Presentation of Diptheria

8/14/2019 Presentation of Diptheria

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Andrew James EscolanoAndrew James Escolano


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DefinitionDefinition

Is an infectious diseases cause by corynebacteruimIs an infectious diseases cause by corynebacteruimdiphtheria, characterized by the formation ofdiphtheria, characterized by the formation ofpseudomembrane, commonly in the faucial area and tonsils,pseudomembrane, commonly in the faucial area and tonsils,and the elotoration of powerful exotoxin affecting theand the elotoration of powerful exotoxin affecting theimportant viscera of the heart and kidneys and the peripheralimportant viscera of the heart and kidneys and the peripheralnervous system.nervous system.

Diphtheria causes the progressive deterioration of myelinDiphtheria causes the progressive deterioration of myelinsheaths in the central and peripheral nervous system leadingsheaths in the central and peripheral nervous system leadingto degenerating motor control and loss of sensation.to degenerating motor control and loss of sensation.Diphtheria is a contagious disease spread by direct physicalDiphtheria is a contagious disease spread by direct physicalcontact or breathing the aerosolized secretions of infectedcontact or breathing the aerosolized secretions of infectedindividuals.individuals.

Acute febrile infection of the tonsils, throat, nose, larynx or aAcute febrile infection of the tonsils, throat, nose, larynx or awound marked by a patches of grayish membrane from whichwound marked by a patches of grayish membrane from whichbacilli is readily cultured.bacilli is readily cultured.


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EtiologyEtiology

Corynebacteruim diphtheriaeCorynebacteruim diphtheriae (Klebs-loeffler(Klebs-loefflerbacillus)bacillus)

Is typically a slender, curved and slightly tapered clubbedIs typically a slender, curved and slightly tapered clubbed

organism which gram + to variable, facultatively aerobicorganism which gram + to variable, facultatively aerobic


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Incubation periodIncubation period

2-6 days, occationally longer2-6 days, occationally longer


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Pathognomonic signPathognomonic sign

Sore throatSore throat


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Mode of transmissionMode of transmission

Contact with a patient, carrier,Contact with a patient, carrier,

articles soiled with discharged ofarticles soiled with discharged of

infected personinfected personSource: discharged from noseSource: discharged from nose

pharynx, eyes or lesion on otherpharynx, eyes or lesion on other

parts of body of infected person.parts of body of infected person.


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Period of communicabilityPeriod of communicability

Variable until virulent bacilli hasVariable until virulent bacilli has

disappeared from secretions anddisappeared from secretions and

lesions: usually 2 weeks andlesions: usually 2 weeks andseldom more than 4 weeks.seldom more than 4 weeks.


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Sign and symptomsSign and symptoms

FatigueFatigue DysphagiaDysphagia Nausea/vomitingNausea/vomiting ChillsChills High feverHigh fever

Neck swellingNeck swelling Bull neckBull neckToxaema (except in nasal type): apathy, malaise,Toxaema (except in nasal type): apathy, malaise,

weakness and pulse disproportionately rapid toweakness and pulse disproportionately rapid totemperature.temperature.


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PathogenesisPathogenesis

The typical pseudomembrane is formed by leukocytes, fibrin,The typical pseudomembrane is formed by leukocytes, fibrin,

necrotic tissue and micro organism; which is adherent to thenecrotic tissue and micro organism; which is adherent to the

underlying tissues and leaves a raw bleeding area whenunderlying tissues and leaves a raw bleeding area when

detached.detached.

The toxin elaborated by the organism initiates and contributesThe toxin elaborated by the organism initiates and contributesto the further growth of lesion and formation of more toxinsto the further growth of lesion and formation of more toxins

which attacks the myocardium, kidneys, liver, cranial andwhich attacks the myocardium, kidneys, liver, cranial and

peripheral nerves producing foci of necrosis and degeneration.peripheral nerves producing foci of necrosis and degeneration.

The site of membrane formation influence the clinical features,The site of membrane formation influence the clinical features,

produced more toxins absorbed from the upper respiratoryproduced more toxins absorbed from the upper respiratory

tract than lower respiratory.tract than lower respiratory.


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PathophysiologyPathophysiology

the damage to body is a results ofthe damage to body is a results of

liberation of soluble toxins in the localliberation of soluble toxins in the local

lesion.lesion.

Size of membrane reflects the amountSize of membrane reflects the amount

of toxins being produce.of toxins being produce.

The larger the membrane the moreThe larger the membrane the more

toxins present in blood.toxins present in blood.

Toxin-tissue union in many body portsToxin-tissue union in many body ports

but special affinity appears to exist inbut special affinity appears to exist in

certain parts, heart and peripheralcertain parts, heart and peripheral

nerves.nerves.


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Diagnostic testDiagnostic test

Nose and throat swabNose and throat swab

Virulence testVirulence test

Shick testShick testMoloney testMoloney test

Differential diagnosisDifferential diagnosis


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Nose and throat swabNose and throat swab

Culture of both nose andCulture of both nose and

throat in all types ( swabthroat in all types ( swab

are streak on fresh paisare streak on fresh pais

loeefler serum apgar, bloodloeefler serum apgar, bloodtellurite or tisdale mediatellurite or tisdale media

and examine 8- 24 hours ofand examine 8- 24 hours of

incubation.incubation.

Negative results do not ruleNegative results do not ruleout diphtheria.out diphtheria.


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Virulence testVirulence test

Direct smear property stained willDirect smear property stained will

appear typical gram (+) organismappear typical gram (+) organism

but although having an advantagebut although having an advantageof being simple delay is notof being simple delay is not

entirely reliable.entirely reliable.


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Schick testSchick test

Intradermal injection of diluteIntradermal injection of dilute

diphtheria toxins ( 0.1cc)diphtheria toxins ( 0.1cc)

(+) to individual w/o immunity,(+) to individual w/o immunity,

hence susceptible to diphtheriahence susceptible to diphtheria After 48-72 hours (+) reactionAfter 48-72 hours (+) reaction

reveals itself as localreveals itself as local

circumscribed area of redness 1-circumscribed area of redness 1-

3 cm in diameter, but3 cm in diameter, butoccasionally larger.occasionally larger.


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Moloney testMoloney test

Test to determined hypersensitivity toTest to determined hypersensitivity to

diphtheria toxoiddiphtheria toxoid

Performed by injecting 1.0cc fluidPerformed by injecting 1.0cc fluid

toxoid intradermally.toxoid intradermally.

If (+) an area erythema will developedIf (+) an area erythema will developed

in 24 hours.in 24 hours.


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MedicationMedication

Serum therapySerum therapy

antibioticantibiotic


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Serum therapy ( diphtheriaSerum therapy ( diphtheria

antitoxin)antitoxin)

Early administration aim toEarly administration aim to

neutralizing the toxins present inneutralizing the toxins present in

general circulation before it absorbedgeneral circulation before it absorbed

by the tissues.by the tissues.

Skin testing is required beforeSkin testing is required before

administration of antitoxin for allergicadministration of antitoxin for allergic

reaction.reaction.


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One must be guided with some severalOne must be guided with some several

factor:factor:

a.a. The day of disease which patient isThe day of disease which patient is

first observedfirst observed

b.b. Apparent severity of the lesion,Apparent severity of the lesion,

namely the extent of membrane.namely the extent of membrane.

c.c. Evidence of toxemia.Evidence of toxemia.


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Dosage and route inDosage and route in

administration of antitoxinadministration of antitoxin

TypeType DoseDose RouteRoute

Anterior nasalAnterior nasal 10,000-20,00010,000-20,000

unitsunits

IntramuscularIntramuscular

FaucialFaucial 15,000-25,00015,000-25,000unitsunits

IM/IVIM/IV

Pharyngeal/laryPharyngeal/laryngealngeal

20,000-40,00020,000-40,000unitsunits

IVIV

Combined, lateCombined, latecasescases

40,000-80,00040,000-80,000unitsunits

IVIV


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AntibioticsAntibiotics

Effective for sensitive strainEffective for sensitive strain

a.a. Penicillin G potassium,Penicillin G potassium,

100,000 mg/kg/day in 4100,000 mg/kg/day in 4

doses, IM or IV.doses, IM or IV.

b.b. Erythromycin, 40mg/kg inErythromycin, 40mg/kg in

4 doses, oral, for 7-104 doses, oral, for 7-10

daysdays


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ProphylaxisProphylaxis

Active immunizationActive immunization

Passive immunizationPassive immunization


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Active immunizationActive immunization

Based on principle that the smallBased on principle that the small

doses of toxins stimulates thedoses of toxins stimulates the

production of antitoxin in the body.production of antitoxin in the body.

Most desirable period is between 6-12Most desirable period is between 6-12

months of age, preferably 9 months.months of age, preferably 9 months.


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Method of activeMethod of active

immunizationimmunizationa.a. toxin-antitoxintoxin-antitoxin is a preparation in w/c the is a preparation in w/c the

active immunizing substance, the toxinactive immunizing substance, the toxinhas been buffered or attenuated, withhas been buffered or attenuated, withsuitable amount of antitoxins.suitable amount of antitoxins.

-has been replace by toxoid w/c is prepared-has been replace by toxoid w/c is preparedby addition of 1.4% formalin, thusby addition of 1.4% formalin, thusattenuating the toxin.attenuating the toxin.

The dose is 0.5cc subQ for 3 doses interval ofThe dose is 0.5cc subQ for 3 doses interval of3 months3 months


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ToxoidToxoid

As in routine of DPT immunization program of infancyAs in routine of DPT immunization program of infancyand childhood and provide protection about 10 years.and childhood and provide protection about 10 years.

Booster doses is given at suitable interval untilBooster doses is given at suitable interval until

adulthood.adulthood. Protection may not absolute, but disease becomeProtection may not absolute, but disease become

milder and minimum of complication.milder and minimum of complication.

Given subQ or IM by large gauge needle coz danger ofGiven subQ or IM by large gauge needle coz danger ofblockage by particles of precipitate.blockage by particles of precipitate.


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Passive immunizationPassive immunization

For susceptible person who has beenFor susceptible person who has been

directly exposed to an unquestioneddirectly exposed to an unquestioned

case of the disease.case of the disease.

Advisable to protect them at once byAdvisable to protect them at once by

injection of 10,000 units of antitoxins,injection of 10,000 units of antitoxins,

IM and last about 3-4 weeks.IM and last about 3-4 weeks.

Antitoxin prevent development of theAntitoxin prevent development of the

disease.disease.


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Nursing managementNursing management

RestRest

Care of nose andCare of nose and

throatthroat

Ice collarIce collarDietDiet


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RestRest

Patient should be confined to bedPatient should be confined to bed

at least 2 weeks, not permittedat least 2 weeks, not permitted

to feed himself, bathe, or toto feed himself, bathe, or to

make exertion.make exertion.

Patient is restless, especiallyPatient is restless, especiallywhen dyspneic of laryngealwhen dyspneic of laryngeal

diphtheria, therefore warm, freshdiphtheria, therefore warm, fresh

air must be ensured.air must be ensured.

In severe cases even making bedIn severe cases even making bedis omitted to conserved energy.is omitted to conserved energy.


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Vomiting is exhausting, therefore noVomiting is exhausting, therefore no

procedure that might nauseate theprocedure that might nauseate the

patient should be used.patient should be used.

This means small, frequent feeding,This means small, frequent feeding,

rather than larger ones at longerrather than larger ones at longer

intervals.intervals.

Another important point in rest is toAnother important point in rest is to

prevent straining at defecationprevent straining at defecation


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Care of nose and throatCare of nose and throat

Nose, throat, mouth should be kept clean.Nose, throat, mouth should be kept clean.

Gentle swabbing must be done to preventGentle swabbing must be done to prevent

bleeding.bleeding.

Liquid albolene is soothing to mucousLiquid albolene is soothing to mucousmembrane after cleansing and it preventmembrane after cleansing and it prevent

dryness and excoriation caused by thedryness and excoriation caused by the

discharges from the lesions.discharges from the lesions.

The whole room must be moist atmosphere,The whole room must be moist atmosphere,with humidity carefully regulated, in order towith humidity carefully regulated, in order to

lessen irritability to nose and throat.lessen irritability to nose and throat.


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Ice collarIce collar

Sometimes ice collar is moreSometimes ice collar is more

effective than warmeffective than warm

application in relieving pain ofapplication in relieving pain of

the sore throat.the sore throat. Kept aroud the neck asKept aroud the neck as

intended.intended.

Rubber collar must be placedRubber collar must be placed

in cloth or gauge to protectin cloth or gauge to protect

patient skin and preventpatient skin and prevent

wetting patient clothing.wetting patient clothing.


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DietDiet

When throat is very sore, softWhen throat is very sore, soft

foods.foods.

Small amounts given frequently.Small amounts given frequently.

Fruit juices help to maintainFruit juices help to maintain

alkalinity of blood, citrus mayalkalinity of blood, citrus may

comfort when in sore throat.comfort when in sore throat.

Creamed soups, purees, soft eggs,Creamed soups, purees, soft eggs,

jellies, custards, broth andjellies, custards, broth and

buttermilk should provide abuttermilk should provide a

balanced ration if a sufficientbalanced ration if a sufficient

amount can be swallowed.amount can be swallowed.


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complicationcomplication

ToxemiaToxemia

NeuritisNeuritis

Difficulty swallowing and breathingDifficulty swallowing and breathingPneumoniaPneumonia

Kidney failureKidney failure

DeathDeath


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ToxemiaToxemia

Due to toxemiaDue to toxemia

a.a. Toxic myocarditis- Myocarditis is inflammation of theToxic myocarditis- Myocarditis is inflammation of the

heart muscle that can cause an irregular heartbeatheart muscle that can cause an irregular heartbeat

and lead to heart failure. It often is fatal.and lead to heart failure. It often is fatal.

b.b. Due to action of toxins in the heart muscles.Due to action of toxins in the heart muscles.

c.c. Usually during the first 10-14 days.Usually during the first 10-14 days.d.d. Diminution in intensity of first heart sound.Diminution in intensity of first heart sound.

e.e. ArrhythmiaArrhythmia

f.f. E.C.G elevation of S-T segment prolongation of P-RE.C.G elevation of S-T segment prolongation of P-R

interval evidence of heart block.interval evidence of heart block.


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Abdominal pain due to enlargement ofAbdominal pain due to enlargement of

the liver caused by cardiac failure, sothe liver caused by cardiac failure, so

called chronic passive congestion.called chronic passive congestion.


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NeuritisNeuritis

Caused by absorption of toxin in the nerves.Caused by absorption of toxin in the nerves.

May appear early o late may affect the:May appear early o late may affect the:

a. Palate (paralysis of soft palate); nasal twanga. Palate (paralysis of soft palate); nasal twang

and regurgitation occurring the 3and regurgitation occurring the 3rdrd

week na lastweek na last1-2 weeks.1-2 weeks.

b. Extra ocular muscles (ocular palsy) bilateralb. Extra ocular muscles (ocular palsy) bilateral

paralysis of ocular muscles of accommodationparalysis of ocular muscles of accommodation

causing blurring of vision during 5causing blurring of vision during 5thth week,week,strabismus.strabismus.


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c. Diaphragm (paralysis) occurs 6c. Diaphragm (paralysis) occurs 6 thth-10-10thth week;week;

simulating guillain-barresimulating guillain-barre

d. Motor and skeletal muscle (motor and sensoryd. Motor and skeletal muscle (motor and sensory

paralysis)) respiratory difficulty limb or trunkparalysis)) respiratory difficulty limb or trunkweakness.weakness.

e. Toxic nephritis with albuminuria, cast ane. Toxic nephritis with albuminuria, cast an

edema may also occuredema may also occur


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Difficulty swallowing andDifficulty swallowing and

breathingbreathing

Soft-palate paralysis prevents normalSoft-palate paralysis prevents normal

swallowing and can lead to choking orswallowing and can lead to choking or

aspiration of food into the lungs, causingaspiration of food into the lungs, causing

aspiration pneumonia.aspiration pneumonia.

Paralysis of the diaphragm can lead to difficultyParalysis of the diaphragm can lead to difficulty

breathing, pneumonia, and even respiratorybreathing, pneumonia, and even respiratory

failure and death. In addition, the membrane atfailure and death. In addition, the membrane at

the back of the throat or in the voice box canthe back of the throat or in the voice box canpartially or completely block the airway,partially or completely block the airway,

resulting in suffocation.resulting in suffocation.


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PneumoniaPneumonia

Pneumonia can result from thePneumonia can result from the

infection itself, or it can be secondaryinfection itself, or it can be secondary

to the swallowing and breathingto the swallowing and breathing

difficultiesdifficulties


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Kidney failureKidney failure

The toxin produced byThe toxin produced by

Corynebacteruim diphtheriae canCorynebacteruim diphtheriae can

cause kidney failure directly, or kidneycause kidney failure directly, or kidney

failure can develop secondarily as afailure can develop secondarily as acomplication of heart failure.complication of heart failure.

h


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DeathDeath

The mortality rate is about 5 to 10The mortality rate is about 5 to 10

percent, although it can climb as highpercent, although it can climb as high

as 20 percent in children under theas 20 percent in children under the

age of five years. In recent years, theage of five years. In recent years, themortality rate in diphtheria epidemicsmortality rate in diphtheria epidemics

in the independent states of thein the independent states of the

former Soviet Union has ranged from 3former Soviet Union has ranged from 3to 23 percent.to 23 percent.


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Types of diphtheria(2)Types of diphtheria(2)

Respiratory diphtheriaRespiratory diphtheria

Non respiratory diphtheriaNon respiratory diphtheria


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Respiratory diphtheriaRespiratory diphtheria

Faucial and pharyngeal (tonsilar, uvular,Faucial and pharyngeal (tonsilar, uvular,

palatar).palatar).

Low grade fever, malaise, H/A, sore throat.Low grade fever, malaise, H/A, sore throat.

w/in 24 hours, small yellowish spot appear inw/in 24 hours, small yellowish spot appear in

tonsils w/c coalesce to form the adherenttonsils w/c coalesce to form the adherentpseudomembrane, w/c extends to the rest ofpseudomembrane, w/c extends to the rest of

fauces and nasopharynx.fauces and nasopharynx.

Cervical nodes enlargedCervical nodes enlarged

Dysphagia and noisy breathing with nasalDysphagia and noisy breathing with nasal

voice, regurgitation of fluids due to palatalvoice, regurgitation of fluids due to palatal

weaknessweakness


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Very toxic infection, the bullneck appearance Very toxic infection, the bullneck appearance

due to massive enlargement of lymph glands.due to massive enlargement of lymph glands.

Death may occur due to bronchopneumonia orDeath may occur due to bronchopneumonia or

toxic myocarditis.toxic myocarditis.


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Laryngotracheal diphtheria (tracheal, bronchial)Laryngotracheal diphtheria (tracheal, bronchial)

More commonly in infantsMore commonly in infants

Hoarseness with barking cough and noisy breathingHoarseness with barking cough and noisy breathing

(croupy cough, braze-metallic cough)(croupy cough, braze-metallic cough)

Inspiratory stridor, aphonia, dyspnea withInspiratory stridor, aphonia, dyspnea with

subclavicular and suprasternal retractions.subclavicular and suprasternal retractions.

In severe cases with progressive obstruction leadsIn severe cases with progressive obstruction leads

to suffocation, cyanosis, cardiac failure and death.to suffocation, cyanosis, cardiac failure and death.


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Nasal (anterior, posterior)Nasal (anterior, posterior)

Occurs mostly at 1Occurs mostly at 1stst three years of life.three years of life.

Persistent serous nasal discharged laterPersistent serous nasal discharged later

become bloody and foul smelling.become bloody and foul smelling. Discharges: serous serosanguinous Discharges: serous serosanguinous

mucopurulent (excoriating anterior nares andmucopurulent (excoriating anterior nares and

upper lips) impetiginous appearance. (Lateralupper lips) impetiginous appearance. (Lateral

or bilateral.)or bilateral.)


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Non respiratory diphtheriaNon respiratory diphtheria

Ocular (conjucntival)Ocular (conjucntival)reddenedreddened

Ears (aural) purulentEars (aural) purulentdischargeddischarged

Wound and ulcer in theWound and ulcer in theskinskin

Genito urinary tract Genito urinary tract external genitalis,external genitalis,ulcerative lesions onulcerative lesions onvulva and vagina.vulva and vagina.

Umbilical of the newborn.Umbilical of the newborn.


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EpidemiologyEpidemiology

IncidenceIncidence

December to February higher prevalenceDecember to February higher prevalence

occurring at cooler months.occurring at cooler months.

Mainly disease of childhood, peak incidenceMainly disease of childhood, peak incidencebetween 2 to 5 years.between 2 to 5 years.

Rare below 6 months due to transplacentalRare below 6 months due to transplacental

transmission of immunity acquired fromtransmission of immunity acquired from

mother who presumably developed activemother who presumably developed active

immunity from inapparent infection.immunity from inapparent infection.


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PrognosisPrognosis

The prognosis depends on the size andThe prognosis depends on the size and

location of the membrane and on earlylocation of the membrane and on early

treatment with antitoxin; the longertreatment with antitoxin; the longer

the delay, the higher the death rate.the delay, the higher the death rate.The most vulnerable patients areThe most vulnerable patients are

children under age 15 and those whochildren under age 15 and those who

develop pneumonia or myocarditis.develop pneumonia or myocarditis.Nasal and cutaneous diphtheria areNasal and cutaneous diphtheria are

rarely fatal.rarely fatal.


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ReferencesReferences

www.wikipedia.comwww.wikipedia.com

www.google.comwww.google.com

compilation of communicable disease incompilation of communicable disease innursing book.nursing book.
http://www.wikipedia.com/http://www.wikipedia.com/http://www.google.com/http://www.google.com/http://www.google.com/http://www.wikipedia.com/


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Presentation of Diptheria