6 Diphtheria

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phther a

phther a

dr. Tjatur Winarsanto SpPD

2011


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Defnition

Diphtheria is an acute, toxin-mediated disease caused by

toxigenic Corynebacteriumdiphtheriae .

Its a very contagious andpotentially lie-threatening

bacterial disease.


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Defnition

Its a localized inectious disease,which usually attacks the throat

and nose mucous membrane


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Defnition

ommon symptoms! malaise, sorethroat, anorexia, and low-grade

ever.

"ypical sign! specifc membraneormation

In serious cases, it can attack theheart and nerves.


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#tiology

Diphtheria is caused byCorynebacterium diphtheriae, abacterium, a bacillus.

C. diphtheriae is an aerobic gram-positive bacillus.

$leomorphic, club-end

%on-spore-orming %on-acid-ast

%on-motile


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#tiology

"he ma&or virulence determinant isan exotoxin, diphtheria toxin. 'terbinding to the host cells, the activesubunit will interrupt the proteinsynthesis o the target host celland results in cell death.

"oxoid made rom diphtheria toxincan be used as vaccine.


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#tiology

"he bacteria can be killed by mildheating()*+ or minutes and

sensitive to /0 or sunlight.1esistance to damage rom drying,be cultured rom the 2oor dust or) weeks or longer, once the 2oor

dust was contaminated.


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#pidemiology

Sources of infection

$atients and asymptomatic

carriers $atients! "ransmission time is

variable, usually persist 3 daysor less, and seldom more than 4

weeks, without antibiotics.


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#pidemiology

Sources of infection

'symptomatic carriers (even

important! 5 in population, butmay be up to -35 duringoutbreaks in the past. 6ost othem were transient carriers (less

than 3 weeks, but chroniccarriers may shed organisms or

7 months or more.


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#pidemiology

Transmission "ransmission is most oten

person-to-person spread rom therespiratory tract (by small dropletwhen coughing or sneezing.

1arely, transmission may occur

rom skin lesions or articles soiledwith discharges rom lesions oinected persons.


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$athogenesis and

pathology8usceptible persons may ac9uiretoxigenic diphtheria bacilli in the

nasopharynx, skin, middle ear oranterior nares.


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$athogenesis and

pathology"he organism produces a toxin thatinhibits cellular protein synthesis

and is responsible or local tissuedestruction and pseudomembrane

ormation.


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$athogenesis and

pathology"he pseudomembrane consists ocoagulated fbrin, in2ammatory

cells, destructed mucous tissuesand bacteria.

"he pseudomembrane in larynx,trachea or bronchia may have the

potential or airway obstruction.


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$athogenesis and

pathology"he toxin produced at the site o thepseudomembrane is absorbed intothe bloodstream and thendistributed to the tissues o the body.

"he toxin is responsible or the ma&orcomplications o myocarditis and

neuritis, and can also cause lowplatelet counts (thrombocytopeniaand protein in the urine (proteinuria.


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linical maniestations

"he incubation period o diphtheria is3-4 days (range, -: days.

"his disease can involve almost anymucous membrane.

"he ma&or sign is pseudomembrane."he typical pseudomembrane is

adherent to the tissue, and orcibleattempts to remove it cause bleeding.

$seudomembrane.


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linical maniestations

;or clinical purposes, it isconvenient to classiy diphtheria

into our categories depending onthe site o disease (orpseudomembrane.


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Pharyngeal diphtheria

It


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6ild type 8ymptoms! malaise, sore throat,

anorexia, and low-grade ever. >ithin 3-? days, small patches o

white pseudomembrane on thetonsils are ound.

@ten occurs in outbreaks and iseasily misdiagnosed.


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@rdinary type 8ymptoms! malaise, sore throat,

anorexia, vomiting and middle-grade ever.

"ypical adherent, bluish- orgreyish-white pseudomembraneorms on the congested tonsils.

>ith lymph nodes enlargement inthe submandibular areas o neck.


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Arave type

8erious early symptoms, high-

grade ever. 8kin becomes pale, tachycardia,

blood pressure may be normal orslightly depressed (8hock.


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Arave type Barge, thick pseudomembrane,

and greyish-green or black incolor i there has been bleeding,covering the tonsils, uvula, andsome sot palate, odorierous inmouth.

>ith enlarged lymph nodes in thesubmandibular areasoneck.


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#xtra-grave type "achycardia, tachypnea, depressed

blood pressure. Cighly congestedtonsils and pharynx.

"he pseudomembrane is largerthan that o grave type, black incolor.

#xtensive pseudomembraneormation may result in respiratoryobstruction.


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#xtra-grave type

$atients develop marked edema othe submandibular areas and the

anterior neck along withlymphadenopathy, giving acharacteristic bullneckE appearance.

omplications, include myocarditis

and thrombocytopenia may occur. 6ay even die within 7 to days.


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Laryngeal diphtheria

Baryngeal diphtheria can be eitheran extension o the pharyngeal orm(oten or the only site involved

(rarely.8ymptoms include mild ever (withlittle absorption o toxin, dyspnea,hoarseness, and a barking cough.

"he pseudomembrane can lead toairway obstruction, coma, and death.


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Anterior nasal diphtheria

"he onset is indistinguishable romthat o the common cold and isusually characterized by amucopurulent nasal discharge(containing both mucus and pus

which may become blood-tinged.

' white pseudomembrane usuallyorms on the nasal septum.


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Anterior nasal diphtheria

"he clinical symptoms o thisdisease is usually airly mildbecause o apparent poor systemicabsorption o toxin in this location,and can be terminated rapidly byantitoxin and antibiotic therapy.


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Cutaneous and Other sitediphtheria

8kin inections are 9uite common inthe tropics and are probablyresponsible or the high levels onatural immunity ound in thesepopulations.


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8kin inections may be maniestedby a scaling rash or by ulcers withclearly demarcated edges andpseudomembrane.

In general, the severity o the skindisease appears to be less than in

other orms o inection.


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@ther sites o involvement includethe mucous membranes o thecon&unctiva and vaginal area, aswell as the external auditory canal.


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Baboratory fndings

1outine examination Beukocytosis, F3 AGB,

neutrophil is dominant. Bow platelet count

(thrombocytopenia, rise profleso the serum enzyme tests and

proteinuria were ound in seriouscases.


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Baboratory fndings

Hacteriological examinations 8mear and gram stain can ound C.

diphtheriae, but can not identiy romthe diphtheroids.

;luorescent antibody-stain can oundtoxigenic C. diphtheriae, avourable orearly diagnosis, but defnitive diagnosis(alse positive.

C. diphtheriae can be cultured rom theswabs rom nose, pharynx or other sites.


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Baboratory fndings

Immunological examinations 8chick< test (not to be used any

more, positive result supportsdiagnosis

8pecifc antibody detection.$ositive results deny the

diagnosis since it is a protectiveantibody.


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omplications

6ost complications o diphtheria,including death, are attributable toeects o the toxin.

"he severity o the disease andcomplications are generally relatedto the extent o local disease.

"he most re9uent complications odiphtheria are myocarditis andneuritis.


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omplications

6yocarditis $resent as abnormal cardiac

rhythms and can occur early inthe course o the illness or weekslater, and can lead to heart ailureand abrupt deterioration (sudden

death. I myocarditis occurs early, it is

oten atal.


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omplications

%euritis 6ost neuritisoten aect motor

nerves and usually recoverscompletely.

$aralysis o the sot palate ismost re9uent during the thirdweek o illness.


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omplications

%euritis #ye muscles, limbs, and

diaphragm paralysis can occurater the fth week.

8econdary pneumonia andrespiratory ailure may resultrom diaphragmatic paralysis.


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Diagnosis

linical diagnosis is usually made based on theepidemiological data and clinical presentationsince it is imperative to begin presumptivetherapy 9uickly.

Aram stain o material rom thepseudomembrane can be helpul when tryingto confrm the clinical diagnosis.

ulture o the lesion is even important toconfrm the clinical diagnosis. It is critical to

take a swab o the pharyngeal area, especiallyany discolored areas, ulcerations, and tonsillarcrypts.


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Diagnosis

I diphtheria bacilli are isolated,they must be tested or toxinproduction by #BI8' or #lek test.

I toxin test is positive, thedefnitive diagnosis can be made.

"he presence o staphylococci andstreptococci do not rule outdiphtheria.


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Dierential diagnosis

8treptococcal pharyngitis

"he pus covering on the tonsils

sometimes is misunderstood asthe pseudomembrane odiphtheria. Its usually yellow incolor, and easy to remove.


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@ral candidiasis

"he oral candidiasis oten occurs

in inants. "he general conditionso such patients are very well."he membrane is very white, andeasy to remove


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Inectious mononucleosis and0incents angina

8ometimes also have things likemembranes on the surace otonsils or pharynx. Cowever, theycan be remove without bleeding

o the tissues.


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$rognosis

"he overall case-atality rate ordiphtheria is about )5, with higherdeath rates (up to 35 in personsJ) and =4 years o age.


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"reatments

8trict isolation

/se antitoxin and antibiotics orneutralization o ree toxin,elimination o urther toxinproduction and to control localinection.

/se supportive interventionsduring disintoxication.


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"reatments

General measures

1elax on bed or more than ?

weeks, 4-7 weeks or patientswith myocarditis.

$rovide ade9uate energy andnutriments


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"reatments

Diphtheria antitoin

Diphtheria antitoxin, produced inhorses.

It will not neutralize toxin that isalready fxed to tissues, but willneutralize circulating toxin.

#arly use will preventprogression o disease.

"he earlier, the better.


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"reatments

Diphtheria antitoin Dose! ?-)K4/ or early (J?-4d

and mild or ordinary patientsL 7- K4 / or later (=?-4d orgrave patientsL reduce in larynxdiphtheria

-3K4 / is given intravenouslyand the rest is givenintramuscularly.


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"reatments

Diphtheria antitoin "he patient must be tested or

sensitivity beore antitoxin is

given. 1espiratory support and airway

maintenance should also beadministered as needed.

($seudomembrane shedding otenhappens during disintoxication


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"reatments

Antibiotics

$revention o urther toxin

production. ontrol local inection.

1eduction o transmission.


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"reatments

Antibiotics

$rocaine penicillin A daily,intramuscularly (?, /Gday or those

weighing kg or less and 7, /Gdayor those weighing more than kg or:- days.

#rythromycin orally or by in&ection (4-)mgGkgGdayL maximum, 3 gmGday or 4days.

"he disease is usually not contagious 4*hours ater antibiotics are used.


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$reventions

!anagement of infection sources

Isolation o patients (=:d, or

elimination o the organismshould be documented by twoconsecutive negative culturesater therapy is completed.


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$reventions


$ersons with suspected

diphtheria should be givenantibiotics and antitoxin inade9uate dosage and placed inisolation (:d ater the

provisional clinical diagnosis ismade and appropriate culturesare obtained.


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$reventions


;or close contacts, especially

household contacts, a diphtheriabooster, appropriate or age,should be given. 'ntitoxin -3 /, intramuscularly


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$reventions


ontacts should also receiveantibioticsMbenzathine penicillinA or a :- to -day course o oralerythromycin.

Interruption o the transmission

routes by disinections odischarges and articles opatients


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$reventions

$rotect the susceptibles byvaccination

"he eective measure

$rimary series (D"$, multivalentvaccine given at age o ?, ), 7months.

Hoosters (D"$ given at ) monthsand 4-7 years old, and booster(D" every years ater then.


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Laryngeal diphtheria

C t " #i $


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Cutaneous "s#in$diphtheria

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6 Diphtheria