Download 05. Diphtheria

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 EpsteinBarr virus, herpes simplex virus,
cytomegalovirus.
Specific tonsillitis
Sometimes, 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
Corynebacterium
diphtheriae
Grampositive, nonmotile
(Leffler rod)
Don’t forms spores and capsules
Coloured by Neisser in brown-yellow color
Ru, Leffler, Clauberg mediums - blood agar with tellurium salts
Cultural-biochemical types of C. diphtheriae - mitis, gravis,
intermedius
Production of very strong exotoxin (gene tox +)
Structure of exotocin - dermanecrotoxin, hemolysin,
neuraminidase, hyaluronidase
Firm to low temperature, long save on a dry surfaces; high
responsive to heating and desinfection solutions
Epidemiology
Source – 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
Pathogenesis
Penetration 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
Pathogenesis
Neuraminidase - 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, hypertoxic
Form - localized, wide-spread, combined
Nature of process - catarrhal, island-like,
paleaceous
Complications - myocarditis, neuritis,
nephritis (early and late)
Subclinical (carriering)
Clinical manifestation
Incubation period – 2-10 days
Phenomena of intoxication (high fever,
malaise, general weakness, headache)
Pharyngalgia - moderate
Changes 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 nodes
Edema 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 shock
Intra 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)
Treatment
Immediate hospitalization
Bed 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
Prophylaxis
Plan 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
Desinfection
Aeration 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. Bedclothes and clothes if necessary to
decontaminate in desinfection camera
Differential diagnosis
Tonsillitis, including Plaut-Vincent-Simanovsky
Herpetic tonsillitis
ARVI (adenoviral infection, false croup)
Paratonsillar abscess
Infectious mononucleosis
Scarlet fever
Pseudotuberculosis
Tonsillo-bubonic form of tularemia
Mycotic affection of tonsills
Epidemic parotitis
Typhoid fever
Lues
Hematological 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.
Complications
Complications 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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