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Diphtheria
Is an acute infectious disease of the childhoodcharacterized 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
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Cont ..
Source : -
- secretions and discharge from an infectedperson or carrier
Human are chief reservoirsMode of transmission : -
Contact or through droplets of secretion
Portal of entry : Respiratory tract
May enter through the conjuntiva or skinwound
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Risk factors1. Poor nutrition.
2. Outbreak in the community.
3. Crowded or unsanitary living conditions.
4. Low vaccine coverage among infants andchildren.
5. Lack of mass immunization programmesamongst children and adults at high risk.
6. Insufficient information for the general public ondangers of the disease and the benefits ofimmunization.
7. Lack of vaccines in many areas.
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Pathogenesis
Entry ------ the bacilli multiply locally in the throat andelaborate a powerful exotoxin ----- produce local andsystemic symptoms.
Local lesions : Exotoxin causes necrosis of the epithelial cells and
liberates serous and fibrinous material which forms agrayish white pseudomembrane
The membrane bleeds on being dislodged
Surrounding tissue is inflamed and edematous
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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
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Clinical features
Incubation period : 2
5 daysConstitutional symptoms:
Onset : acute with fever ( 39 C ) , malaise ,
headache and loss of appetite
Child looks very sick and toxic
Delirium
Circulatory collapse ( myocarditis )
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Local manifestationDepend on the site of
lesion:Nasal diphtheria :
Unilateral or bilateralserosanguineous ( blood andserous fluid ) discharge from
the nose Excoriation of upper lip
Toxemia is minimal
Faucial diphtheria :
Redness and swelling overfauces
Exudates on the tonsilscoalesces to form grayishwhite pseudo membrane
Regional lymph nodes areinflamed
Sore throat and
dysphagia
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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.
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Cont Laryngotracheal diphtheria :
Membrane over the larynx results in
brassy ( hardness ) cough and
hoarse voice
Respiration ------- noisy
Suprasternal and subcostalrecession
Restlessness
Increasing respiratory effort
Use of accessory muscles
Unusual sites :
Conjunctiva andskin
In the skin :
Ulcers ( tender )
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Diagnosis
clinical history , examination and identification of
diphtheria bacilli from the site of lesion.
Culture
Albert`s staining
Fluorescent antibody technique
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Schick Test
Schick test: It is an intradermal test,
the test is carried out by injecting
intradermally into the skin offorearm 0.2 ml of diphtheria toxin,
while into the opposite arm is
injected as a control, the sameamount of toxin which has been
inactivated by heat.
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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 indiameter generally appears within 24-36 hours reachingits maximum development by 4-7 days, the control armshows 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 4th day.This is an allergic type of reaction found in certainindividuals
Combined reaction: the control arm shows pseudopositive reaction and the test arm is true +ve reaction,
susceptible and need vaccination
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Differential diagnosisNasal diphtheria :
Foreign body in nose , Rhinorrhea
Laryngeal diphtheria :
Croup
Acute epiglottitis
Laryngotracheobronchitis Peritonsillar abscess
Retropharyngeal abscess
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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 besidesoral mucosal lesions
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Treatment
Principles :
Neutralization of free circulating toxin byadministration of antitoxin
Antibiotic to eradicate bacteria
Supportive and symptomatic therapy
Management of complication
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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
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Antibiotics
Penicillin :
Procaine penicilline ( 3 6 lac units IM at 12hourly intervals till the patient is able to swallow )
Oral penicillin ( 125 250 mg qid )
Erythromycin ( 25 30 mg / kg / day ) for 14days
Three negative cultures at 24 hours intervalsshould be obtained before the patient isdeclared free of the organism
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Supportive and symptomatic therapy
Bed rest for 2 3 weeks ( to reduce cardiaccomplications )
Antipyretics and sedative ( if required )
Monitor rate and rhythm of the heart
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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 )
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Complications
Myocarditis : Occurs towards the end of the first or beginning
of second week
Abdominal pain , vomiting , dyspnea ,
tachycardiaNeurological complications : ( Traid ) Palatal paralysis ( 2 weeks )
General polyneuritis ( 3 6 weeks )
Loss of accommodation ( 3 weeks )
Renal complications :
Oliguria and proteinuria indicate kidney
complications
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Prevention
Vaccination: Immunisation with diphtheria toxoid,combined with tetanus and pertussis toxoid (DTPvaccine), 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 tobe protected for a further 10 years (16 18years).
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Prognosis
Death may occur due to : -
Respiratory obstruction
Myocarditis
Respiratory paralysis