1. Infectious diseases with tonsillitis. Diphtheria
Lecturer
Gorishna Ivanna Lubomyrivna

2. Plan of the lecture Definition of Diphtheria Etiology Transmission
Pathogenesis
Classification and clinical presentation
Complications
Diagnostic tests
Differential diagnose
Treatment
Prevention

3. Diphtheria is
Diphtheria is an acute toxicoinfection caused by toxigenic strains of Corynebacterium diphtheriae, characterized by a local lesion consisting of a membrane. The constitutional symptoms are due to exotoxin circulation, which has a special affinity for nerve tissue, heart muscle and kidneys.

4. ETIOLOGY
Corynebacterium species are aerobic, nonencapsulated, non-sporeforming, mostly nonmotile, gram-positive bacilli.
Sensitive to high temperature and disinfection
Stabile to freezing and dryness
Three biotypes –
mitis
gravis
intermedius

5. Transmission
Transmission is from person-to-person (from a patient or carrier)
through direct contact
or airborne respiratory droplets
These materials include discharge from the nose, throat, and lesions on the skin, eyes and even the vagina.
Contagious index – 10-15%
Seasonality – autumn-winter
Immunity – instable

6. Incubation period
Short (from one to seven days)

7. Pathogenesis
Entrance for the infection: throat, nose, larynx, sex organs, wound.
Dissemination of the Corynebacterium, production of exotoxin.
Local toxin effects with membranous inflammation.
Toxemia.
Diffuse toxic effects on kidneys, suprarenal glands, cardiovascular system, and peripheral nervous system.

8. Fibrinous inflammation
Diphtheritic (on flat multilayer epithelium)
Crupous (on cylindrical one layer epithelium)

9. Classification of Diphtheria
Diphtheria of the tonsils and pharynx
localized (catarrhal, islet-like, membranous)
spread form
toxic form:
I degree
II degree
III degree
hypertoxic
hemorrhagic form
gangrenous form

10. Diphtheria of the tonsils, localized, membranous (moderate)

11. Diphtheria of the tonsils, localized, membranous (moderate)

12. Diphtheria of the tonsils, spread (moderate)

13. Diphtheria of the tonsils, toxic (severe)

14. Diphtheria of the tonsils, toxic (neck edema)

15. Classification of Diphtheria
Diphtheria of the respiratory tract (croup)
Localized croup (laryngitis)
Spread croup
laryngotracheitis
laryngotracheobronchitis
Stages of croup
Catarrhal croup
Stenosis
Compensated
Subcompensated
Decompensated
Asphyxia

16. Classification of Diphtheria
Diphtheria of the nasopharynx (adenoiditis)
Diphtheria of the nose
localized
catarrhal
islet-like
membranous
Spread
toxic
Combined form
Rare forms (localized, spread, toxic)
eye
ear
skin
genital tract

17. Diphtheria of the nose

18. Diphtheria of the lip

19. Classification of Diphtheria
mild
localized
Tonsils (islet-form), nose
eye
ear
skin
genital tract
moderate
spread
Tonsils (membranous-form)
Nasopharyngeal
Localized croup
Tonsils, nose
severe
Spread
Toxic, hypertoxic
Spread croup
Tonsils , nose

20. Classification of Diphtheria
The course of disease
With complication
Without complication

21. Classification of Diphtheria Bacilli carrying
Transitional carrying
Short time – up to 2 wks
Prolong carrying - more than 1 mo
Chronic carrying – more than 6 mo

22. Complications early: Toxic shock syndrome; DIC syndrome
Acute adrenal insufficiency;
Renal insufficiency
Respiratory insufficiency
Plural organs insufficiency
(in the end of 1st to 2nd week) nephritis; myocarditis; peripheral cranial nerves palsies;
late (on the 3rd to 7th week): myocarditis; peripheral spinal nerves palsies.

23. Death may occur from
Toxemia toward the end of the firth week
Cardiac failure from toxic myocarditis (second week of illness)
Respiratory failure due to peripheral neuritis affecting the vagus nerve (third to seventh week)

24. Diagnostic tests
used to confirm infection combine isolation of C diphtheriae on cultures with toxigenicity testing.
Bacteriologic culturing is essential to confirm the diagnosis of diphtheria.
Toxigenicity testing: Perform toxigenicity testing using the Elek test to determine if the C diphtheriae isolate produces toxin.
Polymerase chain reaction

25. Differential diagnose
Diphtheria of the pharynx must be differentiated from scarlet fever, acute bacterial tonsillitis, infectious mononucleosis;
diphtheria of the upper respiratory tract – with viral croup caused by parainfluenza, measles, chickenpox, and influenza viruses.

26. Bacterial tonsillitis (follicular)

27. Bacterial tonsillitis (lacunar)

28. Bacterial tonsillitis (lacunar)

29. Bacterial tonsillitis (necrotizing)

30. Bacterial tonsillitis (membra-nose) in patient with scarlet fever

31. Candid's tonsillitis

32. Infectious mononucleosis

33. Infectious mononucleosis

34. Infectious mononucleosis

35. Infectious mononucleosis

36. Infectious mononucleosis

37. Infectious mononucleosis

38. Perytonsillitis

39. Perytonsillar abscess

40. Mumps

41. Viral croup: Acute development Stenosis of 1st-2nd degree,
Absence of gradual development,
Absence of aphonia, loud voice
Other clinical signs (rash, rhinitis, pharyngitis)
Moderate or severe intoxication,
Edema of the sub vocal space,
Negative bacterial culture

42. Treatment Absolute bed regime (2-3 wks) Diphtheritic antitoxin therapy
Antibacterial therapy
BENZYLPENICILLIN Na lU/kg/day
Erythromycin мg/кg/day
Roxitromycin 5-8 mg/kg
Rifampicin мg/кg/day
Antiseptic fluids locally
Desensitization (suprastinum)
Vitamins B-group, C
Disintoxication therapy ( ml/kg/day)
In case of severe form corticosteroids therapy prednisolone 2-3 mg/kg/day hydrocortizone 5-10 mg/kg/day

43. Administration of Antitoxin for Treatment of Diphtheria
Clinical form
First dose Thousand U
Repeated dose Thousand U
Total dose Thousand IU
Diphtheria of the pharynx
localized
spread
toxic I
toxic II
toxic III
10, 20-30
40-50
60-70
80-100 10 20 40 50
70-80
10, 30-40

44. Administration of Antitoxin for Treatment of Diphtheria
Clinical form
First dose Thousand U
Repeated dose Thousand U
Total dose Thousand IU
Diphtheria of the larynx
Localized croup
Spread croup
Diphtheria of the nose, eye, skin
Localized
Sex organs,
localized
Toxic
30-40
40-50
15-20
20-30
50-80 -- 10 40
60-80
90-100

45. In case of toxic shock syndrome:
- Immediately intravenous infusion of DAT with prednisone intravenously mg before DAT;
- Prednisone mg/kg/day in equal doses 2-4 times per day;
- Detoxication, correction of acid-base stability and electrolytes;
- Dopamine, trental, corglicon.

46. In case of diphtheria of the larynx (except DAT):
- Inhalation of antiedematous drugs (2% NaHCO3, hydrocortisone, euphyllin, and mucolithics);
suctioning of membranes and mucus;
inhalation of oxygen;
in the III stage of stenosis – intubation;
In case of spread croup, combined with diphtheria of pharynx – tracheotomy.

47. Carriers’ treatment: Antiseptic fluids locally Vitamins B-group, C
Erythromycin мg/кg/day
Roxitromycin 5-8 mg/kg
Rifampicin мg/кg/day
Antiseptic fluids locally
Vitamins B-group, C
Immune modulators in case of chronic site of infection,
Tonsillectomy, adenotomy in case of chronic carrying.

48. Patients discharge healthy;
Patient should be isolated until three consecutive throat swabs take 24 hrs apart after stopping treatment, are negative
Mild and moderate in days;
Severe – in days.

49. Prevention specific
Immunization by DTP vaccine from 3 months age 3 times in 30 days interval (3, 4, 5 months), revaccination in 18 months (DTP), 6, 14, 18 years (DT), later – every 10 years.

50. Prevention nonspecific
Close contacts who were previously immunized longer then 5 years before should receive booster dose of diphtherial toxicoid
Antibiotic (erythromycin, rifampin) orally for 7 days
Revealing, sanation of healthy infected persons,
contacts’ examination for 10 days,
disinfection of epidemic focus.