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April 1, 2008
Anwar Wardy W
FKK UMJ
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Tetanus Epidemiology
Uncommon in the US but not worldwide 1 million cases worldwide per year Mortality rate of 20-50%
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Epidemiology
Fewer than 50 cases per year in the US Majority of cases in temperate climates (Texas, California, and Florida)
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Pathophysiology
tetani
Motile, nonencapsulated, anaerobic, gram positive rod Spore forming and ubiquitous in soil and animal feces
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Pathophysiology
Usually introduced in the spore forming state, then germinates to the toxin producing vegetative form Requires decreased tissue oxygen tension to germinate Vegetative state produces two exotoxins
Tetanolysin Tetanospasmin
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Toxins
Neurotoxin responsible for the clinical manifestations of tetanus Reaches peripheral nerves by hematogenous spread and retrograde intraneuronal transport Does not cross blood brain barrier Reaches CNS by retrograde transport
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Tetanospasmin
Acts on the motor end plates of skeletal muscle, in the spinal cord, and in the sympathetic nervous system Prevents release of inhibitory neurotransmitters glycine and gammaaminobutyric acid (GABA)
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Clinical Features
Tetanospasmin responsible for generalized muscular rigidity, violent muscular contractions, and instability of the ANS. Typical wound is a puncture, but no wound is identified in up to 10% Other routes are surgical procedures, otitis media, abortion, umbilical stump and drug abusers
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Local Tetanus
Rigidity of the muscles in proximity to the site of injury Usually resolves completely in weeks to months
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Generalized Tetanus
Most common form Most common presenting complaint is pain and stiffness of the masseter muscles (Lockjaw) Short axon nerves affected initially therefore starts in the face, then neck, trunk, and extremities
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Generalized Tetanus
Muscle stiffness leads to rigidity Trismus and characteristic sardonic smile develops (risus sardonicus) Reflex convulsive spasms and tonic muscle contraction create dysphasia, opisthotonos (arching of back and neck), flexing arms, clenching fists, and lower extremity extension
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Opisthotonos
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Generalized Tetanus
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Cephalic Tetanus
Results from an injury to the head or otitis media Cranial nerves affected most commonly the seventh
Poor prognosis
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Neonatal Tetanus
400,000 worldwide deaths annually Results from inadequately immunized mothers Frequent after unsterile treatment of the cord stump
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Neonatal Tetanus
Signs
Weakness
Irritability Inability to suck
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Diagnosis
Wound cultures not very useful as C. tetani may be recovered without tetanus
Immunization history usually unknown or inadequate
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Tetanus Ddx
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Treatment
Admit to ICU Be prepared for intubation with neuromuscular blockade as respiratory compromise may develop Minimal environmental stimuli to avoid reflex convulsive spasms Initial wound debridement to improve oxygenation
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Treatment
Neutralizes wound and circulating tetanospasmin Does not neutralize toxin already bound to the nervous system Does not improve clinical symptoms Decreases mortality
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Treatment
TIG
Usual dose is 3,000 to 6,000 units Administered IM opposite side as Td given Give before wound debridement
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Treatment
Antibiotics
Avoid penicillin
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Treatment
Muscle relaxants
Tetanospasmin
prevents neurotransmitter release at inhibitory interneurons and therapy of tetanus is aimed at restoring balance preferred agent as it is water soluble specific GABAB agonist that has also been used
Midazolam
Baclofen
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Treatment
Neuromuscular blockade
Blockade often required to allow respiration and to prevent fractures and rhabdomyolysis Succinylcholine
Vecuronium
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Treatment
Labetalol
useful for treatment due to combined alpha and beta activity inhibits the release of epinephrine and norepinephrine from the adrenal glands central alpha receptor agonist for cardiac stability
Magnesium sulfate
Clonidine
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Immunization
Disease does not confer immunity so those that recover must undergo immunization Tetanus toxoid
0.5 cc IM at presentation, 6 weeks, and 6 months Local reactions are common Less common serous reactions include urticaria, anaphylaxis, or neurologic complications
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Td Yes No
TIG No No
Td Yes Yes
TIG Yes No
Td dose: 0.5cc IM TIG dose: 250 U IM anwar wardy DPT given if under 7, Td given if over 7
Rabies
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Rabies
Rabies ranks number 10 worldwide as a cause of mortality 50,000 60,000 deaths annually worldwide Rare human cases in US but 35,000 people provided prophylaxis annually
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Microbiology
Classic rabies virus common rabies 6 others with less than 10 reported human cases of disease
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Pathophysiology
Virus course
Initial uptake of virus by monocytes in 48-96 hours Crosses motor end-plate to travel up the axon to the dorsal root ganglia to the spinal cord and the CNS Then spreads outward via peripheral nerves to infect almost all tissue of the body
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Pathophysiology
Negri bodies
Eosinophilic intracellular lesions in cerebral neurons Highly specific for rabies Present in 75% of rabies cases
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Negri bodies
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Epidemiology
Primarily a disease of animals Human cases reflect the prevalence in animals and degree of human contact with them Major vectors include
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Epidemiology
7,369 cases of animal rabies in the US in 2000
Raccoons (37.7%) Skunks (30.2%) Bats (16.8%) Foxes (6.2%) Others (2.2%)
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Cats (3.4%) Dogs (1.6%) Cattle (1.1%) Horses, donkeys, mules (0.71%) Sheep, goats, camels (0.15%) Others and ferrets (0.06%)
Epidemiology
Dogs
Less than 5% of animal cases in US, Canada and Europe Greater than 90% of animal cases in developing countries
Squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, domesticated rabbits and other small rodents Almost never requires post exposure prophylaxis
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Epidemiology
Transmission
Saliva though bite of an rabid animal most common Aerosolized in bat caves Mucus membrane transmission also reported
Risk of developing rabies dependant on the location injury, depth, an number of bites
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Infection Risk
Single bite Superficial bite on the extremity Contamination of open wound by saliva Transmission via fomites (e.g. tree branch, or animal)
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Epidemiology
6 dog bites in a foreign country 1 bat bite 8 2 1 1 with with with with a a a a bat dog cow cat
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Preexposure Prophylaxis
Prophylaxis
Individuals with occupations or recreation that place them at risk should receive the series 4 shot series with booster shots required Does not eliminate need for postexposure prophylaxis
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Postexposure Prophylaxis
Exposure is a bite, scratch, abrasion, open wounds, or mucous membrane exposure Contact alone, and contact with blood, urine, or feces does not constitute and exposure
Cleansing wound with 20% soap and water has been show in experimental animals to markedly reduce the rate of infection
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Bats
Increasingly important wildlife vectors of transmission of rabies All cases of possible bat bites the bat should be collected and tested for rabies Bat unavailable
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Observation
CDC recommends 10 days of observation of a healthy dog, cat, or ferret after a bite Normal behavior
No action needed Sacrifice animal, test for rabies, and initiate HRIG and vaccine
Unusual behavior
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Possible animal exposure Carnivore, bat or salivary exposure Bird, reptile, rodent or nonsalivary exposure Bat, skunk, raccoon, cow, bobcat, coyote, or fox Captured No Vaccine needed
Dog or cat
No vaccine needed
Strange behavior Sacrifice, initiate vaccine and HRIG Rabid Vaccine + HRIG Not Rabid Discontinue vaccine Escaped No epidemiologic prevalence in area No vaccine needed
Escaped
Vaccine + HRIG
Epidemiologic prevalence
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Vaccine +HRIG
Escaped
Vaccine + HRIG
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Dog or cat
No vaccine needed
No vaccine needed
Epidemiologic prevalence
Vaccine +HRIG
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Postexposure Prophylaxis
Course
One dose initially May be given up to 7 days after an exposure Infiltrate as much as possible around wound Give on the opposite side as the vaccine
Vaccine
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Postexposure Prophylaxis
Vaccine reactions
Minor reaction
Erythema, swelling, pain 30-74% Headache, nausea, abdominal pain, muscle aches 5-40% Rarely reported
Systemic reaction
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Special Circumstances
Either prior preexposure course or full postexposure course No HRIG Course shortened to 2 doses
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Special Circumstances
Immunocompromised patient
Stop all immunosuppressives if possible Measure antibody titers to assure appropriate response
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Special Circumstances
Travelers
Preexposure prophylaxis
Recommended if prevalence and possible exposure Veterinarians, animal handlers, spelunkers, certain lab workers If initiated in another country contact health department for recommendations
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Special Circumstances
Pregnancy
No adverse effects of the vaccine or HRIG Follow usual course in pregnancy if indicated
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Special Circumstances
Children
Vaccine
Same dose and same course Dose is based on weight If quantity of HRIG not sufficient to infiltrate all wounds may be diluted with saline
HRIG
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Clinical Disease
Incubation period
20 to 90 days 4 days up to 19 years have been reported Greater than 1 year is well documented
Fever, sore throat, chills malaise, headache, N/V, weakness May report limb pain, weakness, and paresthesias Nonspecific neurologic conditions such as anxiety, agitation, irritability or psychiatric disturbances
Prodrome
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Clinical Disease
Furious 80%
Hyperactivity, disorientation, hallucinations, bizarre behavior Symptoms may alternate with calm Autonomic dysfunction Hydrophobia with pharynx spasms in 50% Paralysis in the extremity, diffuse or ascending Fever and nuchal rigidity
Paralytic 20%
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Clinical Disease
Coma
Death
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Diagnosis
Rabies should be in the differential of any acute encephalitis May be confused with poliomyelitis, Guillain-Barre syndrome, transverse myelitis, postvaccinial encephalomyelitis, CVA, atropine-like poisoning, other viral encephalitis
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Diagnosis
Lab testing
No one test is completely informative Test serum, CSF, and skin for antibodies in a non-vacinated person Nuchal skin biopsy most sensitive early PCR from saliva also useful
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Treatment
Limited
No specific treatment exists for clinical course Treatment directed at the clinical complications
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References
Emergency Medicine a Comprehensive Study Guide. Sixth edition. McGrwHill Companies, Inc. 2004. Chapter 146-147. Tetanus and Rabies. Pages 943-953. Centers for Disease Control. http://www.cdc.gov/ncidod/dvrd/rabies/Epidemiology/Epidemiology.htm,
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Questions
1. 2.
The majority of elderly patients have adequate immunity to tetanus. (T/F) A patient with previous tetanus immunization (3 or greater) presents with a puncture wound by a dirty nail. Appropriate tetanus prophylaxis includes:
a) b) c) d)
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Questions
3. 4.
Negri bodies are always present in Rabies. (T or F) Which is not considered to be a vector of rabies:
a) b) c) d)
e)
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Questions
5.
A stay dog bit a child. The dog was not seen by anyone else and escaped and is unavailable for capture. There is no epidemiologic evidence of rabies in dogs in your area. Rabies prophylaxis includes:
a)
b) c) d)
Initiate rabies vaccine and administer HRIG Initiate vaccine only Administer HRIG only No prophylaxis initiated, observation.