Neonatal tetanus in an African newborn

Abstract

•Tetanus is caused by the toxin of Clostridium tetani.•Neonatal tetanus occurs after the contamination of the umbilical stump with the spores of C. tetani in newborns without protective antibodies.•Inadequate maternal vaccination and poor perinatal hygiene are the main risks factors.•The diagnosis is mainly clinical and the early onset of a specific treatment can improve the prognosis.•Prevention of neonatal tetanus is achieved with improvement in perinatal and ante-natal care, with vaccination of unimmunised pregnant women. A 7-day-old newborn was brought to our hospital with fever. The mother had not followed any ante-natal care. She gave birth at home and the umbilical cord was cut with a non-sterile blade. The newborn had been well up to the day of admission, when fever and some difficulties for breastfeeding appeared. Physical examination was unremarkable, including a preserved suction reflex. A urinary dipstick ruled out a urinary infection. A rapid test for malaria was negative. There was no possibility to perform blood cell count or cultures due to the limited resources. A lumbar puncture showed clear spinal fluid, but biochemical or microbiological tests were unavailable. Regardless of ampicillin and gentamicin administration, the fever increased and the baby developed an impossibility to suck. He had muscular spasms, aggravated by touch. Trismus and rigidity were marked (Figure 1). The evolution and epidemiology posed the suspicion of neonatal tetanus, a disease caused by the toxin of Clostridium tetani, still common in low income countries due to limited access to ante-natal care, inadequate maternal vaccination and home-deliveries with no use of clean delivery kits and poor hygiene of the umbilical stump (WHO, 2017). The early onset of a specific treatment may modify the prognosis, so human tetanus immunoglobulin (500 UI intramuscularly) and metronidazole (15 mg/kg as loading dose, followed by 7.5 mg/kg every 12 h for 10 days) were administered. A nasogastric-tube was placed for feeding, the newborn was located in a quiet, dark place, and diazepam was initiated to control the spasms (Thwaites et al., 2015Thwaites C.L. Beeching N.J. Newton C.R. Maternal and neonatal tetanus.Lancet. 2015; 385: 362-370Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, Gibson et al., 2009Gibson K. Bonaventure Uwineza J. Kiviri W. Parlow J. Tetanus in developing countries: a case series and review.Can J Anaesth. 2009; 56: 307-315Crossref PubMed Scopus (36) Google Scholar). Despite the high mortality of this entity (Mwaniki et al., 2010Mwaniki M.K. Gatakaa H.W. Mturi F.N. Chesaro C.R. Chuma J.M. Peshu N.M. et al.An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years.BMC Public Health. 2010; 10: 591-604Crossref PubMed Scopus (34) Google Scholar), the evolution was good, with spasm disappearance and recovery of suction capacity (Figure 2). The baby was discharged 15 days after arrival. As tetanus infection does not confer immunity, he received the first dose of tetanus toxoid vaccination before discharge and was included in immunization program for the following two doses. The mother was also vaccinated. Prevention of neonatal tetanus is achieved with a combination of improvement in perinatal care and vaccination of women of childbearing age and unimmunised pregnant women, since maternal antibodies are passively transferred to the fetus and protect the newborn (Demicheli et al., 2015Demicheli V. Barale A. Rivetti A. Vaccines for women to prevent neonatal tetanus.Cochrane Database Syst Rev. 2015; 7 (CD002959)Crossref Scopus (39) Google Scholar, WHO, 2000WHO Maternal and neonatal tetanus elimination (MNTE).2000Google Scholar).Figure 2Recovery of the capacity to suck after the treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Author contributions: M.A.P.J.A. and M.L gave medical attention to the newborn. M.A.P.J.A. wrote the paper. Funding sources: No funding sources. Conflict of interest: The authors declare no conflict of interest. Acknowledgement: We acknowledge the mother of the baby for giving her written consent for the publication of her son’s images and signing the informed consent form.