pg1 Report on DiptheriaEtiolgy,Epid,Pathogenesis,Treatment Etiologytoxins of corynybacterium diphtheria has two subtypes –toxicogen, non toxicogen.it is an aerobic, non motile non spore forming G+ rod. 3 bio types Gravis, mitis, intermedius(toxicogen 3 subtypes).it is stable in low temp and is inactivated at >100ºC Diphtheria toxinheat liable polypeptide which has A and B subunit. Incubation period :27 days. Epidemiology Airborn transmited by infected individuals or carriers( more dangerous b/c asyptomatic). In air droplets or direct contact. On the mucose membrane of respiratory tract or skin abrasions. Rarely by milk. Pathology:Toxins are absorbed by mucous membranes causing destruction of epithelium and a superficial inflammation the necrotic epithelium becomes embedded by fibrin, RBC,WBC and a grayish white pseudo membrane is formed, commonly in tonsils, pharynx, larynx and nose. Further absorption of toxins into the blood causes distant myocardium, liver, kidney , adrenal damage. ●The pseudo membrane over tonsils, pharynx and nose is difficult to remove and any attempt of removing will cause bleeding .It is difficult to remove b/c these areas contain squamous epithelium. ●the membrane over larynx, trachea, bronchi is easier to remove b/c it contains cylindrical epithelium(columnar). Forms(classification):●according to area involved common forms tonsillar, pharyngeal, laryngeal, nasal, .rare forms eyes, ears, genitals, umbo, skin. ● according to severity –mild, moderate, severe. ●according to progression: Fulminat Hypertoxic form dies within 24hrs of start. Clinical features:symptoms 1st day ●fever(low grade 37.839ºc)●malaise ●fatigue ●sore throat(3 to 4 days continue and then decrease .Toxins have analgesic effect and this reduces the pain).●dysphagia 2nd day symptoms: ●hoarseness b/c of laryngeal involvement ●some grayish membrane on tonsils● edema of neck(sometimes bull neck)●cervical lympadenopathy. ●hyperemia of throat ●enlarged tonsils covered by greyish membrane(bilateral)●dyspnoea. Diagnosis: ●history of contact with diphtheria patient, ●clinical features ●culture of nasal tonsillar swab material in loeffler medium. ●serological IgM↑.IgG↑.(bacteria can not be found in the blood). ●culture must be done b/f antibiotic therapy. after therapy have to do culture to check whether microorganism are present or not ●in serum >1:40(AG:AB)healthy. If < then sick ,if titer is negative then sick. Complications: patient can die due to complications. ●myocarditis(onset at 13 wks) ●polyneuritis(onset after 24 wks) ●peripheral neuritis(start b/w 13 months) ●toxic nephritis(start in 1wk) ●respiratory symptomsobstruction of respiratory tract due to pseudo membrane ,causing stenosis and neck edema. occurs during 1st wk with symptoms of dyspnoea, tachypnea, cyanosis ,use of accessory muscles for respirationtreatment is by hyper baric oxygenation and sometimes tracheostomy.
pg2 Treatment: specific therapy: Diphtheria antitoxins(prepared from horse serum)10,000120,000u/im/iv.B/f administering i/m or i/v test on skin or conjunctival surfaces for anaphylaxis. Anti toxic serum could be used till 5 days from beginning because after 5th day toxins in blood (there is a risk for anaphylaxis immediately after anti toxin administration and of serum sickness 23 wks later). etiolgical treatment:antibiotics(10 –14 days). •Penicillin1 million u/6 x 1d i/m or i/v. • Erythromycin 500mg/4 x d. • Cefazolin 1g/3 xd .•Ceftriaxone 2g/d.For patients 14 days treat, then for 2 days no therapy and order bacterial culture for 2 consecutive days(2x).For carriers one wk(7days) treat ,then 2 days no therapy and do bacterial culture for two consecutive days ,if the culture is + hospitalization(seldom). Pathogenetic treatment :•prednisolone 100200mg/iv 35 days to prevent delayed hypersensitivity. If hypersensitivity is present first give glucocorticoids, then anti toxic serum. Symptomatic therapy;•antipyretics •analgesics •antihistamines • for heartantiarrythmics,riboxin •oxygen therapy, tracheostomy • vit B12 •mostly disintoxication i/vsaline, glucose 6%.After treatment of C.diptheria, patient can not be a carrier because micro organism are destroyed. But after injection, toxoids destroy only toxins, after injection person becomes a carrier. Prophylaxis: ●vaccination DTP + DT;1st vaccinationat 3 month of life,2nd 45 months,3rd 6 months,4th 18 months,5th 9yrs,onlyDT,6th 1516yrsDT,BOOSTER every 5 yrs or 10yrs. ●avoidance of contact with other patients. ●carriersErythromycin 500mg/4 x /d for 7 days. ●toxoids given to healthy persons. Thus those who are carriers ●non immunized patients can not be carriers because if contact they get ill. DD ;●bacterial tonsillitis(streptococcus or staphylococcus);young patients affected, high grade fever >39ºc,easy to remove the membraneno bleeding, patchy membrane only in tonsils, no local edema only if beta hemolytic streptococcus (bull neck),intensive local lymphadenapathy/painful.leckocytosisshift to left, ESR ↑, stap/strept complication may occur, no prophylaxis.therapyAmoxillin. ●viral tonsillitisno membrane, no pus only pain, edema and hyperemia. ●vincent anginacaused by Spirochaeta buccalis and Borrelia vinenti which proliferate when bad oral hygiene.unilateral deep ulcer covered by blackgreen membrane which can be removed easily. ●Candida albicans ● Infectious mononucleosis. ●peritonsilar abscess ●tbc ●syphilis ●haematological diseasesagranulocytosis,acute leukaemia,lymphoma ●mumps.
Report on Report on DiptheriaEtiolgy,Epid,Pathogenesis,Treatment Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom. 2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia. 3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania. Contact: publications [at] infekcijas.eu