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.