Diphtheria

Tonsillitis is inflammation of the tonsils most commonly caused by a viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever.

Under normal circumstances, as viruses and bacteria enter the body through the nose and mouth, they are filtered in the tonsils. Within the tonsils, white blood cells of the immune system mount an attack that helps destroy the viruses or bacteria by producing inflammatory cytokines like Phospholipase A2, which also lead to fever. The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx. This is the area in the back of the throat that lies between the voice box and the tonsils.

Primary tonsillitis

The most common bacterial cause is Group A β-hemolytic streptococcus (GABHS), which causes strep throat. Less common bacterial causes include: Staphylococcus aureus (including methicillin resistant Staphylococcus aureus or MRSA ),

Secondary tonsillitis(symptomatic)

The most common causes of tonsillitis are adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus. It can also be caused by Epstein-Barr virus, herpes simplex virus, cytomegalovirus.

Specific tonsillitisSometimes, tonsillitis is caused by an infection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina.

Sometimes – by fungi.

Sometimes - by Corynebacterium diphtheriae

Acute disease from the group of respiratory infections which characterized by fibrinous inflammation of mucous membranes of oral cavity, nasopharynx, larynx with toxic lesion of cardiovascular and nervous systems

Etiology

Grampositive, nonmotile

Don’t forms spores and capsulesColoured by Neisser in brown-yellow colorRu, Leffler, Clauberg mediums - blood agar with tellurium saltsCultural-biochemical types of C. diphtheriae - mitis, gravis, intermediusProduction of very strong exotoxin (gene tox +)Structure of exotocin - dermanecrotoxin, hemolysin, neuraminidase, hyaluronidaseFirm to low temperature, long save on a dry surfaces; high responsive to heating and desinfection solutions

Corynebacterium diphtheriae (Leffler rod)

EpidemiologySource – sick person or carrier (convalescent or health) of toxicogenic strains

Ways of transmission - airborne, contact - household (occasionally)

Sensibility is high, adults more often become sick (80 %)

Case rate sporadic, outbreaks are possible

Immunodefence antitoxic, postvaccine

Seasonal character - autumn - winter

Diphtheria cases reported to World Health Organization between 1997 and 2007

PathogenesisPenetration of the agent through entrance gate (mucous of upper respiratory tract, sometimes conjunctivas, skin)Production of exotoxin Local and systemic effects of the toxin:Dermonecrotoxin - necrosis of a surface epithelium, retardation of blood stream, rising of a permeability of vessels, their fragility, transuding of plasma in ambient tissues, formation of a fibrinous film, edema of tissues; downstroke of pain sensitivity

PathogenesisNeuraminidase - replacement of cytochrome, blockage of cellular respiration, destruction of a cell, violation of a function of organs and tissues (central and peripheric nervous system, cardiovascular system, kidneys)Hyaluronidase - destruction of a stroma of a connecting tissue (rising of permeability of vessels, edema of tissues) Hemolysin - hemorrhagic set of symptoms

Classification

Localization - otopharynx, nose, larynx, trachea and bronchi; rare localizations (skin, eye)Degree of severity - mild, moderate, severy, hemorrhagic, hypertoxicForm - localized, wide-spread, combinedNature of process - catarrhal, island-like, paleaceousComplications - myocarditis, neuritis, nephritis (early and late)Subclinical (carriering)

Clinical manifestationIncubation period – 2-10 daysPhenomena of intoxication (high fever, malaise, general weakness, headache)Pharyngalgia - moderateChanges of a throat mucous - soft hyperemia, edema of tonsills, covers on their surface (grey colour, dense, hard to remove with bleeding, slime), spread out of tonsills limits (palatopharyngeal arches, uvula, soft palate)Augmentation and moderate morbidness of regional lymph nodesEdema of a hypodermic fat of a neck

Peculiarities of diphtheria covers(Grey colour, dense, hard to remove with bleeding, slime), spread out of tonsills limits (on uvula, soft palate, palatopharyngeal archs)

Edema of a hypodermic tissues of a neck

Swollen neck in diphtheria

Diphtheria of the nose

A diphtheria skin lesion on the leg

Features of diphtheria toxicosis

(In wide-spread, combined, hypertoxical, hemorrhagic forms) toxicosis І, ІІ, ІІІ

Edema of the neck hypodermic tissues

Paleness of skin

Cyanosis of lips

Decreasing of arterial pressure

Tachycardia

Decreasing of a body temperature

Diphtheria of larynx

Real croup (stenosis of a larynx)

І degree (catarrhal) - labored inspiration, retraction of intercostal spaces, rasping “dog barking" cough, “horse” voice

ІІ degree (stenosis) - noisy respiration, inspiratory dyspnea with an elongated inspiration, participation in respiration of auxiliary muscles, aphonia

ІІІ degree (asphyxia) - acute oxygen insufficiency, sleepiness, cyanosis, cold sweat, cramps, paradoxical sphygmus

Complications

Infectious-toxic shockIntra vessels disseminated syndrome Myocarditis (early, late)Polyradiculoneuritis (early, late)Nephrosonephritis etc.

LABORATORY DIAGNOSTIC

Detection of the agent in smears from a throat and nose (taking of material on border between effected area and normal mucous)

Microscopy (colouring by Neisser) – typical locating of rods, grains of volutin in bacterias

Sowing on convolute serum or telluric blood agar for allocation of clean culture and recognizing of toxigenisity

Serological tests mirror a condition of immune defence (efficiency of vaccination)

TreatmentImmediate hospitalizationBed regimen (at localized forms - 10 days, at toxic - not less than 35-45 days)Specific treatment - introducing of antitoxic antidiphtherial Serum (from 30-50 thousand IU at the localized forms up to 100-120 thousand IU at toxic, by Bezredka method) Glucocorticoids (in toxic forms and croup)Antibiotics (penicilini, tetracyclini, erythromycini) Strychninum (in toxic forms) In case of croup - inhalations, broncholitics, diuretics, glucocorticoids, antibiotics, antihistamine, lytic admixture; under the indications - intubation, tracheotomy

Conditions of discharging from a hospital

Clinical convalescence

2 negative results of bacteriological research of smears from a throat and a nose with two-day interval

For decret group - additional double bacteriological examination in polyclinic

ProphylaxisPlan immunization (vaccination in 3, 4, 5 months. With АPДT vaccine, revaccination in 18 months; 6, 11, 14, 18 years and adults every 10 years with АДT-М vaccine)In the focus –

7 days medical observation after contact persons

Bacteriological examination

Sanation of detected carriers

Final disinfection

Revaccination

DesinfectionAeration and ultra-violet lighting of puttings, wet cleaning with usage of 2/3-basic salt of perchloron, calcium of hypochlorite, 3 % of solution of chloraminum, 1 % of solution amfolan

Sputum, the outwashes from a nasopharynx hash with double quantity of solutions, exposition 2 hours. The tableware is boiled in 2 % potassium solution 30 mines. Bed-clothes and clothes if necessary to decontaminate in desinfection camera

Differential diagnosisTonsillitis, including Plaut-Vincent-SimanovskyHerpetic tonsillitisARVI (adenoviral infection, false croup)Paratonsillar abscessInfectious mononucleosisScarlet feverPseudotuberculosisTonsillo-bubonic form of tularemiaMycotic affection of tonsillsEpidemic parotitisTyphoid fever LuesHematological diseases (acute leukosis, agranulocytosis)

Common symptoms of tonsillitis

sore throat red, swollen tonsils pain when swallowing high temperature (fever) coughing headache tiredness chills a general sense of feeling unwell white pus-filled spots on the tonsils swollen lymph nodes (glands) in the neck pain in the ears or neck changes to the voice or loss of voice

The diagnosis of GABHS tonsillitis can be confirmed by culture. Samples are obtained by swabbing both tonsillar surfaces and the posterior pharyngeal wall are plated on sheep blood agar medium. The isolation rate can be increased by incubating the cultures under anaerobic conditions and using selective media. A single throat culture has a sensitivity of 90 %-95 % for the detection of GABHS. False-negative results are possible if the patient received antibiotics. The identification of GABHS requires 24 to 48 hours. Rapid methods for GABHS detection (10–60 minutes), are available. Rapid detection kits have a sensitivity of 85 to 90.

Treatments to reduce the discomfort from tonsillitis symptoms include:pain relief, anti-inflammatory, fever reducing medications (acetaminophen/paracetamol and/or ibuprofen) sore throat relief (warm salt water gargle, lozenges, and iced/cold liquids) If the tonsillitis is caused by group A streptococus, then antibiotics are useful with penicillin or amoxicillin being first line. Cephalosporins and macrolides are considered good alternatives to penicillin in the acute setting. A macrolide such as erythromycin is used for people allergic to penicillin. Individuals who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria such as clindamycin or amoxicillin-clavulanate. Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins. When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week; however, symptoms may last for up to two weeks. Chronic cases may be treated with tonsillectomy (surgical removal of tonsils) as a choice for treatment.

ComplicationsComplications may rarely include dehydration and kidney failure due to difficulty swallowing, blocked airways due to inflammation, and pharyngitis due to the spread of infection. An abscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis. This is termed a peritonsillar abscess (or quinsy). Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of the internal jugular vein giving rise to a spreading septicaemia infection (Lemierre's syndrome).In chronic/recurrent cases (generally defined as seven episodes of tonsillitis in the preceding year, five episodes in each of the preceding two years or three episodes in each of the preceding three years), or in acute cases where the palatine tonsils become so swollen that swallowing is impaired, a tonsillectomy can be performed to remove the tonsils. Patients whose tonsils have been removed are still protected from infection by the rest of their immune system.In very rare cases of strep throat, diseases like rheumatic fever or glomerulonephritis can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations. Tonsillitis associated with strep throat, if untreated, is hypothesized to lead to pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).[

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