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Death results from pneumonia, aspiration, atelectasis, pulmonary edema, and asphyxia in the majority of cases, with septicemia and cardiac arrest accounting for other deaths. The crude fatality rate is approximately 45% but may be as high as 70%. It appears to be somewhat higher in most parts of Africa than in the series reported from South America (135 per 100,000 compared with 63 per 100,000).

The mortality can be significantly lowered by treatment with muscle relaxants and proper pulmonary management, but such treatment requires a high level of medical care and excellent facilities. It is successful: in one series from Durban, Natal (South Africa), only 3 of 171 babies with tetanus neonatorum died. Unfortunately adult tetanus may not respond as well to curarization and aided respiration as does the childhood disease. Opinions and reports differ in their assessment of this complex therapy, and may also reflect the virility of the local organism.

The spasms of tetanus may be sufficiently severe that they cause fractures of the spine and elsewhere. Spinal fractures and, rarely, dislocation seldom have any great clinical significance or effect on the mortality. Neonates are less likely to show spinal fractures than children and young adults, but no age is immune. The number and severity of the spinal fractures vary with the frequency and severity of the reflex spasms. It is probable that fractures result from mechanical stress, although a vascular element cannot be excluded. The exact mechanism has been debated in the literature, but there is no doubt that the reflex spasms are the most likely cause, superimposed on the underlying rigidity. The midthoracic spine is the most commonly affected, and fractures in the lumbar and cervical regions are uncommon, although they can occur. Dislocation is a rare complication and is most frequently seen in neonates and young children. Although the spinal fractures are commonly multiple, it is very rare for them to have any clinical repercussions.

Other fractures may be more frequent than has been previously thought. A retrospective search of the records of 171 neonatal tetanus patients showed ten with bilateral acromion fractures (Kalideen, Satyapal, 1994). All were bilateral and symmetrical, and with one exception, occurred at the same time on each side. These fractures, which appear to be avulsion of the segment of the acromion from which the multipinnate fibers of the subscapularis muscle arise, can occur even when the infants are on paralytic and ventilation therapy. (In such cases the prognosis is poor.)

Rib fractures and even femoral neck fractures can occur. Post-tetanus myositis ossificans and heterotopic ossification following dislocation have also been reported.
It is sad that this fearful illness and form of death should still be so common when it is entirely preventable.


Imaging Diagnosis

The most significant radiological findings are seen in the spine (Figs. 33.1-33.3). However, the radiologist must maintain a sense of proportion because, despite their frequency, spinal fractures are seldom of significance in the management of the acute stages of the disease. They apparently cause no pain and do not affect the prognosis or lead to neurological sequelae; furthermore, should the patient recover, the resulting deformity is often slight. The fractures in the spine are usually multiple and almost always in the midthoracic region, most commonly involving the fourth to the sixth thoracic vertebrae; as many as nine fractures have been observed in the same patient. Lumbar and cervical fractures are uncommon; vertebral dislocation is rare but can occur, in infants in particular.

Fig. 33.1. Subluxation of the upper lumbar vertebrae in a child with tetanus neonatorium. (Courtesy of the University of Capetown, Radiology Library).

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Fig. 33.2. A Severe compression fractures of multiple upper thoracic vertebrae 3 months following tetanus, in a 12 year-old African male from South Africa. B Six months after tetanus this 14 year-old African male from South Africa has healed compression fractures of the upper thoracic spine. (Courtesy of Dr. J. M. Kalideen, Durban).

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Fig. 33.3 A-D. (A,B) Compression of midthoracic vertebrae in an 11 year-old male who had severe tetanus. He had arrived at the hospital 30 hours previously complaining of neck stiffness and later developed convulsions. Even minimal stimulation sent him into gross muscular spasms. However, he was discharged well from the hospital 6 weeks later. (C, D) Compression fractures, of varying severity, affecting six contiguous upper thoracic vertebrae with resulting kyphosis, in an African male from Kenya with severe tetanus.

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