Tetanus case in a herd of sheep in Muğla province

Tail docking and ear tagging are common husbandry practices in lambs, but little is known about the healing process of the resulting wound. Additionally, evidence in other species shows that concurrent injurious procedures may delay wound healing. Thus, the objectives of this study were to 1) describe wound healing following tail docking and ear tagging, and 2) compare healing of ear tag wound in docked and undocked lambs. Within 28 Polypay female twin pairs, one lamb was docked by placing a constrictive rubber ring on the tail 24 to 48 h after birth and the tail of the other lamb was left intact (n = 28/treatment). Plastic-tipped ear tags were applied to both ears of all lambs immediately before tail docking. Wound photos of the ears and tail were taken twice weekly until weaning, resulting in 16 to 22 observations per lamb. Tail wound photos were analyzed to determine when the tail fell off and to score the presence of 6 tissue types: pus, serous exudate, sanguineous exudate, granulation, crust, and slough. A healed tail or ear wound was defined as one that was fully contracted, and no other tissue types were present. Tails took 19 ± 2 d to fall off (mean ± SD; range = 16 to 25 d) and their wound took 41 ± 8 d to heal completely (30 to 60 d). The prevalence of any of the 6 tissue types did not predict how long it took the tail wound to heal (F < 2.50, P > 0.13). Tissue types, indicative of possible infection, such as pus and slough, were present at least once in 89% and 93% of the docked lambs and in 8% and 10% of the total sampling periods, respectively. On average, pus and slough first appeared 12 ± 4 d (range = 5-22) and 11 ± 3 d (5-15) after docking, respectively. Of the 112 ear wounds, only 16% had healed by the time the lambs were weaned (55 to 74 d after tagging). Contrary to our predictions, there was a tendency for more docked lambs to have at least one healed ear wound by the end of the sampling period compared with undocked lambs (11 docked lambs vs 4 undocked lambs; X2 = 3.28, P = 0.07). This may be a result of an increased systemic inflammatory response and possible reduction in activity in the docked lambs. Overall, most ear tag wounds were still not healed after 2 mo, and tail wound took over 1 mo to heal. Further research is needed to determine the welfare implications of routine husbandry practices in sheep, including pain experienced during healing and how other factors may affect the healing process.

Tail docking and ear tagging are common husbandry practices in lambs, but little is known about subsequent wound healing or how it may be affected by performing both procedures concurrently. Our objectives were to: (1) describe wound healing following tail docking and ear tagging, and (2) compare healing of ear wounds in docked and undocked lambs. Within 28 female Polypay twin pairs, one lamb was docked using a rubber ring between 1 and 2 days of age and the other lamb’s tail was left intact. Tags were attached to both ears of all lambs. We photographed tail and ear wounds twice weekly until weaning (mean ± SD; 64 ± 5 days of age). Tail wounds took 43 ± 9 days to heal (range: 30–60 days). Pus, a sign of infection, was present at least once in 89% of tail wounds and was associated with delayed healing. Only 49% of ear wounds had healed by weaning, and tail docking did not predict the probability of healing. Pus and sanguineous exudate (i.e., bleeding) were present at least once in 21% and 96% of ear wounds, respectively. Pus was not associated with the probability of ear wound healing, but ears with more frequent bleeding were less likely to have healed by weaning. The duration of healing and likelihood of infection following both procedures raise welfare concerns and suggest refinements or alternatives are warranted.

Tetanus is an acute, often fatal, infectious neuromuscular disease in all farmed mammals caused by Clostridium tetani. The disease is sporadic but outbreaks of tetanus have been described, as a result of wound contaminated with spores of C. tetani, which sporulates to the vegetative form and produce toxins. The present study reports an outbreak of tetanus in a sheep flock, shortly after ear tagging. Three sheep from a large flock (with a population of 1000 sheep) were presented with signs of: convulsion, limb stiffness, incoordination and trismus (“lock jaw”). There were wounds and scabs in most livestock where ear tags had been attached 1 week prior. Clinical examination revealed tachycardia, dyspnoea with dilated nostrils, mild fever, erected ear pinnae, teeth grinding, mild bloat, muscles rigidity, prolapse of third eyelid and anxiety. According to the history stated by the owner, the case fatality rate of the disease from the beginning was 50% during the outbreak. Necropsy did not reveal any significant finding. Gram‐positive bacilli with terminal spores representing C. tetani were isolated in anaerobic cultures which were taken from ear wounds. Procaine penicillin G was administrated at 20 000 IU/kg BW for 5 days, but antiglobulin was not available to treat affected animals. Mortality significantly declined one day after onset of treatment. In this report, the organism was probably introduced by contaminated instruments which were used for ear tagging of sheep. Wound exudation and adhesion following rubbing, created a favourable anaerobic condition for the spores to germinate with production of neurotoxin. Vaccination can protect animals against tetanus, but it does not preclude the need to apply standard hygienic principles when performing management procedures causing wounds. In pasture holding system, many pathogens are present in environment, so tetanus should be considered important in farm animals, because of its high fatality rate and the long course of convalescence.

Behavioural responses of lambs to common painful husbandry procedures

Procedures including teeth clipping (TEE), tail docking (TAI), and ear tagging (TAG) are conducted routinely in commercial pig production units during the first days of life in piglets. However, as these procedures are conducted without anesthetics, there is controversy surrounding these procedures due to the pain/stress they may cause. The assessment of vasomotor activity using non-invasive infrared thermography (IRT) is increasingly being promoted as a tool to detect acute stress. The objective of this study was to assess changes in the ocular (OCU) window of piglets before, during and after each of the aforementioned procedures using IRT. This study used crossbred piglets (n = 116; Duroc Danish x Landrace x Large white) from multiparous sows. All thermographic images of piglets were taken between 0900 h and 1600 h using a high-resolution handheld infrared camera FLIR T650sc (640 x 480 pixels; FLIR Systems, Wilsonville, USA) at a uniform distance of 1 m on the left side of the face. To assess TEE, TAI and TAG procedures separately, a recovery period (12 ± 2.5 min) was allowed between procedures. Due to order differences in which procedures were conducted, the following study groups were created (procedures in brackets indicate the procedures performed prior to the focal procedure): TEE, (TEE+) TAI, (TEE+TAI+) TAG, TAI, (TAI+) TEE, (TAI+TEE+) TAG, TAG, (TAG+) TEE, (TAG+TEE+) TAI. Temperature values were recorded from images using FLIR Tools software 6.0 (FLIR Systems). Data were analyzed using a linear mixed model for repeated measures and multiple comparisons were calculated using a post-hoc Tukey test (GraphPad Prism 10.0.2). Table 1 shows the mean and standard deviation (SD) values for IRT recordings in the OCU window. Comparison of evaluation times showed a significant reduction in OCU temperature from before to after the procedure(s) in (TEE+) TAI (-1.21 °C, P < 0.001), (TAI+TEE+) TAG (-0.65 °C, P < 0.001), TAG (-0.58 °C, P < 0.05) and (TAG+TEE+) TAI (-0.3 °C, P < 0.01) groups. These changes in the OCU window of piglets may be in response to the procedures performed, resulting in a sympathetically mediated acute vasomotor response as cutaneous capillary blood flow shifts due to transient peripheral vasoconstriction. In turn, IRT detects this blood flow change as a reduction in surface temperature. Comparison between procedure groups found that mean OCU temperature during the procedure was greater (P = 0.01) in (TAI+) TEE and (TAG+) TEE than the rest of the groups, though the reason for this is unclear and requires further investigation. This work shows that IRT can be used as a non-invasive tool to detect surface temperature changes of piglets.

Routine practices such as teeth clipping (TEE), tail docking (TAI) and ear tagging (TAG) can be considered controversial due to the potential pain or stress they might cause. This study sought to evaluate how nasal surface temperature changes before, during and after each of these procedures (TEE, TAI, TAG) as performed routinely on a commercial farm. A total of 116 crossbred piglets (Landrace x Large white x Duroc Danish) from multiparous sows were used. As litters were processed, thermographic images were taken using a high-resolution handheld infrared camera FLIR T650sc (640 x 480 pixels; FLIR Systems, Wilsonville, OR) at a uniform distance of 1 m on the left side of the face. All thermal images were collected between 0900 and 1600 h. To assess procedures separately, a recovery period (12 ± 2.5 min) was allowed between procedures. Due to order differences in which procedures were implemented, the following study groups were created (procedures in brackets indicate the procedures performed prior to the procedure being assessed): TEE, (TEE+) TAI, (TEE+TAI+) TAG, TAI, (TAI+) TEE, (TAI+TEE+) TAG, TAG, (TAG+) TEE, (TAG+TEE+) TAI. Temperature values were recorded from images using FLIR Tools software 6.0 (FLIR Systems). GraphPad Prism 10.0.2 (San Diego, CA) statistical software was used to analyze the obtained data. All data were analyzed via a linear mixed model for repeated measures and Multiple comparisons were calculated using a post-hoc Tukey test (GraphPad Prism 10.0.2). There were no significant differences in Nasal surface temperature among groups at any time points (Table 1, P > 0.05). However, there was a significant reduction in temperature from before the procedure(s) to during and after the procedures in the TAG (P = 0.006) and the (TEE+) TAG (P < 0.001) groups. Changes in the surface temperature of piglets can be related to the sympathetic activity and the hypothalamic-pituitary-adrenal axis activation during the perception of a stressor, which causes a sympathetically mediated acute vasomotor response that shifts cutaneous capillary blood flow due to transient peripheral vasoconstriction. Infrared thermography recognizes such blood flow changes as a reduction in the amount of heat radiated from the skin. Indeed, the nasal surface temperature was reduced in TAG and (TEE+) TAG piglets during and after the procedure(s) which suggests these procedure groups caused a greater degree of thermal change to the piglets. Furthermore, the results suggest that infrared thermography could be a useful tool to assess the impact of routine husbandry practices on piglet welfare. Nonetheless, further research should assess infrared thermography alongside behavioral and physiological assessments to establish the relationship between surface temperature and stress during husbandry procedures.

Identification of cattle by ear tagging is legally required to ensure traceability. However, studies indicate that ear tagging causes pain-associated physiological and behavioural responses. The wound healing process and prevalence of wound lesions in calves remain mostly unknown. Therefore, this study sought to estimate the prevalence of wound lesions and identify associated risk factors by assessing ear tagging management in unweaned dairy calves. We conducted one field study with single visits to estimate the prevalence of wound lesions and associated risk factors (Study 1, 42 farms, 802 calves) and one follow-up study with repeated visits to assess farmers’ view on ear tag management, the relationship between calf health and wound healing, and the development of wound lesions over time (Study 2, five farms, 42 calves). Study 1 comprised a short interview with the farmer (four questions regarding ear tagging). Ear tag position (on or between ridges) and wound lesions were evaluated using a three-level scoring system (1 = no blood, scab, or pus discharge; 2 = incrustation or scab and slight blood or pus discharge; and 3 = heavy purulent discharge, tissue deformation, or both). In Study 2, farmers were interviewed about ear tagging (30 questions), and 10 calves from each farm were assessed on the day of ear tagging and 1, 3, and 6 weeks after tag insertion. Calf health, ear tag position, and wound characteristics were assessed during all visits. Both studies were analysed descriptively, and odds ratios (ORs) for wound lesions in Study 1 were calculated using logistic regression. Of the ears assessed in Study 1, 31.1% showed clinical signs classified as category 2. Score 3 was less common and was found for 6.7% of all ears. Although the highest incidence of wound lesions was found in calves aged 2–4 weeks, wound lesions were also found in calves aged >10 weeks (18.5%). Identified risk factors for wound lesions were small farm size, calf age, single housing, group size, placement of ear tags on ridges, and other ear’s score. Individual farmers in Study 2 were able to place ear tags very accurately, although awareness about ear tag lesions appeared to be low among farmers. Sensitising farmers to this issue, implementing routine check-ups of ear tag wounds 2 weeks after insertion, and considering the identified risk factors may reduce animal welfare impairments associated with ear tagging.

Ear tagging in piglets: the cortisol response with and without analgesia in comparison with castration and tail docking

To interpret changes in EEG in relation to perceived pain of castration, mulesing and docking in lambs. Analysis of covariance (randomised block design) to determine the effects of treatment on eight bandwidths of the EEG frequency spectrum. Ninety-eight, 3- to 4-week-old lambs were subjected to one of seven treatments: castration, tail docking, mulesing, ear tagging, sham shearing, formalin injection (to induce lameness) and handling. EEG was recorded for 15 min before treatment, during treatment, and for 15 min after treatment. Consistently lower mean power values across all bandwidths of the EEG were found at the time of mulesing and docking than at handling and shearing (P < 0.01). Formalin injection resulted in lower power values than handling and shearing (P < 0.01). Castration had lower power values than handling and shearing. Similarly, for 15 min after treatment, mulesing and formalin injection had significantly lower power values than handling, shearing, ear tagging and castration (P < 0.05). The consistent effects associated with mulesing, docking and castration compared to handling, shearing and ear tagging suggest that mulesing at both the time of treatment and during 15 min after treatment results in a response that is similar to that of induced lameness. Docking and castration result in a response at the time of treatment that is similar to induced lameness and mulesing, but during 15 min after treatment is similar to the non-noxious control treatments. However, the depressing effects on the mean power values are the reverse of that anticipated from a previously developed pain model, highlighting the need for further research to develop this technology to evaluate pain associated with husbandry procedures.

Introduction Tetanus has been known since Hippocrates. There have been few, if any, additions to its symptomatology though the pathophysiology has been explored to a molecular level and options for prevention and management have changed enormously. Active immunization programmes have been pursued for over 50 years and new technologically based management strategies have been developed over the past 30 years. In principle, tetanus should by now be a totally preventable disease but, even so, it is expected to have killed 10 million people in the last decade of the 20th century, the majority of them infants [1]. It continues to drain the meagre health resources of many developing countries, and to provide more occasional but nonetheless unpleasant surprises in more developed ones, appearing, as it does in several forms and guises, besides the classic picture following recognized trauma or wounding [2,3]. Reporting, incidences and mortality Tetanus is a notifiable disease in many countries, China being an exception eminently notable in view of its size and population. Overall figures may be reported, or reporting may be in terms of a number of recognized subtypes such as neonatal and maternal tetanus. Even where notification is compulsory, gross under-reporting is commonplace. Routine reporting systems for neonatal tetanus identified only about 4% of the cases estimated to have occurred worldwide in 1990 [4]. In the USA, the completeness of overall reporting to the national surveillance system between 1979 and 1984 was estimated to be 22–46% [5] and, in Switzerland, the reported cases of tetanus probably reflected no more than 13% of the actual number [6]. The available figures reflect a complex of geographical differences in reporting, lifestyle-related predisposition, application of preventative measures such as active immunization programmes, and therapeutic interventions such as the administration of antitoxin and technologically demanding treatments for the manifestations of the disease. The WHO estimates that, in 1992, there were 578 000 infant deaths from neonatal tetanus. Of these, 210 000 occurred in South East Asia, 152 000 in Africa, 114 000 in the Western Pacific region, 90 000 in the Eastern Mediterranian, 112 00 in the Americas and 1000 in Europe [6]. Table 1 summarizes recently published information on aspects of tetanus from different parts of the world. There have been many contributions to the literature from Russia but little is known of the incidence in Russia or in Eastern Europe. The incidence of maternal tetanus is not known. Probably 15 000 to 30 000 cases of maternal tetanus occur worldwide each year [17]: 27% can be attributed to post-abortal and 67% to post-partum sepsis. In Nigeria, 10% of adult tetanus cases were attributed to maternal tetanus [18].Table 1: Global prevalence of tetanus Pathophysiology Tetanus is a toxic infection caused by the obligate anaerobe Clostridium tetani. Clostridial toxins are generally regarded as the most poisonous substances known to mankind. The spores of Clostridium tetani are present in the soil and faeces and can enter the body, proliferate in devitalized tissue and produce the exotoxins, tetanospasmin and tetanolysin, which can gain access to the blood and central nervous system (CNS). Tetanolysin is a haemolysin but plays no presently recognized part in the overall clinical picture in tetanus. Tetanospasmin is primarily a very potent neurotoxin and is probably solely responsible for the manifestations of the disease. Access of the toxin to the CNS The toxin can circulate in the blood stream but does not enter the central nervous system in appreciable amounts by this route because it cannot cross the blood brain barrier except where it is deficient at the fourth ventricle. It enters motor nerves at the neuromuscular junction and travels by intra-axonal transmission at the rate of 72–250 mm day−1. It may thus take 2–14 days to reach the central nervous system. The symptoms appear only after the toxin has gained access to the presynaptic terminals of those inhibitory Renshaw cells that release gamma-aminobutyric acid (GABA) and glycine (rather than those that release acetylcholine). This blocks inhibition at brain stem and spinal cord level resulting initially in more or less localized increases in resting muscle tone (rigidity) and later in more generalized hyperreflexia and spasms [19]. The toxin enters sensory and autonomic nerves via their peripheral endings but, because of slower intra-axonal transport, it takes longer for the toxin to reach the lateral horn cells and autonomic dysfunction sets in a few days after the spasms. Autonomic dysfunction manifests as increased basal sympathetic activity and episodes of sympathetic overactivity or 'crises' involving both alpha and beta receptors. These are caused by reduced inhibition of the postsynaptic sympathetic fibres and adrenal medulla and are evidenced by outpourings of noradrenaline and adrenaline in amounts comparable with those found in patients with phaeochromocytoma (which are about ten times the basal amounts) [20,21]. Another postulated cause is the increased release of thyroid hormone and direct inhibition of the release of endogenous opioid oligopeptides. The cellular actions of tetanus toxin The principal site of action of tetanospasmin in mammals is at inhibitory synapses, though it can also affect the central excitatory synapses, the neuromuscular junction, and autonomic ganglia [22,23]. Injection of tetanus toxin into the hippocampus of the rat establishes a long lasting excitatory focus in the brain [24]. The convulsant effect either releases an inherent tendency for hippocampal nerve cells to fire repetitively or may preferentially block key inhibitory synapses, leaving excitatory influences unchecked. Whatever the cause, an excitatory effect at one group of neurones will have a secondary kindling effect on the other synapses within the brain which will reinforce and maintain the excitatory effect, and promote its extension from any primary focus. Tetanospasmin was initially thought to affect only glycinergic pathways, but effects were subsequently found on pathways mediated by GABA, which is probably the most widespread inhibitory transmitter in the mammalian nervous system. It now appears that the toxin can also interfere with other central inhibitory neurotransmitter processes such as those mediated by dopamine and noradrenaline, as well as transmission at cholinergic synapses in the peripheral somatic and autonomic nervous system [25,26]. Egea et al.[27] found that tetanus toxin blocks the release of acetyl choline from isolated nerve terminals in a dose-dependent manner, an effect prevented by antiserum to tetanus toxin. In GABA-ergic synapses that have been blocked by toxin, the responses to exogenously applied transmitter are unaffected. It follows that the effect is presynaptic, involving some aspect of events leading to release of endogenous transmitter. Tetanus toxin blocks the rearrangement of intramembrane particles at the plasma membrane of experimentally poisoned synapses. It has no effect on uptake, synthesis or storage of transmitter, but directly impairs the calcium-dependent release of GABA [28,29]. It blocks, not only the evoked release of transmitter, but also most of the spontaneous release. The blockade may be preceded by an asynchronous release of quanta of GABA. These effects are believed to result from interference with the movement of synaptic vesicles to the active zones through blockade of most of the calcium channels, because the toxin can selectively block the calcium component of the action potential in cultured neuroblastoma cells. The effects of tetanus toxin are prevented by pretreatment with ethanolamine O-sulphate or sodium valproate, drugs that enhance GABA-ergic mechanisms by inhibiting the enzyme GABA transaminase and/or succinic aldehyde dehydrogenase [30]. At a molecular level, tetanospasmin is synthesized as a single polypeptide chain with a molecular weight of 140 000–160 000, which can be enzymatically split into light and heavy chains. The carboxy terminus of the heavy chain mediates binding to the target cell membrane and the amino terminus mediates the incorporation of the toxin into the cell. Transmitter release at nerve terminals appears to be inhibited by the light chain which may interfere with exocytosis after the entry of calcium ions [2]. The light chain is a zinc endopeptidase that produces a single-site cleavage of an integral membrane protein of small synaptic vesicles, synaptobrevin. Clinical features The precipitating injury A history of some sort of injury is present in most cases, with an incubation period that can vary but is usually between 3 days and 3 weeks. However, the culprit wound may well be so trivial that the victim does not think of seeking medical attention. Tetanus may also occur following skin and middle ear infections [31]. Dental caries or a root canal procedure was considered to be the point of entry for tetanus spores in one instance [32]. Other unusual sources of injury include frostbite, gum ulceration by dentures, infected molluscum contagiosum, scratched atheroma cutis and infected granuloma pyogenicum. Thus it is unwise to exclude tetanus from a differential diagnosis just because there is no obvious portal of entry [33,34]. A series of cases of tetanus with a 96% mortality has been reported after intramuscular injections of quinine which are widely used in treatment. Quinine dihydrochloride, the usual formulation for parenteral administration has a pH of 2 and may cause local vasoconstriction and necrosis. The chemical damage and ischaemia lowers the redox potential at the injection site and provides a favourable milieu for rapid sporulation and growth of Clostridium tetani [35]. In another series reported in 1994, 89% of the cases were heroin addicts [36]. It may be relevant that heroin is often 'cut' with quinine. The cases developed severe tetanus with autonomic dysfunction. Pulmonary and gastrointestinal complications were common and the mortality rate was 25% [21]. In many countries, traditional practices continue to this day that carry a high risk for tetanus—practices such as scarification, circumcision, ear piercing and the application of oils, ghee and dung to the cut umbilical cord [37]. Clinical presentation The commonest presenting symptom is trismus. Rigidity progresses in a descending manner. Dysphagia, risus sardonicus and neck stiffness are soon followed by rigidity of the trunk and limbs. The spasms which follow may vary in severity and be localized or generalized, but tend to affect the trunk more than the limbs. Spasms may occur spontaneously or provoked by some form of stimulation. Arching of the trunk-opisthotonus is a feature of the established disease. Trismus develops to be a prominent feature, leading to considerable difficulty in feeding, maintaining oral hygiene and swallowing saliva. These difficulties often lead to aspiration bronchopneumonia—a frequent life-threatening complication. Neonatal tetanus presents most often on the seventh day of life with a short history of failure to feed. Spasms are typical but the diagnosis can be mistaken for meningitis and sepsis. Cephalic and localized tetanus are uncommon variants that may defy diagnosis for considerable periods. Cephalic tetanus [38,39] is a form that presents after wounding of the head and neck, in which trismus is often preceded by cranial nerve palsies: it accounts for 1–3% of the total number of reported cases and has a mortality of 15–30%. Localized tetanus accounts for a similarly small number of the reported cases. It has a long incubation period and manifestations, including flaccidity, restricted to muscles near the wound. The mechanism of the paralysis is not completely understood, but is likely to be related somehow to the inability of the toxin molecule to be conveyed to the central nervous system [40]. The spasms may spread from one limb to another (recruitment spasm). The signs may mimic other neurological disorders. The important clinical observation of autonomic dysfunction in tetanus was described first in the 1960s [41]. Autonomic dysfunction usually manifests itself as a hyperkinetic circulatory state with tachycardia and arrhythmias, increased stroke volume and increased cardiac index. These may be accompanied by depression of bowel motility and bladder dysfunction and episodes of sweating and pyrexia which may also indicate concurrent infection. These manifestations of sympathetic overactivity may alternate with episodes of hypotension from loss of systemic vascular resistance and bradycardia to the point of cardiac arrest from which resuscitation can be difficult. This has been attributed to sudden withdrawal of sympathetic activity rather than to an increase in parasympathetic activity because the response to atropine is variable. Other explanations for these episodes are catecholamine-induced myocardial damage, vagal stimulation and effects of the toxin on the brain stem that may impair baroreceptor function [42]. There may be complaints of abdominal pain amongst the presenting features and there is a report of a patient with Horner's syndrome and trismus from tetanus [43]. Diagnosis Early treatment is crucial to the chances of survival and recovery. The early diagnosis which enables early treatment must depend purely on clinical observation and may go by default in countries where the disease is uncommon. Tetanus may not come to mind because of the many variants from classical presentations. These can suggest a range of differential diagnoses including acute dental infections, acute tempero-mandibular disease, intracranial lesions, drug induced muscle dystonias and strychnine poisoning. These factors may delay the establishment of a definitive diagnosis [44]. Laboratory findings are virtually of no value except to rule out strychnine poisoning. Blood counts and blood chemical findings are unremarkable. Imaging studies of the head and spine reveal no abnormalities. The cerebrospinal fluid is normal and a lumbar puncture is not necessary. Recently a simple bedside test to diagnose tetanus has been described: the spatula test. A spatula is used to touch the posterior pharyngeal wall, and a positive test result is reflex spasm of the masseters. This occurred in 349 of 350 patients with tetanus (sensitivity 94%) and in no patient without tetanus (specificity 100%) [45]. Severity The severity of tetanus is usually predicted on the basis of the incubation period (time between injury and first symptom) and the onset time (time from first symptom to first spasm). Incubation periods of less than 14 days and onset periods of less than 48 h are said to herald a severe attack, though longer incubation periods and onset times do not guarantee a mild attack. A useful way of grading the severity of established symptoms for purposes of management and study is: Grade I—Trismus; Grade II—Dysphagia, neck rigidity, risus sardonicus, opisthotonus; Grade IIIa—Muscle rigidity, spasms; Grade IIIb—All of above and autonomic dysfunction. Treatment The principles of treatment once symptoms appear are: Eradication of the organism; Neutralization of toxin; Symptomatic treatment of the effects of the toxin; (3a) Control of muscle spasms and rigidity, (3b) Control of autonomic dysfunction; Supportive measures; Active immunization. Eradication of the organism Whatever the specific concerns about tetanus, ordinary clinical common sense dictates that any obvious wound must be cleaned and any devitalized tissue must be debrided, under general anaesthesia as necessary. It is, of course, also routine in all developed healthcare systems to attempt to establish or boost active immunity by giving tetanus toxoid as soon as possible after any at-risk injury. Metronidazole is the antibiotic of choice when there are specific concerns about tetanus because of its activity against anaerobes and effective penetration of devitalized tissues. Penicillin, the antibiotic of choice for decades, is a GABA antagonist and may aggravate the spasms of tetanus [46]. However, by the time symptoms present, the frequent absence of an obvious wound or tissue damage means that treatment based solely on adequate wound care is likely to be futile, and must not delay the more urgent attention that must be given to other measures, particularly neutralization of toxin. Neutralization of toxin. The importance of this measure is illustrated in experience documented by many hospitals. For instance, in a review of 2449 cases in 65 years at Charity Hospital, New Orleans, USA, the fatality rate in the pre antitoxin era (1840–1905) was 76.4%. From 1906 to 1923 the rate was 70% and, by 1966, it had dropped to 31.6%. However, in a review published in 1976, the mortality was 58% with a distinct change in the average age of patients from 25 years to 40 years and a virtual disappearance of neonatal tetanus over the period [47]. Neutralization of the toxin should be effected as early as possible after the appearance of symptoms attributable to tetanus, because the toxin becomes inaccessible to antitoxin after an indeterminate but usually relatively brief period [48]. Human tetanus immuno-globulin (HTIG) should be given intramuscularly (i.m.), preferably within 24 h of diagnosis. A dose of 500 units i.m. is now recommended in place of the larger traditional doses of 3000–5000 units. If HTIG is not available, is used after for of antitoxin the blood brain so these do no more than any toxin. In to the toxin to nerve or HTIG have been given following studies et were amongst the to report the of antitoxin which reduced the mortality from to of was with in an attempt to effects In a in HTIG was given to at an dose of to patients and an intramuscular dose of 1000 to the there were only one with the administration but 15 10 with the intramuscular administration In neonatal tetanus, a out by and to provide that with either or HTIG is of important treatment effects in some not be the for more definitive studies of the and complications of Symptomatic treatment Early treatment. sets the of spasms can be very rapid and there is a risk of In one patients are for and for or at the time as wound so that can be in a high that spasms do not occur or [31]. to the and in a is and observation is particularly to the of spasms. Control of spasms. spasms can be by spasm of either the or spasms lead to and, because is not the patient is and becomes and this often has a traditional place and are widely at in developing countries where there have been few to them with more are on the alpha of GABA and in to enhance the function of GABA by the binding of GABA to its receptors. the rate of of GABA from its receptors. The of to of cell them more to The usual dose of is 1 to a dose as high as 40 h may be necessary. At high doses of can though this is attributable to its has been used for its and mediated muscle It also produces blockade and depression of mediated by the or brain However, one of its effects is the of dopamine as a neurotransmitter in the basal ganglia and of the syndrome has tetanus with The more traditional produce effects in the in which is in short in many developing has been used for the very widely and, on its effects take h to after of et have described the of for to was for resulting in of in of 50 and a of these are no was is another for particularly as therapeutic doses have been to GABA mediated responses However, is known to produce some of and this cause difficulties in the of autonomic which may occur the of the disease. used or in are often for the of severe spasms and do in the muscle rigidity to care and muscle is very often mediated within the nervous system or more at the neuromuscular tetanus has been with of and for and with for muscle In this instance a of was also used to blood which produces muscle by an mechanism in the central nervous system has been used in few is not a prominent effect a GABA transmission of and in the spinal has been reported recently in the management of tetanus. The of injections of was on the basis of of and The first injection was effective in out of 10 patients for effects were but patients developed CNS depression with and of them in of the the difficulties were later by patients were with of of the patients had to be only one has also been used by The the of GABA is In the early of tetanus when only trismus and neck stiffness are present, GABA may produce a of the clinical of the disease. produces muscle without usually the of cardiac muscle or It has a direct action on by the of calcium from the which the of and muscle In most has been used with or as an In one study in of reduced the mortality from in a group to in the group the for neuromuscular and in patients with severe tetanus However, neuromuscular are of treatment in the more cases. The choice of on within the of is has out of in some because of the that its activity aggravate the autonomic dysfunction. In the an of has to be has been used with no effects Control of autonomic dysfunction different therapeutic have been used in the management of sympathetic nervous system depression and peripheral alpha and beta have been at the more peripheral of autonomic dysfunction. and the alpha and beta antagonist have been in the of cardiac bradycardia and cardiac in some patients with tetanus. The beta antagonist has been used on as has blockade with a lumbar of At part of the effect of heavy in autonomic dysfunction is by nervous system depression with and general a of but was by their potential has been found to be particularly to the that the of endogenous are The circulatory effects of and other are but the key feature is probably a depression of sympathetic by actions at in the Whatever the a dose of of useful in blood and rate has been used with It has been found to basal plasma and had been used in the treatment of autonomic a in which there is release of particularly of noradrenaline from nerve as in the autonomic of tetanus. was followed by in plasma noradrenaline though not to within the normal and these were accompanied by a in given has a of actions that may be useful in tetanus. It is a potent and muscle it blocks and adrenal release and has an established place in the management of and has been used to in with phaeochromocytoma There are of its to autonomic dysfunction in tetanus and it has been considered a useful to paralysis and of has used the dose against of spasms and the of the reflex clinical of the of of spasms was at which not without the for was a important Supportive treatment. in in the early the of muscle paralysis and care in the management of tetanus. This reduced the mortality from to and later to This was a not only for the treatment of tetanus, but for the overall of the of care from one restricted to the of one at all systems that were Thus in tetanus, not only are there possible of the disease and its and aspiration of oral and gastrointestinal but there is also the autonomic dysfunction that is a recognized part of the disease as well as the now recognized from fluid from of hormone and infections from There has been as to an or a should be used to of the in patients

In addition to castration, further husbandry procedures are performed in piglets during the first week of life without anaesthesia. The aim of the present study was to investigate the pain-induced stress of the husbandry procedures castration, tail docking and ear tagging performed in piglets in combination in comparison with castration or handling alone. Furthermore, the effect of the presurgical administration of the nonsteroidal anti-inflammatory drug meloxicam alone or in combination with iron was investigated. The levels of pain and stress were evaluated based on cortisol and catecholamine concentrations, as well as from behavioural observations. The compatibility and the effect of combined drug administration were assessed, and the daily weight gain and blood iron level were determined. When comparing the application procedures, the slight changes observed at the iron injection site were reduced by 40% when using the mixture. After performing all three husbandry procedures without administration of meloxicam (KSO group), higher cortisol concentrations were induced for up to 4hours compared to the handling (H) and castration (K) groups. In piglets receiving meloxicam or the mixture of iron and meloxicam presurgically, the cortisol concentration was significantly reduced for 0.5 hours after castration and up to 4hours following all three husbandry procedures when compared to piglets without medication (groups K and KSO, respectively). The results indicate that the blood cortisol concentration significantly rose due to multiple pain and distress when combining castration, ear tagging and tail docking. Application of meloxicam before performing these husbandry procedures reduced pain equally to its application before castration alone. The application of a mixed preparation of iron and meloxicam did not affect the efficacy of either drug and improved the local tolerance of the iron injection.

A rare case of tetanus with early manifestation of apnea but without trismus

ABSTRACT.Tetanus arises from wound contamination with Clostridium tetani, but approximately one fifth of patients have no discernable entry wound. Clostridium tetani is culturable from animal feces, suggesting the gastrointestinal tract could be an endogenous reservoir or direct-entry portal, but human data are lacking. In this study of 101 Vietnamese adults with tetanus and 29 hospitalized control subjects, admission stool samples were cultured for C. tetani. Anti-tetanus toxin antibodies were measured by ELISA. Clostridium tetani toxigenicity was evaluated using polymerase chain reaction and sequencing. Toxigenic C. tetani was cultured from stool samples in 50 of 100 (50%) tetanus cases and 12 of 28 (42.9%) control subjects (P = 0.50), and stool samples of 44 of 85 (52.4%) tetanus cases with clinically identified wounds compared with 6 of 15 (47.6%) patients without clinically identified wounds (P = 0.28). Nine of 12 (75%) control subjects with toxigenic C. tetani in their stool samples lacked protective antibody concentrations. These findings fail to show evidence of an association between gastrointestinal C. tetani and tetanus infection, but emphasize the importance of increasing vaccination coverage.

INTRODUCTION. Cases of tetanus are registered annually throughout the world, mainly in unimmunised or incompletely immunised populations. Analysis of tetanus cases and identification of the reasons for non-vaccination, including refusal to vaccinate, are important for drawing the attention of health professionals to this issue.AIM. This study aimed to review case reports of tetanus in unvaccinated or partially vaccinated individuals, analyse reasons for non-vaccination, and identify problems associated with preventive vaccination against tetanus.DISCUSSION. According to epidemiological data, cases of tetanus are recorded every year in almost every country in the world. In 2023, the World Health Organisation (WHO) reported 21,830 cases of tetanus worldwide, and the Russian Federation reported 8 tetanus patients, including children. The main issue with diagnosing tetanus lies in the lack of reliable laboratory tests for confirming tetanus. Tetanus-specific therapy with tetanus antitoxin (equine) is associated with the risk of allergic reactions. Traditionally, tetanus is considered an infection that develops only in patients with deep and soil-contaminated wounds. However, unvaccinated or partially vaccinated individuals are at high risk of tetanus, even with minor wounds. This study involved an analysis of case reports of tetanus (13 cases) in unvaccinated or partially vaccinated individuals with minor wounds or wounds minimally contaminated with soil. In all the paediatric tetanus cases discussed in this article, the parents had not vaccinated their children for religious and/or personal reasons. The analysis of case reports of tetanus in adults showed that the patients had not taken their wounds seriously and had not sought medical help before the onset of the disease.CONCLUSIONS. The concerning incidence of tetanus is attributed to insufficient public awareness of the dangers of the disease and the rising number of people refusing vaccines. Health professionals, public organisations, and religious communities should work together to promote vaccination and improve health education. This will enhance public confidence in vaccination, increase preventive vaccination coverage, and reduce the incidence of tetanus.

Tetanus, analysis of 29 cases