Autonomic nervous system dysfunction predicts poor prognosis in patients with mild to moderate tetanus

Abstract

BackgroundAutonomic nervous system (ANS) dysfunction is present in up to one third of patients with tetanus. The prognostic value of ANS dysfunction is known in severe tetanus but its value is not well established in mild to moderate tetanus.MethodsMedical records of all patients admitted with tetanus at two academic tertiary care centers in Karachi, Pakistan were reviewed. The demographic, clinical and laboratory data was recorded and analyzed. ANS dysfunction was defined as presence of labile or persistent hypertension or hypotension and sinus tachycardia, tachyarrythmia or bradycardia on EKG. Patients were divided into two groups based on presence of ANS dysfunction (ANS group and non ANS group). Tetanus severity was classified on the basis of Ablett criteria.ResultsNinety six (64 males; 32 females) patients were admitted with the diagnosis over a period of 10 years. ANS group had 31 (32%) patients while non ANS group comprised of 65 (68%) patients. Both groups matched for age, gender, symptom severity, use of tetanus immunoglobulin and antibiotics. Twelve patients in ANS group had mild to moderate tetanus (Ablett I and II) and 19 patients had severe/very severe tetanus (Ablett III and IV). Fifteen (50%) patients in ANS group required ventilation as compared to 28 (45%) in non-ANS group (p = 0.09). Fourteen (47%) patients died in ANS group as compared to 10 (15%) in non ANS group (p= 0.002). Out of those 14 patients died in ANS group, six patients had mild to moderate tetanus and eight patients had severe/ very severe tetanus. Major cause of death was cardiac arrhythmias (13/14; 93%) in ANS group and respiratory arrest (7/10; 70%) in non ANS group. Ten (33%) patients had complete recovery in ANS group while in non ANS group 35(48%) patients had complete recovery (p= 0.05).ConclusionsANS dysfunction was present in one third of our tetanus population. 40% patients with ANS dysfunction had only mild to moderate tetanus. ANS dysfunction, irrespective of the need of mechanical ventilation or severity of tetanus, predicted poor outcome.

Tetanus in adults: Clinical presentation, treatment and predictors of mortality in a tertiary hospital in Ethiopia

“…This might be due to increased agricultural activities during this period in our area. The commonest clinical manifestations were: lockjaw (100%), generalized rigidity (92.6%) and spasm (91.2%) and dysphagia (82.4%) which is similar to other studies [10,12,16,17,19,22,24]. None of the patients had primary immunization and of the patients with recent trauma (n =49, 72.1%) only 10 (20.4%) sought medical care and none of these received tetanus (equine) antitoxin (human tetanus immune globulin was not available).…”

“…Most patients (75%) had one or more complication(s) identified and the common complications include: dysautonomia (58.8%), aspiration pneumonia (44.1%), hypoxemia (41.2%) and generalized sepsis (25%). Dysautonomia was more frequent in our cases compared to other studies [22,24] which was 29% and 32%, respectively. Hypokalemia which required potassium chloride replacement therapy was identified in 13 of 55 cases with potassium level determination (23.6%).…”

“…The percentage of patients with no clinically identifiable portal of entry, which was 10.3% in our cases, varied from as low as 4.7%-18.2% [8,12,[14][15][16][17] and as high as 36.6%-49% in other studies [9,24].…”

“…Lack of clean delivery is an important risk factor for neonatal tetanus. Tetanus is a severe disease associated with a high mortality which varies from 15% to 72.2% [3,4,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] depending on the available treatment facilities. Treating tetanus patients in intensive care unit (ICU) improves the survival rate [23].…”

Maternal and Neonatal Tetanus

“…33,37,38,40,42 Autonomic dysfunction also predicts high mortality, especially if it manifests early in the disease course. 38,61 The risk of death is highest for very young and very old patients. Neonatal tetanus mortality approached 100% in community-based surveys in the 1980s, 2,37 but is now 10-60% with hospital care.…”