Local tetanus

Kretzschmar R, Meyer HJ, Teschendorf HJ, Zollner B (1969). [Antagonistic action of natural 5,6-hydrogenated kava pyrones against strychnine poisoning and experimental local tetanus]. Arch Int Pharmacodyn Ther. Dec. 182(2) 251-68. 

C. Neonatal tetanus occurs frequently in developing countries, owing to inadequate maternal immunity and poor hygiene, especially around the necrotic umbilical stump. Localized tetanus has been reported, involving rigidity and... 

General interventions, such as increasing the fluids in the diet, allowing for adequate rest, and keeping the atmosphere quiet and nonstimulating, may be beneficial. The primary health care provider may prescribe acetaminophen, every 4 hours, to control these reactions. Local irritation at the injection site may be treated with warm or cool compresses, depending on the patient s preference. A lump may be palpated at the injection site after a diphtheria, pertussis, tetanus (DPT) injection or other immunization. This is not abnormal and will resolve itself within several days to several months. 

Tetanus occurs when Cl. tetani, ubiquitous in the soil and faeces, contaminates wounds, especially deep puncture-type lesions. These might be minor traumas such as a splinter, or major ones such as battle injury. At these sites, tissue necrosis and possibly microbial growth reduce the oxygen tension to allow this anaerobe to multiply. Its growth is accompanied by the production of a highly potent toxin which passes up peripheral nerves and diSuses locally within the central nervous system. It acts like strychnine by affecting normal function at the synapses. Since the motor nerves of the brain stem are the shortest, the cranial nerves are the first affected, with twitches of the eyes and spasms of the jaw (lockjaw). 

Adsorption. The adsorption of the components of a vaccine on to a mineral adjuvant. The mineral adjuvants, or carriers, most often used are aluminium lydroxide, aluminium phosphate and calcium phosphate and their effect is to increase the immunogenieity and decrease the toxicity, local and systemic, of a vaccine. Diphtheria vaccine, tetanus vaccine, diphtheria/tetanus vaccine and diphtheriaAetanus/pertussis vaccine are generally prepared as adsorbed vaccines. 

The first pertussis whole cell vaccine was a mixture of killed organisms that was associated with frequent local and systemic reactions. In the late 1980s, an acellular pertussis vaccine was introduced that contains purified pertussis components that are immunogenic but associated with fewer adverse reactions. Acellular pertussis vaccine is available in combination with tetanus and diphtheria toxoids. Pertussis is not available as a separate vaccine component. In the spring of 2005, the Food and Drug Administration (FDA) approved tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines for use in adolescents and adults. 

Adolescents 11 to 18 years of age An interval of 5 years, with a minimum of 2 years, between the last tetanus-containing vaccine is recommended to minimize local and systemic adverse events however, shorter intervals may be used. Adults 19 to 64 years of age Tdap should replace the next routine tetanus booster. Intervals as short as 2 years between Tdap and Td maybe used. 

Tetanus-containing vaccines are well known for causing localized reactions however, all vaccines can cause local reactions. 

Tetanus toxin fragment C Tobacco leaves Systemic IgG and local IgA responses. Immuno- -genic in mice when administered nasally. 113... 

The delayed type hypersensitivity response (DTH) is an assay frequently used to assess the T cell response to commonly encountered microbial antigens. It involves intradermal injection of antigens to which the majority of individuals are immune (known as recall antigens) such as vaccinia, herpes simplex, and mumps viruses, Candida, and tetanus toxoid. In normal individuals, after 24-48 hours, an inflammatory filtrate results in local edema and induration, the diameter of which can be measured. A negative reaction to all the antigens (anergy) is usually reflected by decreased lymphocyte function as measured in vitro and is frequently seen in AIDS and ARC patients. 

Muscle relaxant As an adjunct for the relief of skeletal muscle spasm because of reflex spasm caused by local pathology, spasticity caused by uppermotor neuron disorders, athetosis, stiff-man syndrome, used parenterally in the treatment of tetanus (diazepam). 

Acute convulsive episodes Emergency control of certain acute convulsive episodes (eg, those associated with status epilepticus, cholera, eclampsia, meningitis, tetanus, and toxic reactions to strychnine or local anesthetics). 

An adjunct for the relief of skeletal muscle spasm caused by reflex spasm to local pathology (such as inflammation of the muscles or joints, or secondary to trauma) spasticity caused by upper motor neuron disorders athetosis stiff-man syndrome. Injectable diazepam may also be used as an adjunct in tetanus. 

Where antigens are introduced into the body intravenously, they usually travel rapidly to the spleen, followed by the fast production of an antibody. Subcutaneous or lntradermal injection of antigens most frequently localizes in the lymph nodes and antigens that are inhaled favor local sensidzadon. In some cases, such as tetanus immunization, loxin produced by the bacteria may be slow and insufficient to provoke a significant immunologic reaction. Thus, the requirement for properly timed booster injections. 

The local injection of 0.1 to 2% procaine or other anesthetics blocks the centripetal proprioceptive impulses and thereby relaxes muscular tonus, normal and abnormal, such as spasmodic torticollis. It effects almost instantaneous relief of the pain, stiffness, malposition, and incapacity of fibrositis, lumbago, and acute sprains and fractures. The site of greatest tenderness may be infiltrated with 10 to 30 cc of 1 or 2% procaine hydrochloride. Injected systemically, it relaxes traumatic tetanus and removes decerebrate rigidity, so that spontaneous movements of the limbs and of the respiration return. Its curare action may also be concerned in this effect. It relaxes parkinsonian, but not myotonic, rigidity. 

Adverse events after diphtheria-tetanus vaccine in the USA in 1982-84 have been reviewed in detail (SEDA-13, 273). The usual types of local intolerance can be seen. For example, some 5% of schoolchildren develop redness and swelling, whilst some older children develop enlargement of the regional lymph nodes. Such reactions are much less common in young children, and much more common in children given combined vaccines. 

The occurrence of epidemic diphtheria in Eastern Europe led to the recommendation in the UK that those aged 15-18 years should receive a combined tetanus and low-dose diphtheria toxoid vaccine instead of a tetanus booster alone. In March 1995, 220 children aged 14—16 years were inadvertently given high-dose diphtheria and tetanus toxoid vaccine, and their parents were sent a questionnaire 153 replied. A total of 141 (92%) of adolescents reported one or more reactions, most of which were classified as mild or moderate and lasted less than 1 week. However, 47 (31%) reported at least one severe local or systemic reaction (2). 

The Hexavalent Study Group has compared the immuno-genicity and safety of a new liquid hexavalent vaccine against diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, and Haemophilus influenzae type b (DTP + IPV + HB + Hib vaccine, manufactured by Aventis Pasteur MSD, Lyon, France) with two reference vaccines, the pentavalent DTP -I- IPV -i- Hib vaccine and the monovalent hepatitis B vaccine, administrated separately at the same visit (9). Infants were randomized to receive either the hexavalent vaccine (n = 423) or (administered at different local sites) the pentavalent and the HB vaccine (n = 425) at 2, 4, and 6 months of age. The hexavalent vaccine was well tolerated (for details, see the monograph Pertussis vaccines). At least one local reaction was reported in 20% of injections with hexavalent vaccine compared with 16% after the receipt of pentavalent vaccine or 3.8% after the receipt of hepatitis B vaccine. These reactions were generally mild and transient. At least one systemic reaction was reported in 46% of injections with hexavalent vaccine, whereas the respective rate for the recipients of pentavalent and HB vaccine was 42%. No vaccine-related serious adverse event occurred during the study. The hexavalent vaccine provided immune responses adequate for protection against the six diseases. 

Tetanus toxoid is prepared from Clostridium tetani and can be given either in a fluid form (plain) or an adsorbed form. The slight local reactions that tend to occur (induration, erythema, tenderness) are more common with the adsorbed type. Intramuscular injection of tetanus toxoid... 

About 2 weeks after receiving a second dose of adsorbed tetanus toxoid a 50-year-old woman developed generalized morphea, a rare condition, in which multiple patches of skin sclerosis occur over much larger areas than in the localized variant. The patient denied taking any drugs. After prednisone therapy, a month later the lesions had dramatically improved (12). 

In children aged 15-16 years receiving routine reinforcement tetanus immunization, adsorbed vaccine caused more intense and more frequent local reactions than did plain tetanus toxoid, and a higher incidence of pjrexia. The incidence of swelling and erythema at the inoculation site increased with serum antitoxin titre at the time of administration, whereas pain and tenderness were related to the presence of the aluminium hydroxide adjuvant (17). Based on similar experiences it has been widely recommended that plain and not adsorbed tetanus toxoid should be used when reinforcement of immunity to tetanus alone is desired. 

Positive merthiolate tests were found in eight of 30 patients with suspected adverse reactions to tetanus or tick-borne encephalitis vaccine (local inflammatory reactions at the injection site, fever, lymphadenopathy, urticarial or lichenoid exanthemas) (1). 

Treatment is symptomatic and supportive. The wound should be cleaned with soap and water tetanus prophylaxis should be administered. Application of ice packs or the topical application of a corticosteroid, antihistamine, or local anesthetics may be useful in relieving symptoms. Severe pain has been treated with injection of a local anesthetic. Antibiotics are reserved for documented infections. 

Many controversial techniques have been employed in the management of true Brown Recluse spider bites. Unfortunately, no scientific evidence exists which supports an ideal method or methods of management. However, case reports advocate a variety of therapies as potentially useful. Most agree, however, that good local management of the cutaneous lesion is the most important aspect of care. Tetanus prophylaxis should always be included. In... 

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