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Letters to the Editor Indian Pediatrics 2003; 40:176-177 |
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Intrathecal Immunoglobulin in Tetanus |
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1. The authors have not classified their cases with regard to the severity of tetanus. Various classifications are available to grade the severity of tetanus including the modified Patel and Joag classification(2). It appears that the authors may have had more number of cases with mild tetanus. This may explain the low mortality, the fact that ventilatory support was required only in 3 cases (out of 41) and the short median period of hospital stay. 2. Though the authors have studied factors like short incubation period, period of onset less than 3 days, fever at onset and generalized disease in relation to morbidity, mortality and duration of hospital stay; other factors like autonomic imbalances, frequency and duration of spasms and the mode of acquisition of tetanus have not been adequately elaborated upon. 3. The authors have cited our study(3) and compared the morbidity, mortality, dose of muscle relaxants, requirement for mechanical ventilation and duration of hospital stay with our study. We had only 3 cases with mild tetanus and 37 cases having moderate to severe tetanus. More number of moderate to severe cases of tetanus may explain the higher need for mechanical ventilation and high doses of sedatives and muscle relaxants required in our study. In our study, factors significantly increasing the mortality included mechanical ventilation, tracheostomy, autonomic instability, period of onset <48 hours and duration of spasms >3 days. Patients with severe grade of tetanus had higher mortality in our study(3). Menon, et al.(1) have not clearly classified the severity of tetanus in their study population. Hence, the outcome of their study cannot be compared to that of ours. 4. There is no control group (patients receiving intravenous tetanus immuno-globulin) in the study by Menon, et al.(1) and hence the superiority of using intrathecal tetanus immunoglobulin remains questionable. We had presented data on 40 patients in our previous study(3). Presently, we have data for 80 cases of tetanus (mean age: 4.07 years) studied over a period of 3 years and 9 month. We wish to present the same in brief here (Table 1). Out of the 80 cases, 11 had mild grade tetanus, 56 had moderate tetanus and 13 had severe tetanus as per the modified Patel and Joag classification(2). Sixty seven cases (83.75%) were unimmunized, 10 cases (12.5%) were incompletely immunized and only 3 cases (3.75%) were fully immunized. The mean duration of hospital stay was 19.6 days (range: 0.5 to 56 days). Twenty five patients (31.3%) died. Age, sex, incubation period and presence of lower respiratory tract infection did not affect the mortality significantly. Increasing severity of the disease, post-injury tetanus, period of onset <48 hours, duration of spasms >3 days, endotracheal intubation/tracheostomy and mechanical ventilation and autonomic imbalances adversely affected the survival(3). Table 1–Factors Significantly Affecting Mortality in Tetanus
The authors of the present study(1) may analyze factors like grade of severity, mode of acquiring tetanus, duration of spasms and autonomic imbalances in their study population. This may be immensely valuable in increasing the current literature on tetanus. A randomized controlled clinical trial using intrathecal immmnogiobulin may help to determine the utility of this mode of treatment. Acknowledgement The authors thank Dr N.A. Kshirsagar, Dean, Seth G.S. Medical College & K.E.M. Hospital for granting permission to send this letter for publication. Milind S. Tullu, | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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References | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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1. Menon J, Mathews L. Intrathecal immunoglobulin in the treatment of tetanus. Indian Pediatr 2002; 39: 654-657. 2. Patel JC, Joag GG. Grading of tetanus to evaluate prognosis. Indian J Med Sci 1959; 13: 834-840.
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