this potentially life-threatening disease are not well known. With a literature review and discussion of tetanus management in pediatric patients, we describe a clinical course of a rare and fatal but vaccine-preventable disease, the generalized tetanus, in an adolescent who was successfully treated.
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Affiliation(s)
- Melis Deniz
- Sanlıurfa Training and Research Hospital, Department of Pediatric Infectious Diseases, Sanlıurfa, Turkey
| | - Tugba Erat
- Ankara City Hospital, Department of Pediatric Infectious Diseases, Ankara, Turkey
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8
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Mavrouli M, Mavroulis S, Lekkas E, Tsakris A. The Impact of Earthquakes on Public Health: A Narrative Review of Infectious Diseases in the Post-Disaster Period Aiming to Disaster Risk Reduction. Microorganisms 2023; 11:microorganisms11020419. [PMID: 36838384 PMCID: PMC9968131 DOI: 10.3390/microorganisms11020419] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/10/2023] Open
Abstract
Earthquakes are among the most impressive natural phenomena with very high potential to set off a chain of effects that significantly affects public health through casualties and injuries. Related disasters are attributed not only to the strong ground motion and coseismic phenomena but also to secondary effects, comprising mainly landslides and tsunamis, among others. All these can create harsh conditions favorable for the emergence of infectious diseases that are capable of causing additional human and economic losses and disruption of the emergency and recovery process. The present study comprises an extensive narrative review of the existing literature on the earthquake-triggered infectious diseases recorded worldwide, along with their symptoms, causative pathogens, associated risk factors, most vulnerable population groups, and prevention strategies. Respiratory, gastrointestinal, and vector-borne diseases, as well as wound and skin infections, are mainly recorded among the earthquake-affected population. Measures for effectively preventing earthquake-triggered infectious diseases are also proposed. One of the widely proposed measures is the establishment of a proper disease surveillance system in order to immediately and effectively identify the pre- and post-disaster occurrence of infectious diseases. This approach significantly contributes to disease trends monitoring, validation of early warning, and support of the emergency response and recovery actions.
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Affiliation(s)
- Maria Mavrouli
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence:
| | - Spyridon Mavroulis
- Department of Dynamic Tectonic Applied Geology, Faculty of Geology and Geoenvironment, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece
| | - Efthymios Lekkas
- Department of Dynamic Tectonic Applied Geology, Faculty of Geology and Geoenvironment, School of Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece
| | - Athanassios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
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9
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Yamaguchi J, Kinoshita K. The threat of a new tetanus outbreak due to urban flooding disaster requires vigilance: a narrative review. Acute Med Surg 2023; 10:e839. [PMID: 37077453 PMCID: PMC10106935 DOI: 10.1002/ams2.839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/28/2023] [Indexed: 04/21/2023] Open
Abstract
Vaccines for tetanus prevention have rapidly progressed, and the number of outbreaks, especially the incidence of tetanus in developed countries, has decreased dramatically. However, the mortality rate associated with severe tetanus remains high. Tetanus eradication is difficult owing to the widespread presence of the spores of tetanus bacteria in the environment, but tetanus can be prevented by acquired immunity from vaccines. Older people, intravenous drug users, and migrants are at a high risk of tetanus in developed countries owing to the lack of booster vaccination programs. Natural disasters, especially floods, often cause an increase in the prevalence of tetanus because of the associated injuries. Precautions should be taken to combat the threat of a new tetanus outbreak due to floods in urban areas owing to global warming. In particular, Japan is facing a high risk of urban flooding-induced tetanus, despite its status as a developed country. This review aims to highlight the data on the epidemiology, causes, treatment, and prevention of tetanus and problems associated with tetanus countermeasures during future floods.
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Affiliation(s)
- Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute MedicineNihon University School of MedicineTokyoJapan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute MedicineNihon University School of MedicineTokyoJapan
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Presumed Tetanus in a Temminck's Pangolin (Smutsia temminckii). J Wildl Dis 2022; 58:943-946. [PMID: 36240743 DOI: 10.7589/jwd-d-22-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/14/2022] [Indexed: 12/03/2022]
Abstract
An adult female Temminck's pangolin (Smutsia temminckii) confiscated from the illegal wildlife trade presented with an ulcerated lesion of the right forelimb. Neurologic signs and tonic spasms characteristic of tetanus developed after 5 d. Despite supportive treatment, the pangolin died. Tetanus has not previously been reported in any pangolin species.
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Samson TK, Bono KT. The Role of Surgical Debridement in the Treatment of Systemic Tetanus: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00029. [PMID: 36862111 DOI: 10.2106/jbjs.cc.22.00367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/27/2022] [Indexed: 03/03/2023]
Abstract
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.
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Affiliation(s)
- Trinity K Samson
- Department of Orthopedics, Akron Children's Hospital, Akron, Ohio.,Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Kenneth T Bono
- Department of Orthopedics, Akron Children's Hospital, Akron, Ohio
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12
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Generalized tetanus in an elderly patient: A case report. Ann Med Surg (Lond) 2022; 81:104465. [PMID: 36147146 PMCID: PMC9486737 DOI: 10.1016/j.amsu.2022.104465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/14/2022] [Accepted: 08/14/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction and importance Tetanus is a rare disease caused by Clostridium tetani causing painful muscle spasms and respiratory failure. Case Presentation A patient from a rural part of the country presented with a nonhealing and increasingly painful penetrating wound. The patient had a purulent wound and later developed risus sardonicus and muscle spasms of tetanus and his blood culture grew the bacteria. His condition was later complicated by respiratory failure, sepsis, and multiorgan failure. He was managed in the ICU with Intravenous antibiotics, respiratory support with endotracheal Intubation and mechanical ventilation, Intravenous Immunoglobin, and multiple organ support. The patient was taken off the ICU by the family for financial reasons and ultimately succumbed to the illness. Clinical Discussion Tetanus, is a rare vaccine-preventable illness that is underreported. Spasms control and organ support is still the mainstay of treatment. Conclusion Strict clinical vigilance is important for the early diagnosis and management of tetanus. Tetanus is rare in the modern world and yet cases are encountered in the developing world. Strict clinical vigilance is essential for diagnosing this potentially fatal disease. Duration of treatment is long and requires support, often in the ICU. Prognosis is variable with many patients in the developing world not affording the long treatment in the ICU.
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Lu P, Ghiasi S, Hagenah J, Hai HB, Hao NV, Khanh PNQ, Khoa LDV, Thwaites L, Clifton DA, Zhu T. Classification of Tetanus Severity in Intensive-Care Settings for Low-Income Countries Using Wearable Sensing. SENSORS (BASEL, SWITZERLAND) 2022; 22:6554. [PMID: 36081013 PMCID: PMC9460354 DOI: 10.3390/s22176554] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 06/15/2023]
Abstract
Infectious diseases remain a common problem in low- and middle-income countries, including in Vietnam. Tetanus is a severe infectious disease characterized by muscle spasms and complicated by autonomic nervous system dysfunction in severe cases. Patients require careful monitoring using electrocardiograms (ECGs) to detect deterioration and the onset of autonomic nervous system dysfunction as early as possible. Machine learning analysis of ECG has been shown of extra value in predicting tetanus severity, however any additional ECG signal analysis places a high demand on time-limited hospital staff and requires specialist equipment. Therefore, we present a novel approach to tetanus monitoring from low-cost wearable sensors combined with a deep-learning-based automatic severity detection. This approach can automatically triage tetanus patients and reduce the burden on hospital staff. In this study, we propose a two-dimensional (2D) convolutional neural network with a channel-wise attention mechanism for the binary classification of ECG signals. According to the Ablett classification of tetanus severity, we define grades 1 and 2 as mild tetanus and grades 3 and 4 as severe tetanus. The one-dimensional ECG time series signals are transformed into 2D spectrograms. The 2D attention-based network is designed to extract the features from the input spectrograms. Experiments demonstrate a promising performance for the proposed method in tetanus classification with an F1 score of 0.79 ± 0.03, precision of 0.78 ± 0.08, recall of 0.82 ± 0.05, specificity of 0.85 ± 0.08, accuracy of 0.84 ± 0.04 and AUC of 0.84 ± 0.03.
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Affiliation(s)
- Ping Lu
- Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
| | - Shadi Ghiasi
- Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
| | - Jannis Hagenah
- Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
| | - Ho Bich Hai
- Oxford University Clinical Research Unit, Ho Chi Minh City 700000, Vietnam
| | - Nguyen Van Hao
- Hospital of Tropical Diseases, Ho Chi Minh City 700000, Vietnam
| | | | - Le Dinh Van Khoa
- Oxford University Clinical Research Unit, Ho Chi Minh City 700000, Vietnam
| | | | - Louise Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City 700000, Vietnam
| | - David A. Clifton
- Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
- Hthe Oxford Suzhou Centre for Advanced Research, University of Oxford, Suzhou Dushu Lake Science and Education Innovation District, Suzhou 215123, China
| | - Tingting Zhu
- Department of Engineering Science, University of Oxford, Oxford OX1 3PJ, UK
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14
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Imanishi K, Yasuo K. Application of noninvasive positive pressure ventilation to respiratory complications of severe tetanus: a case report. Int J Infect Dis 2022; 119:160-162. [DOI: 10.1016/j.ijid.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022] Open
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Carvalho LCD, Marques CPC, Rodrigues VP. Temporal trends in tetanus incidence and lethality in Brazil: analysis of the national database from 2009 to 2018. Rev Assoc Med Bras (1992) 2021; 67:1804-1809. [PMID: 34909953 DOI: 10.1590/1806-9282.20210736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE This study aimed to analyze the epidemiological and hospital characteristics of cases and deaths due to accidental tetanus in Brazil. METHODS A time-series study with secondary data extracted from the Department of Informatics of the Brazilian Unified Health System. The time series were evaluated by linear regression parameters, considering a significance level of 1%. RESULTS A total of 2,772 cases were reported between 2009-2018. Predominant cases were men and aged between 40-59 years old, with incomplete 1st-4th grade. The lethality rate was found to be predominant in women, whites, illiterates, and those who aged above 80 years. The overall lethality was 32.5%. The incidence rate reduced from 1.6 in 2009 to 0.95 per million inhabitants in 2018, but lethality increased from 30.77-40.70%. The highest rate of incidence and lethality occurred in the elderly people and in the northern region. CONCLUSION The high cost and lethality of tetanus configure it as a public health problem. The demonstration of the epidemiology of patients who most evolve to death can help to contribute to a reduction in lethality, which shows an increase in the analysis period. Finally, special attention should be given to the elderly people and those living in the northern region.
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Abstract
Neuroinfectious diseases can affect immunocompetent and immunosuppressed individuals and cause a variety of emergencies including meningitis, encephalitis, and abscess. Neurologic infections are frequently complicated by secondary injuries that also present emergently such as cerebrovascular disease, acute obstructive hydrocephalus, and seizure. In most cases, timely recognition and early treatment of infection can improve the morbidity and mortality of infectious neurologic emergencies.
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Abstract
Tetanus is a nervous system disorder characterized by muscular spasms and autonomic hyperactivity, such as unstable blood pressure. We herein report a case of tetanus in a patient in shock complicated with a rectus sheath hematoma caused by rupture of a pseudo-aneurysm of the inferior epigastric artery. A rectus sheath hematoma might be misdiagnosed as unstable blood pressure associated with autonomic hyperactivity, which is usually observed in patients with tetanus. The possibility of the occurrence of bleeding complications should be considered if a patient with tetanus has severe and persistent blood pressure reduction.
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Affiliation(s)
- Fumiya Inoue
- Department of Emergency Medicine, Hiroshima Citizens Hospital, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima Citizens Hospital, Japan
| | - Hiroshi Naitou
- Department of Emergency Medicine, Hiroshima Citizens Hospital, Japan
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Qaderi S, Qaderi F, Tarki FE, Shah J, Afaghi S, Delsoz M, Shah A. Generalized, non-neonatial tetanus is a highly fatal disease in Afghanistan: A case series study. Int J Infect Dis 2020; 103:568-572. [PMID: 33340666 DOI: 10.1016/j.ijid.2020.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/08/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES To describe the clinical features and outcomes of a case series of adult tetanus and illustrate inadequacies in confronting this preventable disease. DESIGN AND METHODS This study retrospectively evaluated 24 relatively severe, confirmed cases of tetanus, diagnosed between March 2017 and December 2018, in Kabul Antani Hospital, Afghanistan. RESULTS Regarding the source of the infection: 18 patients (75%) had a history of injuries, 1 had a history of a dog bite and 1 was an intravenous drug user; 4 patients had no external injuries or wounds. Dysphagia was the main clinical manifestation for which patients sought medical treatment (50%). Of the 12 patients who died, 7 presented with confusion and seizure, 1 with acute kidney injury, and 2 with pneumonia. CONCLUSIONS Mortality due to tetanus is high in Afghanistan (Case Fatality Rate (CFR) 50%)), suggesting an urgent need for vaccination policy and programs, post-exposure protocols, and facilities equipped for the treatment of adult tetanus. The Ministry of Public Health of Afghanistan should seek to improve the accessibility, distribution and recording of tetanus immunization through vaccination.
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Affiliation(s)
- Shohra Qaderi
- Department of Communicable Disease, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Communicable Disease, Kabul Antani Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan.
| | - Farah Qaderi
- Department of Communicable Disease, Emam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Farzad Esmaeili Tarki
- Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Jaffer Shah
- Drexel University College of Medicine, Pennsylvania, USA.
| | - Siamak Afaghi
- Department of Internal Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohmmad Delsoz
- Department of Communicable Disease, Kabul Antani Hospital, Kabul University of Medical Sciences, Kabul, Afghanistan.
| | - Asghar Shah
- Division of Biology and Medicine, Brown University, Providence, Rhode Island, USA.
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Orellana CA, Zaragoza NE, Licona-Cassani C, Palfreyman RW, Cowie N, Moonen G, Moutafis G, Power J, Nielsen LK, Marcellin E. Time-course transcriptomics reveals that amino acids catabolism plays a key role in toxinogenesis and morphology in Clostridium tetani. ACTA ACUST UNITED AC 2020; 47:1059-1073. [DOI: 10.1007/s10295-020-02330-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/02/2020] [Indexed: 10/23/2022]
Abstract
Abstract
Tetanus is a fatal disease caused by Clostridium tetani infections. To prevent infections, a toxoid vaccine, developed almost a century ago, is routinely used in humans and animals. The vaccine is listed in the World Health Organisation list of Essential Medicines and can be produced and administered very cheaply in the developing world for less than one US Dollar per dose. Recent developments in both analytical tools and frameworks for systems biology provide industry with an opportunity to gain a deeper understanding of the parameters that determine C. tetani virulence and physiological behaviour in bioreactors. Here, we compared a traditional fermentation process with a fermentation medium supplemented with five heavily consumed amino acids. The experiment demonstrated that amino acid catabolism plays a key role in the virulence of C. tetani. The addition of the five amino acids favoured growth, decreased toxin production and changed C. tetani morphology. Using time-course transcriptomics, we created a “fermentation map”, which shows that the tetanus toxin transcriptional regulator BotR, P21 and the tetanus toxin gene was downregulated. Moreover, this in-depth analysis revealed potential genes that might be involved in C. tetani virulence regulation. We observed differential expression of genes related to cell separation, surface/cell adhesion, pyrimidine biosynthesis and salvage, flagellar motility, and prophage genes. Overall, the fermentation map shows that, mediated by free amino acid concentrations, virulence in C. tetani is regulated at the transcriptional level and affects a plethora of metabolic functions.
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Affiliation(s)
- Camila A Orellana
- grid.1003.2 0000 0000 9320 7537 Australian Institute for Bioengineering and Nanotechnology (AIBN) The University of Queensland 4072 Brisbane QLD Australia
- grid.7870.8 0000 0001 2157 0406 Department of Chemical and Bioprocess Engineering, School of Engineering Pontificia Universidad Católica de Chile Santiago Chile
| | - Nicolas E Zaragoza
- grid.1003.2 0000 0000 9320 7537 Australian Institute for Bioengineering and Nanotechnology (AIBN) The University of Queensland 4072 Brisbane QLD Australia
| | - Cuauhtemoc Licona-Cassani
- grid.1003.2 0000 0000 9320 7537 Australian Institute for Bioengineering and Nanotechnology (AIBN) The University of Queensland 4072 Brisbane QLD Australia
- grid.419886.a 0000 0001 2203 4701 Centro de Biotecnología FEMSA Tecnológico de Monterrey Nuevo León Mexico
| | - Robin W Palfreyman
- grid.1003.2 0000 0000 9320 7537 Metabolomics Australia The University of Queensland 4072 Brisbane QLD Australia
| | - Nicholas Cowie
- grid.1003.2 0000 0000 9320 7537 Australian Institute for Bioengineering and Nanotechnology (AIBN) The University of Queensland 4072 Brisbane QLD Australia
| | - Glenn Moonen
- Zoetis. 45 Poplar Road 3052 Parkville VIC Australia
| | | | - John Power
- Zoetis. 45 Poplar Road 3052 Parkville VIC Australia
| | - Lars K Nielsen
- grid.1003.2 0000 0000 9320 7537 Australian Institute for Bioengineering and Nanotechnology (AIBN) The University of Queensland 4072 Brisbane QLD Australia
- grid.1003.2 0000 0000 9320 7537 Metabolomics Australia The University of Queensland 4072 Brisbane QLD Australia
- grid.5170.3 0000 0001 2181 8870 The Novo Nordisk Foundation Centre for Biosustainability Technical University of Denmark Kgs. Lyngby Denmark
| | - Esteban Marcellin
- grid.1003.2 0000 0000 9320 7537 Australian Institute for Bioengineering and Nanotechnology (AIBN) The University of Queensland 4072 Brisbane QLD Australia
- grid.1003.2 0000 0000 9320 7537 Metabolomics Australia The University of Queensland 4072 Brisbane QLD Australia
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Vicente-Alcalde N, Martín-Casquero T, Ruescas-Escolano E, Tuells J. The Survivor: A Clinical Case of Tetanus in a Non-Immunized, Parenteral Drug User, Former Female Convict with HIV and HCV. Vaccines (Basel) 2020; 8:vaccines8020308. [PMID: 32560315 PMCID: PMC7350239 DOI: 10.3390/vaccines8020308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022] Open
Abstract
Tetanus is a serious and potentially fatal systemic disease, caused by the bacterium Clostridium tetani. It is estimated that 1 million cases occur worldwide annually. Immunization programs have drastically decreased tetanus in developed countries, and the sporadic cases have been linked to injecting drug users (IDUs), immunosuppressed individuals, or those older than 65 without complete vaccination. Regrettably, it is still endemic in under-developed countries. In Spain, an average of 10 cases are notified each year, especially affecting those older than 65. The present article describes a case of a 48-year-old Spanish woman, an ex-convict and IDU with infection antecedents of Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV), who was admitted to the Emergency Department of a University Hospital with cervical rigidity and trismus. In a few hours, a neurological and respiratory deterioration was observed, resulting in admittance to the intensive care unit under the suspicion of a generalized tetanus infection. The treatment included hemodynamic support and respiratory therapy, antibiotics, muscle relaxants, sedatives, and tetanus immunoglobulin. Her stay in the ICU lasted 47 days. The clinical suspicion, the antecedents of risk, and the verification of the vaccination records should provide early guidance for diagnostics and the establishment of a treatment in these cases.
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Affiliation(s)
- Nancy Vicente-Alcalde
- Penitentiary Center Alicante II, Villena, Alicante, Carretera N-330, Km. 66, 03400 Villena, Spain;
| | - Tamara Martín-Casquero
- Servicio de Urgencias, Hospital Universitario del Vinalopó-Elche, Calle Tonico Sansano Mora, 03293 Elche, Spain; (T.M.-C.); (E.R.-E.)
| | - Esther Ruescas-Escolano
- Servicio de Urgencias, Hospital Universitario del Vinalopó-Elche, Calle Tonico Sansano Mora, 03293 Elche, Spain; (T.M.-C.); (E.R.-E.)
| | - José Tuells
- Department of Community Nursing, Preventive Medicine and Public Health and History of Science, University of Alicante, San Vicente del Raspeig, 03690 Alicante, Spain
- Correspondence:
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Abstract
OBJECTIVES Clinical diagnostics in sudden onset disasters have historically been limited. We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type 2 emergency medical team (EMT) field hospital. METHODS Available diagnostic platforms were reviewed and selected against in field need. Platforms included HemoCue301/WBC DIFF, i-STAT, BIOFIRE FILMARRAY multiplex rt-PCR, Olympus BX53 microscopy, ABO/Rh grouping, and specific rapid diagnostic tests. This equipment was trialed in Katherine, Australia, and Dili, Timor-Leste. RESULTS During the initial deployment, an evaluation of FilmArray tests was successful using blood culture identification, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) hemoglobin values were compared on Sysmex XN 550 (r = 0.94). HemoCue WBC DIFF had some variation, dependent on the cell, when compared with Sysmex XN 550 (r = 0.88-0.16). i-STAT showed nonsignificant differences against Vitros 250. Further evaluation of FilmArray in Dili, Timor-Leste, diagnosed 117 pathogens on 168 FilmArray pouches, including 25 separate organisms on blood culture and 4 separate cerebrospinal fluid pathogens. CONCLUSION This mobile laboratory represents a major advance in sudden onset disaster. Setup of the service was quick (< 24 hr) and transport to site rapid. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostic capability.
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22
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Ulfa M, Husna NA. A case report of generalized tetanus in a 42-year-old man with dental infection. J Basic Clin Physiol Pharmacol 2019; 30:/j/jbcpp.ahead-of-print/jbcpp-2019-0243/jbcpp-2019-0243.xml. [PMID: 31811803 DOI: 10.1515/jbcpp-2019-0243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/27/2019] [Indexed: 06/10/2023]
Abstract
Background In the post-vaccination era, as it is today, generalized tetanus is a rare diagnosis, although mortality and morbidity continue to increase significantly throughout the world. Infection occurs when the Clostridium tetani spores are introduced into wounds, skin lesions and infections. The symptoms often begin with stiffness or spasms in the jaw muscles; they are called trismus or "lockjaw" and/or then spread to the neck and abdominal muscles. Case presentation This is a report of a 42-year-old man who was referred to the hospital with dysphagia, rigidity and trismus. He was diagnosed with generalized tetanus with a Philips score of 15. The patient was admitted to the isolation unit, received treatment that included procaine penicillin, metronidazole, diazepam, human tetanus immunoglobulin (TIG) and anti-tetanus serum (ATS). Treatment was considered according to the guidelines of the World Health Organization, and also, the drug dose has no adverse event reaction during the treatment. Conclusion The therapeutic response is related to the identification and appropriate treatment, especially in hospitalized patients with inadequate immunization so that patients recover soon.
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Affiliation(s)
- Maria Ulfa
- Magister of Clinical Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Kampus C Unair, Jl. Mulyorejo, Surabaya50115,Indonesia
| | - Nuril Auliya Husna
- General Hospital RSUD Dr. Soetomo, Department of Pharmacy, Surabaya East Java, Indonesia
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23
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Moore RJ, Lacey JA. Genomics of the Pathogenic Clostridia. Microbiol Spectr 2019; 7:10.1128/microbiolspec.gpp3-0033-2018. [PMID: 31215504 PMCID: PMC11257213 DOI: 10.1128/microbiolspec.gpp3-0033-2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Indexed: 12/12/2022] Open
Abstract
Whole-genome sequences are now available for all the clinically important clostridia and many of the lesser or opportunistically pathogenic clostridia. The complex clade structures of C. difficile, C. perfringens, and the species that produce botulinum toxins have been delineated by whole-genome sequence analysis. The true clostridia of cluster I show relatively low levels of gross genomic rearrangements within species, in contrast to the species of cluster XI, notably C. difficile, which have been found to have very plastic genomes with significant levels of chromosomal rearrangement. Throughout the clostridial phylotypes, a large proportion of the strain diversity is driven by the acquisition and loss of mobile elements, including phages, plasmids, insertion sequences, and transposons. Genomic analysis has been used to investigate the diversity and spread of C. difficile within hospital settings, the zoonotic transfer of isolates, and the emergence, origins, and geographic spread of epidemic ribotypes. In C. perfringens the clades defined by chromosomal sequence analysis show no indications of clustering based on host species or geographical location. Whole-genome sequence analysis helps to define the different survival and pathogenesis strategies that the clostridia use. Some, such as C. botulinum, produce toxins which rapidly act to kill the host, whereas others, such as C. perfringens and C. difficile, produce less lethal toxins which can damage tissue but do not rapidly kill the host. The genomes provide a resource that can be mined to identify potential vaccine antigens and targets for other forms of therapeutic intervention.
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Affiliation(s)
- Robert J Moore
- Host-Microbe Interactions Laboratory, School of Science, RMIT University, Bundoora, Victoria 3083, Australia
- Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria 3800, Australia
| | - Jake A Lacey
- Doherty Department, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000, Australia
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Siddiqui AA, Khan M, Khan JA, Haseeb SS, Mohib A, Kadri HM. Awareness, Knowledge, and Coverage of Vaccination Against Tetanus, Diphtheria, and Pertussis Among Medical Students of Karachi: A Cross-sectional Analysis. Cureus 2019; 11:e4472. [PMID: 31249750 PMCID: PMC6579328 DOI: 10.7759/cureus.4472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Along with reducing the global burden of diphtheria, pertussis and tetanus, the DPT3 (diphtheria-pertussis-tetanus) vaccine protects health care professionals (HCPs) as well as vulnerable patients in their care. This study evaluates awareness, knowledge and coverage of DPT3 vaccine and boosters among medical students of public university in Karachi, Pakistan. Methods A cross-sectional study consisting of 281 participants selected through convenience sampling was conducted from July 2017 to July 2018 using a self-administered questionnaire. Results While 93% participants received childhood doses of DPT3, only 39.2% received adult boosters. Students with positive immunization history in childhood and family vaccination routines were more likely to get adult boosters. Eighty-six percent of the students were unaware that their university had a recommended vaccination program as a part of the admission process. The assessment of awareness and knowledge revealed that only 10.5% individuals could be regarded as well-aware, 20.3% (n = 58) students as unaware, and 69.2% (n = 198) participants as moderately aware. Conclusion The level of awareness, knowledge and coverage of DPT3 vaccine is insufficient among medical students of a public university of Karachi; universities are recommended to take measures to enhance knowledge and ensure strict adherence of students to appropriate vaccination programs.
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Affiliation(s)
- Amna A Siddiqui
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Meeshal Khan
- Medicine, Civil Hospital Karachi, Dow University of Health Sciences, Karachi , PAK
| | - Jehanzeb A Khan
- Internal Medicine, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Syed Saad Haseeb
- Internal Medicine, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Aleena Mohib
- Medicine, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Hasina M Kadri
- Community Medicine, Dow University of Health Sciences, Karachi, PAK
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Enriquez CAG, Abejero JEE, Ramiro PA, Maligaso CPD. Rocuronium for control of muscle spasms in a tetanus patient with chronic methamphetamine use disorder. BMJ Case Rep 2018; 2018:bcr-2018-224391. [PMID: 29636338 DOI: 10.1136/bcr-2018-224391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This is a case of a 31-year-old Filipino man with chronic methamphetamine use disorder who developed tetanus from a necrotic skin graft over his left calcaneus, which was fractured after a motor vehicular accident. During the course of his illness, the patient's muscle spasms were unusually refractory to benzodiazepine, which is the first-line drug used in the management of muscle spasms. The muscle spasms were successfully controlled on the seventh day of illness with rocuronium at a dose of 10 μg/kg/min and midazolam at 0.30 mg/kg/hour. Both infusions were tapered off until the 23rd day of illness. The patient was discharged on the 30th day of illness, improved and stable.
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Affiliation(s)
| | | | - Philip A Ramiro
- Department of Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Carissa Paz Dioquino Maligaso
- Department of Neurosciences, University of the Philippines-Philippine General Hospital, Manila, Philippines.,National Poison Management and Control Center (Toxicology), University of the Philippines- Philippine General Hospital, Manila, Philippines
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Abstract
Tetanus is a severe and potentially fatal infection caused by the bacterium Clostridium tetani. Presentations of tetanus include generalized tetanus, neonatal tetanus, cephalic tetanus, and localized tetanus, the latter two being much rarer. We present case of a 55-year-old male farmer, presented with an injury to the left toe. A surgical wound exploration and washout with administration of human tetanus immunoglobulin and tetanus toxoid were given as treatment with antibiotic support. This case report points out the importance of the early recognition of a rare form of this fatal infectious disease, which may present with prodromal symptoms before the generalized form shows its clinical effects. Successful management includes prompt diagnosis, neutralization of circulating toxin and elimination of C. tetani infection, control of spasms, maintenance of the airway, and management of respiratory failure and autonomic dysfunction.
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Affiliation(s)
- Deepak S Sharma
- Department of Intensive Care Medicine, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India
| | - Mit B Shah
- Department of Intensive Care Medicine, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India
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Nakajima M, Aso S, Matsui H, Fushimi K, Yasunaga H. Clinical features and outcomes of tetanus: Analysis using a National Inpatient Database in Japan. J Crit Care 2017; 44:388-391. [PMID: 29304489 DOI: 10.1016/j.jcrc.2017.12.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/05/2017] [Accepted: 12/28/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE This study was performed to elucidate the current clinical features and outcomes of tetanus using a national inpatient database in Japan. MATERIALS AND METHODS We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively investigate patients with tetanus from July 2010 to March 2016. We examined the patients' characteristics; the proportions of patients requiring tracheal intubation, mechanical ventilation, and tracheostomy; and the discharge status. RESULTS We identified 499 patients who were diagnosed with tetanus. No patient had a diagnosis of tetanus neonatorum or obstetric tetanus. The median age was 74years. Overall, 53.5% of the patients required intubation and mechanical ventilation. Among patients who required intubation and mechanical ventilation, 80.6% started it within 3days of admission, and 77.5% required tracheostomy during hospitalization. The median duration of mechanical ventilation was 23days. The median length of hospitalization was 35days. The proportions of patients who were discharged to home and to locations other than home were 58.1% and 35.1%, respectively. The in-hospital mortality was 6.8%. CONCLUSION The present study suggests that acute-care physicians should be ready to provide intensive care for patients with tetanus and cooperate with medical social workers and families for subsequent long-term nursing care.
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Affiliation(s)
- Mikio Nakajima
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan; Department of Emergency Medicine, Kyorin University School of Medicine, Mitaka-shi, Tokyo, Japan.
| | - Shotaro Aso
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Admission of tetanus patients to the ICU: a retrospective multicentre study. Ann Intensive Care 2017; 7:112. [PMID: 29116572 PMCID: PMC5676569 DOI: 10.1186/s13613-017-0333-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/25/2017] [Indexed: 01/18/2023] Open
Abstract
Background
An extended course of tetanus (up to 6 weeks) requiring ICU admission and protracted mechanical ventilation (MV) may have a significant impact on short- and long-term survival. The subject is noteworthy and deserves to be discussed. Methods Twenty-two ICUs in France performed tetanus screenings on patients admitted between January 2000 and December 2014. Retrospective data were collected from hospital databases and through the registers of the town hall of the patients. Results Seventy patients were included in 15 different ICUs. Sixty-three patients suffered from severe or very severe tetanus according to the Ablett classification. The median age was 80 years [interquartile range 73–84], and 86% of patients were women. Ninety per cent of patients (n = 63) required MV for a median of 36 days [26–46], and 66% required administration of a neuromuscular-blocking agent for 23 days [14–29]. A nosocomial infection occurred in 43 patients (61%). ICU and 1-year mortality rates were 14% (n = 10) and 16% (n = 11), respectively. Forty-five per cent of deaths occurred during the first week. Advanced age, a higher SAPS II, any infection, and the use of vasopressors were significantly associated with a lower number of days alive without ventilator support by day 90. Age was the only factor that significantly differed between deceased and survivors at 1 year (83 [81–85] vs. 79 [73–84] years, respectively; p = 0.03). Sixty-one per cent of survivors suffered no impairment to their functional status. Conclusion In a high-income country, tetanus mainly occurs in healthy elderly women. Despite prolonged MV and extended ICU length of stay, we observed a low 1-year mortality rate and good long-term functional status.
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Abstract
Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.
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van Galen G, Saegerman C, Rijckaert J, Amory H, Armengou L, Bezdekova B, Durie I, Findshøj Delany R, Fouché N, Haley L, Hewetson M, van den Hoven R, Kendall A, Malalana F, Muller Cavalleri J, Picavet T, Roscher K, Verwilghen D, Wehrli Eser M, Westermann C, Mair T. Retrospective evaluation of 155 adult equids and 21 foals with tetanus in Western, Northern, and Central Europe (2000-2014). Part 1: Description of history and clinical evolution. J Vet Emerg Crit Care (San Antonio) 2017; 27:684-696. [PMID: 28960717 DOI: 10.1111/vec.12668] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 03/07/2016] [Accepted: 04/07/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To describe clinical data of hospitalized adult equids and foals with tetanus. DESIGN Multicenter retrospective study (2000-2014). SETTING Twenty Western, Northern, and Central European university teaching hospitals and private referral centers. ANIMALS One hundred fifty-five adult equids (>6 months) and 21 foals (<6 months) with tetanus. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Information on geographic, annual and seasonal data, demographic- and management-related data, clinical history, clinical examination and blood analysis on admission, complications, treatments, and outcomes were described and statistically compared between adults and foals. The described cases were often young horses. In 4 adult horses, tetanus developed despite appropriate vaccination and in 2 foals despite preventive tetanus antitoxin administration at birth. Castration, hoof abscesses, and wounds were the most common entry sites for adults; umbilical cord infections and wounds for foals. Stiffness was the commonest observed initial clinical sign. Blood analyses frequently revealed an inflammatory response, hemoconcentration, muscle damage, azotemia, negative energy balance, liver damage, and electrolyte and acid base disturbances. Common complications or clinical signs developing during hospitalization included dysphagia, dyspnea, recumbency, hyperthermia, seizures, hyperlipemia, gastrointestinal impactions, dysuria, and laryngeal spasms. Cases were supported with wound debridement, antimicrobial treatment, tetanus antitoxin, muscle spasm and seizure control, analgesia, anti-inflammatory drugs, fluid therapy, and nutritional support. Mortality rates were 68.4% in adult horses and 66.7% in foals. Foals differed from adult horses with respect to months of occurrence, signalment, management-related data, potential causative events, clinical signs on admission, blood analysis, complications, and severity grades. CONCLUSIONS This is the first study that rigorously describes a large population of equids affected by tetanus. The information provided is potentially useful to clinicians for early recognition and case management of tetanus in adult horses and foals. Tetanus affects multiple organ systems, requiring broad supportive and intensive care. Neonatal and adult tetanus in the horse should be considered as distinct syndromes, as in human medicine.
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Affiliation(s)
- Gaby van Galen
- Department of Medicine and Surgery and Large Animal Sciences, University of Copenhagen, Denmark
| | - Claude Saegerman
- the Equine Hospital and Center for Fundamental and Applied Research for Animal and Health (FARAH), Faculty of Veterinary Medicine, University of Liege, Belgium
| | - Joke Rijckaert
- the Equine Hospital, Faculty of Veterinary Medicine, University of Ghent, Belgium
| | - Helene Amory
- the Equine Hospital and Center for Fundamental and Applied Research for Animal and Health (FARAH), Faculty of Veterinary Medicine, University of Liege, Belgium
| | - Lara Armengou
- the Unitat Equina, Fundació Hospital Clínic Veterinari, Universitat Autònoma de Barcelona, Spain
| | - Barbora Bezdekova
- the Equine Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Czech Republic
| | - Inge Durie
- Evidensia Strömsholm Equine Hospital, Strömsholm, Sweden
| | - Rikke Findshøj Delany
- Department of Medicine and Surgery and Large Animal Sciences, University of Copenhagen, Denmark
| | - Nathalie Fouché
- the Swiss Institute of Equine Medicine (ISME), Vetsuisse-Faculty, University of Bern, Switzerland
| | - Laura Haley
- the University Veterinary Teaching Hospital, School of Veterinary Medicine, University College Dublin, Ireland
| | - Michael Hewetson
- the Faculty of Veterinary Medicine, University of Helsinki, Finland
| | | | - Anna Kendall
- the Equine Hospital, Faculty of Veterinary Medicine, University of Uppsala SLU, Sweden
| | - Fernando Malalana
- the Philip Leverhulme Equine Hospital, University of Liverpool, United Kingdom
| | | | | | - Katja Roscher
- the Equine Clinic, Faculty of Veterinary Medicine, University of Giessen, Germany
| | - Denis Verwilghen
- Department of Medicine and Surgery and Large Animal Sciences, University of Copenhagen, Denmark
| | - Meret Wehrli Eser
- the Clinic for Equine Internal Medicine, Vetsuisse-faculty, University of Zurich, Switzerland
| | - Cornélie Westermann
- the Equine Hospital, Faculty of Veterinary Medicine, University of Utrecht, The Netherlands
| | - Tim Mair
- Bell Equine Veterinary Clinic, Maidstone, United Kingdom
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Nass SS, Danawi H, Cain L, Sharma M. Verification of Neonatal Tetanus Surveillance Systems in Katsina State, Nigeria. Health Serv Res Manag Epidemiol 2017; 4:2333392817729585. [PMID: 28944276 PMCID: PMC5602213 DOI: 10.1177/2333392817729585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 11/25/2022] Open
Abstract
Background: The incidence and mortality rates of neonatal tetanus (NNT) remain underreported in Nigeria. The goal of the study was to compare the NNT prevalence and the mortality rates from the existing surveillance system and active surveillance of health facility records in 7 selected health facilities from 2010 to 2014 in Katsina State, Nigeria. Methods: The study is a retrospective record review using extracted data from NNT records and analyzed using descriptive statistics. Results: The prevalence of NNT and mortality rate were 336 cases and 3.4 deaths per 100 000 population, respectively, whereas the prevalence of NNT and mortality rate reported through the Integrated Disease Surveillance and Response (IDSR) system were 111 cases and 1.0 death per 100 000 population, respectively. Conclusion: The study shows underreporting of NNT in the existing IDSR system. Implications: Active surveillance is a good strategy for verifying underreporting of NNT in the surveillance system. The IDSR system should be strengthened with the capacity to detect events associated with a disease toward global elimination.
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Affiliation(s)
| | - Hadi Danawi
- World Health Organization, Katsina State Office, Katsina State, Nigeria
| | - Loretta Cain
- World Health Organization, Katsina State Office, Katsina State, Nigeria
| | - Monoj Sharma
- World Health Organization, Katsina State Office, Katsina State, Nigeria
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Affiliation(s)
- Bill Matney
- Division of Music Education and Music Therapy, University of Kansas, Lawrence, KS, USA
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An unexpected tetanus case. THE LANCET. INFECTIOUS DISEASES 2017; 16:746-752. [PMID: 27301930 DOI: 10.1016/s1473-3099(16)00075-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 12/29/2015] [Accepted: 02/01/2016] [Indexed: 10/21/2022]
Abstract
1 million cases of tetanus are estimated to occur worldwide each year, with more than 200 000 deaths. Tetanus is a life-threatening but preventable disease caused by a toxin produced by Clostridium tetani-a Gram-positive bacillus found in high concentrations in soil and animal excrement. Tetanus is almost completely preventable by active immunisation, but very rarely unexpected cases can occur in individuals who have been previously vaccinated. We report a case of generalised tetanus in a 22-year-old woman that arose despite the protective antitoxin antibody in her serum. The patient received all her vaccinations in the USA; her last vaccination was 6 years ago. The case was unusual because the patient had received all standard vaccinations, had no defined port of entry at disease onset, and had symptoms lasting for 6 months. Tetanus can present with unusual clinical forms; therefore, the diagnosis and management of this rare but difficult disease should be updated. In this Grand Round, we review the clinical features, epidemiology, treatment, and prognosis of C tetani infections.
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Yang Y, Yu R, Yang X, Liu S, Fang T, Song X, Hou L, Yu C, Xu J, Fu L, Yi S, Chen W. Protection against Staphylococcus aureus and tetanus infections by a combined vaccine containing SasA and TeNT‑Hc in mice. Mol Med Rep 2017; 15:2369-2373. [PMID: 28259925 DOI: 10.3892/mmr.2017.6227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/19/2016] [Indexed: 11/06/2022] Open
Abstract
In developing countries, trauma patients and neonates are vulnerable to Staphylococcus aureus (S. aureus) and Clostridium tetani infections. It has been suggested that a combined vaccine against the two infections may be a reliable and cost‑effective strategy. Previous studies have indicated that the S. aureus surface protein A (SasA) and the C fragment of tetanus neurotoxin (TeNT‑Hc) may be suitable candidates for a vaccine against S. aureus and tetanus infections, respectively. In the present study, mice were immunized with a combined vaccine containing SasA and TeNT‑Hc, which induced a robust immune response to both antigens, and mutual interference between SasA and TeNT‑Hc was not observed. In the S.aureus challenge model, the combined vaccine fully protected BALB/c mice against lethal intraperitoneal challenges with 3x109 colony‑forming units of a methicillin‑resistant S. aureus USA300 strain. In the TeNT challenge model, the combined vaccine conferred complete protection against a lethal dose of (2x103) xLD50 tetanus toxin. These results implied that SasA and TeNT‑Hc promising components for a combined vaccine against S. aureus and tetanus infections.
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Affiliation(s)
- Yilong Yang
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Rui Yu
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Xiuxu Yang
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Shuling Liu
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Ting Fang
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Xiaohong Song
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Lihua Hou
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Changming Yu
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Junjie Xu
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Ling Fu
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Shaoqiong Yi
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
| | - Wei Chen
- Laboratory of Vaccine and Antibody Engineering, Beijing Institute of Biotechnology, Fengtai, Beijing 100071, P.R. China
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Abstract
BACKGROUND Tetanus is a potentially fatal condition that is rare in urban environments but is seen in developing countries and post-natural-disaster. Therefore, the purpose of this report was to review the epidemiology, pathogenesis, and management of tetanus in the trauma patient. METHODS A thorough literature review was conducted to look for the most current and thorough guidelines on the prophylaxis and treatment of tetanus. PUBMED (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), MEDLINE (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), and Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom) databases were searched for articles in English, published from 2005 to 2015, using the keywords "Tetanus," "Trauma/Surgery," and "Disaster." Controlled trials, randomized controlled trials, trials of adult patients, published guidelines, expert opinions, and review articles were selected and extracted. RESULTS Current vaccination schedules in developed countries provide prophylaxis for tetanus. However, when severe natural disasters occur, many patients may not be able to provide a reliable vaccination history. In these situations, tetanus immune globulin (TIG) is indicated; if resources are not limited, both tetanus toxoid and TIG should be given to those with high-risk wounds. If resources are limited, TIG should be reserved for those that would benefit most or those least likely to have the protective antibodies. CONCLUSIONS Although tetanus is a disease that has a low incidence in the developed world due to high rates of immunization, during large-scale natural disasters, compounding factors like the types of injuries, lack of medical services and supplies, and the delay in treatment associated with an already low immunization rate result in an increased incidence and outbreaks of the disease that has higher mortality in an underdeveloped society. It is important for the urban physician that cares for trauma and critical patients to become familiar with the protocols for treatment and immunization of patients that have tetanus-prone wounds, as well as recognize the potential for outbreaks in the settings of major natural disasters. Finkelstein P , Teisch L , Allen CJ , Ruiz G . Tetanus: a potential public health threat in times of disaster. Prehosp Disaster Med. 2017;32(3):339-342.
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Principles of Infectious Diseases: Transmission, Diagnosis, Prevention, and Control. INTERNATIONAL ENCYCLOPEDIA OF PUBLIC HEALTH 2017. [PMCID: PMC7150340 DOI: 10.1016/b978-0-12-803678-5.00516-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Infectious disease control and prevention relies on a thorough understanding of the factors determining transmission. This article summarizes the fundamental principles of infectious disease transmission while highlighting many of the agent, host, and environmental determinants of these diseases that are of particular import to public health professionals. Basic principles of infectious disease diagnosis, control, and prevention are also reviewed.
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Abstract
Many anaerobic spore-forming clostridial species are pathogenic, and some are industrially useful. Although many are strict anaerobes, the bacteria persist under aerobic and growth-limiting conditions as multilayered metabolically dormant spores. For many pathogens, the spore form is what most commonly transmits the organism between hosts. After the spores are introduced into the host, certain proteins (germinant receptors) recognize specific signals (germinants), inducing spores to germinate and subsequently grow into metabolically active cells. Upon germination of the spore into the metabolically active vegetative form, the resulting bacteria can colonize the host and cause disease due to the secretion of toxins from the cell. Spores are resistant to many environmental stressors, which make them challenging to remove from clinical environments. Identifying the conditions and the mechanisms of germination in toxin-producing species could help develop affordable remedies for some infections by inhibiting germination of the spore form. Unrelated to infectious disease, spore formation in species used in the industrial production of chemicals hinders the optimum production of the chemicals due to the depletion of the vegetative cells from the population. Understanding spore germination in acetone-butanol-ethanol-producing species can help boost the production of chemicals, leading to cheaper ethanol-based fuels. Until recently, clostridial spore germination is assumed to be similar to that of Bacillus subtilis However, recent studies in Clostridium difficile shed light on a mechanism of spore germination that has not been observed in any endospore-forming organisms to date. In this review, we focus on the germinants and the receptors recognizing these germinants in various clostridial species.
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Matsuzawa G, Sano H, Ohnuma H, Tomiya A, Kuwahara Y, Hashimoto C, Imamura I, Ishibashi S, Kobayashi M, Kobayashi M, Ishii T, Kaneda I, Itoi E. Patient trends in orthopedic traumas and related disorders after tsunami caused by the Great East Japan Earthquake: An experience in the primary referral medical center. J Orthop Sci 2016; 21:507-511. [PMID: 27067290 DOI: 10.1016/j.jos.2016.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 02/14/2016] [Accepted: 03/12/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the Great East Japan Earthquake, the Japanese Red Cross Ishinomaki Hospital played an important role as a principal referral center within the Ishinomaki region, one of the most severely affected areas in eastern Japan. The present study describes the patient population, clinical characteristics, and time courses of the medical problems observed at this hospital. METHODS A retrospective survey of medical logs and records was conducted on the first 2 weeks after the earthquake to characterize orthopedic traumas and related disorders treated during this catastrophe. Patient number, severity of injuries, number of patients secondarily transported to the referral medical centers in the inland area, and the number of surgeries performed during the study period were investigated. RESULTS Totally, 7686 patients visited the hospital. Of which, 1807 patients suffered from exogenous diseases, such as trauma, burns, crush syndrome, deep venous thrombosis, and infectious diseases. Patients who suffered from hypothermia were the most frequently seen within the first 2 weeks after the earthquake. Interestingly, most patients' conditions were not severe and required only simple treatments. Four patients (0.2% of patients with exogenous diseases) were secondarily transported to the referral medical centers in the inland area and only four patients were surgically treated because of a lack of available implants, surgical devices, and electric power supply. DISCUSSION AND CONCLUSIONS The Great East Japan Earthquake and subsequent tsunami, which occurred during an early spring afternoon, resulted in a unique orthopedic patient population, which included few severely injured patients compared with numerous deaths. We believe that each coastal region hospital should develop its own emergency medical care system to address future tsunami events while considering their surrounding environment. The information described in the present study should be important for preparation toward future events involving massive earthquakes followed by tsunami disasters.
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Affiliation(s)
- Gaku Matsuzawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Japan
| | - Hirotaka Sano
- Division of Orthopedics, Sendai City Hospital, Japan.
| | - Hideji Ohnuma
- Department of Orthopaedic Surgery, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Akihito Tomiya
- Department of Orthopaedic Surgery, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Yoshiyuki Kuwahara
- Department of Orthopaedic Surgery, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Chihiro Hashimoto
- Department of Orthopaedic Surgery, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Itaru Imamura
- Department of Orthopaedic Surgery, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Satoru Ishibashi
- Medical Emergency Center, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Michio Kobayashi
- Medical Emergency Center, Japanese Red Cross Ishinomaki Hospital, Japan
| | | | - Tadashi Ishii
- Medical Emergency Center, Japanese Red Cross Ishinomaki Hospital, Japan
| | - Iwao Kaneda
- Japanese Red Cross Ishinomaki Hospital, Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Japan
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Pascapurnama DN, Murakami A, Chagan-Yasutan H, Hattori T, Sasaki H, Egawa S. Prevention of Tetanus Outbreak Following Natural Disaster in Indonesia: Lessons Learned from Previous Disasters. TOHOKU J EXP MED 2016; 238:219-27. [DOI: 10.1620/tjem.238.219] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Dyshelly Nurkartika Pascapurnama
- Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science (IRIDeS), Tohoku University
- International Post-Graduate Program in Human Security, Tohoku University
| | - Aya Murakami
- Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science (IRIDeS), Tohoku University
| | - Haorile Chagan-Yasutan
- International Post-Graduate Program in Human Security, Tohoku University
- Division of Disaster-related Infectious Diseases, International Research Institute of Disaster Science (IRIDeS), Tohoku University
| | - Toshio Hattori
- International Post-Graduate Program in Human Security, Tohoku University
- Division of Disaster-related Infectious Diseases, International Research Institute of Disaster Science (IRIDeS), Tohoku University
| | - Hiroyuki Sasaki
- Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science (IRIDeS), Tohoku University
| | - Shinichi Egawa
- Division of International Cooperation for Disaster Medicine, International Research Institute of Disaster Science (IRIDeS), Tohoku University
- International Post-Graduate Program in Human Security, Tohoku University
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Disaster-Related Injury Management: High Prevalence of Wound Infection After Super Typhoon Haiyan. Disaster Med Public Health Prep 2015; 10:28-33. [DOI: 10.1017/dmp.2015.100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackgroundAfter Super Typhoon Haiyan, a category 5 tropical cyclone, insufficient resources were available for medical management. Many patients in the Philippines were wounded as a result of the disaster. We examined the prevalence, risk factors, and consequences of disaster-related wounds and wound infection in the post-disaster period.MethodsWe performed a retrospective review of consecutive patients admitted to a Korean Disaster Relief Team clinic at St. Paul’s Hospital, Tacloban City, Republic of Philippines, between December 9 and 13, 2013. Traumatic injury patients were included; patients not exhibiting a wound were excluded.ResultsOf the 160 patients enrolled in the study, 71 (44.4%) had infected wounds. There were no significant differences in the age, sex, past medical history, wound site, wound depth, injury mechanism, or inducer of injury between the uninfected and infected groups. In the univariate analysis, a foreign-body-contaminated wound, a chronic wound, elapsed time from injury to medical contact, an inadequately cared for wound, and need for subsequent wound management were associated with wound infection (P<0.05). The multivariate analysis revealed that foreign body contamination and having an inadequately cared for wound were associated with wound infection (odds ratio [OR]: 10.12, 95% confidence interval [CI]: 3.59-28.56; OR: 3.51, 95% CI: 1.07-11.51, respectively).ConclusionIn the post-disaster situation, many wound infections required definitive care. Wound infection was associated with inadequately cared for wounds and foreign-body-contaminated wounds. (Disaster Med Public Health Preparedness. 2016;10:28–33)
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Xia Y, Cutrona A, Barreiro TJ. A Man With Intractable Convulsion. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2015; 23:e28-e29. [PMID: 27330266 PMCID: PMC4885531 DOI: 10.1097/ipc.0000000000000238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Tetanus is a rare disease in the United States. Fewer than 40 cases are reported annually because of the high incidence of vaccination. Recognition of the clinical presentations is important because laboratory recovery of pathogen is only 30%, and toxin detection is rare because of consumption at motor neurons. We report a case of tetanus in an elderly man who had a reaction to tetanus vaccination as a child and was nonvaccinated through adult life.
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Affiliation(s)
- Yun Xia
- From the *Department of Medical Education and Research, St Elizabeth Health Center, Youngstown; †Department of Medicine, Northeast Ohio Medical University, Rootstown; and ‡ College of Osteopathic Medicine, Ohio University Heritage, Athens, OH
| | - Anthony Cutrona
- From the *Department of Medical Education and Research, St Elizabeth Health Center, Youngstown; †Department of Medicine, Northeast Ohio Medical University, Rootstown; and ‡ College of Osteopathic Medicine, Ohio University Heritage, Athens, OH
| | - Timothy J. Barreiro
- From the *Department of Medical Education and Research, St Elizabeth Health Center, Youngstown; †Department of Medicine, Northeast Ohio Medical University, Rootstown; and ‡ College of Osteopathic Medicine, Ohio University Heritage, Athens, OH
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Wuthisuthimethawee P, Lindquist SJ, Sandler N, Clavisi O, Korin S, Watters D, Gruen RL. Wound management in disaster settings. World J Surg 2015; 39:842-53. [PMID: 25085100 PMCID: PMC4356884 DOI: 10.1007/s00268-014-2663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management. METHODS We undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy. RESULTS We included 62 studies in the review that described wound care challenges in a diverse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons. CONCLUSION Good wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.
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Affiliation(s)
- Prasit Wuthisuthimethawee
- />Department of Emergency Medicine, Songklanagarind Hospital, Prince of Songkla University, Hatyai, Songkhla Thailand
| | | | | | - Ornella Clavisi
- />National Trauma Research Institute, The Alfred Hospital, Monash University, Level 4, 89 Commercial Road, Melbourne, VIC 3004 Australia
| | - Stephanie Korin
- />Royal Australasian College of Surgeons, Melbourne, VIC Australia
| | - David Watters
- />Department of Surgery, Barwon Health Geelong, Barwon Health and Deakin University, Geelong, VIC Australia
- />Royal Australasian College of Surgeons, Melbourne, VIC Australia
| | - Russell L. Gruen
- />The Alfred Trauma Service, Melbourne, VIC Australia
- />National Trauma Research Institute, The Alfred Hospital, Monash University, Level 4, 89 Commercial Road, Melbourne, VIC 3004 Australia
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Meningitis, clinical presentation of tetanus. Case Rep Infect Dis 2015; 2015:372375. [PMID: 25789186 PMCID: PMC4348616 DOI: 10.1155/2015/372375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 01/28/2015] [Indexed: 11/17/2022] Open
Abstract
Background. Tetanus is an acute disease caused by a neurotoxin produced by Clostridium tetani. Tetanus immunization has been available since the late 1930s but sporadic cases still occur, usually in incompletely vaccinated or unvaccinated individuals. Case Report. An elderly previously vaccinated female contracted tetanus following foot injury. Clinically she presented with meningitis causing diagnostic and therapeutic delays. Why Should Physician Be Aware of This? Even in developed countries the differential diagnosis of meningitis, especially in the elderly, should include tetanus. Treatment in intensive care unit is required. General population might benefit from vaccine boosters and education on this potentially fatal disease.
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Abstract
INTRODUCTION The causative agent of tetanus, Clostridium tetani is widespread in the environment throughout the world and cannot be eradicated. To reduce the number of cases of tetanus efforts are focussed on prevention using vaccination and post-exposure wound care. SOURCES OF DATA Medline, Pubmed and Cochrane databases; World Health Organization and United Nations Children's Fund publications. AREAS OF AGREEMENT The maternal and neonatal tetanus elimination initiative has resulted in significant reductions in mortality from neonatal tetanus throughout the world. AREAS OF CONTROVERSY Although there are few data available it is likely that large numbers of children and adults, particularly men, remain unprotected due to lack of booster immunization. AREAS TIMELY FOR DEVELOPING RESEARCH It remains unclear how HIV and malaria affect both responses to vaccination and transplacental transfer of antibodies or how this might affect timing of vaccination doses.
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Affiliation(s)
- C L Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - H T Loan
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Ho Chi Minh City, Vietnam
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Verde F, Riboldi G, Zappa C, Ferretti M, Silani V, Mari D, Priori A. An old woman with pressure ulcer, rigidity, and opisthotonus: never forget tetanus! Lancet 2014; 384:2266. [PMID: 25625401 DOI: 10.1016/s0140-6736(14)61832-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Carlo Zappa
- Università degli Studi di Milano, Milan, Italy
| | - Marco Ferretti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vincenzo Silani
- Università degli Studi di Milano, Milan, Italy; IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Daniela Mari
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Priori
- Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Prognosis of neonatal tetanus in the modern management era: an observational study in 107 Vietnamese infants. Int J Infect Dis 2014; 33:7-11. [PMID: 25499039 PMCID: PMC4396701 DOI: 10.1016/j.ijid.2014.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 12/03/2014] [Accepted: 12/05/2014] [Indexed: 11/23/2022] Open
Abstract
Large contemporary case-series in a setting of improved critical care facilities. Analysis of variables, some not analysed in previous studies/meta-analyses. Age and weight were associated with a poor outcome. Delay in admission to hospital and leukocytosis were also associated with a poor outcome.
Objectives Most data regarding the prognosis in neonatal tetanus originate from regions where limited resources have historically impeded management. It is not known whether recent improvements in critical care facilities in many low- and middle-income countries have affected indicators of a poor prognosis in neonatal tetanus. We aimed to determine the factors associated with worse outcomes in a Vietnamese hospital with neonatal intensive care facilities. Methods Data were collected from 107 cases of neonatal tetanus. Clinical features on admission were analyzed against mortality and a combined endpoint of ‘death or prolonged hospital stay’. Results Multivariable analysis showed that only younger age (odds ratio (OR) for mortality 0.69, 95% confidence interval (CI) 0.48–0.98) and lower weight (OR for mortality 0.06, 95% CI 0.01–0.54) were significantly associated with both the combined endpoint and death. A shorter period of onset (OR 0.94, 95% CI 0.88–0.99), raised white cell count (OR 1.17, 95% CI 1.02–1.35), and time between first symptom and admission (OR 3.77, 95% CI 1.14–12.51) were also indicators of mortality. Conclusions Risk factors for a poor outcome in neonatal tetanus in a setting with critical care facilities include younger age, lower weight, delay in admission, and leukocytosis.
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Olguín-Araneda V, Banawas S, Sarker MR, Paredes-Sabja D. Recent advances in germination of Clostridium spores. Res Microbiol 2014; 166:236-43. [PMID: 25132133 DOI: 10.1016/j.resmic.2014.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 07/30/2014] [Accepted: 07/31/2014] [Indexed: 12/23/2022]
Abstract
Members of Clostridium genus are a diverse group of anaerobic spore-formers that includes several pathogenic species. Their anaerobic requirement enhances the importance of the dormant spore morphotype during infection, persistence and transmission. Bacterial spores are metabolically inactive and may survive for long times in the environment and germinate in presence of nutrients termed germinants. Recent progress with spores of several Clostridium species has identified the germinant receptors (GRs) involved in nutrient germinant recognition and initiation of spore germination. Signal transduction from GRs to the downstream effectors remains poorly understood but involves the release of dipicolinic acid. Two mechanistically different cortex hydrolytic machineries are present in Clostridium spores. Recent studies have also shed light into novel biological events that occur during spore formation (accumulation of transcriptional units) and transcription during early spore outgrowth. In summary, this review will cover all of the recent advances in Clostridium spore germination.
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Affiliation(s)
- Valeria Olguín-Araneda
- Laboratorio de Mecanismos de Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile
| | - Saeed Banawas
- Department of Biomedical Sciences, College of Veterinary Medicine, Corvallis, OR, USA; Department of Microbiology, College of Science, Oregon State University, Corvallis, OR, USA; Medical Laboratories Department, College of Science Al-Zulfi, Majmaah University, Saudi Arabia
| | - Mahfuzur R Sarker
- Department of Biomedical Sciences, College of Veterinary Medicine, Corvallis, OR, USA; Department of Microbiology, College of Science, Oregon State University, Corvallis, OR, USA
| | - Daniel Paredes-Sabja
- Laboratorio de Mecanismos de Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias Biológicas, Universidad Andrés Bello, Santiago, Chile; Department of Biomedical Sciences, College of Veterinary Medicine, Corvallis, OR, USA.
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Dapul G, Patel P, Pannu T, Meythaler J. Treatment of severe tetanus with intrathecal baclofen via implantable infusion device: a case report. Neuromodulation 2014; 17:791-3. [PMID: 24934627 DOI: 10.1111/ner.12191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/11/2014] [Accepted: 02/13/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Severe tetanus remains a serious issue in less developed countries, leading to prolonged hospitalization due to prolonged neuromuscular contraction of muscles. We present a case of severe tetanus in the United States that was successfully managed with intrathecal baclofen. CASE REPORT A 42-year-old male without tetanus vaccination history presented to the emergency department with intractable jaw pain and worsening diffuse muscle contractures due to severe generalized tetanus requiring prolonged paralysis and ventilator support. After 14 days of continuous neuromuscular treatment with benzodiazepines, vecuronium, propofol, and magnesium sulfate, a baclofen pump trial was performed 14 days post-admission as an alternative to prolonged neuromuscular blockade. After demonstrable improvement in spasms and paroxysmal contractures due to intrathecal baclofen (ITB), a baclofen pump was implanted on hospital day 17. The catheter was threaded to T4 for maximal effect of intrathecal baclofen on the upper and lower extremities at an initial rate of 100 μg/day. ITB was titrated upward, the vecuronium was slowly weaned, and the patient was weaned off a ventilator by day 14 of ITB treatment. At an ITB dose of 450 μg/day, propofol was discontinued. ITB was continued over the next four weeks and eventually weaned over the next two weeks. The ITB pump was removed eight weeks after placement, and the patient was successfully discharged to home. CONCLUSION Due to prolonged muscle weakness associated with long-term use of paralytic agents and sedation, early ITB trial and pump placement should be considered as an alternative in the treatment of severe tetanus to shorten length of stay and improve the functional outcome of the patient.
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Affiliation(s)
- Geraldine Dapul
- Department of Physical Medicine and Rehabilitation Oakwood, School of Medicine, Wayne State University, Dearborn, MI, USA
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Ozer-Cinar S, Isil CT, Paksoy I. Dexmedetomidine in the management of severe tetanus. Indian J Anaesth 2014; 58:96-7. [PMID: 24700920 PMCID: PMC3968675 DOI: 10.4103/0019-5049.126847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Surhan Ozer-Cinar
- Department of Anaesthesiology and Reanimation, Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey
| | - Canan Tulay Isil
- Department of Anaesthesiology and Reanimation, Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey
| | - Inci Paksoy
- Department of Anaesthesiology and Reanimation, Sisli Etfal Teaching and Research Hospital, Istanbul, Turkey
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Al Salman J, Al Agha R, Al Aradi K. Tetanus in an unvaccinated laborer in Bahrain. J Infect Public Health 2014; 7:240-4. [PMID: 24656722 DOI: 10.1016/j.jiph.2014.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/17/2014] [Accepted: 01/25/2014] [Indexed: 10/25/2022] Open
Abstract
Mr. M.D.S., a 27-year-old Indian male, presented with complaints of diffuse body pain and spasms, 7 days after a needle penetrated his right foot at his place of work. He was diagnosed clinically with tetanus. The patient was electively intubated to protect the airway and transferred to an intensive care unit. In addition to his tetanus, he developed multiple hospital-acquired infections. After 34 days, he was successfully extubated and extensive physiotherapy commenced. He was discharged 10 days after extubation.
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Affiliation(s)
- Jameela Al Salman
- Infectious Disease & Geriatric Medicine, Salmaniya Medical Center, Bahrain.
| | | | - Khalil Al Aradi
- Infectious Diseases Unit, Department of Internal Medicine, Bahrain
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