Diphtheria

1. Diphtheria

2. Tonsillitis is inflammation of the tonsils most commonly caused by a viral or bacterial infection. Symptoms of tonsillitis include sore throat and fever.

3. Under normal circumstances, as viruses and bacteria enter the body through the nose and mouth, they are filtered in the tonsils.Within the tonsils, white blood cells of the immune system mount an attack that helps destroy the viruses or bacteria by producing inflammatory cytokines like Phospholipase A2, which also lead to fever.The infection may also be present in the throat and surrounding areas, causing inflammation of the pharynx.This is the area in the back of the throat that lies between the voice box and the tonsils.

4. Primary tonsillitis • The most common bacterial cause is Group A β-hemolytic streptococcus (GABHS), which causes strep throat.Less common bacterial causes include: Staphylococcus aureus (including methicillin resistant Staphylococcus aureus or MRSA ),

5. Secondary tonsillitis(symptomatic) • The most common causes of tonsillitis are adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus.It can also be caused by Epstein-Barr virus, herpes simplex virus, cytomegalovirus.

6. Specific tonsillitis • Sometimes, tonsillitis is caused by an infection of spirochaeta and treponema, in this case called Vincent's angina or Plaut-Vincent angina. • Sometimes – by fungi. • Sometimes - byCorynebacterium diphtheriae

7. Acute disease from the group of respiratory infections which characterized by fibrinous inflammation of mucous membranes of oralcavity, nasopharynx, larynx with toxic lesion of cardiovascular and nervous systems

8. Etiology Corynebacterium diphtheriae (Leffler rod) • Grampositive, nonmotile • Don’t forms spores and capsules • ColouredbyNeisser in brown-yellow color • Ru, Leffler, Claubergmediums - blood agar with tellurium salts • Cultural-biochemical types of C.diphtheriae - mitis, gravis, intermedius • Production of very strong exotoxin (gene tox +) • Structure of exotocin - dermanecrotoxin, hemolysin, neuraminidase, hyaluronidase • Firm to low temperature, long save on a dry surfaces; high responsive to heating and desinfection solutions

9. Epidemiology • Source – sick person or carrier (convalescent or health) of toxicogenic strains • Ways of transmission - airborne, contact - household (occasionally) • Sensibility is high, adultsmore often become sick (80 %) • Case rate sporadic, outbreaks are possible • Immunodefence antitoxic, postvaccine • Seasonal character - autumn - winter

10. Diphtheria cases reported to World Health Organization between 1997 and 2007

11. Pathogenesis • Penetration of the agent through entrance gate (mucous of upper respiratory tract, sometimes conjunctivas, skin) • Production of exotoxin • Local and systemic effects of the toxin: • Dermonecrotoxin - necrosis of a surface epithelium, retardation of blood stream, rising of a permeability of vessels, their fragility, transuding of plasma in ambient tissues, formation of a fibrinous film, edema of tissues; downstroke of pain sensitivity

12. Pathogenesis • Neuraminidase - replacement of cytochrome, blockage of cellular respiration, destruction of a cell, violation of a function of organs and tissues (central and peripheric nervous system, cardiovascular system, kidneys) • Hyaluronidase - destruction of a stroma of a connecting tissue (rising of permeability of vessels, edema of tissues) • Hemolysin - hemorrhagic set of symptoms

13. Classification • Localization - otopharynx, nose, larynx, trachea and bronchi;rare localizations (skin, eye) • Degree of severity - mild, moderate, severy, hemorrhagic, hypertoxic • Form - localized, wide-spread, combined • Nature of process - catarrhal, island-like, paleaceous • Complications - myocarditis, neuritis, nephritis (early and late) • Subclinical (carriering)

14. Clinical manifestation • Incubation period – 2-10 days • Phenomena of intoxication (high fever, malaise, general weakness, headache) • Pharyngalgia - moderate • Changes of a throat mucous - soft hyperemia, edema of tonsills, covers on their surface (grey colour, dense, hard to remove with bleeding, slime), spread out of tonsills limits(palatopharyngeal arches, uvula, soft palate) • Augmentation and moderate morbidness of regional lymphnodes • Edema of a hypodermic fat of a neck

15. Peculiarities of diphtheria covers (Grey colour, dense, hard to remove with bleeding, slime), spread out of tonsills limits(on uvula, soft palate, palatopharyngeal archs)

16. Edema of a hypodermic tissues of a neck

17. Swollen neck in diphtheria

18. Diphtheria of the nose

19. A diphtheria skin lesion on the leg

20. Features of diphtheria toxicosis (In wide-spread, combined, hypertoxical, hemorrhagic forms)toxicosis І, ІІ, ІІІ • Edema of the neck hypodermic tissues • Paleness of skin • Cyanosis of lips • Decreasing of arterial pressure • Tachycardia • Decreasing of a body temperature

21. Diphtheria of larynx Real croup (stenosis of a larynx) • І degree (catarrhal) - labored inspiration, retraction of intercostal spaces, rasping “dog barking" cough, “horse” voice • ІІ degree (stenosis) - noisy respiration, inspiratory dyspnea with an elongated inspiration, participation in respiration of auxiliary muscles, aphonia • ІІІ degree (asphyxia) - acute oxygen insufficiency, sleepiness, cyanosis, cold sweat, cramps, paradoxical sphygmus

23. Complications • Infectious-toxic shock • Intra vessels disseminated syndrome • Myocarditis (early, late) • Polyradiculoneuritis (early, late) • Nephrosonephritis etc.

24. LABORATORY DIAGNOSTIC • Detection of the agent in smears from a throat and nose (taking of material on border between effected area and normal mucous) • Microscopy (colouring byNeisser) – typical locating of rods, grains of volutin in bacterias • Sowing on convolute serum or telluric blood agar for allocation of clean culture and recognizing oftoxigenisity • Serological tests mirror a condition of immune defence (efficiency of vaccination)

28. Treatment • Immediate hospitalization • Bed regimen (at localized forms - 10 days, at toxic - not less than 35-45 days) • Specific treatment - introducing of antitoxic antidiphtherial Serum (from 30-50 thousand IU at the localized forms up to 100-120 thousand IU at toxic, byBezredka method) • Glucocorticoids (in toxic forms and croup) • Antibiotics (penicilini, tetracyclini, erythromycini) • Strychninum (in toxic forms) • In case of croup - inhalations, broncholitics, diuretics, glucocorticoids, antibiotics, antihistamine, lytic admixture; under the indications - intubation, tracheotomy

29. Conditions of discharging from a hospital • Clinical convalescence • 2 negative results of bacteriological research of smears from a throat and a nose with two-day interval • For decret group - additional doublebacteriological examination in polyclinic

30. Prophylaxis • Plan immunization(vaccination in 3, 4, 5 months.With АPДT vaccine, revaccination in 18 months; 6, 11, 14, 18 yearsand adults every 10 yearswith АДT-М vaccine) • In the focus – 7 daysmedical observation after contact persons Bacteriological examination Sanation of detected carriers Final disinfection Revaccination

31. Desinfection • Aeration and ultra-violet lighting of puttings, wet cleaning with usage of 2/3-basic salt of perchloron, calcium of hypochlorite, 3 % of solution of chloraminum, 1 % of solution amfolan • Sputum, the outwashes from a nasopharynx hash with double quantity of solutions, exposition 2 hours. The tableware is boiled in 2 % potassium solution 30 mines. Bed-clothes and clothes if necessaryto decontaminate in desinfection camera

32. Differential diagnosis • Tonsillitis, including Plaut-Vincent-Simanovsky • Herpetic tonsillitis • ARVI (adenoviral infection, false croup) • Paratonsillar abscess • Infectious mononucleosis • Scarlet fever • Pseudotuberculosis • Tonsillo-bubonic form of tularemia • Mycotic affection of tonsills • Epidemic parotitis • Typhoid fever • Lues • Hematological diseases (acute leukosis, agranulocytosis)

45. Common symptoms of tonsillitis • sore throat • red, swollen tonsils • pain when swallowing • high temperature (fever) • coughing • headache • tiredness • chills • a general sense of feeling unwell • white pus-filled spots on the tonsils • swollen lymph nodes (glands) in the neck • pain in the ears or neck • changes to the voice or loss of voice

46. The diagnosis of GABHS tonsillitis can be confirmed by culture. Samples are obtained by swabbing both tonsillar surfaces and the posterior pharyngeal wall are plated on sheep blood agar medium. The isolation rate can be increased by incubating the cultures under anaerobic conditions and using selective media. A single throat culture has a sensitivity of 90%-95% for the detection of GABHS. False-negative results are possible if the patient received antibiotics. The identification of GABHS requires 24 to 48 hours. Rapid methods for GABHS detection (10–60 minutes), are available. Rapid detection kits have a sensitivity of 85 to 90.

47. Treatments to reduce the discomfort from tonsillitis symptoms include: • pain relief, anti-inflammatory, fever reducing medications (acetaminophen/paracetamol and/or ibuprofen) • sore throat relief (warm salt water gargle, lozenges, and iced/cold liquids) • If the tonsillitis is caused by group A streptococus, then antibiotics are useful with penicillin or amoxicillin being first line. Cephalosporins and macrolides are considered good alternatives to penicillin in the acute setting. A macrolide such as erythromycin is used for people allergic to penicillin. Individuals who fail penicillin therapy may respond to treatment effective against beta-lactamase producing bacteria such as clindamycin or amoxicillin-clavulanate. Aerobic and anaerobic beta lactamase producing bacteria that reside in the tonsillar tissues can "shield" group A streptococcus from penicillins. When tonsillitis is caused by a virus, the length of illness depends on which virus is involved. Usually, a complete recovery is made within one week; however, symptoms may last for up to two weeks. Chronic cases may be treated with tonsillectomy (surgical removal of tonsils) as a choice for treatment.

48. Complications • Complications may rarely include dehydration and kidney failure due to difficulty swallowing, blocked airways due to inflammation, and pharyngitis due to the spread of infection. • An abscess may develop lateral to the tonsil during an infection, typically several days after the onset of tonsillitis. This is termed a peritonsillar abscess (or quinsy). Rarely, the infection may spread beyond the tonsil resulting in inflammation and infection of the internal jugular vein giving rise to a spreading septicaemia infection (Lemierre's syndrome). • In chronic/recurrent cases (generally defined as seven episodes of tonsillitis in the preceding year, five episodes in each of the preceding two years or three episodes in each of the preceding three years),or in acute cases where the palatine tonsils become so swollen that swallowing is impaired, a tonsillectomy can be performed to remove the tonsils. Patients whose tonsils have been removed are still protected from infection by the rest of their immune system. • In very rare cases of strep throat, diseases like rheumatic fever or glomerulonephritis can occur. These complications are extremely rare in developed nations but remain a significant problem in poorer nations. Tonsillitis associated with strep throat, if untreated, is hypothesized to lead to pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).[

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