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Indian Pediatr 2011;48:
987-988 |
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Tetanus in Pediatric Patients - Predictors
Affecting Mortality and Role of Immunoglobulin |
Mukul Aggarwal, Vikrant Sood and KC Aggarwal
Department of Pediatrics, Vardhamaan Mahavir Medical
College and Safdarjang Hospital,
New Delhi 110 029, India.
Email: [email protected]
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Analysis of pediatric tetanus cases was carried out to study the
predictors of mortality and role of tetanus immunoglobulin (TIG).
Shorter incubation period, onset time and autonomic dysfunction were
significantly associated with mortality and may be used to stratify
patients requiring intensive care. TIG may not have independent role
in decreasing mortality in sick patients.
Key words: Child, Immunoglobulin, Outcome, Tetanus.
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Tetanus is an important cause of preventable mortality and morbidity,
particularly in the developing world [1]. Short incubation period (less
than 7 days), short onset time (less than 3 days), autonomic dysfunction
and cephalic tetanus are known predictors of mortality [2]. Tetanus
immunoglobulin is one of the pillars of management [1]. There is a dearth
of studies on tetanus from developing countries with resource constraint,
especially in pediatric patients. Therefore, this study was planned to
analyze the clinical profile, predictors of mortality and outcome of
patients receiving TIG.
We present a retrospective analysis of 57 pediatric
(<18 years age, excluding neonates) cases (non consecutive) of tetanus.
The diagnosis was established clinically, in patients presenting with
trismus, other rigid muscles and a clear sensorium.
Patients were given supportive therapy (including
diazepam and chlorpromazine), and antimicrobials (crystalline penicillin
200,000 IU/kg/ day in 6 divided doses). Mechanical ventilation was
implemented when necessary. TIG (500 IU stat dose) was given as per the
patient’s affordability. Socio economic status of ≤ class 4 and 5
was considered as low [3]. Autonomic dysfunction included heart rate and
blood pressure abnormalities, diaphoresis etc [4].
The analysis was done between the two groups; the
survival group and mortality group to see the relation between the final
outcome and various possible risk factors (Table I).
TABLE I Analysis of Cases and Comparison Between the Survival and Mortality Groups
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Survival group (n=35) |
Mortality group (n=22) |
P value |
Incubation period (d) |
17.11 ± 21.18 |
8.32 ± 9.38 |
0.025 |
Onset time (h) |
63.89 ± 24.11 |
27.82 ± 12.30 |
0.001 |
Immunization (complete) |
11 (31.4%) |
4 (18.2%) |
0.269 |
Sex – male |
24 (68.6%) |
18 (81.8%) |
0.269 |
Age |
7.9 6 ± 4.59 |
9.32 ± 4.63 |
0.981 |
Drug abuse |
1(2.8%) |
2 (9.0%) |
0.305 |
Socio economic status - low |
28 (80.0%) |
21(95.5%) |
0.102 |
Trismus |
27 (77.1%) |
18 (81.8%) |
0.673 |
Risus sardonicus |
26 (74.3%) |
18 (81.8%) |
0.509 |
Refusal to feed |
20 (57.1%) |
16 (72.7%) |
0.233 |
Ophistotonus |
32 (91.4%) |
18 (81.8%) |
0.282 |
Autonomic dysfunction |
3 (8.6%) |
7 (31.8%) |
0.025 |
Type-generalized |
32 (91.42%) |
18 (81.81%) |
0.282 |
TIG |
24 (68.6%) |
18 (81.8%) |
0.269 |
Mechanical ventilation |
7 (20.0%) |
22 (100%) |
0.001 |
Mean age of the patients was 8.48 ± 4.61 years and
73.7% were males. Tetanus was classified as generalized (87.7%
-statistically insignificant) and localized. Trismus was the presenting
symptom in >3/4th of cases [6] as in our study (78.9 %). Incubation
period, related to the amount of toxin and immunization status of the
patient, averages 2-14 days [1,2]. In our study, mean incubation period in
survival group and mortality group was 17.11 ± 21.18 and 8.32 ±9.38 days,
respectively whereas mean onset period was 63.89 ±24.11 and 27.82 ±12.30
days, respectively. Shorter incubation and onset times are associated with
more severe disease [1, 5]. In our study, both were confirmed as risk
factors for mortality (P= <0.05).
Autonomic instability usually develops few days after
the onset [1,5] in >1/3rd cases [6,7]. However, in
our study, it was found in only 17.5 % cases, but this was statistically
significant risk factor for mortality (P=0.025).
TIG has been an integral part of tetanus management and
may reduce the severity of the illness [1,8]. In the survival group, 24
out of 35 received TIG, as against 18 out of 22 in the mortality group.
This difference was not statistically significant (P=0.269). In the
survival group, the duration of treatment in the survival group had very
poor correlation with incubation period (correlation coefficients ‘r’
– 0.076), onset time (r- 0.079) and age (r- 0.272).
Although mechanical ventilation appeared to be a risk
factor for mortality, this is to be considered as a confounding factor
indicating severity as only the sicker patients were considered for
mechanical ventilation. Recovery period from tetanus is usually long.
Patients’ hospital stay has ranged from 14-28 days [7]. Similarly, in our
study, mean duration of treatment in the survival group was 19.2 ±
10.7days. Country-wise mortalities are 41.0% in India [9] and 18.0% in USA
[10], highlighting the importance of quality of care. The mortality rate
in our study group was 38.6 %, comparable to the Indian data [9].
Contributors: KCA conceived, analyzed and
critically reviewed the paper. MA and VS collected data, analyzed and
interpreted and drafted the article. VS will act as guarantor of the
article.
Funding: None.
Competing interests: None stated.
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