DIPHTHERIA

DIPHTHERIA…
• An acute bacterial disease primarily involving tonsils,
pharynx, larynx, nose…
• Occasionally other mucous membranes or skin and
sometimes conjunctiva or vagina.
• Infectious agent-Corynebacterium diphtheriae of
gravis, mitis or intermediate bio-types
• Aerobic gram-positive bacteria
Comment..!
•The characteristic lesion, caused by liberation of
a specific cytotoxin, is an asymmetrical adherent
greyish white membrane with surrounding
inflammation.
•The throat is moderately to severely sore in
facial or pharyngotonsillar diphtheria, cervical
lymph nodes somewhat enlarged and tender..
•There is marked swelling in moderate to sever
cases with edema of neck with extensive
tracheal membranes that progress to airway
obstruction.
 EPIDEMIOLOGY

• Transmission:
• Contact with a patient or carrier…
• More rarely, contact with articles soiled with
discharges from lesions of infected people.
• Raw milk has served as a vehicle.
• Asymptomatic respiratory tract carriage is important
in transmission.
• Diphtheria is endemic in INDIA.
• The infection usually occurs in the spring or winter
months.
 EPIDEMIOLOGY

• Reservoir Human
• Incubation period-Usually 2-5 days, occasionally
longer.
• Children aged 1-5 years are commonly infected
• A herd immunity of 70% is required to prevent
epidemics
• Overcrowding, poor sanitation and hygiene,
illiteracy, urban migration and close contacts can
lead to outbreak
•Period of communicability … Variable,
until virulent bacilli have disappeared from
discharge and lesions , usually 2 weeks or less ,
seldom more than 4 weeks.
•Effective antibio-therapy terminates shedding.
•The rare carrier may shed organism for 6
months or more …!!!
Susceptibility
• Infants born to immune mothers have passive
protection, which is usually lost before the
6th month.
• Disease or inapparent infection usually, but not
always, induces lifelong immunity.
• Immunization with toxoid produces prolonged but not
lifelong immunity.
 PATHOGENESIS

Entry into nose or mouth

The organism remains in the superficial layers of skin lesions or respiratory
tract mucosa, inducing local inflammatory reaction

The major virulence of the organism lies in its ability to produce the
potent 62-kd polypeptide exotoxin, which inhibits protein synthesis and
causes local tissue necrosis

Within the first few days of respiratory tract infection , a dense necrotic
coagulum of organisms, epithelial cells, fibrin, leukocytes and erythrocytes
forms, advances, and becomes a gray-brown, leather-like
adherent pseudomembrane . Removal is difficult and reveals a bleeding
edematous submucosa
• Local effect of diphtheritic toxin:
ØParalysis of the palate and hypopharynx
ØPneumonia
qSystemic effects (Toxin absorption ):
Økidney tubule necrosis
ØHypoglycemia
• Myocarditis:10-14 days … progressive congestive failure
• Later effect include neuropathies that mimics Guillain-
Barre syndrome
 CLINICAL MANIFESTATIONS

• Influenced by the anatomic site of infection, the immune status

of the host and the production and systemic distribution of
toxin
• Incubation period: 2-5 days
• Classification (location):
Ønasal
Øpharyngeal
Øtonsillar
Ølaryngeal or laryngotracheal
Ø skin, eye or genitalia
 CLINICAL MANIFESTATIONS

• Nasal diphtheria: Infection of the anterior nares-

more common among infants, purulent, erosive
rhinitis with membrane formation
• Shallow ulceration of the external nares and upper lip
is characteristic
• Unilateral nasal discharge is quite pathognomic of
nasal diphtheria
• Tonsillar and pharyngeal diphtheria:
sore throat is the universal early
symptom
• Only half of patients have fever and fewer have
dysphagia, hoarseness, malaise, or headache
• Mild pharyngeal injection tonsillar membrane
formation extend to involve the uvula, soft palate,
posterior oropharynx, hypopharynx, or glottic areas
• Underlying soft tissue edema and enlarged lymph
nodes: bull-neck appearance
• Laryngeal diphtheria: At significant risk for
suffocation because of local soft tissue edema and
airway obstruction by the diphtheritic membrane
• Classic cutaneous diphtheria is an indolent, non
progressive infection characterized by a superficial,
ecthymic, nonhealing ulcer with a gray-brown
membrane
Infection at Other Sites:
Ear (otitis externa), the eye (purulent and ulcerative
conjunctivitis), the genital tract (purulent and ulcerative
vulvovaginitis) and sporadic cases of pyogenic arthritis
Diagnosis
• Clinical features
• Culture: from the nose and throat and any other
mucocutaneous lesion. A portion of membrane should be
removed and submitted for culture along with underlying
exudate
• Elek test: rapid diagnosis (16-24 hrs)
 Preventive measures :
What are your ideas about the prevention measures??
Preventive measures :
• Educational measures are important : inform the public
particularly parents of young children, of the hazards of
diphtheria and need for active immunization.
• The only effective control is widespread active immunization
with Diphtheria toxoid which is part of DTP vaccine .
• The schedule recommended in developing countries is at
least 3 primary doses with booster dose.
IMMUNIZATION
• For children under 7-
A primary series of diphtheria toxoid combined with other
antigens, such as DTaP, or DTP-Hib ..
• For persons 7 and older-
Because adverse reactions may increase with age, a
preparation with a reduced concentration of diphtheria toxoid
(adult Td) is usually given after the seventh birthday for
booster doses. For a previously unimmunized individual, a
primary series of 3 doses of adsorbed tetanus and diphtheria
toxoids (Td) is advised …
Control of patient , contacts
and enviroment
WHAT ARE YOUR MEASURES ?!!
Control of patient , contacts and enviroment
•Report to local health authority …
• Isolation: Strict isolation for pharyngeal diphtheria,
contact isolation for cutaneous diphtheria , until 2
cultures from both throat and nose ( and skin lesion
in cutaneous diphtheria), not less than 24 hours
apart , and not less than 24 hours after cessation of
antibiotic therapy , that fail to show C. diphtheriae .
Where culture is impractical, isolation may end after
14 days of appropriate antibiotic therapy ).
• Concurrent disinfection: of all articles in contact with
patient…
• Management of contacts:
• All close contacts should have cultures from nose and
throat and kept under surveillance for 7 days.
• A single dose of benzathine penicillin ( or erythromycin for
7-10 days) is recommended for all household exposure to
diphtheria, regardless immunization status,
• Previously immunized contacts should received a booster
dose of diphtheria toxoid if more 5 years have elapsed since
their last dose.
• A primary series doses should be initiated for non
immunized contacts
 TREATMENT
1. Antitoxin:
Sensitivity test ( skin or eye testing) should be
used before giving antitoxin !!
Ø Mainstay of therapy
Ø Neutralizes only free toxin, efficacy diminishes
with elapsed time
Ø Antitoxin is administered as a single empirical dose
of 20,000-100,000 U based on the degree of
toxicity, site and size of the membrane, and duration
of illness
2. Antimicrobial therapy
Ø Halt toxin production, treat localized infection and prevent
transmission of the organism to contacts
Ø Erythromycin (40-50 mg/kg/day 6 hrly parenteral
Ø Crystalline penicillin G (100,000-150,000 U/kg/day 6 hrly IV or
[IM]), or procaine penicillin (25,000-50,000 U/kg/day 12 hrly IM)
for 14 days
Ø Antibiotics are not a substitute for antitoxin …!
• Prognosis: depends on the virulence of the organism
(subspecies gravis), patient age, immunization status,
site of infection and speed of administration of the
antitoxin
• The case fatality rate of almost 5- 10% for
respiratory tract diphtheria have change little in 50
years.

•Thanks ...