Diphtheria

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Diphtheria
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• Tonsillitis is inflammation of the tonsils
  most commonly caused by a viral or bacterial
  infection. Symptoms of tonsillitis include sore
  throat and fever.

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• 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.

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Primary tonsillitis

• The most common bacterial cause is Group A
  ß-hemolytic streptococcus (GABHS), which causes
  strep throat. Less common bacterial causes
  include Staphylococcus aureus (including
  methicillin resistant Staphylococcus aureus or
  MRSA ),

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Secondary tonsillitis(symptomatic)

• The most common causes of tonsillitis are
  adenovirus, rhinovirus, influenza, coronavirus,
  and respiratory syncytial virus. It can also be
  caused by Epstein-Barr virus, herpes simplex
  virus, cytomegalovirus.

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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

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• 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

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Etiology
Corynebacterium diphtheriae (Leffler rod)

• Grampositive, nonmotile
• Dont 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

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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

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Diphtheria cases reported to World Health
Organization between 1997 and 2007
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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

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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

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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)

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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

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Peculiarities of diphtheria covers (Grey colour,
dense, hard to remove with bleeding, slime),
spread out of tonsills limits (on uvula, soft
palate, palatopharyngeal archs)
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Edema of a hypodermic tissues of a neck
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Swollen neck in diphtheria
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Diphtheria of the nose
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A diphtheria skin lesion on the leg
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Features of diphtheria toxicosis

• (In wide-spread, combined, hypertoxical,
  hemorrhagic forms) toxicosis ?, ??, ???
• Edema of the neck hypodermic tissues
• Paleness of skin
• Cyanosis of lips
• Decreasing of arterial pressure
• Tachycardia
• Decreasing of a body temperature

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Diphtheria of larynx

• Real croup (stenosis of a larynx)
• ? degree (catarrhal) - labored inspiration,
  retraction of intercostal spaces, rasping dog
  barking" cough, horse voice
• ?? degree (stenosis) - noisy respiration,
  inspiratory dyspnea with an elongated
  inspiration, participation in respiration of
  auxiliary muscles, aphonia
• ??? degree (asphyxia) - acute oxygen
  insufficiency, sleepiness, cyanosis, cold sweat,
  cramps, paradoxical sphygmus

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Complications

• Infectious-toxic shock
• Intra vessels disseminated syndrome
• Myocarditis (early, late)
• Polyradiculoneuritis (early, late)
• Nephrosonephritis etc.

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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)

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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

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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

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Prophylaxis

• Plan immunization (vaccination in 3, 4, 5 months.
  With ?P?T vaccine, revaccination in 18 months 6,
  11, 14, 18 years and adults every 10 years with
  ??T-? vaccine)
• In the focus
• 7 days medical observation after contact
  persons
• Bacteriological examination
• Sanation of detected carriers
• Final disinfection
• Revaccination

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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. Bed-clothes and clothes if
  necessary to decontaminate in desinfection camera

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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)

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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

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• 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
  (1060 minutes), are available. Rapid detection
  kits have a sensitivity of 85 to 90.

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• 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.

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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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