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Diphtheria

Diphtheria. Dr. Harivansh Chopra, MD, DCH Professor, Department of Community Medicine, LLRM Medical College, Meerut. harichop@gmail.com. Objectives. To study the epidemiology of Diphtheria. To study the complications of diphtheria, and their management.

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Diphtheria

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

  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. Diphtheria Acute 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 diphtheria Dr.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

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

  10. Diphtheria – Agent Factor • .Types – • Gravis. • Mitis. Dr.Harivansh Chopra

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

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

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

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

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

  16. Mode of Transmission • Droplet infection. • Droplet nuclei. • Through infected cutaneous lesions. • Through – • Milk. • Foods. • Fomites. Dr.Harivansh Chopra

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

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

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

  20. Diphtheria – Clinical Features Anterior Nasal: • White membrane. • Delayed systemic manifestations. 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

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

  31. Differential Diagnosis Tonsillopharyngeal type: • Herpes tonsillitis. • Thrush. • Infectious mononucleosis. Dr.Harivansh Chopra

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

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

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

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

  36. Dosage of antitoxin (equine) Must be used only after sensitivity test. Dr.Harivansh Chopra

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

  41. 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: Dr.Harivansh Chopra

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

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

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

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

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