Infectious diseases with tonsillitis.
Diphtheria
Lecturer Lecturer Gorishna Ivanna Gorishna Ivanna
LubomyrivnaLubomyrivna
Plan of the lecturePlan of the lecture
1.1. Definition of DiphtheriaDefinition of Diphtheria
2.2. EtiologyEtiology
3.3. TransmissionTransmission
4.4. PathogenesisPathogenesis
5.5. Classification and clinical presentationClassification and clinical presentation
6.6. ComplicationsComplications
7.7. Diagnostic testsDiagnostic tests
8.8. Differential diagnoseDifferential diagnose
9.9. TreatmentTreatment
10.10. PreventionPrevention
Diphtheria isDiphtheria isDiphtheria is an acute Diphtheria is an acute toxicoinfection caused by toxicoinfection caused by toxigenic strains of toxigenic strains of Corynebacterium Corynebacterium diphtheriaediphtheriae, characterized , characterized by a local lesion consisting by a local lesion consisting of a membrane. The of a membrane. The constitutional symptoms constitutional symptoms are due to exotoxin are due to exotoxin circulation, which has a circulation, which has a special affinity for nerve special affinity for nerve tissue, heart muscle and tissue, heart muscle and kidneys. kidneys.
ETIOLOGYETIOLOGY Corynebacterium species are aerobic, Corynebacterium species are aerobic,
nonencapsulated, non-sporeforming, nonencapsulated, non-sporeforming, mostly nonmotile, gram-positive bacilli.mostly nonmotile, gram-positive bacilli.
Sensitive to high temperature and Sensitive to high temperature and disinfectiondisinfection
Stabile to freezing and dryness Stabile to freezing and dryness Three biotypes – Three biotypes –
– mitismitis– gravisgravis– intermediusintermedius
TransmissionTransmission
Transmission is from person-to-person (Transmission is from person-to-person (from a from a patient or carrierpatient or carrier))
through direct contact through direct contact or airborne respiratory droplets or airborne respiratory droplets
These materials include discharge from the These materials include discharge from the nose, throat, and lesions on the skin, eyes nose, throat, and lesions on the skin, eyes and even the vagina.and even the vagina.
Contagious index – 10-15%Contagious index – 10-15%
Seasonality – autumn-winterSeasonality – autumn-winter
Immunity – instable Immunity – instable
Incubation periodIncubation period
Short (from one to seven days)Short (from one to seven days)
PathogenesisPathogenesis
Entrance for the infection: throat, nose, Entrance for the infection: throat, nose, larynx, sex organs, wound.larynx, sex organs, wound.
Dissemination of the Corynebacterium, Dissemination of the Corynebacterium, production of exotoxin.production of exotoxin.
Local toxin effects with membranous Local toxin effects with membranous inflammation.inflammation.
Toxemia.Toxemia. Diffuse toxic effects on kidneys, suprarenal Diffuse toxic effects on kidneys, suprarenal
glands, cardiovascular system, and glands, cardiovascular system, and peripheral nervous system.peripheral nervous system.
Fibrinous inflammationFibrinous inflammation
Diphtheritic (on flat multilayer Diphtheritic (on flat multilayer epithelium)epithelium)
Crupous (on cylindrical one layer Crupous (on cylindrical one layer epithelium)epithelium)
Classification of Diphtheria Classification of Diphtheria Diphtheria of the tonsils and Diphtheria of the tonsils and
pharynxpharynx localized (catarrhal, islet-like, localized (catarrhal, islet-like,
membranous) membranous) spread form spread form toxic form:toxic form:
– I degree I degree – II degree II degree – III degreeIII degree– hypertoxic hypertoxic
hemorrhagic formhemorrhagic form gangrenous formgangrenous form
Diphtheria of the tonsils, Diphtheria of the tonsils, localized, membranous (moderatelocalized, membranous (moderate))
Diphtheria of Diphtheria of the tonsils, the tonsils, localized, localized,
membranous membranous (moderate(moderate))
Diphtheria of the tonsils, Diphtheria of the tonsils, spread (moderatespread (moderate))
Diphtheria of the tonsils, Diphtheria of the tonsils, toxic (severetoxic (severe))
Diphtheria of the tonsils, Diphtheria of the tonsils, toxic (neck edema)toxic (neck edema)
Classification of DiphtheriaClassification of DiphtheriaDiphtheria of the respiratory tract (croup)croup)
Localized croup (laryngitis) Localized croup (laryngitis) Spread croup Spread croup
– laryngotracheitis laryngotracheitis – laryngotracheobronchitislaryngotracheobronchitis
Stages of croup Stages of croup – Catarrhal croupCatarrhal croup– Stenosis Stenosis
Compensated Compensated SubcompensatedSubcompensated Decompensated Decompensated
– AsphyxiaAsphyxia
Classification of DiphtheriaClassification of Diphtheria Diphtheria of the nasopharynx Diphtheria of the nasopharynx (adenoiditis)(adenoiditis) Diphtheria of the noseDiphtheria of the nose
o localizedlocalized catarrhal catarrhal islet-likeislet-like membranousmembranous
o SpreadSpreado toxictoxic
Combined formCombined form Rare forms Rare forms (localized, spread, toxic)(localized, spread, toxic) eye eye earear skinskin genital tractgenital tract
Diphtheria of the nose
Diphtheria of the lipDiphtheria of the lip
Classification of Diphtheria Classification of Diphtheria mild localized Tonsils (islet-form), nose
eye earskingenital tract
moderate
localized
spread
Tonsils (membranous-form)NasopharyngealLocalized croup
Tonsils, noseeye earskingenital tract
severe Spread
Toxic, hypertoxic
Spread croup
Tonsils , noseeye earskingenital tract
Classification of Diphtheria Classification of Diphtheria The course of disease The course of disease
– With complicationWith complication– Without complicationWithout complication
Classification of Diphtheria Classification of Diphtheria
Bacilli carryingBacilli carrying
Transitional carryingTransitional carrying Short time – up to 2 wksShort time – up to 2 wks Prolong carrying - more than 1 moProlong carrying - more than 1 mo Chronic carrying – more than 6 moChronic carrying – more than 6 mo
ComplicationsComplications earlyearly::
– Toxic shock syndrome; Toxic shock syndrome; – DIC syndromeDIC syndrome– Acute adrenal insufficiency; Acute adrenal insufficiency; – Renal insufficiencyRenal insufficiency– Respiratory insufficiencyRespiratory insufficiency– Plural organs insufficiencyPlural organs insufficiency– (in the end of 1(in the end of 1stst to 2 to 2ndnd week) nephritis; week) nephritis;
myocarditis; peripheral cranial nerves palsies; myocarditis; peripheral cranial nerves palsies; late late (on the 3(on the 3rdrd to 7 to 7thth week): myocarditis; week): myocarditis;
peripheral spinal nerves palsies.peripheral spinal nerves palsies.
Death may occur fromDeath may occur from Toxemia toward the end of the firth Toxemia toward the end of the firth
weekweek Cardiac failure from toxic myocarditis Cardiac failure from toxic myocarditis
(second week of illness)(second week of illness) Respiratory failure due to peripheral Respiratory failure due to peripheral
neuritis affecting the vagus nerve neuritis affecting the vagus nerve (third to seventh week) (third to seventh week)
Diagnostic testsDiagnostic tests
used to confirm infection combine used to confirm infection combine isolation of isolation of C diphtheriaeC diphtheriae on cultures on cultures with toxigenicity testing.with toxigenicity testing.– Bacteriologic culturing is essential to Bacteriologic culturing is essential to
confirm the diagnosis of diphtheria. confirm the diagnosis of diphtheria. – Toxigenicity testing: Perform toxigenicity Toxigenicity testing: Perform toxigenicity
testing using the Elek test to determine if testing using the Elek test to determine if the the C diphtheriae C diphtheriae isolate produces toxin. isolate produces toxin.
Polymerase chain reactionPolymerase chain reaction
Differential diagnoseDifferential diagnose
Diphtheria of the pharynxDiphtheria of the pharynx must must be differentiated from scarlet fever, be differentiated from scarlet fever, acute bacterial tonsillitis, infectious acute bacterial tonsillitis, infectious mononucleosis; mononucleosis;
diphtheria of the upper diphtheria of the upper respiratory tractrespiratory tract – with viral croup – with viral croup caused by parainfluenza, measles, caused by parainfluenza, measles, chickenpox, and influenza viruses.chickenpox, and influenza viruses.
Bacterial tonsillitis (follicular)Bacterial tonsillitis (follicular)
Bacterial tonsillitis Bacterial tonsillitis (lacunar)(lacunar)
Bacterial tonsillitis Bacterial tonsillitis (lacunar)(lacunar)
Bacterial tonsillitis Bacterial tonsillitis (necrotizing)(necrotizing)
Bacterial Bacterial tonsillititonsillitis s (membr(membra-nose) a-nose) in patient in patient with with scarlet scarlet feverfever
Candid's tonsillitisCandid's tonsillitis
Infectious mononucleosisInfectious mononucleosis
Infectious Infectious mononucleosimononucleosi
ss
Infectious mononucleosisInfectious mononucleosis
Infectious Infectious mononucleosimononucleosi
ss
Infectious Infectious mononucleosimononucleosi
ss
Infectious mononucleosisInfectious mononucleosis
Perytonsillitis Perytonsillitis
Perytonsillar abscess Perytonsillar abscess
MumpsMumps
Viral croupViral croup::• Acute developmentAcute development• Stenosis ofStenosis of 11stst-2-2ndnd degreedegree, , • Absence of gradual Absence of gradual
developmentdevelopment, , • Absence of aphoniaAbsence of aphonia, , loud loud
voicevoice • Other clinical signs (rash, Other clinical signs (rash,
rhinitis, pharyngitis)rhinitis, pharyngitis)• Moderate or severe Moderate or severe
intoxicationintoxication,,• Edema of the sub vocal Edema of the sub vocal
spacespace, , • Negative bacterial cultureNegative bacterial culture
Treatment Treatment Absolute bed regime (2-3 wks)Absolute bed regime (2-3 wks) Diphtheritic antitoxin therapyDiphtheritic antitoxin therapy Antibacterial therapyAntibacterial therapy
– BENZYLPENICILLIN Na 50-BENZYLPENICILLIN Na 50-100 000 lU/kg/day100 000 lU/kg/day– Erythromycin 40Erythromycin 40--5050 м мgg/к/кg/dayg/day – Roxitromycin 5-8 mg/kgRoxitromycin 5-8 mg/kg– Rifampicin 10-15 Rifampicin 10-15 ммgg/к/кg/day g/day
Antiseptic fluids locallyAntiseptic fluids locally Desensitization (suprastinum)Desensitization (suprastinum) Vitamins B-group, C Vitamins B-group, C Disintoxication therapy (50-100 ml/kg/day)Disintoxication therapy (50-100 ml/kg/day) In case of severe form In case of severe form corticosteroids therapy corticosteroids therapy
prednisolone 2-3 mg/kg/day hydrocortizone 5-10 prednisolone 2-3 mg/kg/day hydrocortizone 5-10 mg/kg/daymg/kg/day
Administration of Antitoxin for Administration of Antitoxin for Treatment of Diphtheria Treatment of Diphtheria
Clinical formClinical form First dose First dose Thousand UThousand U
Repeated dose Repeated dose Thousand UThousand U
Total dose Total dose Thousand IUThousand IU
Diphtheria of the Diphtheria of the pharynxpharynx
localized localized
spread spread
toxic Itoxic I
toxic IItoxic II
toxic IIItoxic III
10, 20-3010, 20-30
40-5040-50
60-7060-70
80-10080-100
100-120100-120
1010
2020
4040
5050
70-8070-80
10, 30-4010, 30-40
60-7060-70
100-120100-120
130-180130-180
200-250200-250
Administration of Antitoxin for Administration of Antitoxin for Treatment of Diphtheria Treatment of Diphtheria
Clinical formClinical form First dose First dose Thousand UThousand U
Repeated dose Repeated dose Thousand UThousand U
Total dose Total dose Thousand IUThousand IU
Diphtheria of the Diphtheria of the larynxlarynx
Localized Localized croup croup
Spread croup Spread croup
Diphtheria of the Diphtheria of the nose, eye, skinnose, eye, skin
Localized Localized
Sex organs,Sex organs,
localized localized
ToxicToxic
30-4030-40
40-5040-50
15-2015-20
20-3020-30
50-8050-80
----
20-3020-30
----
1010
4040
30-4030-40
60-8060-80
15-2015-20
30-4030-40
90-10090-100
In case of toxic shock syndrome:In case of toxic shock syndrome: - Immediately intravenous infusion of - Immediately intravenous infusion of
DAT with prednisone intravenously DAT with prednisone intravenously 30-50 mg before DAT;30-50 mg before DAT;
- Prednisone 10-20 mg/kg/day in - Prednisone 10-20 mg/kg/day in equal doses 2-4 times per day;equal doses 2-4 times per day;
- Detoxication, correction of acid-base - Detoxication, correction of acid-base stability and electrolytes;stability and electrolytes;
- Dopamine, trental, corglicon.- Dopamine, trental, corglicon.
In case of diphtheria of the larynxIn case of diphtheria of the larynx (except (except
DAT):DAT): - Inhalation of antiedematous drugs (2% - Inhalation of antiedematous drugs (2%
NaHCONaHCO33, hydrocortisone, euphyllin, and , hydrocortisone, euphyllin, and mucolithics);mucolithics);
suctioning of membranes and mucus;suctioning of membranes and mucus; inhalation of oxygen;inhalation of oxygen; in the III stage of stenosis – intubation;in the III stage of stenosis – intubation; In case of spread croup, combined with In case of spread croup, combined with
diphtheria of pharynx – tracheotomy.diphtheria of pharynx – tracheotomy.
Carriers’ treatmentCarriers’ treatment::– Erythromycin 40Erythromycin 40--5050 м мgg/к/кg/dayg/day – Roxitromycin 5-8 mg/kgRoxitromycin 5-8 mg/kg– Rifampicin 10-15 Rifampicin 10-15 ммgg/к/кg/day g/day
• Antiseptic fluids locallyAntiseptic fluids locally• Vitamins B-group, C Vitamins B-group, C • Immune modulators in case of Immune modulators in case of
chronic site of infectionchronic site of infection,,• Tonsillectomy, adenotomy in case of Tonsillectomy, adenotomy in case of
chronic carryingchronic carrying..
Patients dischargePatients discharge
healthyhealthy;; Patient should be isolated until three Patient should be isolated until three
consecutive throat swabs take 24 hrs consecutive throat swabs take 24 hrs apart after stopping treatment, are apart after stopping treatment, are negative negative
Mild and moderate inMild and moderate in 14-21 14-21 daysdays;; Severe Severe – – inin 30-60 30-60 daysdays..
Prevention specificPrevention specific
Immunization by DTP vaccine from 3 Immunization by DTP vaccine from 3 months age 3 times in 30 days months age 3 times in 30 days interval (3, 4, 5 months), interval (3, 4, 5 months), revaccination in 18 months (DTP), 6, revaccination in 18 months (DTP), 6, 14, 18 years (DT), later – every 10 14, 18 years (DT), later – every 10 years.years.
Prevention nonspecificPrevention nonspecific Close contacts who were previously Close contacts who were previously
immunized longer then 5 years before immunized longer then 5 years before should receive booster dose of should receive booster dose of diphtherial toxicoiddiphtherial toxicoid– Antibiotic (erythromycin, rifampin) orally Antibiotic (erythromycin, rifampin) orally
for 7 daysfor 7 days Revealing, sanation of healthy infected Revealing, sanation of healthy infected
persons, persons, contacts’ examination for 10 days,contacts’ examination for 10 days, disinfection of epidemic focus.disinfection of epidemic focus.