CASE PRESENTATION

TETANUS
dr. Yohanes Adeo Caesar E.S
Pembimbing : dr. Franky Sientoro Sp.A
IDENTITAS
 Nama : An. A

 Usia : 4 th

 Jenis Kelamin : Laki-Laki

 Agama : Islam

 No. RM : 29 72 xx

 Tanggal masuk : 5 Januari 2018 Tanggal keluar : 22 Januari 2018

Ayah Ibu
Nama Tn.K Ny.A
Pekerjaan Buruh Bangunan Ibu Rumah Tangga
Pendidikan Terakhir SD SD
Usia 33 thn 29 thn
ANAMNESIS
 KELUHAN UTAMA :

Kaku Seluruh Tubuh

 Riwayat Penyakit Sekarang
 3HSMRS: Anak mengeluh batuk. Orang tua mengatakan batuk
berdahak.Dahak berwarna putih ,tidak ada darah.Keluhan demam
disangkal.Anak tidak mengeluh pilek.Mual dan muntah disangkal. Ibu
memberi Anak obat batuk namun tidak membaik.
 HMRS: Anak dibawa ke RSUD Tarakan oleh orang tuanya dengan keluhan
kaku pada seluruh tubuh sejak 6 jam sebelum masuk RS(subuh).Kaku
dirasakan hingga anak kesulitan membuka mulut.Oleh orang tuanya
dikatakan anak kesulitan bernafas dan terlihat biru pada bibirnya.Selama
keluhan berlangsung anak tetap dalam keadaan sadar.Sebelumnya anak
sempat dibawa ke puskesmas namun langsung diberi rujukan ke
RSUD.Orangtua mengatakan anaknya masih batuk.Demam
disangkal.Awalnya orangtua mengatakan anaknya kesusahan membuka
mulut dan menelan saat makan lalu kaki dan tangan mulai kaku.Anak
memiliki kebiasaan mengorek gigi/gusi dengan kayu/lidi setelah makan
kadang hingga tergores dan berdarah.Orangtua mengatakan anaknya
memiliki gigi berlubang sejak usia 3 tahun dan jarang menyikat gigi.
 Riwayat Penyakit Dahulu

 Riwayat infeksi tali pusat saat lahir disangkal

 Riwayat Kejang demam disangkal
 Riwayat Batuk lama(TB)/Asma disangkal
 Riwayat Tumor/Keganasan disangkal
 Riwayat Infeksi otak disangkal

Simpulan : tidak terdapat riwayat penyakit serupa yang berhubungan

dengan penyakit sekarang.
 Riwayat Penyakit Keluarga
 Riwayat Tumor otak disangkal
 Riwayat Kejang disangkal
 Riwayat TB atau Asma disangkal

Simpulan : tidak terdapat riwayat penyakit keluarga yang

berhubungan dengan kondisi pasien sekarang.
Genogram
75 thn

35 thn 29 thn

14thn 11 thn 9thn 4 thn

Riwayat TB
Pasien
 Riwayat Antenatal Care
 Ibu G4P3A0 usia 29 tahun kontrol kehamilan di puskesmas dan bidan
namun tidak rutin sesuai jadwal(kurang dari 4 kali) . Selama hamil tidak
keluhan. Selama hamil mengkonsumsi zat besi, Folat, dan Kalsium. Vaksin
tetanus sudah dilakukan sebanyak 2 kali.

Simpulan: Riwayat ANC kurang baik

Riwayat Natal Care
 Bayi lahir di rumah, lahir spontan ditolong oleh dukun
beranak, presentasi kepala. Bayi menurut ibu lahir cukup
bulan .Berat badan dan panjang badan tidak dilakukan
pengukuran. Saat lahir langsung menangis. Tidak dilakukan
Inisiasi menyusui dini.
 Perawatan tali pusat dilakukan oleh dukun

Simpulan: Riwayat kelahiran normal ,namun kurang baik

Riwayat Post-Natal Care
 Riwayat ikterik disangkal
 Bayi tidak diberi vaksin HepB dan vit K.
 Tidak ada keluhan pasca melahirkan dan tidak kontrol ke bidan atau puskesmas
kembali

Simpulan: Riwayat Post Natal Care kurang baik

Riwayat Makanan
 0-6 bln : ASI eksklusif (6-8x/ hari)
 7-9 bln : ASI + bubur saring + (2-3x/hr)
 9-12 bln : ASI + bubur nasi kental + buah parut (3-4x/hr)
 12bln-2thn : ASI + susu formula + makanan keluarga (2-3x/hari)
 2 thn-skrg : Makanan keluarga +susu formula (2-3x/hari)

Simpulan: asupan nutrisi cukup

 Riwayat Perkembangan
Motorik Kasar Motorik Halus Bicara Personal-Sosial

Miring-miring: 2 bulan Memegang Bicara 3-5 kata dengan Saat ini anak selalu
Berdiri berpegangan: 10 benda/mainan: 4 arti: 15 bln dapat diajak
bulan bulan berkomunikasi dan
Berjalan: 24 bulan dapat berinteraksi
dengan lingkungan
sekitar

Simpulan: riwayat perkembangan sesuai usia

Status Imunisasi
Jenis Waktu Waktu pemberian Tempat
imunisasi pemberian standar pemberian
BCG - 0 – 2 bulan -
Hep B - 0, 2, 3, 4 bulan -
DPT - 2,3,4 bulan -
Polio 2 bulan 0-2,2,3,4 bulan posyandu
Campak - 9 bulan -

Simpulan: status imunisasi tidak lengkap

Sosial Ekonomi dan Lingkungan
Anak tinggal bersama ayah dan ibu serta kakaknya di rumah proyek tempat
bekerja ayahnya(berpindah-pindah) dengan atap genteng, lantai semen,
dinding tembok, ventilasi dan sanitasi baik, sumber air dari PAM .

Ayah bekerja sebagai buruh bata dengan gaji ±1.000.000/bulan.

.

Simpulan: ekonomi menengah kebawah,lingkungan tidak ada risiko penyakit sekarang

Anamnesis sistem
 Termoregulasi : tidak demam
 Sistem serebrospinal : tidak kejang,tidak ada penurunan kesadaran
 Sistem kardiovaskular : akral hangat, nadi kuat, CRT<2s
 Sistem respiratorius : sesak, batuk (+), pilek (-)
 Sistem gastrointestinal : tidak mual, tidak muntah, BAB normal
 Sistem urogenital : BAK normal
 Sistem muskuloskeletal : Kaku diseluruh tubuh
 Sistem integumentum : pucat(-),bintik merah(-),kuning(-)

Simpulan: Terdapat sesak,batuk,kaku pada seluruh tubuh

Pemeriksaan Fisik (5/1/2018)
 Kesan umum : compos mentis, gizi kurang
 Tanda Vital
 Nadi : 110/menit, isi tegangan cukup, teratur
 Respirasi : 26/menit, tipe abdominothorakal
 Suhu : 36,0oC, axilla
 SpO2 : 97%
Status Gizi
 Klinis : tampak gizi kurang

 Antropometris :
 BB : 13,0 kg
 TB : 99,0 cm -BB/U : -3 < Z <- 2 SD
 LK: 48,0 cm -TB/U : -3 < Z < -2 SD
 LD: 51,0 cm -BB/TB : -2 < Z < 0 SD
 LP: 43,0 cm -BMI/U : -2 < Z < 0 SD
 LLA: 12 cm
 BMI : 13,3 kg/m2

Simpulan : Status gizi kurang,pendek

Pemeriksaan Fisik
 Leher :JVP tidak meningkat, lomfonodi tidak teraba

 Thoraks : simetris, retraksi (-)

 Jantung : batas jantung

SIC II LPSD SIC II LPSS

SIC IV LPSD SIC IV LMCS

suara jantung : S1 S2 tunggal reguler, murmur(-),gallop(-)

Simpulan : leher dan thorax dalam batas normal

 Pemeriksaan Fisik
 Paru-paru

Kanan Kiri
DEPAN
Simetris Inspeksi Simetris
Ketinggaln gerak(-) Palpasi Ketinggaln gerak(-)
Sonor Perkusi Sonor
Suara dasar vesikular, Auskultasi Suara dasar vesikular,
suara tambahan (-) suara tambahan (-)

Kanan Kiri
BELAKANG
Simetris Inspeksi Simetris
Ketinggaln gerak(-) Palpasi Ketinggaln gerak(-)
Sonor Perkusi Sonor
Suara dasar vesikular, Auskultasi Suara dasar vesikular,
suara tambahan (-) suara tambahan (-)
Simpulan : paru-paru dalam batas normal.
Pemeriksaan Fisik
 Abdomen :
 Inspeksi : datar

 Auskultasi : peristaltik usus positif

 Perkusi : timpani

 Palpasi
 Teraba keras seperti papan,spasme otot(+)

 Hati: tidak teraba

 Limpa: tidak teraba

Simpulan : spasme otot abdomen

 Pemeriksaan Fisik
 Ekstremitas : akral hangat,nadi kuat,CRT<2 detik,opistotonus (+)
Tungkai Lengan
Tungkai kiri Lengan kiri
kanan kanan
Gerakan terbatas Terbatas Terbatas terbatas
Kekuatan tdp tdp tdp tdp
Tonus meningkat meningkat meningkat meningkat
Trofi Eutrofi Eutrofi Eutrofi Eutrofi
Clonus - -
Refleks fisiologis +meningkat +meningkat +meningkat +meningkat
Refleks
(-)
pathologis
Meningeal sign (-)
Sensibilitas Normal Normal Normal Normal

Simpulan : terdapat peningkatan tonus dan reflex fisiologis

Pemeriksaan Fisik
 Kepala:
 Bentuk : normosefall
 Ubun-ubun : menutup,tidak cekung
 Mata : mata cowong (-), konjungtiva anemis (-).pupil isokor,reflex cahaya+/+
 Hidung : tidak ada sekret
 Telinga : tidak ada sekret
 Mulut : bibir kering (+),trismus(+)
 Faring : hiperemis (-)
 Gigi : caries dentis (+)

Simpulan :terdapat trismus dan bibir kering

Pemeriksaan Penunjang
 Hasil pemeriksaan darah rutin (5/1/2018) :
Diagnosis
 Tetanus
Tatalaksana di IGD
 O2 3lpm basal kanul
 NGT
 D5½NS 10 tpm ,drip fortanest 0,1mg/kgbb/jam (k/p)
 Inj.Ceftriaxon 500mg/12jam
 Inj.Methylprednisolon 10mg/8jam
 Tetagam 500IU i.m
 Rawat ruang observasi
FOLLOW UP
6/1 7/1 8/1 9/1 10/1 11/1 12/1
S Kaku seluruh tubuh Bibir terasa nyeri Lemas Nyeri bibir(-) Mulut mulai bisa
Batuk (+) Bibir pecah-pecah(+) Batuk dibuka ± 1 cm
Berkurang Kaku di tubuh
berkurang
O Trismus(+) HR 108x/m Dental Status HR 106x/m BB/TB < -2SD HR :107x/m Exfoliatif labialis
Perut Papan (+) RR 24x/m Gingiva Eritema (+) RR 24x/m RR :19x/m
Ektremitas spastik HR :110x/m
T 36,2 Plak (+) T 36,6 HR :110x/m T :36,7
Refleks Fisiologis (+) RR :24x/m
HR 126x/m SaO2 98% dg Debris (+) RR :20x/m
HR 101x/m T : 36,3
RR 28x/m nasal kanul 3lpm Rampant Caries (+) T :36,4
RR 23x/m Reflek patologis (-)
T 36,6 Reflek fisiologis dbn
T 36,4
SaO2 99% dg nasal SaO2 99% dg nasal kanul Tonus normal
kanul 3lpm 3lpm Clonus (-)
A Tetanus + Caries Multiple + Cheilitis Labialis
+Gingivitis Marginalis Inferior
Kronis
P • D5 ½ NS + Drip Fortanest Co drg Sp.PM + Paracetamol 3x1cth Drip Fortanest D5 ½ NS +Kenalog 3x1
1000cc/24 jam 0,1 mg/kgBB/jam +Alocrail Gel 0,05mg/kgbb/jam 20tpm Cek DL
(0,13cc/jam)
• Ceftriaxon (0,26cc/jam)
500mg/12jam Co Ahli Gizi
• MP 10mg/8jam + Diet Bubur Cair
• Tetagam 500IU TKTP
• Comtusy 3x1cth + F75
• Vectrin 3x1cth 110cc/2jam
D5 ½ NS 10tpm
• Aminofusin Ped
500cc/24jam
• Nutrisi per NGT
FOLLOW UP
13/1 14/1 15/1 16/1 17/1 18/1 19/1

S Kaki dan Buka mulut ± 2cm Bisa berdiri Bicara Mulai jelas
Tangan mulai Kaki dan tangan Mulut blm bisa Berjalan dibantu
bs digerakkan bisa diluruskan membuka maksimal Luka dibibir (-)
Bisa duduk Bicara belum jelas

O HR :104 HR :114 HR :106 Deskuamasi Status lokalis Labium HR :114x/m Deskuasmasi

RR :22 RR : 19 RR : 22 Labialis Inferior • Deskuasmasi RR :23x/m berkurang
T :36,4 T :36,8 T :36,7 berkurang T : 36,5 Ulcer membaik
HR :109x/m • Fisurra (-) Plak pada bagian
RR :21x/m Status Lokalis Glossus lateral kanan lidah
T : 36,8 • Ulcer minor (+) Tonus otot normal
• Plak putih(+) Klonus (-)
HR :110x/m HR :112x/m
RR :24x/m RR :20x/m
T : 36,6 T :36,4
A +Stomatitis

P • Venflon • Aminofusin
• Ceftriaxon stop Ped Stop
• MP 7,5mg/8jam • +Neurobion
• Paracetamol Stop 5000/24jam
FOLLOW UP
20/1 21/1 22/1

S Kaki dan Tangan mulai bs Mulut bs membuka

digerakkan lebar

O HR :110x/m HR :102x/m HR :100x/m

RR :24x/m RR :22x/m RR :20x/m
T :36,4 T :36,6 T :36,5
Status lokalis Labium :
• Deskuamasi (-)
• Plak (-)

P +Fisioterapi Acc Pulang

+ Sanvita Syr 1x1cth Terapi oral :
Aff NGT -Paracetamol Syr 3x1cth
-Comtusy Syr 3x1cth
-Sanvita Syr 1x1cth

Kontrol poli anak dan Gigi

tgl 25/1/2018
PEMBAHASAN
TETANUS
Backg r ound

 An infectious disease caused by

contamination of wounds from the
bacteria Clostridium tetani, or the
spores they produce that live in the
soil, and animal feces

 Greek words -“tetanus and teinein”,

meaning rigid and stretched, which
describe the condition of the muscles
affected by the toxin, tetanospasmin,
produced by Clostridium tetani
 Brief history of disease
 5th century BC: Hippocrates first described the disease
 1884: Carle and Rattone discovered the etiology (cause/origin of disease)
 Produced tetanus by injecting pus from a fatal human case
 Nicolaier was able to do the same by injecting soil samples into animals

 1889: Kitasato isolated the organism from human victim, showed

that it could produce disease when injected into animals. Reported
that toxin could be neutralized by specific antibodies.
 1897: Nocard demonstrated the protective effect of passively
transferred antitoxin  used in WWI
 1924: Descombey developed tetanus toxoid for active
immunization  used in WWII
Epidemiology
A sharp decrease after tetanus toxoid
was introduced into routine childhood
immunization in the late 1940s.
All time low in 2002 – 25 cases (0.4
cases in 100,000 population)

From 2009 through 2015, a total of 197

cases and 16 deaths from tetanus were
reported in the United States.

Surveillance Manual Tetanus: Chapter 16.1 CDC

Indonesia
Causative agent
 Clostridium tetani

Left. Stained pus from a mixed anaerobic infection

Right. Electron micrograph of vegetative Clostridium tetani cells.
Morphology & Physiology

 Relatively large, Gram-positive, rod-shaped bacteria

 Spore-forming, anaerobic.
 Found in soil, especially heavily-manured soils, and in the
intestinal tracts and feces of various animals.
 Strictly fermentative mode of metabolism.
Virulence & Pathogenicity

 Not pathogenic to humans and

animals by invasive infection but by
the production of a potent protein
toxin
 tetanus toxin or tetanospasmin
 The second exotoxin produced is
tetanolysin—function not known.
Tetanus toxin
 Produced when spores germinate and vegetative cells grow after
gaining access to wounds. The organism multiplies locally and
symptoms appear remote from the infection site.
 One of the three most poisonous substances known on a weight
basis, the other two being the toxins of botulism and diphtheria.
 Tetanus toxin is produced in vitro in amounts up to 5 to 10% of the bacterial
weight.
 Estimated lethal human dose of Tetanospamin = 2.5 nanograms/kg body
 Because the toxin has a specific affinity for nervous tissue, it is
referred to as a neurotoxin. The toxin has no known useful
function to C. tetani.
  Initially binds to peripheral nerve
terminals
 Transported within the axon and
across synaptic junctions until it
reaches the central nervous
system.
 Becomes rapidly fixed to
gangliosides at the presynaptic
inhibitory motor nerve endings,
then taken up into the axon by
endocytosis.

 Blocks the release of inhibitory neurotransmitters (glycine and gamma-amino

butyric acid) across the synaptic cleft, which is required to check the nervous
impulse.
 If nervous impulses cannot be checked by normal inhibitory mechanisms, it leads to
unopposed muscular contraction and spasms that are characteristic of tetanus.
Mechanism of Action of Tetanus Toxin
 Methods of transmission

 C. tetani can live for years as spores in animal feces and

soil. As soon as it enters the human body through a
major or minor wound and the conditions are anaerobic,
the spores germinate and release the toxins.
 Tetanus may follow burns, deep puncture wounds, ear or
dental infections, animal bites, abortion.
 Only the growing bacteria can produce the toxin.
 It is the only vaccine-preventable disease that is
infectious but not contagious from person to person.
Symptoms
 Tetanic seizures (painful, powerful bursts of muscle contraction) .
 if the muscle spasms affect the larynx or chest wall, they may
cause asphyxiation
 stiffness of jaw (also called lockjaw)
 stiffness of abdominal and back muscles (Opisthotonus)
 contraction of facial muscles (Risus sardonicus)
 fast pulse
 sweating
The back muscles are more
powerful, thus creating the arc
backward

“Oposthotonus” by Sir
Charles Bell, 1809.

Baby has neonatal tetanus

with complete rigidity
CLASSIFICATION
 Types of tetanus:
local, cephalic, generalized, neonatal
 Incubation period: 3-21 days, average 8 days.

Uncommon types:
 Local tetanus: persistent muscle contractions in the same anatomic area as
the injury, which will however subside after many weeks; very rarely fatal;
milder than generalized tetanus, although it could precede it.

 Cephalic tetanus: occurs with ear infections or following injuries of the head;
facial muscles contractions;Trismus and localised paralysis,usually facial nerve,
often unilateral.
Involvement of cranial nerves VI,III, IV, and XII may also occur either alone or in
combination with others.High mortality
 Most common types:
Generalized tetanus
- Descending pattern: lockjaw  stiffness of neck  difficulty
swallowing  rigidity of abdominal and back muscles.
- Spasms continue for 3-4 weeks, and recovery can last for months
- Death occurs when spasms interfere with respiration.

Neonatal tetanus:
- Form of generalized tetanus that occurs in newborn infants born
without protective passive immunity because the mother is not
immune.
- Usually occurs through infection of the unhealed umbilical stump,
particularly when the stump is cut with an unsterile instrument.
 Methods of diagnosis
 Based on the patient’s account and physical findings that are
characteristic of the disease. Diagnosis is done clinically based on
the presence of trismus or risus sardonicus or generalized muscular
contraction.

 Diagnostic studies generally are of little value, as cultures of the wound site
are negative for C. tetani two-thirds of the time

 Tests that may be performed include the following:

 Culture of the wound site (may be negative even if tetanus is present)
 Other tests may be used to rule out meningitis, rabies, strychnine
poisoning, or other diseases with similar symptoms.
 Spatula test

Current recommendation for treatment of tetanus during humanitarian emergencies ,WHO

 PRINCIPLE OF TREATMENT
1. Neutralization of unbound toxin
-HTIG/ATS
2. Prevention of further toxin production
-Wound debridement & antibiotics
3. Antibiotics
4. Control of spasm
-Anticonvulsants, Sedatives, Muscle relaxants etc.
5.Supportive care
-Physiotherapy, Nutrition, Thromboembolism
prophylaxis ABC etc…

Daniel J Sexton, MD,www.uptodate.com/contents/tetanus

 1.TOXIN
• A single intramuscular dose of ATS 3000-5000
units (100U/kg-half in each buttocks) is generally
recommended for children and adults, with part of
the dose infiltrated around the wound if it can be
identified.
• WHO recommends TIG 500 units by IM/IV
(depending on the available preparation) as soon as
possible; in addition, administer age-appropriate
TT-containing vaccine (Td, Tdap, DT, DPT, DTaP,
or TT depending on age or allergies), 0.5 cc by
intramuscular injection at separate site with HTIG.
• TIG can only help remove unbound tetanus
toxin, but it cannot affect toxin bound to nerve
endings.
•

Pedoman Pelayanan Medis IDAI,2009

 2. PREVENTION OF FURTHER TOXIN PRODUCTION

• Debridement of Wound to remove organisms and to

create an aerobic environment.
 The current recommendation is to excise at least 2 cm of normal
viable-appearing tissue around the wound margins.
 Incise and drain abscesses.
 Delay any wound manipulation until several hours after
administration of antitoxin due to risk of releasing
tetanospasmin into the bloodstream.
 Wound Management

Surveillance Manual Tetanus: Chapter 16.1 CDC

 3. ANTIBIOTICS
 Theoretically, antibiotics may prevent multiplication of C
tetani, thus halting production of toxin.

Metronidazole: 30 mg/kg per day, given at 6-hour intervals; maximum 4 g/day)

Penicillin G : 100 000 U/kg per day, given at 4- to 6-hour intervals;
maximum 12 million U/day

A 10 to 14 day course of treatment is recommended. Some consider

metronidazole as the DOC since penicillin G is also a GABA agonist, which
may enhance effects of the toxin.
Doxycycline, Clindamycin and Erythromycin are alternative for
penicillin allergic patients who can not tolerate metronidazole.

Report of the Committee on Infectious Diseases,Red Book,2012 AAP

 
4. Control of spasm
• Nursing in quiet environment, avoid unnecessary stimuli,
-Protecting the airway.
• Drugs used to treat muscle spasm, rigidity, and tetanic seizures
include sedative-hypnotic agents, general anesthetics, centrally
acting muscle relaxants, and neuromuscular blocking agents.
-
-

Anticonvulsants
Sedative-hypnotic agents are the mainstays of tetanus treatment.
Benzodiazepines are the most effective primary agents for muscle spasm
prevention and work by enhancing GABA inhibition.
 Diazepam:
• Mainstay of treatment of tetanic spasms and tetanic seizures. Depresses all
levels of CNS, including limbic and reticular formation, possibly by increasing
activity of GABA, a major inhibitory neurotransmitter.
• Diazepam can be used as 10 mg/kg/day or 0,1-0,2mg/kg iv/im every 3-6 hrly.

Pedoman Pelayanan Medis IDAI,2009

PREVENTION
Reference
 Pedoman Pelayanan Medis IDAI,2009
 Surveillance Manual Tetanus: Chapter 16.1 CDC
 Report of the Committee on Infectious Diseases,Red Book,2012 AAP
 Current recommendation for treatment of tetanus during humanitarian
emergencies ,WHO
 Daniel J Sexton, MD,www.uptodate.com/contents/tetanus
TERIMA KASIH 
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