Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 26 (2014) 68–72
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Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology
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linical observation
etanus: An unusual finding in dental practice
ernando Antoninia,∗, Fábio Augusto Coelho de Oliveiraa, Leandro Eduardo Klüppelb,elson João da Costaa, Nelson Luis Barbosa Rebellatoa, Paulo Roberto Müllera
Oral and Maxillofacial Surgery Department, Parana Federal University, Hospital XV – Cirurgia Buco-Maxilo-Facial, Rua XV de Novembro, 2223, CEP 80045-125, Curitiba, Paraná,razilOral and Maxillofacial Surgery Department, Ponta Grossa State University, Ponta Grossa, Brazil
r t i c l e i n f o
rticle history:eceived 15 October 2012eceived in revised form 2 May 2013ccepted 18 June 2013vailable online 31 July 2013
a b s t r a c t
Tetanus is an infectious non-contagious disease caused by the bacillus Clostridium tetani, which entersthe body through open wounds. Psychomotor dysfunction enables accidents among the elderly and vac-cination coverage is low in this year range, hence contributing to high mortality rate. The aim of this paperis to show a case of tetanus in a geriatric patient referred for an oral and maxillofacial surgery practice.
eywords:etanusound infection
accination
The patient presented signs and symptoms of the disease in the maxillofacial and neck regions, such astrismus and muscle spasms in the masticatory musculature, neck muscles and diaphragm. Symptomsshortly progressed to severe dysphagia and respiratory failure. Treatment involved intravenous antibi-otics, tetanus immunoglobulin and muscle relaxant. The patient was discharged from the hospital after26 days in a satisfactory condition.
Tetanus is defined by many authors as an infectious non-ontagious disease caused by the bacillus Clostridium tetani, whichnters the body through open wounds [1,2]. It is commonly dividednto acute and chronic, according to whether the incubation period,s 7–10 days or more than 10 days [3]. This arbitrary division affordsconvenient method of estimating the probable severity and mor-
ality of the disease in a majority of instances. Another criterionf the severity of tetanus is afforded by the extent and rate ofevelopment of the symptoms after the appearance of first stiff-ess of muscles, but this evidence is obviously not available at thenset of the disease. The way in which the bacillus gain entry intohe body is also important to presume the severity of tetanus [4].ontamination through wounds are more complicated because theoxin is not received all at once, but is absorbed gradually as fasts produced. The rate of production depends in turn both on the
mount of organisms introduced and on whether they find favor-ble or unfavorable conditions of growth. Conditions of growth maye favorable at once after the receipt of the wound, as in a deep
� AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asianociety of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-gy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japaneseociety of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.∗ Corresponding author. Tel.: +55 41 98151628.
puncture, or extensive laceration, or multiplication of the orga-nisms may begin only after several days or weeks have elapced[5]. The World Health Organization (WHO) reports that the exo-toxin released by these bacillus causes a hyperexcitability state ofthe central nervous system which is clinically manifested by lowor absent fever, muscle hypertonia in masticatory, neck and phar-ynx muscles, causing symptoms such as trismus, neck stiffness anddysphagia. Furthermore, it normally causes generalized and pro-gressive muscle contracture of lower and upper member muscles,recto-abdominal muscles, paravertebral muscles and diaphragm,hence leading to respiratory failure. Moreover, hyperreflexia, mus-cle spasms orparoxystic contractures caused by different stimulisuch as sounds, light, injections or even touching or handling mayoccur; however, the patient normally remains conscious and lucid.
As the etiological agent, tetanus is caused by a Gram-positiveanaerobic bacillus (C. tetani), morphologically similar to a pinhead with 4–10 �m in length. It is commonly found in soil, feces,water rotting, rusty metal objects and dust, although it may be alsoencountered in the skin or gastrointestinal tract of humans withoutcausing a disease, usually in the spore form, which allows long sur-vival in the environment. There is no direct or indirect transmission.The infection occurs when the spores of the bacillus gain access toa blood vessel through a superficial or deep open wound in skin ormucosa. In favorable condition, the spores transform into vegeta-
tive forms that are responsible for tetanus toxins (tetanospasmins)release [3,4]. This toxin bonds to peripheral nervous endings andmigrates to the central nervous system and then inhibit the releaseof inhibitory neurotransmitters from presynaptic membranes
I. Published by Elsevier Ltd. All rights reserved.�
ial Surgery, Medicine, and Pathology 26 (2014) 68–72 69
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F. Antonini et al. / Journal of Oral and Maxillofac
nhibitory neurons of the spinal cord and brainstem in mammals,hich catalyzes the proteolytic cleavage of the synaptic mem-
rane protein of secretory vesicles—synaptobrevin—resulting inn increase in the excitability causing continuous and muscleontractions and intermittent spasms that are observed mainly inhe masticatory and neck muscles [4].
The incubation period is the period required by the spore toerminate, produce, release toxins and allow these toxins to reachhe central nervous system and is clinically defined by the intervaletween the injury and first appearance of symptoms. It varies fromday to several months, but is commonly 3–21 days [3], although
n uncommon occasions incubation periods of up to 3 months haveeen reported [5]. In the majority of cases, the incubation periodxpresses a fair degree of the severity of the disease, although somelements such as conditions in the wound, extent of surface injured,r amount of infection introduced may vary from the usual to suchn extent that symptoms appear 4 or 5 days after an injury, butevelop slowly, so that the course of the disease is relatively mild.n the other hand, the production of tetanospasmin may be delayed
or a number of days, and then proceed rapidly so that a fulminantisease develops after a long incubation period. If toxin is producedlowly in small amounts, time is afforded for the production of anti-oxin by the host, and this probably has a part in the spontaneousecovery from the disease.
Psychomotor dysfunction caused by tetanus facilitates accidentsmong the elderly and vaccination coverage is low in this popula-ion contributing to high mortality rate among them. Moreover, theinear decrease of serum tetanus antitoxin with advancing age andhe negligence in booster doses of anti-tetanic vaccine, as well asmmunosenescence [6], which refers to the gradual deteriorationf the immune system brought on by natural age advancement canontribute to the occurrence of tetanus in the elderly [6–8].
Currently, tetanus is a rare disease in developed countries. How-ver, it remains a major cause of death worldwide and is associatedith a high mortality rate, especially in non-developed or devel-
ping regions [9]. According to the World Health Organization,n estimated 400,000 cases of tetanus still occur each year, withhigher prevalence for neonatal tetanus [10]. Fortunately, this
isease is successfully controlled through immunization. Due tohe high success rate obtained through immunization programs,etanus has been virtually eradicated in developed countries. Spo-adic cases, however, still occur. Hence, due to this eradication,linicians are not familiar with tetanus, which can delay diagnosis.urthermore, some physicians still believe that tetanus does notccur in a patient who has previously been vaccinated. A history ofrevious immunization should not dissuade a physician to make aiagnosis of tetanus. Even though the amount of anti-tetanus to be
n an acceptable level, one cannot rule out the condition [4]. Despitehe current focus on developed countries, mortality remains at 50%n patients older than 60 years old, which is the highest risk groupo contract the disease [11].
This paper reports a case of tetanus in a 76 years old patientfter burn injury in skin and mucosa by fireworks who presentedlassic signs and symptoms of tetanus infection and was suc-essfully treated by debridement of the wound, medications anddministration of tetanus human immunoglobulin after patientospitalization.
. Case report
A 76-year-old male patient was admitted in a hospital in
uritiba, Brazil, referring burn by fireworks in the groin and genitalrgans on a 15 days history. As the patient referred onset of severerismus and spasms in facial, jaw and neck muscles causing pain andimitation of neck function (Figs. 1 and 2) that had initiated 7 days
Fig. 1. Trismus and muscle spasms in the masticatory and neck musculature.
after the injury, the patient was referred to the oral and maxillofa-cial department for further examination. Also, the patient reporteddysphagia, which started 10 days after the injury and graduallyprogressed. Spasms in other muscles were not reported. Duringphysical examination the patient attempted to protect from light,featuring photofobia. The patient was asked about immunizationof tetanus for the last 10 years and denied anti-tetanus vaccina-tion throughout the previous 10 years period. Blood was collectedfor lab exams and showed CBC values within normal range. Dis-crete leukocytosis was present, showing a very mild increase inthe WBC value (11,000/mm3). Based on the patient and injury his-tory as well as all signs and symptoms presented, the physician andthe infectologist opted for hospitalization of the patient and treat-ment focused on tetanus infection. The patient received a singledose of 5000 IU of tetanus human immunoglobulin intramuscu-larly, parenteral hydration with dextrose 10% 1000 ml every 12 h byintravenous access and antibiotic therapy (Metronidazole 500 mgevery 8 h intravenously) for 12 days. In addition muscle relaxantwas obtained with the use of Diazepam 10 mg every 12 h, alsointravenously. Injured tissue was collected for aerobic and anaer-obic culture. No bacterial growth was obtained for aerobic culture.Antibiogram tests were also conducted to establish bacteriologicprofile. Debridement of the wound was then performed. The patientcondition became worse as progressive diaphragm contractionsbecame more frequent and more severe, causing respiratory failure.The patient was immediately transferred to the intensive care unit(ICU) and tracheostomy was promptly performed for patient venti-lation. Moreover, the patient developed pneumonia during patient
assisted mechanical ventilation. The antibiotic regimen changedto Ceftrixone (Rocephin) 2 g I.V. once a day for 10 days and Van-comycin 1 g I.V. every 12 h for 7 days. The patient condition then
70 F. Antonini et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 26 (2014) 68–72
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Fig. 2. Limitation of neck mobility and mouth opening.
rogressed satisfactorily and hospital discharged was allowed after6 days of hospitalization without complaints of trismus, spasms,
ysphagia or photophobia (Figs. 3 and 4). Laboratory exams forBC and leukogram were obtained throughout the hospitalizationourse and show all values within normal range for all exams per-ormed. Final WBC count was 7500/mm3. Table 1 shows the main
able 1vents, clinical condition of the patient, treatments performed, laboratory findings, micro
Day Day 0 Day 7 Day 10 Day 15
Events Burn Hospital admission
Patient clinicalcondition
Moderate trismusand face/neckmuscle spasms
DisphagiaPhotofobia
Severe trismus andface/neck musclespasms (cervicalrigidity) +disphagia
Treatments Muscle relaxantmedication
Protection fromlight; Wounddebridement;5000 IU of tetanusimmunoglobulinIM; parenteralhydration;antibiotics(Metronidazole);muscle relaxant(Diazepam)
Laboratory Findings WBC = 11,000/mm3
Microbiologicalexaminations
Anaerobic culture
Diagnosis Tetanus infection
Fig. 3. Patient immediately after hospital discharge. No complaints of trismus,spasms, limitation of neck function, dysphagia or photophobia.
events, patient clinical conditions, treatments performed, microbi-ological examination and laboratory findings throughout the entirecourse of the disease. After 18 months of outpatient treatment,
patient follow-up shows no signs of the disease and/or patientcomplaints. The case was notified to Brazilian health authoritiesfor epidemiologic and statistic purposes.
biological tests and diagnosis throughout the course of the disease.
Day 21 Day 28 Day 35 Day 41
ICU admission Patient under ICU Hospitaldischarge
Patient conditionworsened day byday, causingrespiratory failure;Pneumonia
Very mild trismus;No muscle spasms;Normal respiration
Tracheostomy (5thhospital day)Mild IV sedation(propofol)Ceftriaxone(Rosephin)2g + vancomycin1 g IV
Mechanicalventilation + IVsedationMuscle relaxant(Diazepan)Ceftriaxone(Rocephin)2g + vancomycin1 g IV
Ceftriaxone(Rocephin) 2 g IV –until 31st dayMuscle relaxant(diazepam)
WBC = 7500/mm3
F. Antonini et al. / Journal of Oral and Maxillofacial Sur
Fig. 4. Patient immediately after hospital discharge showing normal mouth open-i
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for the treatment of tetanus. The immunity conferred by vaccina-tion is not permanent and should be boostered every 5–10 years.
ng.
. Discussion
All the above mentioned involuntary reactions caused byetanus infection are a consequence of the action of the tetanusoxin named tetanospasmin. It is an extremely potent neurotoxinroduced and released by the vegetative cell of C. tetani in anaerobiconditions. It is also called spasmogenic toxin, abbreviated to TeTxr TeNT. The LD50 of this toxin has been measured to be approxi-ately 1 mg/kg, making it second only to botulinum toxin D as the
eadliest toxin in the world. Tetanus toxin spreads through tissuepaces into the lymphatic and vascular systems. It reaches the ner-ous system at the neuromuscular junction and migrates througherve trunks and into the central nerve system (CNS) by retrogradexonal transport by using motor proteins named dyneins. The A-hain present in the tetanospasmin structure acts by stopping theffected neurons from releasing the inhibitory neurotransmittersABA (gamma-aminobutyric acid) and glycine, but also excitatory
ransmitters, by degrading the protein synaptobrevin [2]. The con-equence of this is dangerous over-activity in the muscles fromhe smallest stimulus, which means a failure of inhibition of motoreflexes by sensory stimulation; hence causing generalized andontinuous contractions of the agonist and antagonist musculature,ermed as tetanic spasm [10,11]. The toxin bind to the neuronss irreversible and the nerve function can only be returned byrowth of new terminals and synapses [11]. Furthermore, due to itsxtreme potency, even a lethal dose of tetanospasmin may be insuf-cient to provoke an immune response. Naturally-acquire tetanus
nfections thus do not provide immunity to subsequent infections.
mmunization (which is impermanent and must be repeated peri-dically) instead utilizes the less deadly toxoid derived from the
gery, Medicine, and Pathology 26 (2014) 68–72 71
toxin, as in the tetanus vaccine and some combination vaccinessuch as DPT.
Tetanic spasms can occur in a distinctive form calledopisthotonos and be sufficiently severe to fracture long bones. Theshorter the nerves are the first to be inhibited, which leads to thecharacteristic early symptoms in the face and jaw such as trismus(lockjaw) and abnormal and sustained spasms of the facial and neckmuscles.
The diagnosis of tetanus is mainly clinical, based on patient andinjury history as well as clinical signs and symptoms, and doesnot depend on laboratory exam confirmation [3]. In the reportedcase, the patient had initial complaint of severe trismus and spasmsin the face, jaw and neck muscles, which was deeply investigatedby the oral surgeon in association with the physician. Laboratorydata was within the normal range values, except for a very discreteleukocytosis. Investigation of all signs encountered and symptomsreported, as well as the injury history and patient immunizationhistory suggested contamination by the bacillus C. tetani throughopen wounds in groin skin and genital mucosa. Moreover, thepatient sought treatment 15 days after injury and onset of the signsand symptoms, which agrees to the incubation period for this typeof infection. As mentioned before, the incubation period for thetoxin to reach the CNS varies from 3 to 21 days.
The mortality rate is quite high, especially in the extreme agegroups (elderly) [12–14]. Between 1991 and 1994 there were 201cases of tetanus reported to the National Notifiable Disease Surveil-lance System [15]. More than 50% of cases occurred in elderlypatients and 5% in the population aged under 20 years. All deathsoccurred in people over 30 years. The mortality ranged from 11% inpeople 30–49 years to 54% in those older than 80 years [16]. Thirtyto fifty cases of tetanus are reported each year in the United King-dom, with a higher prevalence among the elderly. In addition, 50%of all deaths reported occurred in patients over 60 years of age [17].As well, Heath et al. [7] reported an age shit in tetanus susceptibil-ity in Australia. Since 1980, 80% of all reported cases of tetanus and90% of deaths from tetanus were reported in patients over 50 yearsof age.
Following a similar epidemiologic pattern, tetanus was alsomore frequent in the elderly in Brazil [19–21]. Meneghel [22] alsoreported an increased incidence of tetanus in older patients in thesouthern region of Brazil. According to Moraes and Pedroso [23],Brazil lacks trustful epidemiological data on tetanus age distri-bution and only neonatal tetanus are usually reported to healthauthorities. Therefore, the authors emphasize the relevance ofthis report as the case mentioned in this paper was reported tolocal health authorities and encourage this type of action by otherauthors and doctors for statistics purposes.
The World Health Organization (WHO) chronologically classi-fies as elderly people over 65 years of age in developed countriesand over 60 years of age in developing countries. In the past, theevaluation of antitetanic serum and human tetanus immunoglobu-lin in developed tetanus, a disease which presents so many variablefactors influencing the prognosis, was a matter of considerable dif-ficulty; and many experienced clinicians have doubted whetherthe results obtained from its use have been any better than thosefrom symptomatic treatment. A study of the statistics of mortalityof many hospitals shows that too often this skepticism has beenwell founded. Opposed to this pessimistic view are the reportsin which the evidence seems strong that antitoxin deserved largecredit for the recovery of some of the patients. It is now well docu-mented that antitetanic serum is indicated for tetanus preventionand treatment. Tetanus human immunoglobulin is also indicated
Moreover, the disease does not confer immunity. The immunityconferred by antitetanic serum lasts up to 14 days, but only a week
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n average. The immunity conferred by human immunoglobulinasts 2–4 weeks, but only 14 days in average [3]. As well, the pro-hylactic value of tetanus antitoxin is established, and needs norgument for its support. That tetanus antitoxin properly used mayave the life of a patient in whom tetanus has already developedhould be more generally recognized, and the treatment employedn every case at the earliest moment possible. Every hour lost beforehe giving of the antitoxin decreases the chance of saving life. Byo means every case will recover but certainly more can be savedhan have been in the past 5 years, and there is every reason tonticipate that with a proper use of antitoxin a mortality consider-bly lower than the present will be obtained. It is important thathe full effect of the antitoxin should be obtained immediately andhis may be accomplished by giving 3000–5000 units at the earliestossible moment after symptoms of tetanus appear. Some otheruthors [10,14] suggest to repeat doses on the second, third andourth day, but it is doubtful whether the enormous doses givenn some cases over periods of many days are any more effectivehan the more limited dosage outlined above by which the max-mum concentration of antitoxin in the body is attained at once.his use of antitoxin in no respect replaces other necessary rec-gnized non-specific methods of treatment in tetanus. In the caseeported the patient had no clinical immunization against tetanusor the past 10 years and immunity was conferred by an intra-
uscular injection of tetanus human immunoglobulin in a singleose. Although antitetanic serum and human immunoglobulin con-er immunization for a relatively shot period, it seems to decreasehe mortality rate in tetanus cases. An ancient research study byrons in 1914 have reported that the mortality rate could be 20%ower in cases receiving serum than in those cases treated withouterum. Many other studies have corroborated with these resultsnd have indicated antitetanic serum and/or human immunoglob-lin as an important step in tetanus treatment [9,11,18]. Accordingo the Brazilian Health Organization (2005), 3 basic principles ofetanus treatment are: sedation of the patient and muscle relax-tion through the use of benzodiazepines and, neutralization ofetanus toxin through early administration of antitetanic serum oruman tetanus immunoglobulin and debridement of devitalizedissue in and around the suspect wound as well as removal of anyoreign body. Surgical treatment of the site of infection should benstituted at once. The patient should be placed at rest in bed inquiet darkened room, and should receive sufficient sedatives to
ontrol convulsions, together with adequate supply of fluid nour-shment, and attention to the elimination by kidney and bowel. Theondition of the patient should be carefully watched, and a revi-ion of the standing orders for sedatives made whenever symptomsuggest the decrease or increase of dose. All these procedures werehoroughly performed in the reported case to achieve a satisfactoryutcome.
. Conclusions
Although tetanus is fortunately a rare disease in developedountries nowadays, and is entirely preventable by vaccination, itemains a serious health problem in developing or non-developedegions. Many cases are reported each year in the elderly
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gery, Medicine, and Pathology 26 (2014) 68–72
population, especially those who have never been vaccinated ordoes not booster the tetanus vaccine every 5–10 years. Mortalityis high in these cases unless it is properly treated. The main ther-apeutic challenges are in control of muscle stiffness and spasms,particularly in the neck, jaw and diaphragm, as these symptomscan cause severe dysphagia and even respiratory failure. Return tonormal functions can be expected for those who survive tetanusas such case reported above.
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