CASE 4

“THE DISEASE
OF THE
SEVENTH DAY”
 “THE DISEASE OF THE
SEVENTH DAY”
 Baby J.D. is a 7-day old neonate born
term in a faraway Bukidnon baragay
reachable only by horseback and
delivered by a traditional “hilot”. He
was admitted because of poor sucking
and inability to open the jaw. He
was crying excessively and went into
spasms when touched. A few hours
later, he became highly febrile and his
entire body became completely rigid
Questions to be answered
1. What is the most likely diagnosis of
this patient?
2. Explain the pathophysiology of
Tetanus
3. How is a diagnosis of Tetanus
achieved?
4. What are the differential diagnoses of
Tetanus?
5. What are the goals of treatment of
Tetanus?
6. What are the necessary Preventive
 Q1:
What is the most
likely diagnosis of
this patient?
Answer: Neonatal Tetanus
 WHO estimates that >500,000
deaths due to Tetanus neonatorum
still occurs
 Tetanus is an acute toxemic
disease caused by Clostridium
tetani , a spore forming gram (+)
bacillus widely distributed in the
soil, animal and human feces,
house dust and even in
Neonatal Tetanus
 Absence of immunity in the mother
and contamination of the umbilical
cord account for the occurrence in
regions where home delivery is
conducted by untrained personnel
with the cord cut by an unclean
knife, scissors, bamboo etc. and
the umbilical stump dressed with
earth or animal dung
Neonatal Tetanus
 Inability to suck,
persistent crying,
followed by fever
and recurrent
generalized
Risus sardonicus
spasms with deep
cyanosis are the
usual presenting
symptoms
Tetanus
 The most frequest
presenting symptom
is painful trismus
(lockjaw) due to
spasm of the
masseter muscles
 When the jaw
remains tightly
clenched together
with spasm of the
facial muscles, the
typical “risus
sardonicus”
Risus sardonicus
expression results
Tetanus
 Over the next 24-48
hrs., muscle rigidity
spreads to involve
the muscles of the
neck,back, abdomen
and limbs
culminating in a very Opisthotonus
characteristic spasm.•During these spasms, the
 The head is child remains mentally alert
retracted, the spine but apprehensive
arches backwards •
The spasms may be
and the abdomen
attains a board-like precipitated by a variety
rigidity of stimuli as light or noise
 Q2:
Explain the
pathophysiology of
Tetanus
 Pathophysiology
 The potent Tetanus neurotoxin (Tetanospasmin) is
synthesized intracellularly. After release it binds to
motor end-plates in skeletal muscles. It acts by
inhibiting acetylcholine release thereby impairing
neuromuscular transmission
It reaches the CNS through the perineural spaces of
nerve trunks of by hemotagenous dissemination
The toxin enters the neurones and becomes
irreversibly fixed on to the gangliosides
 Produces presynaptic inhibition resulting in
unopposed muscle contraction and seizures
 Q3:
How is a diagnosis
of Tetanus
achieved?
Diagnosis
 The diagnosis of tetanus is entirely
clinical
 It is often difficult to isolate the
bacilli from the wound + the
presence of C. tetani does not
mean the patient has tetanus
(Paediatric Problems in Developing Countries, edited by
Robinson M.J)
 Q4:
What are the
differential
diagnoses of
Tetanus?
Differential diagnosis of
Tetanus
 Other convulsive
disorders posing a
problem in
diagnosis:
meningitis,
phenothiazine
dystonia,
strychnine
poisoning, tetany
 Trismus may be
seen in rabies
Hydrophobia of Rabies
Differential diagnosis of
Tetanus

Tetany with carpopedal spasm

 Q5:
What are the goals
of treatment in the
management of
Neonatal Tetanus
 Treatment of Neonatal Tetanus
Goals of therapy:
 Neutralization of toxin still present in the
blood before it comes in contact with the
CNSantitoxin (human tetanus immune
globulin) or Equine antitoxin
 Penicillin kills the vegetative forms
3. Surgical removal of the site of entry of the
organism
4. General measures: mainly supportive
 Constant and meticulous nursing care
 Control of seizures
5. Close monitoring of fluid, electrolyte and
caloric balance
 Treatment of Neonatal
Tetanus
 Incubator care
 External stimulation kept to a minimum
but suction of pharyngeal secretions
must be done
 NGT feeding best avoided during the
initial 2-3 days (aspiration precaution)
 IVF therapy
 Temporary nutritional support with
dextrose, amino acids and lipids before
onset of gavage feedings
 Periodic change of posture
 Catheterisation for distended bladder
and enemata for constipation
 Q6:
What are the
necessary
Preventive
measures?
Prevention of Neonatal
Tetanus
By a combination of:
2. Improving maternity care with
emphasis on increasing the
immunization coverage of women
of childbearing age esp. pregnant
women with tetanus toxoid
3. Increasing the proportion of
deliveries attended by trained
attendants
Key Learning Points
 Tetanus is a totally preventable
disease. Its occurrence is a
reflection of the failure of health
delivery
 Immunization of pregnant mothers
at least 6 wks before delivery is
the most efficient method of
eliminating neonatal tetanus
 CASE 4:
“The Disease of the
Seventh Day”