Diphtheria

Is an acute infectious disease of the childhood

characterized by local inflammation of the
epithelial surface , formation of a membrane ,
and severe toxemia

Epidemiology : -
Age groups : Pre school age children
Occurs in the autumn and winter months.

Caused by ---- Gram positive bacilli,
Corynebacterium diphtheria
Cont ..
Source : -
- secretions and discharge from an infected
person or carrier
Human are chief reservoirs
Mode of transmission : -
Contact or through droplets of secretion
Portal of entry :
Respiratory tract
May enter through the conjuntiva or skin
wound
Risk factors
1. Poor nutrition.
2. Outbreak in the community.
3. Crowded or unsanitary living conditions.
4. Low vaccine coverage among infants and
children.
5. Lack of mass immunization programmes
amongst children and adults at high risk.
6. Insufficient information for the general public on
dangers of the disease and the benefits of
immunization.
7. Lack of vaccines in many areas.



Pathogenesis
Entry ------ the bacilli multiply locally in the throat and
elaborate a powerful exotoxin ----- produce local and
systemic symptoms.
Local lesions :
Exotoxin causes necrosis of the epithelial cells and
liberates serous and fibrinous material which forms a
grayish white pseudomembrane

The membrane bleeds on being dislodged

Surrounding tissue is inflamed and edematous
Cont
Systemic lesions :
Exotoxin affects the heart , kidney and CNS

Heart :
Myocardial fibers are degenerated and the
heart is dilated
Conduction disturbance

CNS : polyneuritis

Kidney : renal tubular necrosis
Clinical features
Incubation period : 2 5 days
Constitutional symptoms:

Onset : acute with fever ( 39 C ) , malaise ,
headache and loss of appetite

Child looks very sick and toxic

Delirium

Circulatory collapse ( myocarditis )
Local manifestation
Depend on the site of
lesion:
Nasal diphtheria :
Unilateral or bilateral
serosanguineous ( blood and
serous fluid ) discharge from
the nose
Excoriation of upper lip
Toxemia is minimal

Faucial diphtheria :
Redness and swelling over
fauces
Exudates on the tonsils
coalesces to form grayish
white pseudo membrane
Regional lymph nodes are
inflamed
Sore throat and
dysphagia
Fauces ( throat )
Fauces : - two pillars of mucous membrane.
Anterior : known as the palatoglossal arch and
Posterior : the palatopharyngeal arch
Between these two arches is the palatine tonsil.
Cont
Laryngotracheal diphtheria :
Membrane over the larynx results in
brassy ( hardness ) cough and
hoarse voice
Respiration ------- noisy
Suprasternal and subcostal
recession
Restlessness
Increasing respiratory effort
Use of accessory muscles

Unusual sites :
Conjunctiva and
skin
In the skin :
Ulcers ( tender )
Diagnosis

clinical history , examination and identification of
diphtheria bacilli from the site of lesion.

Culture

Albert`s staining

Fluorescent antibody technique
Schick Test
Schick test: It is an intradermal test,
the test is carried out by injecting
intradermally into the skin of
forearm 0.2 ml of diphtheria toxin,
while into the opposite arm is
injected as a control, the same
amount of toxin which has been
inactivated by heat.
Interpretation
Negative reaction: If a person had immunity to diphtheria,
no reaction will be observed on either arm.

Positive reaction: An area of in duration 10-15 mm in
diameter generally appears within 24-36 hours reaching
its maximum development by 4-7 days, the control arm
shows no change. The person is susceptible to diphtheria.

False positive reaction: A red flush develops in both arms,
the reaction fades very quickly, and disappears by 4
th
day.
This is an allergic type of reaction found in certain
individuals
Combined reaction: the control arm shows pseudo
positive reaction and the test arm is true +ve reaction,
susceptible and need vaccination
Differential diagnosis
Nasal diphtheria :
Foreign body in nose ,
Rhinorrhea


Laryngeal diphtheria :
Croup
Acute epiglottitis
Laryngotracheobronchitis
Peritonsillar abscess
Retropharyngeal abscess

Cont .
Faucial diphtheria :
Acute streptococcal membranous tonsillitis (
high grade fever , child less toxic )

Viral membranous tonsillitis :
high grade fever ,
WBC : normal or low ,
Antibiotic : no effects

Herpetic tonsillitis ( Gingivitis and stomatitis )

Infectious mononeucleosis :
Generalised rash and lymphadenopathy besides
oral mucosal lesions

Treatment
Principles :
Neutralization of free circulating toxin by
administration of antitoxin

Antibiotic to eradicate bacteria

Supportive and symptomatic therapy

Management of complication
Antitoxin
Diphtheria antitoxin :
Pharyngeal or laryngeal diphtheria of 48 hours
duration : 20,000 to 40,000 units.
Nasopharyngeal lesions : 40,000 60,000 units
Extensive disease of 3 or more days duration or
patient with swelling of neck : 80,000 120,000
units
Antitoxin may be repeated if the clinical
improvementis slower
Antibiotics
Penicillin :
Procaine penicilline ( 3 6 lac units IM at 12
hourly intervals till the patient is able to swallow )
Oral penicillin ( 125 250 mg qid )

Erythromycin ( 25 30 mg / kg / day ) for 14
days

Three negative cultures at 24 hours intervals
should be obtained before the patient is
declared free of the organism






Supportive and symptomatic therapy

Bed rest for 2 3 weeks ( to reduce cardiac
complications )

Antipyretics and sedative ( if required )

Monitor rate and rhythm of the heart
Management of complication
Respiratory obstruction :
Humidified oxygen
Tracheostomy

Myocarditis :
Fluids and salt restriction
Sedation and oxygen supply
Diuretics and digoxin

Neurological complications :
Palatal paralysis ( NG feeding )
Generalised weakness ( as polio )
Complications
Myocarditis :
Occurs towards the end of the first or beginning
of second week
Abdominal pain , vomiting , dyspnea ,
tachycardia
Neurological complications : ( Traid )
Palatal paralysis ( 2 weeks )
General polyneuritis ( 3 6 weeks )
Loss of accommodation ( 3 weeks )
Renal complications :
Oliguria and proteinuria indicate kidney
complications
Prevention

Vaccination: Immunisation with diphtheria toxoid,
combined with tetanus and pertussis toxoid (DTP
vaccine), should be given to all children at two,
three and four months of age. Booster doses are
given between the ages of 3 and 5 .


The child is given a further booster vaccine
before leaving school and is then considered to
be protected for a further 10 years (16 18
years).


Prognosis
Death may occur due to : -

Respiratory obstruction

Myocarditis

Respiratory paralysis