Tetanus in developing countries: a case series and review

Purpose Few anesthesiologists have expertise in the diagnosis and treatment of tetanus, a disease that remains prevalent in developing countries. We report on a series of four cases of tetanus cases recently encountered in Rwanda. We review the clinical epidemiology, pathophysiology, diagnosis and the treatment of tetanus, and provide implications for anesthesiologists and critical care physicians. Clinical features We report four cases, two involving adults who were inadequately vaccinated and experienced injuries, and two involving neonates, both of whom underwent umbilical cord transection using unsterilized equipment. All patients required tracheal intubation, and were mechanically ventilated when equipment was available. One adult and one neonate succumbed to the disease. These cases highlight the difficulties of diagnosis and management of complicated diseases in the resource-challenged health care setting of developing countries. Conclusions The differential diagnosis of tetanus may be confusing, and survival depends on the rapidity of treatment with antitoxin, as well as adequate supportive care. High doses of sedatives and muscle relaxants, as well as prolonged mechanical ventilation, are usually necessary. Mortality remains high, usually resulting from late respiratory failure and cardiovascular collapse, associated with autonomic instability. Anesthesiologists and critical care physicians have an important role to play in the management of these patients. Increased involvement in humanitarian health organizations, immigration from developing countries, and emergence of high risk groups in developed countries will likely result in more exposure of anesthesiologists to the complexities of this disease. Résumé Objectif Très peu d’anesthésiologistes sont experts du diagnostic et du traitement du tétanos, une pathologie qui demeure prévalente dans les pays en voie de développement. Nous rapportons une série de quatre cas de tétanos survenus récemment au Rwanda. Nous passons en revue l’épidémiologie clinique, la physiopathologie, le diagnostic et le traitement du tétanos, et proposons des pistes intéressantes pour les anesthésiologistes et les médecins en soins critiques. Éléments cliniques Nous rapportons quatre cas dont deux impliquent des adultes mal vaccinés et qui ont subi des blessures, et deux concernent des nouveaux-nés, tous deux ayant subi une coupe transversale du cordon ombilical à l’aide d’instruments non stérilisés. Tous les patients ont nécessité une intubation trachéale et ont été ventilés mécaniquement lorsque le matériel était disponible. Ces cas soulignent les difficultés rencontrées lors du diagnostic et de la prise en charge de pathologies complexes dans le contexte des soins de santé manquant de ressources des pays en voie de développement. Conclusions Le diagnostic différentiel du tétanos peut porter à confusion, et la survie dépend de la rapidité du traitement avec de l’antitoxine ainsi que de soins d’accompagnement adaptés. En général, des doses élevées de sédatifs et de curares ainsi qu’une ventilation mécanique prolongée sont nécessaires. La mortalité demeure élevée, en général causée par une insuffisance respiratoire tardive et d’une défaillance cardiovasculaire combinées à une instabilité du système nerveux autonome. Les anesthésiologistes et les médecins en soins critiques ont un rôle important à jouer dans la prise en charge de ces patients. Un engagement accru dans les organisations sanitaires humanitaires, l’immigration des pays en voie de développement et l’émergence de groupes à haut risque dans les pays développés auront probablement pour résultat une plus grande exposition des anesthésiologistes aux éléments complexes de cette pathologie. The treatment of tetanus has many implications for anesthesiologists and critical care physicians, but most physicians in developed countries lack experience in dealing with such cases. With developed nations progressively more involved in the medical aid programs in developing countries, and with increased immigration and emerging risk groups in developed countries, physicians may increasingly be called upon to diagnose and treat this complex disease. Since 2006, the Canadian Anesthesiologists’ Society International Education Foundation (CAS-IEF), in conjunction with the American Society of Anesthesiologists, has made visiting faculty available as teachers for local anesthesiology residents and allied personnel in Rwanda. We recently participated in the CAS-IEF program in Rwanda and, during the month of February, 2008, encountered four new cases of tetanus presenting to the Intensive Care Unit of the Centre Hospitalier Universitaire de Kigali (CHUK), Rwanda’s largest public hospital. With approval of the institutional ethics committee, the Comité de Recherche Scientifique au CHUK, we present a summary of these cases and a review of the pathophysiology, treatment options, and anesthetic considerations of tetanus. Case 2 A 30-year-old farmer suffered a machete injury to his left index finger while working in the field. Ten days after injury, he first consulted with his local health clinic complaining of difficulty chewing and swallowing. The clinicians quickly decided to refer him to the district hospital, where, in turn, he was transferred to CHUK. On admission to CHUK, he was alert and oxygenating well on room air, but was manifesting all the typical signs of tetanus: generalized muscle spasms, opisthotonus, trismus, risus sardonicus facies, as well as nuchal rigidity, rigid abdomen, and a small healing wound on the index finger. The diagnosis of tetanus was made at this time, Day 1 of his illness, as was the diagnosis of malaria. The patient had no known history of having received a tetanus vaccination and was negative for antibodies to human immunodeficiency virus (HIV). Tetanus treatment included equine antitetanus immunoglobulin 3000 IU IM, metronidazole, diazepam 10 mg · h−1, oxygen by nasal cannula, and admission to the intensive care unit. Phenobarbital 50 mg iv qid was initiated for persistent paroxysms. Intravenous and nebulized atropine was administered for bronchial secretions. On Day 10 of his illness, pneumonia was diagnosed, based on a productive cough, fever of 38.5°C, and changes on chest radiograph. This was treated with ceftriaxone 2 g bid and gentamicin 80 mg bid. On Day 12 of the onset of his illness, the patient was intubated for respiratory distress in the face of persistent paroxysms of muscular spasm. Sedation and relaxation consisted of diazepam and sodium thiopentone 40 mg · h−1, morphine boluses, and vecuronium. The patient’s trachea was extubated on Day 18. He was discharged from hospital 24 days after admission, his only deficit being a flaccid left hand. He has returned to work with his community to promote awareness of the importance of tetanus vaccination. Case 3 A 10-week-old male infant was admitted to the intensive care unit at CHUK. The infant was born at term at home with a traditional birth attendant. The 19-year-old mother had only once been medically evaluated antenatally and had received one dose of tetanus vaccine. The umbilical cord had been cut with a previously used razor blade with no sterile precautions taken. No perinatal problems were noted. The family visited the district hospital shortly after the birth for a well-baby check-up; however, the infant’s vaccinations were delayed by 1 week due to refrigeration problems. Six weeks after birth, the infant developed episodic convulsions, spasms of his lower extremities, increased oral secretions, and cervical rigidity. The patient was not admitted to hospital until 1 week later, at which time he presented with generalized nonfebrile convulsions, muscular rigidity and spasms, transient apnea, and reduced reflexes. During a 3-week course in the district hospital for an undetermined illness, the infant received oxygen by mask, diazepam, and hydrocortisone. Lumbar puncture was performed during the course in hospital and reported as “blood-tinged.” Fever prompted a blood smear for malaria, which was positive, and antimalarial drugs were started. On Day 28 after onset of illness, the infant was eventually transferred late in his course to CHUK for suspected hemorrhagic meningitis, malaria, and possible tetanus. Upon admission to CHUK, he received his first dose of equine antitetanus immunoglobulin 500 IU im. The infant also received rectal diazepam 0.5 mg · kg−1, phenobarbital infusion 20 mg · d, dexamethasone, ceftriaxone, metronidazole, and oxygen by face mask. The infant was fed by gastric tube, and his trachea was intubated for airway protection following an episode of emesis after feeding. Ventilation was impaired due to muscle spasms and opisthotonus; however, there was no neonatal ventilator available at this time in the intensive care unit. The infant maintained spontaneous respiration via endotracheal tube for 2 days. His trachea was extubated on Day 30 after the convulsions and spasms had regressed. The infant was discharged 5 weeks after admission to CHUK and 9 weeks after onset of illness. Case 4 A male infant was diagnosed with tetanus only 4 days after birth. This infant was a second child born at home to an HIV negative mother who had only been seen once prenatally and had received a single dose of antitetanus immunoglobulin at 8 months’ gestation. After delivery, the umbilical cord was cut with unsterilized hairstyling scissors. At 4 days of age, the infant presented to a local hospital with generalized muscle spasms and was treated with diazepam and metronidazole. No antitetanus immunoglobulin was given. After making little improvement, he was transferred to CHUK on Day 10 after onset of illness. On arrival to CHUK on Day 10, the infant was opisthotonic; he also had trismus and excessive oral secretions. There was no bulging of fontanelles. The umbilical stump appeared infected. Intensive care admission and treatment included oxygen by face mask, intramuscular equine antitetanus immune globulin 500 IU im, cefotaxime, metronidazole, diazepam 0.4 mg · h, acetaminophen, magnesium sulfate, and calcium gluconate. Persistent muscle spasms necessitated increased diazepam doses as well as sodium thiopentone. He was nourished with nasogastric feeds. The infant remained agitated, and because he had difficulty managing his copious secretions, the infant was tracheally intubated but not mechanically ventilated. The intubation was difficult in the absence of muscle relaxants, which were avoided in order to maintain spontaneous respiration. Continued problems with endotracheal tube obstruction due to secretions necessitated tube replacement. Four days following his intubation, the infant became increasingly hypoxemic and subsequently bradycardic. Cardiac arrest ensued, and no epinephrine was available for resuscitation. The child expired following failed attempts at improving oxygenation