Vol 14, No 2, April – June 2005 Serial cases of tetanus and its complication 117

Secondary pneumonia in tetanus patients: a review of six selected cases

(Case report)

Herdiman T Pohan

Abstrak
Tetanus merupakan infeksi oleh C.tetani yang menjadi masalah kesehatan penting di negara-negara berkembang. Perjalanan
penyakitnya biasanya lama, memerlukan waktu berminggu-minggu atau berbulan-bulan untuk perawatan hingga sembuh. Beberapa
penelitian telah dilakukan untuk menentukan berbagai faktor yang berpengaruh terhadap prognosis tetanus. Faktor tersebut adalah
derajat spasme, usia, sedasi dan takikardia yang berpengaruh signifikan terhadap mortalitas pasien tetanus. Bila pasien tetanus dapat
melewati fase akut penyakitnya, masalah lain timbul seperti disfungsi otonom dan pneumonia nosokomial (sering disebabkan oleh
organisme multiresisten) sebagai penyebab tersering kematian. Laporan kasus berikut menampilkan 6 kasus tetanus, tiga di antaranya
mengalami pneumonia nosokomial, dan dua di antara tiga pasien tersebut geriatri berusia 70 dan 72 tahun meninggal saat di rumah
sakit. (Med J Indones 2005; 14: 117-21)

Abstract
Tetanus, an infection by C.tetani continues to be a major health problem in the developing world. The course of the disease is typically
prolonged, requiring weeks to months of supportive management to resolve. Several studies have been conducted to determine which
factor/s really influenced the outcome of tetanus. Factors such as severity of spasms, age, sedation and tachycardia were found to
significantly influence mortality. Patients now surviving the initial acute phase of their illness, but new problems have emerged
autonomic dysfunction and hospital acquired pneumonia (often with multiresistant organisms) are now the commonest causes of
death. This serial cases report presents six selected cases of tetanus, three patients acquired secondary pneumonia during treatment,
among the three, two patients are elderly age 70 and 72 years old. Both of the presented patients died during treatment in the hospital.
(Med J Indones 2005; 14: 117-21)

Keywords: tetanus, pneumonia complication

Tetanus is caused by a toxin secreted by Clostridium Nowadays much more is known about the tetanus
tetani, a Gram-positive, obligate anaerobic bacillus toxin; its deoxyribonucleic acid has been sequenced
that forms a stable terminal spore.1,2 The spores are and its mechanism of action established. We are
noninvasive, and inoculation usually requires a equipped with antitoxin and a vaccine to prevent the
disruption of the skin barrier by a foreign body. The disease, yet tetanus continues to be a major public
insult to the skin barrier typically follows a deep health problem throughout much of the developing
penetrating wound. The early onset of symptoms (ie, world.3
< 48 h) typically correlates with more severe disease.
In most instances, clinical symptoms occur within 7 to In 2000 only 18,833 cases of tetanus were reported to
14 days after inoculation, although cases also have the World Health Organization worldwide. Seventy
occurred almost 9 months after the injury.1,2 six countries, including many of the countries most at
risk, did not supply data, and the information of those
that did was often incomplete. On the basis of the
WHO data, studies by Stanfield and Galazka, and data
from Vietnam (the hospital admits about 300 patients
Division of Tropical Medicine and Infectious Diseases, with tetanus each year) it is estimated a true global
Department of Internal Medicine, Faculty of Medicine University incidence of 700,000 to 1,000,000 cases per year.3
of Indonesia/Dr. Cipto Mangunkusumo National General Due to tetanus, about 9,8 percent of 184 thousand
Hospital, Jakarta, Indonesia birth in Indonesia faced deaths. In the eighties, tetanus
118 Pohan Med J Indones

became the leading cause of death for Indonesian tetanus. Fifty-three cases of tetanus, 25 females and 28
neonates. Beside tetanus neonatorum, maternal males, were treated in Çukurova University Hospital
tetanus also compulsive to be eliminated.4 during 1994-2000 by multivariate analysis, the time to
mortality caused by tetanus, and also the mortality
The diagnosis of tetanus is based on clinical features.1 rate, were both related significantly to age and
The clinical features of tetanus arise from the action tachycardia.5 Another study on tetanus conducted in
of tetanus toxin, which blocks inhibitory input of Nigeria, records of 114 patients with tetanus aged 16
gamma aminobutyric acid to motor neurones, and above over a ten-year period (1992-2001). Factors
resulting in unchecked motor nerve activity. Muscle such as severity of spasms, age, sedation and
tone is increased. The manifestations of tetanus can be tachycardia were found to significantly influence
either local or general. Generalized tetanus is the most mortality.6 Complications include spasm of the vocal
common form, with the patient presenting with pain, cords and/or spasms of the respiratory muscles that
headache, muscle rigidity (including trismus, risus cause interference with breathing. Other complications
sardonicus, and opisthotonus), generalized spasms, include fractures of the spine or long bones,
and autonomic instability. Trismus is often the hypertension, abnormal heartbeats, coma, generalized
presenting symptom. Progression of the disease may infection, clotting in the blood vessels of the lung,
lead to laryngeal obstruction and a reduction in chest pneumonia, and death. Patients experience severe pain
wall compliance, causing respiratory failure. Respiratory during each spasm. During the spasm, the upper
failure is the most common direct cause of death from airway can be obstructed, or the diaphragm may
tetanus worldwide. Manifestations of autonomic participate in the general muscular contraction.
instability are diverse, including hypertension or Sympathetic overactivity is the major cause of tetanus-
hypotension, diaphoresis, cardiac arrhythmias, and related death in the intensive care unit.7
hypermetabolism. Hypotension and tachycardia com-
plicated the course of the disease in our patient. Prognosis of tetanus also depends on the facilities
Increased urine and plasma catecholamine levels also available. Without mechanical ventilation, asphyxia is
reflect sympathetic overactivity. In contrast, localized the commonest cause of death, resulting from laryngeal
tetanus is less severe, and is characterized by rigidity muscle spasm (and acute airway obstruction), respiratory
and pain confined to the muscles adjacent to the muscle spasm, or extreme fatigue. In places fortunate
wound.2,3 enough to have facilities for ventilation these
problems can be overcome by using sedation and
The course of the disease is typically prolonged, non-depolarising neuromuscualr blocking agents.
requiring weeks to months of supportive management Unfortunately, with patients now surviving the initial
to resolve. The spasms and autonomic instability are acute phase of their illness, new problems have
usually most prominent in the first few weeks, emerged autonomic dysfunction and hospital acquired
peaking near the second week and then resolving. pneumonia (often with multiresistant organisms) are
However, the muscular rigidity may persist for several now the commonest causes of death.3
months. Recognizing the clinical symptoms is
essential in making the diagnosis of tetanus.2
SERIAL CASES REPORTS
Laboratory tests usually are beneficial in riding out
other diseases rather than in confirming tetanus, There are six selected cases of tetanus from 1998 to
Wound cultures, which are positive for C tetani in 2003 in Medistra Hospital Jakarta, that will be
only 30% of documented cases, have limited value. presented in this report. Two of the patients are
The differential diagnosis for an adult includes elderly (age 70 and 72 years old) and the other four
strychnine poisoning, orofacial infection or trauma, are patients in their productive years. The patients
rabies, and drug-induced dystonic reaction.2 demographics, source of infectrion, risk factors/underlying
disease, clinical/laboratory assesments and the
Several studies have been conducted to determined complications that prevails in the course of tetanus are
which factor/s really influenced the outcome of further described in the Table 1, 2, and 3.
Vol 14, No 2, April – June 2005 Serial cases of tetanus and its complication 119

Table 1. Patient demographics data

Sex Age (years) Duration of treatment (days) Presenting signs and symptoms
/ Outcome
Female 72 Died in hospital Trismus, periodic convulsions, stridor
Male 70 Died in hospital Neck spasm, risus sardonicus, trismus,
periodic convulsions, Opistotonus
Male 39 9/Survived Complains of stiffness in the face, neck,
back and abdomen, no abnormalities in
physical examination
Male 47 18/Survived Neck spasm, trismus,risus sardonicus
Male 29 10/Survived Trismus + 2 cm,abdominal mucles rigidity
Male 45 16/Survived Muscular spasms especially in
extremities

Table 2. Source of infection, risk factors/underlying disease

Source of infection Risk Factors / Underlying disease

Laceration in the second right toe -
Laceration in finger, dental focal infection Diabetes mellitus, hypertension
Dental focal infection -
Penetration wound(by nail) in the sole of the foot -
Wound in foot -
Laceration in the fifth left toe, followed by aseptic amputation Ashtma

Table 3. Clinical, laboratory and radiographic data and complications

Clinical, laboratory, radiographic evaluation Complications

3
Respiratory failure, elevated WBC count (30,9x10 /uL), Pneumonia, Urinary tract infection, Renal
bronchoalveolar lavage : Ps aeruginosa, fungal. Blood insufficiency, liver dysfunction, Respiratory
culture : negative failure
Sputum culture: Ps aeruginosa, E coli, Klebsiella
Elevated serum ureum and creatinine (ur 242; cr1,7),
impaired liver function test
(serum albumin 3,3 globulin 3,7 AST 47 ALT 21,
gamma GT 348, phospatase alkaline 154 )

BP151/101mmHg,HR 106x/min, urine glucose (+), Pneumonia (Klebsiella and Candida) with
hypernatremia (147mEq), hyperkalemia (5,3), mild hypertension and diabetes mellitus as underlying
elevation of WBC (10,5 x103/uL), Sputum culture : disease
Klebsiella pneumonia, Candida albicans. Chest X-Ray:
Cardiomegaly
Elevated WBC count(18,9 x 103 /uL) , CXR: mild basal Mild basal pneumonia
pneumonia
All in normal ranges None
All in normal ranges. None
Blood culture: negative
Elevated WBC count (12,5 x 103/uL), CXR: no signs of Ulcer in the fifth left toe amputee
infection. Sputum culture: Staphylococcus hemolyticus
and Pseudomonas stutzeri, Blood culture:negative
120 Pohan Med J Indones

DISCUSSION To determined the complications of tetanus in these

patients other laboratories and radiological examination
The first two patients with tetanus are elderly, age 72 was performed. The results of blood gas analysis in
and 70 years old. Morbidity and mortality are high the first patient showed that the patient had respiratory
among elderly patients with the disease. The case- failure, commencing an assisted ventilatory and
fatality rate increases with age, reaching 50% in respiratory intubation. Further morbidities followed
patients above 60 years of age. Both of the presented the course of illness in the first patient, pneumonia
patients died during treatment in the hospital. Elderly with Ps aeruginosa, E coli and Klebsiella as the
patients account for 75% of the tetanus deaths in the infecting agents (common in hospital acquired
United States.2 Adults aged above 60 years are at pneumonia), urinary tract infection could be elicited
greatest risk for tetanus and tetanus-related mortality. by the used of cathetherization, and renal insufficiency
During 1998--2000, the average annual incidence of with liver dysfunction. The complexities of the
tetanus in persons aged above 60 years was 0.03 with problems highly suggested of MODS (multiple organ
a case-fatality ratio of 31%, both more than twice that dysfunction syndrome) that usually prevails in the
of adults aged less than 60 years. The increased risk course of Sepsis, this patient died possibly cause of
for tetanus with increasing age is thought to be related sepsis and respiratory failure. The second patient had
to the lower prevalence of protective immunity in two underlying disease which became the risk factors
older age groups. Protective levels of antibodies for worse prognosis in the patient, they are diabetes
against tetanus toxoid decline with age; by age 70 mellitus and hypertension. Diabetes contributes to
years, only 30% of the population is protected. Older immunocompromised status in the patient, predisposing
persons might never have received a primary the patient for secondary infection. In the second
vaccination series or might not have received tetanus patient, the complication is Klebsiella pneumonia
subsequent Tetanus toxoid boosters.8 coinfection with candida albicans (diagnosis was
confirmed from sputum culture). The patient during
Source of tetanus infection in the patients are easily treatment was still in uncontrolled hypertension, the
recognized, lacerations or wounds located in the intense pain from opistotonus could raised the tension,
extremities, and two patients with focal infection from beside the lack of proper management. The cause of
the teeth. This data is similar with other reports on death in the patient is unknown, one of the possible
tetanus. The source of infection is usually from a cause of death is cardiac arrest cause of autonomic
wound (about 65%), which often is minor (eg, wood instability in tetanus patient. The third patient at
or metal splinters, thorns). Chronic skin ulcers are the admission presented with complains of stiffness with
source in approximately 5% of cases, and in the minor injury suggesting the diagnosis of tetanus, no
remainder of cases, no obvious source is identified. physical signs of tetanus that could impair the
The US Centers for Disease Control and Prevention outcome of illness. During treatment the patient had
(CDC) statistics from 1982-84 are as follows:7 infected mild basal pneumonia. Patient number 4 and 5 have
lacerations or puncture wounds (69%), infected no complications, but the course of the disease caused
chronic wounds and abscesses (20%), exposure via longer length of stay in the hospital. Patient number 6
intravenous drug abuse (3%), neonates (1%), other or with leucocytosis presumed to be from the healing
no identifiable cause (7%). process of his left toe amputee, there was a history of
aseptic amputation after a recent laceration in the fifth
The presenting sign in most of the patients typically left toe. Allthough the sputum culture is positive for
presented as clinical features of tetanus, except for Staphylococcus hemolyticus and Pseudomonas stutzeri,
one patient (number 3) with complains of stiffness in but no clinical signs or symptoms and radiologic
the face, neck and back but no signs of muscular finding confirm the diagnosis of pneumonia. The
spasms or rigidity in those areas from physical result of the culture could very well be contaminants
examination. The mode of clinical signs are as from taking the sputum sample.
trismus/lock jaw (occurred in 4 of the patients), it
appears that convulsions occurred more frequently in Why pneumonia become a frequent secondary infection
the elderly patients while muscular spasms and in tetanus patient? The proposed pathopyhisiology is
rigidity highlighted the clinical pictures in younger ensuing muscle rigidity and poor chest movements
patients. Opistotonus only occurs in patient number 2. lead to the abolition of protective reflexes such as
Risus sardonicus appeared in two of the patients swallowing and coughing. This predisposes patients
(number 2 and 4). to pulmonary infections which threaten life maximally
Vol 14, No 2, April – June 2005 Serial cases of tetanus and its complication 121

towards the end of the second week, when the severity duration of stay in the hospital. We suggested further
of tetanus has just passed its peak. A study in India in studies on this issue to gain more evidence and thorough
1986 tries to determined phagocytic and chemotactic understanding towards the emergence and treatment of
function of human polymorphonuclear cells during secondary pneumonia in tetanus patients.
tetanus infection. Phagocytosis on the day of
admission was found to be half of the control values,
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