Image of the Day 37: Neonatal Tetanus; Unsterile Delivery Practice and Lack of Maternal Immunity

This day 24 of life baby boy, non Malaysian, home delivery with un sterile method and not immunized was brought by mother to casualty because of muscle stiffness 3 days prior to admission associated with fever, refuse oral feeding and body rash.

On examination, term baby, fully conscious and alert to surrounding, mildly dehydrated, weak looking but not septic looking. There was on and off muscle spasm with episthotonus which lasting for three minutes in frequency of five minute intervals. However, no tongue biting or lock jaw. There was maculopapular rash at his right left chest. Anterior fontanel was soft and not bulging. Neck stiffness was not accurate because of muscle spasm. Vitals were normal except for tachycardia 190 b.p.m and temperature at that time was 39 degree Celsius. Dextrostik at that time was 3.9.

A diagnosis of Neonatal tetanus was made. He was given IM Tetanus immunoglobulin 500 i.u and S/C Anti tetanus toxoid 0.5 ml on contra lateral shoulder. IV Metronidazole 15mg/Kg was given stat dose followed by maintenance. He was kept nil by mouth and starts on IV drip bolus 20 CC/kg normal saline followed by  IV drip maintenance. For fever, suppositories PCM 62.5 mg stat given followed by tepid sponging.  After discuss with Pediatrician, he was intubated and sedated with IV Midazolam to control the muscle spasm and admitted to intensive care unit.

Meanwhile, mother did not attend antenatal follow up due to financial constraint and unable to clarify regarding the status of tetanus immunization.

Episthotonus with painful muscular contraction of bilateral upper and lower limbs.

Discussion

An estimation made by WHO shows that 58 000 newborn dies of Neonatal Tetanus with almost 93% reduction of death compared to 1980s (787,000 death). By November 2012, 31 countries have not reach the call to eliminate tetanus after it has been announced in 1989 during the 42nd WHO assembly.

The figure shows two things. Firstly, immunization schedule has successfully reduce the death due to tetanus up until 93 percents in which, it is a great victory. However, what factor contributes to the failure of another seven percents? Is there any lack of access to public health care or failure to provide tetanus immunization plan.

Discussing about preventable death, data from WHO in 2008 shows that 1.5 millions of under five years old mortality can actually be prevented by giving routine vaccination. Four percents of this figure are attributed to tetanus.

In Malaysia, data from WHO shows a pattern of increasing number of reported case of (Total Tetanus/Neonatal Tetanus); 2012 (34/9), 2011(11/3), 2010(28/10), 2009 (19/5). This is exclusion of under reported case especially among the non locals who resides in Malaysia illegally.

Tetanus is due to infection of an obligate anaerobic gram positive bacillus; Clostridium tetani. This non encapsulated organism have the ability to produce spores that are resistant to heat, desiccation and disinfectants and can be found not only in soil but also in human feces, house dust or animal intestines. Scary part is, it can persist in our tissue for years. Infection result from un sterile cord clamp and cutting, unsanitary delivery as well as lack of maternal immunization. It usually presented at day three to eleven after delivery. However, in this case, the development of onset is late, possibly because of late manifestation.

Germination of spores produce two type of toxin; the non dangerous tetanolysin and tetanospasmin that cause acute onset of hypertonia and painful muscular contraction. Mortality arise due to secondary infection, poor nutrition due to inadequate feeding, and complication of the persistent muscular contraction itself including hypoxia and over sympathetic activation.

Tetanospasmin will travel from contaminated site into the spinal cord. Once it enter the motor neuron, it will travel via retrograde axonal transport. This process will take about 2-14 days. In spinal cord, it enters central inhibitory neurons and the light chain cleaves the protein synaptobrevin, which is integral to the binding of neurotransmitter containing vesicles to the cell membrane. ( Patrick B Hinfey). This will prevent the release of GABA and glycine vesicles containing and lead to loss of motor inhibition. These neuron that is fix to toxin cannot be neutralized with anti toxin and the recovery of nerve function require sprouting of new nerve terminals and formation of new synapse.(Patrick B Hinfey)

The best way to prevent the death arising from tetanus is by preventing the disease itself. This includes maintenance of hygiene and sterility of instrument and place during delivery and also vaccination of the mother.

Meanwhile, managing tetanus involve 1) Eradicating of the organism through antibiotic, 2) To debride any obvious wound in order to remove the spores and prevent germination, 3) To stop the toxin production and neutralize the unbound toxin, 4) Symptomatic treatment of disease manifestation especially the painful muscular contraction, 5) supportive therapy like nutrition, fluid, ventilator and also bed sore and gastric ulcer prevention and also 6) To treat the complications. Since tetanus infection provides no immunity to the patient, therefore tetanus toxoid or vaccine should be given to the infected neonate as well.

Reference:

1. Patrick B Hinfey et al, "Tetanus", http://emedicine.medscape.com/article/229594

2. "Maternal and Neonatal Tetanus (MNT) elimination", http://www.who.int/immunization_monitoring/diseases/MNTE_initiative/en/index.html

3. Vaccine-preventable diseases",

http://www.who.int/immunization_monitoring/diseases/en/