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Diphtheria Dr. Harivansh Chopra, MD, DCH Professor, Department of Community Medicine, LLRM Medical College, Meerut.

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Presentation on theme: "Diphtheria Dr. Harivansh Chopra, MD, DCH Professor, Department of Community Medicine, LLRM Medical College, Meerut."— Presentation transcript:

1 Diphtheria Dr. Harivansh Chopra, MD, DCH Professor, Department of Community Medicine, LLRM Medical College, Meerut.

2 Dr.Harivansh Chopra Objectives 1.To study the epidemiology of Diphtheria. 2.To study the complications of diphtheria, and their management. 3.To study the treatment and prevention of Diphtheria.

3 Dr.Harivansh Chopra Diphtheria Acute infectious disease characterised by liberation of an exotoxin resulting in: 1.Formation of greyish / yellowish membrane (“false membrane”) over tonsils, pharynx, or larynx, with well- defined edges.

4 Dr.Harivansh Chopra Diphtheria 2.Congestion, Oedema, or Local Tissue Destruction. 3.Regional lymphadenopathy (Bullneck). 4.Toxemia. Child with bullneck diphtheria

5 Dr.Harivansh Chopra Problem Statement – World 1.Rare disease in most developed countries owing to vaccination. 2.Global burden in 2002: 1.185,000 DALYs deaths.

6 Dr.Harivansh Chopra Problem Statement – India Endemic, with declining trend %

7 Dr.Harivansh Chopra Diphtheria – Major Types 1.Anterior Nasal. 2.Faucial. 3.Laryngeal.

8 Dr.Harivansh Chopra Diphtheria – Other Types 1.Conjunctival. 2. Skin. 3.Genital.

9 Dr.Harivansh Chopra Diphtheria – Agent Factor 1..Corynebacterium diphtheriae. 2.Gram positive, Non-motile.

10 Dr.Harivansh Chopra Diphtheria – Agent Factor 3.. Types – 1.Gravis. 2.Mitis.

11 Dr.Harivansh Chopra Diphtheria – Agent Factor 3.. Types – 3.Intermedius. 4.May be – 1.Toxigenic. 2.Non-toxigenic – bacteriophage can convert them into toxigenic. C. diptheriae intermedius

12 Dr.Harivansh Chopra Diphtheria – Host Factors 1.Source of infection – 1.Cases. 2.Carriers – 95 carriers for 5 cases: 1.Types – Temporary & Chronic. 2.May be nasal or throat. 3.Incidence is 0.1 – 5.0%.

13 Dr.Harivansh Chopra Diphtheria – Infective Material 1.Nasopharyngeal secretions. 2.Discharge from skin lesions. 3.Fomites – 1.Throat spatulas. 2.Utensils. 3.Toys. 4.Pencils.

14 Dr.Harivansh Chopra Period of Infectivity 1.14 – 28 days unless treated. 2.Carriers may remain infective for much longer period.

15 Dr.Harivansh Chopra Diphtheria – Portal of entry Respiratory Route Non-Respiratory Route

16 Dr.Harivansh Chopra Mode of Transmission 1.Droplet infection. 2.Droplet nuclei. 3.Through infected cutaneous lesions. 4.Through – 1.Milk. 2.Foods. 3.Fomites.

17 Dr.Harivansh Chopra Incubation Period 2 – 6 days.

18 Dr.Harivansh Chopra Diphtheria – Environmental Factors Transmission favoured in winter season.

19 Dr.Harivansh Chopra Diphtheria – Clinical Features Anterior Nasal: More common in Infants. 1.Rhinorrhoea – Discharge may be: 1.Watery. 2.Serosanguinous. 3.Purulent. 4.Foul-smelling.

20 Dr.Harivansh Chopra Diphtheria – Clinical Features Anterior Nasal: 2.White membrane. 3.Delayed systemic manifestations.

21 Dr.Harivansh Chopra Diphtheria – Clinical Features Pharyngeal/Tonsillar : 1.Symptoms: 1.Sore throat. 2.50% have fever. 3.Few have dysphagia, hoarseness, malaise, or headache.

22 Dr.Harivansh Chopra Diphtheria – Clinical Features Pharyngeal/Tonsillar : 2.Signs: 1.Unilateral or bilateral tonsillar membrane formation, which extends to cover uvula, soft palate, posterior oropharynx, hypopharynx, and glottis.

23 Dr.Harivansh Chopra Diphtheria – Clinical Features Pharyngeal/Tonsillar : 2.Signs: 2.Soft tissue oedema. 3.Enlarged lymph nodes, resulting in bull-neck appearance. 4.Effort to remove membrane results in haemorrhage.

24 Dr.Harivansh Chopra Diphtheria – Clinical Features Laryngeal: 1.Noisy breathing. 2.Stridor. 3.Hoarseness of voice. 4.Dry cough. 5.Fever. 6.May lead to asphyxia.

25 Dr.Harivansh Chopra Diphtheria – Clinical Features Cutaneous: 1.Ulcers around mouth and nose. 2.Ulcers: 1.Defined border. 2.Membranous base.

26 Dr.Harivansh Chopra Diphtheria – Clinical Features Conjunctival: 1.Affects palpebral conjunctiva. 2.Presentation: 1.Oedematous. 2.Membrane formation.

27 Dr.Harivansh Chopra Diphtheria – Clinical Features Aural: 1.Otitis externa. 2.Discharge: 1.Persistant. 2.Purulent. 3.Foul-smelling.

28 Dr.Harivansh Chopra Diphtheria – Diagnosis 1.Specimen: Nasal and throat swab, or any other muco-cutaneous lesion. 2.Portion of membrane, and underlying exudate submitted. 3.Laboratory notified to use selective media.

29 Dr.Harivansh Chopra Diagnosis 1.Early diagnosis is important. 2.Diagnosis based on high suspicion in a child with: 1.Sore throat. 2.Dyspnea. 3.Noisy breathing. 4.Fever.

30 Dr.Harivansh Chopra Differential Diagnosis Tonsillopharyngeal type: 1.Acute streptococcal membranous tonsillitis. 2.Viral membranous tonsillitis.

31 Dr.Harivansh Chopra Differential Diagnosis Tonsillopharyngeal type: 3.Herpes tonsillitis. 4.Thrush. 5.Infectious mononucleosis.

32 Dr.Harivansh Chopra Differential Diagnosis Nasal type: 1.Foreign body in the nose. 2.Snuffle. 3.Rhinorrhoea.

33 Dr.Harivansh Chopra Treatment 1.Start treatment at earliest on clinical suspicion. 2.Don’t wait for the laboratory report.

34 Dr.Harivansh Chopra Treatment – Principles Antitoxins – Neutralising circulating Toxins. Antibiotics – Eradicate Bacteria. Supportive Treatment. Manage Complications.

35 Dr.Harivansh Chopra Passive Immunisation – Immunoglobulins 1.ADS of horse origin. 2.ADS of human origin.

36 Dr.Harivansh Chopra Dosage of antitoxin (equine) Duration of disease48 hours LesionsThroatLarynx Dose (I.U.) – – Must be used only after sensitivity test.

37 Dr.Harivansh Chopra Dosage of antitoxin (equine) Duration of disease Over 48 hours Lesions Membrane in naso- pharynx Swelling in neck Extensive disease > 3 days Dose (I.U.) – – – Must be used only after sensitivity test.

38 Dr.Harivansh Chopra Antitoxin Treatment – human 1.Dose: 0.6 ml/kg body weight Intramuscular (Available as 2ml vial with 300 mg Globulins). 2.Advantage over ADS (horse origin): 1.Hypersensitivity absent. 2.Longer protection.

39 Dr.Harivansh Chopra Treatment 1.Antibiotics: 1.No substitute to anti-toxin. 2.Stops production of more toxin. 2.Dosage: 1.Erythromycin: 40-50mg/kg/24 hrs. divided 6 hourly orally QID X 14 days.

40 Dr.Harivansh Chopra Treatment 2.Dosage: 2.Crystalline Penicillin G: 100,000 – 150,000 IU/kg/24 hrs in 4 – 6 divided doses I.V./I.M. X 14 days. OR 3.Procaine Penicillin: 25,000 – 50,000 IU/kg/24 hrs in 2 divided doses IM X 14 days.

41 Dr.Harivansh Chopra Supportive Therapy Isolation Hospitalization Bed rest 2 weeks Monitor Respiratory/ Cardiac Functions Wash cutaneous lesions Check Gag Reflex Sedatives/ Hypnotics Contraindicated High calorie Soft diet Suction Of Secretion Avoid Exertion

42 Dr.Harivansh Chopra Diphtheria Complication – Asphyxia Obstruction of respiratory passage by membrane: 1.Tachypnea. 2.Stridor. 3.Use of accessory muscles of respiration. 4.Cyanosis.

43 Dr.Harivansh Chopra Treatment of Asphyxia 1.Tracheostomy. 2.Humidified air.

44 Dr.Harivansh Chopra 1.In acute phase. 2.Toxic cardiomyopathy occurs in approx % patients and is responsible for 50-60% of deaths. 3.Usually in 2 nd – 3 rd week of illness. Diphtheria Complication – Myocarditis

45 Dr.Harivansh Chopra Treatment of Myocarditis 1.Bed rest, Avoid exertion. 2.Restrict fluid and salt intake. 3.Diuretics. 4.May need sedation and oxygen. 5.Digoxin in decompensated heart.

46 Dr.Harivansh Chopra Diphtheria Complication – Neurological involvement 1.Parallel the onset of primary infection. 2.Multiphasic in onset: Time periodNeurological involvement 2 – 3 weeks Palatal and pharyngeal paralysis 5 th weekCranial neuropathies 10 days – 3 monthsPolyneuropathy

47 Dr.Harivansh Chopra 1.Palatal and Pharyngeal paralysis: 1.Swallowing difficulty. 2.Nasal voice. 3.Regurgitation through nose. Diphtheria Complication – Neurological involvement

48 Dr.Harivansh Chopra Peripheral Neuropathy: 1.Occurs 1 – 3 months after. 2.Paraesthesia. 3.Resolves completely. Diphtheria Complication – Neurological involvement

49 Dr.Harivansh Chopra Treatment of Neurological complications 1.Nasogastric feeding. 2.Treatment of general weakness.

50 Dr.Harivansh Chopra Case fatality rate 1.With Treatment – <5% (Unchanged for the past 50 years). 2.Without treatment – 10%.

51 Dr.Harivansh Chopra Prognosis Prognosis is associated with: 1.Virulence of organism: Gravis strain has poor prognosis. 2.Age. 3.Immunisation status. 4.Site of infection.

52 Dr.Harivansh Chopra Prognosis Prognosis is associated with: 5.Speed of administration of toxin. 6.Myocarditis, CHF. 7.Poor respiratory monitoring. 8.Phrenic nerve paralysis.

53 Dr.Harivansh Chopra Contact and Carrier 1.Reported rates of carriage in household contacts of case patients are 0-25%. 2.Risk of developing diphtheria after exposure: 1.To case: approx. 2%. 2.To carrier: approx. 0.3%.

54 Dr.Harivansh Chopra Management of contacts – Detection “Schick Test” 0.2 ml of (1/50 MLD) of Schick Test Toxin ID. 0.2 ml of (1/50 MLD) of Schick Test Toxin ID inactivated by heat. TEST ARMCONTROL ARM

55 Dr.Harivansh Chopra Schick Test – Analysis of findings Test ArmControl ArmResult No reaction Negative. Immunity to Diphtheria hrs. – Circumscribed red flush (10 – 50 mm). 4 th -7 th day – maximum size of rash. Thereafter – fades into brown patch, & desquamation. No reaction Positive. Susceptible to Diphtheria.

56 Dr.Harivansh Chopra Schick Test – Analysis of findings Test ArmControl ArmResult Red flush of smaller size than positive reaction. Fades quickly by 4 th day. Red flush exactly as test arm. Pseudo- positive. Allergic reaction. Positive reaction. Pseudo- positive reaction Combination reaction. Person susceptible but allergic.

57 Dr.Harivansh Chopra Management of Contacts – Treatment Prophylactic Antibiotics – Given to all contacts, regardless of immunisation status. 1.Erythromycin: 40-50mg/kg/24 hrs divided QID orally X 7 days (Max. 2gm/24 hrs). 2.Benzathine Penicillin G: 600,000 U IM for <30kg, & 1,200,000 U IM for ≥30kg single dose.

58 Dr.Harivansh Chopra Management of Contacts – Treatment 1.Non-immunised Contacts: units of Diphtheria antitoxin. 2.Actively immunised against diphtheria.

59 Dr.Harivansh Chopra Management of Contacts – Treatment 2.Immunised contacts: Booster dose, or Primary Immunisation within past 2 years. Booster dose, or Primary Immunisation more than 2 years ago. No action Required. Booster dose of dT.

60 Dr.Harivansh Chopra 1.Medical surveillance of all contacts for 1 week after exposure. 2.Bacteriological surveillance weekly for several weeks. Management of Contacts – Surveillance

61 Dr.Harivansh Chopra Management of Carriers 1.Detection of carriers by nasal & throat swab examination. 2.Age appropriate diphtheria toxoid given immediately if booster has not been given for past 1 year.

62 Dr.Harivansh Chopra Management of Carriers 3.Antibiotic Treatment: 1.Erythromycin – 500mg QID X 7 days. 2.Rifampicin – 600mg OD X 7 days. 4.Bacteriological surveillance needed.

63 Dr.Harivansh Chopra Immunisation 1.Does not prevent the occurrence of Carrier State. 2.Combined or mixed vaccines: 1.DPT (Diphtheria-pertussis- tetanus). 2.DT (Diphtheria-tetanus toxoid). 3.dT (Diphtheria-tetanus, adult type).

64 Dr.Harivansh Chopra Immunisation 2.Single vaccines: 1.FT (formal-toxoid). 2.APT (alum-precipitated toxoid). 3.PTAP (purified toxoid aluminium phosphate). 4.PTAH (purified toxoid aluminium hydroxide). 5.TAF (toxoid-antitoxin floccules). 3.Antisera: 1.Diphtheria anti-toxin.

65 Dr.Harivansh Chopra DTP Vaccine 1.Content (BE ltd.): 1.Diptheria toxoid ≥20Lf to ≤30Lf. 2.Pertussis ≥4 IU. 3.Tetanus toxoid ≥5Lf to ≤25Lf. 2.Dose – 0.5 ml. 3.Route – Deep intramuscular. 4.Recommended site – Antero-lateral part of thigh.

66 Dr.Harivansh Chopra DTP vaccine – Schedule 1.1 st dose – 6 th week. 2.2 nd dose – 10 th week. 3.3 rd dose – 14 th week. 4.1 st booster – months. 5.2 nd booster – 4-5 years.

67 Dr.Harivansh Chopra DTP vaccine – Side-effects 1.Local swelling. 2.Tenderness. 3.Slight fever.

68 Dr.Harivansh Chopra DTP vaccine – Side-effects 4.Excessive somnolence. 5.Protracted inconsolable crying. 6.Neurological reactions: 1.Convulsions. 2.Encephalopathy.

69 Dr.Harivansh Chopra DTP vaccine – Contraindications 1.Acute febrile illness. 2.Evolving or suspected neurological illness. 3.Severe reaction to a prior dose of DPT.

70 Dr.Harivansh Chopra dT vaccine – Adult type 1.Contains: 1.Diphtheria toxoid = 2lf. 2.Tetanus toxoid. 2.Indications: 1.Non-immunised children > 7 years of age.

71 Dr.Harivansh Chopra dT vaccine – Adult type 3.Dosage: 1.Two doses at an interval of 4 – 8 weeks. 2.Booster: 1.First, after 6 – 12 months. 2.Second after 10 years.

72 boostrix

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 and 2.5 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 contraindications Severe 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 Dr.Harivansh Chopra Conclusions 1.Diphtheria is a vaccine-preventable disease characterised by formation of a pseudo-membrane, tissue destruction, and lymph node enlargement. 2.Early detection and treatment is essential to prevent life-threatening complications.

81 Dr.Harivansh Chopra 1.Which of the following is not true for diphtheria 1.Diphtheria bacilli produces a powerful exotoxin 2.The source of infection is either a case or a carrier 3.Chronic carrier state may last up to 2 years 4.Incubation period of diphtheria is 2-6 days Ans. 3. M.C.Q

82 Dr.Harivansh Chopra 2.All of the following are true for diphtheria except 1.Immunization does not prevent carrier state. 2.Unless treated, period of infectivity varies from 1-2 weeks from the onset of disease. 3.Unapparent infections result in the development of immunity. 4.99% of children over the age of 5 years are immune to diphtheria usually. Ans. 2.

83 Dr.Harivansh Chopra 3. Which of the following is not true for toxic myocardiopathy of diphtheria 1.It occurs in 10-25% patients of diphtheria 2.It is responsible for 50-60% of deaths in diphtheria 3.Elevation of serum Aspartate Aminotransferase concentration does not parallel the severity of myonecrosis 4.All degree of heart blocks can occur in it Ans. 3.

84 Dr.Harivansh Chopra 4. Cranial neuropathy in diphtheria occurs in 1.1st week of illness 2.3rd week of illness 3.5th week of illnees 4.6th week of illness Ans. 3.

85 Dr.Harivansh Chopra 5. Which of the following is not true for diphtheria 1.Neurological complications are multiphasic in onset 2.Cranial neuropathy lead to oculomotor & ciliary paralysis 3.CSF findings can differentiate between polyneuropathy of diphtheria &GB syndrome 4.Paralysis of diaphragm can occur Ans. 3.

86 Dr.Harivansh Chopra 6. The prognosis of diphtheria depends on 1.Virulence of the organism 2.Site of infection 3.Speed of administration of antibiotic 4.All of the above Ans. 4.

87 Dr.Harivansh Chopra 7. Majority of deaths in diphtheria occur due to 1.Mechanical obstruction 2.Myocarditis 3.Both of the above 4.None of the above Ans. 3.

88 Dr.Harivansh Chopra 8. The dose of Antitoxin of human origin (Dipglobe) for the treatment of diphtheria ml/kg ml/kg ml/kg ml/kg Ans. 3.

89 Dr.Harivansh Chopra 9. The management of asymptomatic case contact includes 1.Monitoring of individuals for 7 days 2.Monitoring + culture of lesion 3.Monitoring + culture + antimicrobial prophylaxis 4.Monitoring + culture + antimicrobial prophylaxis + diphtheria toxoid vaccine irrespective of immunization status Ans. 3.

90 Dr.Harivansh Chopra 10. Antimicrobial therapy in diphtheria can be given by 1.Erythromycin mg/kg/day for 14 days 2.Crystalline Penicillin lac I.U./kg/day for 14 days 3.Procaine Penicillin I.U./kg/day for 14 days 4.Any of the above Ans. 4.

91 Dr.Harivansh Chopra


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