Presentation on theme: "Diphtheria Dr. Harivansh Chopra, MD, DCH Professor,"— Presentation transcript:
1 Diphtheria Dr. Harivansh Chopra, MD, DCH Professor, Department of Community Medicine,LLRM Medical College, Meerut.
2 Objectives To study the epidemiology of Diphtheria. To study the complications of diphtheria, and their management.To study the treatment and prevention of Diphtheria.Dr.Harivansh Chopra
3 DiphtheriaAcute infectious disease characterised by liberation of an exotoxin resulting in:Formation of greyish / yellowish membrane (“false membrane”) over tonsils, pharynx, or larynx, with well-defined edges.Dr.Harivansh Chopra
4 Diphtheria Congestion, Oedema, or Local Tissue Destruction. Regional lymphadenopathy (Bullneck).Toxemia.Child with bullneck diphtheriaDr.Harivansh Chopra
5 Problem Statement – World Rare disease in most developed countries owing to vaccination.Global burden in 2002:185,000 DALYs.5000 deaths.Dr.Harivansh Chopra
6 Problem Statement – India Endemic, with declining trend.99.06%Dr.Harivansh Chopra
7 Diphtheria – Major Types Anterior Nasal.Faucial.Laryngeal.Dr.Harivansh Chopra
8 Diphtheria – Other Types Conjunctival.Skin.Genital.Dr.Harivansh Chopra
21 Diphtheria – Clinical Features Pharyngeal/Tonsillar :Symptoms:Sore throat.50% have fever.Few have dysphagia, hoarseness, malaise, or headache.Dr.Harivansh Chopra
22 Diphtheria – Clinical Features Pharyngeal/Tonsillar :Signs:Unilateral or bilateral tonsillar membrane formation, which extends to cover uvula, soft palate, posterior oropharynx, hypopharynx, and glottis.Dr.Harivansh Chopra
23 Diphtheria – Clinical Features Pharyngeal/Tonsillar :Signs:Soft tissue oedema.Enlarged lymph nodes, resulting in bull-neck appearance.Effort to remove membrane results in haemorrhage.Dr.Harivansh Chopra
24 Diphtheria – Clinical Features Laryngeal:Noisy breathing.Stridor.Hoarseness of voice.Dry cough.Fever.May lead to asphyxia.Dr.Harivansh Chopra
25 Diphtheria – Clinical Features Cutaneous:Ulcers around mouth and nose.Ulcers:Defined border.Membranous base.Dr.Harivansh Chopra
26 Diphtheria – Clinical Features Conjunctival:Affects palpebral conjunctiva.Presentation:Oedematous.Membrane formation.Dr.Harivansh Chopra
27 Diphtheria – Clinical Features Aural:Otitis externa.Discharge:Persistant.Purulent.Foul-smelling.Dr.Harivansh Chopra
28 Diphtheria – Diagnosis Specimen: Nasal and throat swab, or any other muco-cutaneous lesion.Portion of membrane, and underlying exudate submitted.Laboratory notified to use selective media.Dr.Harivansh Chopra
29 Diagnosis Early diagnosis is important. Diagnosis based on high suspicion in a child with:Sore throat.Dyspnea.Noisy breathing.Fever.Dr.Harivansh Chopra
35 Passive Immunisation – Immunoglobulins ADS of horse origin.ADS of human origin.Dr.Harivansh Chopra
36 Dosage of antitoxin (equine) Duration of disease48 hoursLesionsThroatLarynxDose(I.U.)20 000– 40000Must be used only after sensitivity test.Dr.Harivansh Chopra
37 Dosage of antitoxin (equine) Duration of diseaseOver 48 hoursLesionsMembrane in naso-pharynxSwelling in neckExtensive disease > 3 daysDose(I.U.)40000– 6000080000–Must be used only after sensitivity test.Dr.Harivansh Chopra
38 Antitoxin Treatment – human Dose: 0.6 ml/kg body weight Intramuscular (Available as 2ml vial with 300 mg Globulins).Advantage over ADS (horse origin):Hypersensitivity absent.Longer protection.Dr.Harivansh Chopra
39 Treatment Antibiotics: Dosage: No substitute to anti-toxin. Stops production of more toxin.Dosage:Erythromycin: 40-50mg/kg/24 hrs. divided 6 hourly orally QID X 14 days.Dr.Harivansh Chopra
40 TreatmentDosage:Crystalline Penicillin G: 100,000 – 150,000 IU/kg/24 hrs in 4 – 6 divided doses I.V./I.M. X 14 days.ORProcaine Penicillin: 25,000 – 50,000 IU/kg/24 hrs in 2 divided doses IM X 14 days.Dr.Harivansh Chopra
42 Diphtheria Complication – Asphyxia Obstruction of respiratory passage by membrane:Tachypnea.Stridor.Use of accessory muscles of respiration.Cyanosis.Dr.Harivansh Chopra
43 Treatment of Asphyxia Tracheostomy. Humidified air. Dr.Harivansh Chopra
44 Diphtheria Complication – Myocarditis In acute phase.Toxic cardiomyopathy occurs in approx 10-25% patients and is responsible for 50-60% of deaths.Usually in 2nd – 3rd week of illness.Dr.Harivansh Chopra
45 Treatment of Myocarditis Bed rest, Avoid exertion.Restrict fluid and salt intake.Diuretics.May need sedation and oxygen.Digoxin in decompensated heart.Dr.Harivansh Chopra
46 Diphtheria Complication – Neurological involvement Parallel the onset of primary infection.Multiphasic in onset:Time periodNeurological involvement2 – 3 weeksPalatal and pharyngeal paralysis5th weekCranial neuropathies10 days – 3 monthsPolyneuropathyDr.Harivansh Chopra
47 Diphtheria Complication – Neurological involvement Palatal and Pharyngeal paralysis:Swallowing difficulty.Nasal voice.Regurgitation through nose.Dr.Harivansh Chopra
49 Treatment of Neurological complications Nasogastric feeding.Treatment of general weakness.Dr.Harivansh Chopra
50 Case fatality rateWith Treatment – <5% (Unchanged for the past 50 years).Without treatment – 10%.Dr.Harivansh Chopra
51 Prognosis Prognosis is associated with: Virulence of organism: Gravis strain has poor prognosis.Age.Immunisation status.Site of infection.Dr.Harivansh Chopra
52 Prognosis Prognosis is associated with: Speed of administration of toxin.Myocarditis, CHF.Poor respiratory monitoring.Phrenic nerve paralysis.Dr.Harivansh Chopra
53 Contact and CarrierReported rates of carriage in household contacts of case patients are 0-25%.Risk of developing diphtheria after exposure:To case: approx. 2%.To carrier: approx. 0.3%.Dr.Harivansh Chopra
54 Management of contacts – Detection “Schick Test” TEST ARMCONTROL ARM0.2 ml of (1/50 MLD) ofSchick Test Toxin ID.0.2 ml of (1/50 MLD) ofSchick Test Toxin IDinactivated by heat.Dr.Harivansh Chopra
55 Schick Test – Analysis of findings Test ArmControl ArmResultNo reactionNegative.Immunity to Diphtheria.24-36 hrs. – Circumscribed red flush (10 – 50 mm).4th-7th day – maximum size of rash.Thereafter – fades into brown patch, & desquamation.Positive.Susceptible to Diphtheria.Dr.Harivansh Chopra
56 Schick Test – Analysis of findings Test ArmControl ArmResultRed flush of smaller size than positive reaction.Fades quickly by 4th day.Red flush exactly as test arm.Pseudo-positive.Allergic reaction.Positive reaction.Pseudo-positive reactionCombination reaction.Person susceptible but allergic.Dr.Harivansh Chopra
57 Management of Contacts – Treatment Prophylactic Antibiotics – Given to all contacts, regardless of immunisation status.Erythromycin: 40-50mg/kg/24 hrs divided QID orally X 7 days (Max. 2gm/24 hrs).Benzathine Penicillin G: 600,000 U IM for <30kg, & 1,200,000 U IM for ≥30kg single dose.Dr.Harivansh Chopra
58 Management of Contacts – Treatment Non-immunised Contacts:units of Diphtheria antitoxin.Actively immunised against diphtheria.Dr.Harivansh Chopra
59 Management of Contacts – Treatment Immunised contacts:Booster dose, or PrimaryImmunisation withinpast 2 years.Booster dose, or PrimaryImmunisation more than2 years ago.No actionRequired.Booster doseof dT.Dr.Harivansh Chopra
60 Management of Contacts – Surveillance Medical surveillance of all contacts for 1 week after exposure.Bacteriological surveillance weekly for several weeks.Dr.Harivansh Chopra
61 Management of Carriers Detection of carriers by nasal & throat swab examination.Age appropriate diphtheria toxoid given immediately if booster has not been given for past 1 year.Dr.Harivansh Chopra
62 Management of Carriers Antibiotic Treatment:Erythromycin – 500mg QID X 7 days.Rifampicin – 600mg OD X 7 days.Bacteriological surveillance needed.Dr.Harivansh Chopra
63 Immunisation Does not prevent the occurrence of Carrier State. Combined or mixed vaccines:DPT (Diphtheria-pertussis-tetanus).DT (Diphtheria-tetanus toxoid).dT (Diphtheria-tetanus, adult type).Dr.Harivansh Chopra
73 Each 0.5mL dose contains: • ≥ 2 IU (2.5 Lf U) of diphtheria toxoid • ≥ 20 IU (5 Lf U) of tetanus toxoid• 8 mcg of pertussis toxoid,8 mcg of filamentous haemagglutinin and2.5 mcg of pertactin
74 The inactive ingredients in the vaccine are: Aluminium hydroxide,Aluminium phosphate, formaldehyde,phenoxyethanol, polysorbate 80,sodium chloride (salt),glycine and water.
75 Dosage and administration A single intramuscular injection (0.5 mL).Suspension for injection in 0.5-mL single-dose vials or syringes.
76 Boostrix is the brand name for the Tdap vaccine, which is designed for teens and preteens aged 10 to 18 years old.Boostrix, which was approved for use in 2005 by the Food and Drug Administration (FDA), gives this age group protection against whooping cough (pertussis), tetanus and diphtheria.
77 It is at this age in particular that the protection received from vaccinations given in early childhood begins to wear off.The vaccine, which is currently made and marketed by GlaxoSmithKline, is recommended by the Society for Adolescent Medicine and the American Academy of Pediatrics (AAP).
78 BOOSTRIX is a vaccine indicated for active booster immunization against tetanus, diphtheria, and pertussis as a single dose. BOOSTRIX is approved for use in individuals 10 through 64 years of age.
79 contraindicationsSevere allergic reaction (e.g., anaphylaxis) to any component of BOOSTRIX.Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures) within 7 days of administration of a previous pertussis antigen-containing vaccine.
80 ConclusionsDiphtheria is a vaccine-preventable disease characterised by formation of a pseudo-membrane, tissue destruction, and lymph node enlargement.Early detection and treatment is essential to prevent life-threatening complications.Dr.Harivansh Chopra
81 Which of the following is not true for diphtheria M.C.QWhich of the following is not true for diphtheriaDiphtheria bacilli produces a powerful exotoxinThe source of infection is either a case or a carrierChronic carrier state may last up to 2 yearsIncubation period of diphtheria is 2-6 daysAns. 3.Dr.Harivansh Chopra
82 All of the following are true for diphtheria except Immunization does not prevent carrier state.Unless treated, period of infectivity varies from 1-2 weeks from the onset of disease.Unapparent infections result in the development of immunity.99% of children over the age of 5 years are immune to diphtheria usually.Ans. 2.Dr.Harivansh Chopra
83 It occurs in 10-25% patients of diphtheria 3. Which of the following is not true for toxic myocardiopathy of diphtheriaIt occurs in 10-25% patients of diphtheriaIt is responsible for 50-60% of deaths in diphtheriaElevation of serum Aspartate Aminotransferase concentration does not parallel the severity of myonecrosisAll degree of heart blocks can occur in itAns. 3.Dr.Harivansh Chopra
84 4. Cranial neuropathy in diphtheria occurs in 1st week of illness 3rd week of illness5th week of illnees6th week of illnessAns. 3.Dr.Harivansh Chopra
85 5. Which of the following is not true for diphtheria Neurological complications are multiphasic in onsetCranial neuropathy lead to oculomotor & ciliary paralysisCSF findings can differentiate between polyneuropathy of diphtheria &GB syndromeParalysis of diaphragm can occurAns. 3.Dr.Harivansh Chopra
86 6. The prognosis of diphtheria depends on Virulence of the organism Site of infectionSpeed of administration of antibioticAll of the aboveAns. 4.Dr.Harivansh Chopra
87 7. Majority of deaths in diphtheria occur due to Mechanical obstructionMyocarditisBoth of the aboveNone of the aboveAns. 3.Dr.Harivansh Chopra
88 8. The dose of Antitoxin of human origin (Dipglobe) for the treatment of diphtheria 0.2 ml/kg0.4 ml/kg0.6 ml/kg0.8 ml/kgAns. 3.Dr.Harivansh Chopra
89 9. The management of asymptomatic case contact includes Monitoring of individuals for 7 daysMonitoring + culture of lesionMonitoring + culture + antimicrobial prophylaxisMonitoring + culture + antimicrobial prophylaxis + diphtheria toxoid vaccine irrespective of immunization statusAns. 3.Dr.Harivansh Chopra
90 10. Antimicrobial therapy in diphtheria can be given by Erythromycin mg/kg/day for 14 daysCrystalline Penicillin lac I.U./kg/day for 14 daysProcaine Penicillin I.U./kg/day for 14 daysAny of the aboveAns. 4.Dr.Harivansh Chopra
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