Tetanus toxoid


Tetanus toxoid has been in use for several decades and has proven its effectiveness and safety. However, a few immediate and delayed reactions have been observed.
 
Incidence
Local reactions after booster injections:
 
pain - tenderness: 50 -85%
 
erythema-edema: 20 - 30%
 
marked swelling: 2%
 
abscess: 6 to 10/million doses.
 
Anaphylaxis: 1/million.
 
Risk factors
Previous history of reaction to tetanus toxoid.
 
Clinical manifestations
Anaphylactic shock.
 
Bronchospasm.
 
Nasal and ophthalmic pruritus.
 
Urticaria, angioedema.
 
Vasculitis, rashes.
 
Glomerulonephritis.
 
Diagnostic methods
Cutaneous testing (controversial).
 
Skin prick tests positive at 1/1000.
 
Intradermal skin tests positive at 1/10000.
 
Positive in a few patients with anaphylaxis. False positive and negative are frequent.
 
Specific IgE (controversial)
 
Positive in patients with anaphylaxis but:
 
50% of infants develop specific IgE antibodies after vaccination.
 
25% of subjects receiving tetanus booster injections have substantial IgE antibodies.
 
IgE response to tetanus toxoid is higher in atopic children.
 
Detection of circulating immune complexes in patients with vasculitis.
 
Mechanisms
IgE-mediated hypersensitivity: exceedingly rare.
 
Type III reaction (hyperimmunization): there is correlation between circulating tetanus toxoid IgG levels and the degree of local reaction.
 
Do not overlook the role played by thimerosal and aluminum hydroxide in some reactions.
 
Management
Obtain an antitetanus IgG titer to verify the need for a booster.
 
Use a tetanus toxoid formulation with a different preservative.
 
Use an isolated tetanus toxoid which has less reactogen than associations (diphtheria/ tetanus)
 
Desensitization has been reported to be effective.
 
1               0.02 cc       1/1 000           ID 
2               0.02 cc       1/100              ID
3               0.02 cc       1/10                SC
4               0.10 cc       1/10                SC         At 30 min intervals
5               0.05 cc       Full strength     SC
6               0.10 cc       Full strength     SC
7               0.15 cc       Full strength     SC
8               0.20 cc       Full strength     SC

References

  1. Piletta PA, Pasche-Koo F, Saurat JH, Hauser C, "Immediate local reaction to tetanus toxoid booster", Allergy. 1997; 52 (6): 676-7
  2. Barbaud A, Schmutz JL, Mougeolle JM, "Reactions immunoallergiques cutanées dues aux vaccins", Ann. Dermatol. Venereol. 1995; 122: 129-38
  3. Uriel AJ, Boyter AC, Mac Connachie AM, Nathwani D, "Immunization against tetanus in a hypersensitive individual using a graded dosing regimen (letter)", J. Infect. 1995; 30 (1): 83-4
  4. Sutter RW, "Adverse reactions to tetanus toxoid", JAMA. 1994; 271 (20): 1629
  5. Carey AB, Meltzer EO, "Diagnosis and "desensitization" in tetanus vaccine hypersensitivity", Ann. Allergy. 1992; 69 (4): 336-8 
     

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.