PAPERS PRESENTED AT THE XVII ANNUAL CONFERENCE OF HOSPITAL INFECTION

Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 106-108

A case series of clinically suspected cases of tetanus

Y Kathyayani
Department of Microbiology, Government Medical College, Guntur, Andhra Pradesh, India

Correspondence Address:
Dr. Y Kathyayani
Department of Microbiology, Government Medical College, Guntur, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jpsic.jpsic_15_22

Tetanus is a serious illness contracted through exposure to the spores of the bacterium, Clostridium tetani, which live in soil, saliva, dust and manure. The bacteria can enter the body through a deep cuts, wounds or burns affecting the nervous system. The infection leads to painful muscle contractions, particularly of the jaw and neck muscle, and is commonly known as “lockjaw. The disease remains an important public health problem in many parts of the world, but especially in low-income countries or districts, where immunization coverage is low and unclean birth practices are common. WHO estimates that in 2018 for which estimates are available), 25 000 newborns died from neonatal tetanus, 88% reduction from the situation in 2000. Global tetanus vaccination programs contributed to a 95% reduction in neonatal tetanus deaths in the last 30 years and continue to decrease tetanus burden.

Keywords: Ablett classification, severity of tetanus, tetanus

Introduction

Case Reports

• Laxma Reddy, a 60-year-old male, private employee by occupation, resident of Chanda Nagar, Hyderabad, presented with complaints of:



• Fever, inability to open mouth, loss of appetite, malaise and spasms localised to wound
• History of (H/O) rusty nail injury to the left foot on the plantar surface 12 days ago



• The patient was a known hypertensive and not a known diabetic
• Laboratory investigations included:

• Haemoglobin (Hb) – 12 g/dL, total cholesterol (TC) – 13,500/mm³, polymorphs (P) – 78%, Lymphocytes (L) – 18%, Monocytes (M) – 2% and Eosinophils (E) – 2%
• Erythrocyte sedimentation rate (ESR) – 35 mm – 1^st h and 60 mm – 2^nd h
• Platelet count – 2 lakh/mm³ and random blood sugar (RBS) – 168 mg/dL.

• Samakka, a 50-year-old female, farmer by occupation, from the rural area of Warangal presented with chief complaints of:



• Inability to open mouth, stiffness of back muscles, rigidity of the abdomen and leg pain for 7 days
• H/O thorn prick to the left leg on the plantar surface 15 days ago
• She had fever for 3–4 days after the injury.



• Laboratory investigations included:

• Hb – 11.7 g/dL, white blood cell (WBC) – 9100 cells/mm³, Neutrophils (N) – 69%, L – 23%, Eosinophils (E) – 4%, Monocytes (M) – 4%, platelet – 3.92 lakh/mm³, Packed Cell Volume (PCV) – 34%, Mean Corpuscular Volume (MCV) – 81.5 fL, Mean Corpuscular Hemoglobin (MCH) – 26.7 pg, Mean Corpuscular Hemoglobin Concentration (MCHC )– 32.8 g/dL and Fasting Blood Sugar (FBS) – 66 mg/dL
• Blood urea: 35 mg/dL and serum creatinine: 0.9 mg/dL
• Serum electrolytes: normal
• Creatinine phosphokinase: 118 U/L
• Blood C/S: No bacterial growth
• Urine C/S: No bacterial growth
• Plasmodium falciparum/Plasmodium vivax, (Pf/Pv): negative; dengue NS1, IgM and IgG: negative; Non Contrast CT (NCCT) brain: normal.

• Md Salman, a 3-year-old child weighing 10 kg from Asif Nagar, Hyderabad, brought by his mother presented with chief complaints of:



• Difficulty in opening mouth, difficulty in swallowing and difficulty in walking for 5 days
• H/O left ear discharge from 20 days
• Vaccination status: unvaccinated.



• Laboratory investigations included:

• RBS: 105 mg/dL
• Blood urea: 30 mg/dL
• Serum creatinine: 0.7 mg/dL
• Serum electrolytes: normal.

• Akash, a 12-year-old male child, brought by his mother, resident of urban Hyderabad presented with chief complaints of:



• Inability to open mouth, pain abdomen, neck stiffness and occasional muscle spasms for 10 days
• H/O left ear discharge from 30 days



• Vaccination status:

• The child was vaccinated only with Oral Polio Vaccine (OPV).

• Karthik, a 7-year-old male child, from Makthal Village, Mahaboobnagar (Dt), presented with chief complaints of:



• Inability to open mouth, abdominal stiffness, neck stiffness, occasional muscle spasms and inability to walk and sit properly for 5 days
• H/O thorn prick injury to the right foot 7 days ago



• Vaccination status:

• The child took Bacillus Calmette Guerin (BCG), three doses of Diphtheria, Pertussis, Tetanus, (DPT) and Oral Polio Vaccine (OPV) but missed the booster dose of Diphtheria Tetanus, (DT) vaccine.

• Santhosha, a 6-year-old female child, from Kotacheruvu Village, Mahaboobnagar (Dt), presented with chief complaints of:



• Inability to open mouth completely, abdominal stiffness and occasional muscle spasms for 5 days
• H/O injury hit by bullock with trauma to the forehead 10 days ago



• At the time of admission, injury healed
• Vaccination status:



• The child received only OPV vaccination



• Laboratory investigations included:

• Blood urea: 18 mg/dL
• Serum creatinine: 0.6 mg/dL.

• Yellaiah, a 58-year-old male, farmer by occupation, from Gandivat (V), Nizamabad (Dt), presented with chief complaints of:

• Inability to open mouth, neck stiffness, rigidity of lower limbs and muscle spasms for 5 days
• H/O thorn prick to the left foot 20 days ago
• No H/O diabetes mellitus or hypertension.

Ablett Classification of Severity of Tetanus

• I mild: Mild-to-moderate trismus; general spasticity; no respiratory embarrassment; no spasms; little or no dysphagia
• II moderate: Moderate trismus; well-marked rigidity; mild-to-moderate but short spasms; moderate respiratory embarrassment with an increased respiratory rate greater than 30; mild dysphagia
• III severe: Severe trismus; generalised spasticity; reflex prolonged spasms; increased respiratory rate greater than 40; apnoeic spells; severe dysphagia; tachycardia greater than 120
• IV very severe: Grade III and violent autonomic disturbances involving the cardiovascular system. Severe hypertension and tachycardia alternating with relative hypotension and bradycardia, either of which may be persistent^[3]
• Laboratory diagnosis – Excised tissue bits/deep wound swabs were collected under local aseptic conditions
• Three swabs were inoculated into three tubes of cooked meat broth
• Out of three tubes of cooked meat broth, one was heated to 80°C for 10 min, the second to 70°C for 30 min and the third left unheated
• The medium was overlaid with paraffin oil for maintaining anaerobiosis and incubated at 37°C
• One swab was inoculated onto anaerobic blood agar plates and incubated anaerobically at 37°C for 48 h in an anaerobic jar with Gas Pak (HiMedia laboratories) [Table 1] [Figure 1].

Figure 1: Figure showing cooked meat broths and gram staining Click here to view

Table 1: Showing all the details of all cases Click here to view

References

1.	Ogunrin OA. Tetanus - A Review of Current Ogunrin,Journal of Post Graduate Medicine 2009;11:46-61.
2.	Available from: https://www.wpro.who.int/immunization/factsheets/tetanus-nt/en/. [Last accessed on 2022 Apr 06].
3.	Cook TM, Protheroe RT, Handel JM. Tetanus: A review of the literature. Br J Anaesth 2001;87:477-87.
4.	Gulatti AK, Diagnostic and practical microbiology, Calcutta Medical and allied agency 1st edition, 1985.