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"Emergency medicine" 8 (55) 2013

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Tetanus: Insidiousness and Rational Therapy. Clinical Case of Successful Treatment

Authors: Lysenko V.I., Golyanischev M.A. - Kharkiv Medical Academy of Postgraduate Education; Karamushko I.V. - Municipal Health Care Institution « Kharkiv City Clinical Hospital № 2», Kharkiv, Ukraine

Sections: Clinical researches

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Tetanus is a toxicoinfectious disease caused by the exotoxin produced by an anaerobic Gram-positive bacterium Clostridium tetani and which mainly results in the hyperactivity of the skeletal muscles. The characteristic features of this disease are: the high level of lethality (in Ukraine up to 80%), general sensitivity, low morbidity, long rehabilitation. These are the features of the tetanus that pointed out the importance of the experience exchange and the need of writing an article in the Clinical case format.

Nowadays, the most legitimate scheme of prevention, diagnostics and treatment of tetanus in Ukraine is the public Order from the Health Ministry of Ukraine N 198 from 05.08.99 "About the improvement of the prevention, diagnostics and treatment of tetanus". In order to update the knowledge and as an addition, the main points of the modern diagnostics and treatments of this pathology are given below.

Patients have an anamnesis of damage of the integuments. The trismus, as well as the hypertone of the neck muscles and spasms of the trunk muscles is observed. Specific immunotherapy using one of the following medicines is obligatory: human anti-tetanus immunoglobulin (HATIG) or equine immunoglobulin (anti-tetanus serum; ATS). The effective reduction of the skeletal muscles hyperactivity is very important: diazepam, midazolam, morphine, atracurium, vecuronium etc. The antibacterial therapy is prescribed in all cases: metronidazole, cephalosporin, and such alternatives as clindamycin, erythromycin, tetracycline. The following procedures take place: the correction of haemodynamics, water-electrolytic and acid-base balances. Autonomic dysfunctions are suppressed: esmolol, atropine. Measures of the respiratory therapy are held at all stages of the illness. The preventive measures and treatment of any complications caused by the tetanus are carried out. The individual approach of all the therapy, medical diet and protective regimen are applied.

In June 2013 at the Acute Poisoning Department of the Kharkiv municipal clinic №2 the positive result of the treatment of a patient diagnosed with «The wound generalized tetanus, medium-severe current»  was achieved. The patient, B., a 62-year old female was hospitalized with the diagnosis: Tetanus? Allergic reaction on Tetanus Antitoxin. High blood pressure illness. At arrival: the condition of moderate severity, complaints about weakness, face swelling, ptosis, pain and convulsive twitchings in the right leg.

The incubatory period lasted 11 days which corresponds to a lethality of 75-50% and a moderate severity of tetanus.  The hospitalization took place on the second day of the developed clinical manifestations stage which corresponded to the 13th day of the exotoxin distribution from the inoculation area (the right plantar area). The serious condition of diagnosis instability remained for ten days from the 5th to the 12th day and only by the 13th day of the treatment the positive dynamics of the patient's condition was achieved. 8 days were required for the securing of the positive dynamics of the condition. After that, on the 20th day after the hospitalization, the patient was transferred to the specialized neurologic department for her rehabilitation.

During the analysis of the dynamics of the values of the arterial pressure and pulse rate the concordance of the dynamics of these parameters and the health condition of the patient was revealed.  Diuresis was normal throughout the entire period of treatment.  From the 10th day the decrease of the volumes of the infusional therapy took place, while the diuresis was kept at normal values.

The data of the electrocardiography was constant. Only on the 7th day of the treatment the negative dynamics was noted, the electrocardiographic signs were eliminated 5 days later without any specific cardiotropic therapy required. The body temperature exceeded the norm twice during the whole period of treatment – to the values of 37,0 °C. Leukocytosis, a stab alteration to the left, and hyperazotemia weren't revealed.

Thus, the disease progression should be qualified as typical: the wound way of infection, elderly age, the incubatory period of 11 days, the first symptom – a trizm, noted electrophysiological signs of the cardiotropic influence of the exotoxin.

The mutual relation of the clinical course changes of the disease and the applied treatment causes the unconditional interest. The immediate introduction of an anti-toxic medicine was executed upon the termination of the first days of the treatment with a dose of 150 000 ME and didn't cause any deterioration of the patient's condition. The antimicrobic therapy consisted of ciprofloxacin and penicillin, while the prescription of penicillin with a dose of 6 million units per day coincided with the first day of the deterioration of the patient' condition (likely as the result of the increase of the extra microbic fraction of the exotoxin). The treatment of the hyperactivity of skeletal muscles was carried out by the introduction the diazepam, promedol and mydocalm. The medicine was introduced since the date of the arrival of the patient. The entire period of the treatment the patient was conscious, focused, able to handle the available volume of movements. The maximum dose of the diazepam per day constisted of 120 mg, the maximum dose of the promedol was 100 mg. The greatest capacity of the anticonvulsant therapy was introduced on the 4-6th day of the treatment that corresponds with the aggravation both clinical and instrumental symptoms of the disease. Since the 9th day of the treatment the patient started receiving mydocalm with a dose of 100 mg. As a result, out of 21 days of the treatment the patient received diazepam for 16 days, promedol for 10 days, mydocalm for 7 days. From day 1 till day 15 of the treatment the patient was receiving furosemide which is one of the reasons for the steadily sufficient volume of diuresis.

Thus, the positive outcome of the treatment of tetanus in this specific clinical case  was most likely caused by a number of the following factors: from the first day of the infection the patient received an antibiotic (from the anamnesis at a pre-hospital stage); Serum antitetanicum equinum purificatum concentratum liquidum is introduced in the shortest terms; the multimodal treatment of the hyperactivity of skeletal muscles was provided; the bactericidal medicine to which Cl.Tetani is highly sensitive was introduced; maintaining the patient in "zero" level of water balance; the continuity and the high level of the professionalism of the medical staff.

The factors which aggravated the prognosis are the following: the choice of the antimicrobic medicine with proconvulsive properties (penicillin), the age factor and the accompanying pathology, the lack of opportunity to remove the spot of the introduction of the Cl.Tetani (full healing of the trauma zone) at a hospital stage.

The given clinical case of the successful treatment of tetanus shows the opportunity for the timely and modern level the specialized aid to the patients of this profile even under the hard conditions of the organization of the national medicine.

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