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.
Highlights
Autonomic nervous system (ANS) dysfunction is present in up to one third of patients with tetanus
Respiratory arrest used to be a common problem during preventilation era, ANS dysfunction has been emerged as a major problem in these patients in post ventilation era [1]
There are reports that certain arrhythmias e.g. tachycardia carry poor prognosis [2], ANS dysfunction has been attributed to severe tetanus, which carry poor prognosis anyways
Summary
Autonomic 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. Tetanus is still a major health problem in developing world. Care of this potentially fatal, though preventable, disease has been revolutionized with advent of mechanical ventilation. Respiratory arrest used to be a common problem during preventilation era, ANS dysfunction has been emerged as a major problem in these patients in post ventilation era [1]. There are reports that certain arrhythmias e.g. tachycardia carry poor prognosis [2], ANS dysfunction has been attributed to severe tetanus, which carry poor prognosis anyways. Our study highlights the importance of this previously not well-known aspect of tetanus
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